Cost-effectiveness analysis of strategies for colorectal cancer screening in Japan

Cost of Increasing Years-of-Life-Gained (YLG) Using Fecal Immunochemical Testing as a Population-Level Screening Model in a Rural Appalachian Population

PURPOSE

Given the innovation of fecal immunochemical testing (FIT) to detect polyps in the rectum and colon for removal by colonoscopy, it is important to determine the cost per Life-Year Gained (LYG) when using FIT as a population-level screening model. This is particularly true for medically underserved rural populations. Accordingly, the purpose of this study was to make this determination among rural Appalachians experiencing isolation and economic challenges.

METHODS

The study occurred in an 8-county area of southeastern Kentucky. Kits were distributed to 1,424 residents. Seven hundred thirty-two kits (51.4%) were completed and returned. A Markov decision-analytic model was developed using PrecisionTree 7.6.

FINDINGS

Reactive test results occurred for 144 of the completed kits (19.7%). Thirty-seven colonoscopies were verified, with 15 of these indicating precancerous changes or actual cancer. Program costs were estimated at $461,952, with the average cost per person screened estimated at $324. Cost per LYG was $7,912.

CONCLUSIONS

In contrast to an average cost per LYG of $17,200, our findings suggest a highly favorable cost-effectiveness ratio for this population of medically underserved rural residents. Cost-benefit analyses suggest that the screening program begins to yield positive net benefits at the stage when project recipients undergo colonoscopy, suggesting that this is the key step for behavioral intervention and intensified outreach.

Trends in incidence, mortality rates, and survival of colorectal cancer in Western Australia from 1990 to 2014: a retrospective whole-population longitudinal study

PURPOSE

This study aimed to investigate the trends in colorectal cancer (CRC) incidence and mortality rates among the Western Australian (WA) population. This study further compared the trends with the timing of the implementation and rollout of the National Bowel Cancer Screening Program (NBCSP) and examined the survival predictors in CRC cases.

METHODS

This study was a whole-population, retrospective longitudinal study and included all individuals with a confirmed histological diagnosis of primary invasive CRC diagnosed in WA from 1990 to 2014 (n = 25,932). The temporal trends were assessed by Joinpoint regression models and Kaplan-Meier survival curves were used to asses 5-year survival. Predictors of survival were examined using multivariable Cox proportional hazard regression models, adjusting for age of diagnosis.

RESULTS

The overall CRC incidence showed an upward trend between 1990 and 2010 (annual percent change (APC) = 1.1%); then, there was a downward trend from 2010 to 2014 (APC = - 5.0%). In younger people (< 50 years), the incidence rate increased steadily (APC = 0.9%) over the study period. The overall CRC mortality trend increased from 1990 to 1999 (APC = 1.6%), decreasing after that (APC = - 2.1%). Younger people had better CRC-related 5-year survival than older people (HR = 0.81, 95%CI 0.75-0.87, p = < 0.001).

CONCLUSION

This study found that CRC incidence and mortality rates decreased among older people over the last 10 years in Western Australia. However, incidence continues to rise for younger people. Hence, more widespread adoption of the screening program, and potential preventive and early diagnostic strategies should become key priorities for the CRC control in WA.

Critical Analysis of Markov Models Used for the Economic Evaluation of Colorectal Cancer Screening: A Systematic Review

BACKGROUND

The economic evaluation of colorectal cancer screening is challenging because of the need to model the underlying unobservable natural history of the disease.

OBJECTIVES

To describe the available Markov models and to critically analyze their main structural assumptions.

METHODS

A systematic search was performed in eight relevant databases (MEDLINE, Embase, Econlit, National Health Service Economic Evaluation Database, Health Economic Evaluations Database, Health Technology Assessment database, Cost-Effective Analysis Registry, and European Network of Health Economics Evaluation Databases), identifying 34 models that met the inclusion criteria. A comparative analysis of model structure and parameterization was conducted using two checklists and guidelines for cost-effectiveness screening models.

RESULTS

Two modeling techniques were identified. One strategy used a Markov model to reproduce the natural history of the disease and an overlaying model that reproduced the screening process, whereas the other used a single model to represent a screening program. Most of the studies included only adenoma-carcinoma sequences, a few included de novo cancer, and none included the serrated pathway. Parameterization of adenoma dwell time, sojourn time, and surveillance differed between studies, and there was a lack of validation and statistical calibration against local epidemiological data. Most of the studies analyzed failed to perform an adequate literature review and synthesis of diagnostic accuracy properties of the screening tests modeled.

CONCLUSIONS

Several strategies to model colorectal cancer screening have been developed, but many challenges remain to adequately represent the natural history of the disease and the screening process. Structural uncertainty analysis could be a useful strategy for understanding the impact of the assumptions of different models on cost-effectiveness results.

Optimal use of colonoscopy and fecal immunochemical test for population-based colorectal cancer screening: a cost-effectiveness analysis using Japanese data

OBJECTIVE

There have been few cost-effectiveness analyses of population-based colorectal cancer screening in Japan, and there is no consensus on the optimal use of total colonoscopy and the fecal immunochemical test for colorectal cancer screening with regard to cost-effectiveness and total colonoscopy workload. The present study aimed to examine the cost-effectiveness of colorectal cancer screening using Japanese data to identify the optimal use of total colonoscopy and fecal immunochemical test.

METHODS

We developed a Markov model to assess the cost-effectiveness of colorectal cancer screening offered to an average-risk population aged 40 years or over. The cost, quality-adjusted life-years and number of total colonoscopy procedures required were evaluated for three screening strategies: (i) a fecal immunochemical test-based strategy; (ii) a total colonoscopy-based strategy; (iii) a strategy of adding population-wide total colonoscopy at 50 years to a fecal immunochemical test-based strategy.

RESULTS

All three strategies dominated no screening. Among the three, Strategy 1 was dominated by Strategy 3, and the incremental cost per quality-adjusted life-years gained for Strategy 2 against Strategies 1 and 3 were JPY 293 616 and JPY 781 342, respectively. Within the Japanese threshold (JPY 5-6 million per QALY gained), Strategy 2 was the most cost-effective, followed by Strategy 3; however, Strategy 2 required more than double the number of total colonoscopy procedures than the other strategies.

CONCLUSIONS

The total colonoscopy-based strategy could be the most cost-effective for population-based colorectal cancer screening in Japan. However, it requires more total colonoscopy procedures than the other strategies. Depending on total colonoscopy capacity, the strategy of adding total colonoscopy for individuals at a specified age to a fecal immunochemical test-based screening may be an optimal solution.

Population screening for colorectal cancer means getting FIT: the past, present, and future of colorectal cancer screening using the fecal immunochemical test for hemoglobin (FIT)

Fecal immunochemical tests for hemoglobin (FIT) are changing the manner in which colorectal cancer (CRC) is screened. Although these tests are being performed worldwide, why is this test different from its predecessors? What evidence supports its adoption? How can this evidence best be used? This review addresses these questions and provides an understanding of FIT theory and practices to expedite international efforts to implement the use of FIT in CRC screening.

Cost-effectiveness of total colonoscopy in screening of colorectal cancer in Japan

Introduction. In Japan, the cost-effectiveness of total colonoscopy (TCS) for primary screening of colorectal cancer (CRC) is unclear. We compared the cost of identifying a patient with CRC using two primary screening strategies: TCS (strategy 1) and the immunochemical fecal test (FIT) (strategy 2). Materials and Methods. We retrospectively analyzed the TCS screening database at our institution from February 2004 to August 2010 (strategy 1, n = 15,348) and the Japanese nationwide survey of CRC screening in 2008 (strategy 2, n = 5,267,443). Results. 112 and 6,838 CRC cases were detected in strategies 1 and 2, costing 2,124,000 JPY and 1,629,000 JPY, respectively. The rate of earlier-stage CRC was higher in strategy 1. Conclusions. The cost was higher using TCS as a primary screening procedure. However, the difference was not excessive, and considering the increased rate of detecting earlier CRC, the use of TCS as a primary screening tool may be cost-effective.

Cost-effectiveness of colorectal cancer screening

Colorectal cancer is an important public health problem. Several screening methods have been shown to be effective in reducing colorectal cancer mortality. The objective of this review was to assess the cost-effectiveness of the different colorectal cancer screening methods and to determine the preferred method from a cost-effectiveness point of view. Five databases (MEDLINE, EMBASE, the Cost-Effectiveness Analysis Registry, the British National Health Service Economic Evaluation Database, and the lists of technology assessments of the Centers for Medicare and Medicaid Services) were searched for cost-effectiveness analyses published in English between January 1993 and December 2009. Fifty-five publications relating to 32 unique cost-effectiveness models were identified. All studies found that colorectal cancer screening was cost-effective or even cost-saving compared with no screening. However, the studies disagreed as to which screening method was most effective or had the best incremental cost-effectiveness ratio for a given willingness to pay per life-year gained. There was agreement among studies that the newly developed screening tests of stool DNA testing, computed tomographic colonography, and capsule endoscopy were not yet cost-effective compared with the established screening options.

FIT: a valuable but underutilized screening test for colorectal cancer-it's time for a change

Although fecal immunochemical tests (FITs) have been used for colorectal cancer (CRC) screening in several countries for years, this has not been the case in the United States. The reasons for this are multifactorial, but if the United States hopes to increase screening rates, the evidence is in regarding FIT's benefits and potential. A publication in this issue of the American Journal of Gastroenterology provides "gold standard" evidence of its superiority over the standard guaiac test and opens opportunities for investigators to discover the most effective uses of this test for population screening.

Cost-effectiveness of colorectal cancer screening - an overview

There are several modalities available for a colorectal cancer (CRC) screening program. When determining which CRC screening program to implement, the costs of such programs should be considered in comparison to the health benefits they are expected to provide. Cost-effectiveness analysis provides a tool to do this. In this paper we review the evidence on the cost-effectiveness of CRC screening. Published studies universally indicate that when compared with no CRC screening, all screening modalities provide additional years of life at a cost that is deemed acceptable by most industrialized nations. Many recent studies even find CRC screening to be cost-saving. However, when the alternative CRC screening strategies are compared against each other in an incremental cost-effectiveness analysis, no single optimal strategy emerges across the studies. There is consensus that the new technologies of stool DNA testing, computed tomographic colonography and capsule endoscopy are not yet cost-effective compared with the established CRC screening tests.

Cost-effectiveness of screening for colorectal cancer in France using a guaiac test versus an immunochemical test

Objectives: The aim of this study was to compare the cost and the effectiveness of two biennial fecal occult blood screening tests for colorectal cancer: a guaiac nonrehydrated test (G-FOBT) and an immunochemical test (I-FOBT) with the absence of screening.

Methods: A Markov model was developed to compare these strategies in a general population of subjects aged 50 to 74 over a 20-year period.

Results: Compared with the absence of screening, G-FOBT and I-FOBT were associated with a decrease in colorectal cancer mortality of 17.4 percent and 25.2 percent, respectively. With regard to cost-effectiveness, expressed as cost per life-year gained, I-FOBT was the most effective and most costly alternative. Compared with no screening, G-FOBT and I-FOBT presented similar discounted incremental cost-effectiveness ratios: €2,739 and €2,819 respectively per life-year gained. When compared with G-FOBT, I-FOBT presented an incremental cost-effectiveness ratio of €2,988 per life-year gained. Sensitivity analyses showed the strong influence of the I-FOBT lead time, of the participation rate to screening for I-FOBT, and of the purchase price of the I-FOBT on the discounted incremental cost-effectiveness ratios.

Conclusions: Compared with the absence of screening and with G-FOBT, the biennial two-stool immunochemical test can be considered a promising method for mass screening for colorectal cancer.

What is the most cost-effective strategy to screen for second primary colorectal cancers in male cancer survivors in Korea?

AIM

To identify a cost-effective strategy of second primary colorectal cancer (CRC) screening for cancer survivors in Korea using a decision-analytic model.

METHODS

A Markov model estimated the clinical and economic consequences of a simulated 50-year-old male cancer survivors' cohort, and we compared the results of eight screening strategies: no screening, fecal occult blood test (FOBT) annually, FOBT every 2 years, sigmoidoscopy every 5 years, double contrast barium enema every 5 years, and colonoscopy every 10 years (COL10), every 5 years (COL5), and every 3 years (COL3). We included only direct medical costs, and our main outcome measures were discounted lifetime costs, life expectancy, and incremental cost-effectiveness ratio (ICER).

RESULTS

In the base-case analysis, the non-dominated strategies in cancer survivors were COL5, and COL3. The ICER for COL3 in cancer survivors was $5593/life-year saved (LYS), and did not exceed $10,000/LYS in one-way sensitivity analyses. If the risk of CRC in cancer survivors is at least two times higher than that in the general population, COL5 had an ICER of less than $10,500/LYS among both good and poor prognosis of index cancer. If the age of cancer survivors starting CRC screening was decreased to 40 years, the ICER of COL5 was less than $7400/LYS regardless of screening compliance.

CONCLUSION

Our study suggests that more strict and frequent recommendations for colonoscopy such as COL5 and COL3 could be considered as economically reasonable second primary CRC screening strategies for Korean male cancer survivors.

Screening for colorectal cancer in Uruguay with an immunochemical faecal occult blood test

An observational prospective study was carried out in Uruguay to evaluate the feasibility of colorectal cancer screening using immunochemical faecal occult blood tests with no dietary restrictions in an average-risk population. An automated system was used for processing the samples with a cut-off haemoglobin level of 100 ng/ml. Of the 11,734 study participants who received an immunochemical test kit (OC-Hemodia), 10,573 (90.1%) returned samples for screening. The results of 1170 (11.1%) of the responders were positive. Subsequently, colonoscopy was performed on 879 (75.1%) of the participants with a positive test result and showed neoplasia in 330 participants. Fifty four had advanced cancer, 47 had early cancer, 131 had high-risk adenoma and 98 had low-risk adenoma. The detection rates and the positive predictive values were 0.95 and 8.6% for cancer, and 1.24 and 11.2% for high-risk adenoma, respectively. The high compliance and high detection rates for cancer and high-risk adenoma achieved in the colorectal cancer screening programme verifies the feasibility of an immunochemical faecal occult blood test in screening an average-risk population in Uruguay, a country with a small population, but with high morbidity and mortality rates for this disease.

Cost-effectiveness of pravastatin for primary prevention of coronary artery disease in Japan

OBJECTIVE

This analysis was designed to estimate the cost-effectiveness of pravastatin for the primary prevention of coronary heart disease in Japan.

METHODS

A state-transition model was used to compare the cost-effectiveness of pravastatin therapy with no intervention. Hypothetical cohorts were assumed according to patients' age, sex, initial serum total cholesterol (TC) levels, and other cardiac risk factors. For the baseline analysis, 20 mg/day of pravastatin was used for people aged 60 years who had an initial TC level of 240 mg/dl. Epidemiological, clinical, and economic data were collected from published articles. Incremental cost-effectiveness ratios (ICERs) in yen per quality-adjusted life year (QALY) were calculated. To confirm the effects of different variables, a sensitivity analysis was performed. The assumptions of our model were in accordance with the Japan Atherosclerosis Society Guidelines for the Diagnosis and Treatment of Atherosclerotic Cardiovascular disease.

RESULTS

ICERs were respectively 44 million and 76 million yen/QALY for men and women at low cardiac risk (i.e., the risks of hypercholesterolemia and old age) and 7.5 million and 4.3 million yen/QALY for those at high cardiac risk (i.e., the risks of hypercholesterolemia, old age, cigarette smoking, hypertension, and hyperglycemia).

CONCLUSIONS

The cost-effectiveness of pravastatin therapy differs substantially according to the level of cardiac risk. At present, pravastatin therapy is not cost-effective for persons at low cardiac risk.

[Cost-effectiveness of colorectal cancer screening]

Colorectal cancer (CRC) screening in France is based on a faecal occult blood test every two years in average risk subjects 50-74 years of age while other endoscopic or non-endoscopic screening methods are used in Europe and in the USA. Beside the reduced incidence of and mortality from CRC found in available studies, cost-effectiveness data need to be taken into account. Because of the delay between randomized controlled trials and clinical results, transitional probabilistic models of screening programs are useful for public health policy makers. The aim of the present review was to promote the implementation of cost-effectiveness studies, to provide a guide to analyze cost-effectiveness studies on CRC screening and, to propose a French cost effectiveness study comparing CRC screening strategies. Most of these trials were performed by US or UK authors and demonstrate that the incremental cost-effectiveness ratio varies between 5 000 and 15 000 US dollars/one year life gained, with wide variations: these results were highly dependent on the unit costs of the different devices as well as the predictive values of the screening tests. Although CRC screening programs have been implemented in several administrative districts of France since 2002, and the results of these randomized controlled trials using fecal occult blood have been updated, cost-effectiveness criteria need to be integrated; especially since the results of screening campaigns based on other tools such as flexible sigmoidoscopy should be available in 2007.

Feasible economic strategies to improve screening compliance for colorectal cancer in Korea

AIM: While colorectal cancer (CRC) is an ideal target for population screening, physician and patient attitudes contribute to low levels of screening uptake. This study was carried out to find feasible economic strategies to improve the CRC screening compliance in Korea.

METHODS: The natural history of a simulated cohort of 50-year-old Korean in the general population was modeled with CRC screening until the age of 80 years. Cases of positive results were worked up with colonoscopy. After polypectomy, colonoscopy was repeated every 3 years. Baseline screening compliance without insurance coverage by the national health insurance (NHI) was assumed to be 30%. If NHI covered the CRC screening or the reimbursement of screening to physicians increased, the compliance was assumed to increase. We evaluated 16 different CRC screening strategies based on Markov model.

RESULTS: When the NHI did not cover the screening and compliance was 30%, non-dominated strategies were colonoscopy every 5 years (COL5) and colonoscopy every 3 years (COL3). In all scenarios of various compliance rates with raised coverage of the NHI and increased reimbursement of colonoscopy, COL10, COL5 and COL3 were non-dominated strategies, and COL10 had lower or minimal incremental medical cost and financial burden on the NHI than the strategy of no screening. These results were stable with sensitivity analyses.

CONCLUSION: Economic strategies for promoting screening compliance can be accompanied by expanding insurance coverage by the NHI and by increasing reimbursement for CRC screening to providers. COL10 was a cost-effective and cost saving screening strategy for CRC in Korea.

Colorectal cancer screening in Australia: an economic evaluation of a potential biennial screening program using faecal occult blood tests

OBJECTIVE

To evaluate whether the introduction of a national, co-ordinated screening program using the faecal occult blood test represents 'value-for-money' from the perspective of the Australian Government as third-party funder.

METHODS

The annual equivalent costs and consequences of a biennial screening program in 'steady-state' operation were estimated for the Australian population using 1996 as the reference year. Disability-adjusted life years (DALYs) and the years of life lost (YLLs) averted, and the health service costs were modelled, based on the epidemiology and the costs of colorectal cancer in Australia together with the mortality reduction achieved in randomised controlled trials. Uncertainty in the model was examined using Monte Carlo simulation methods.

RESULTS

We estimate a minimum or 'base program' of screening those aged 55 to 69 years could avert 250 deaths per annum (95% uncertainty interval 99-400), at a gross cost of dollarsA55 million (95% UI dollarsA46 million to dollarsA96 million) and a gross incremental cost-effectiveness ratio of dollarsA17,000/DALY (95% UI dollarsA13,000/DALY to dollarsA52,000/DALY). Extending the program to include 70 to 74-year-olds is a more effective option (cheaper and higher health gain) than including the 50 to 54-year-olds.

CONCLUSIONS

The findings of this study support the case for a national program directed at the 55 to 69-year-old age group with extension to 70 to 74-year-olds if there are sufficient resources. The pilot tests recently announced in Australia provide an important opportunity to consider the age range for screening and the sources of uncertainty, identified in the modelled evaluation, to assist decisions on implementing a full national program.

The cost-effectiveness of life-saving interventions in Japan. Do chemical regulations cost too much?

This paper compares the cost-effectiveness of life-saving interventions in Japan, based on information collected from the health, safety and environmental literature. More than 50 life-saving interventions are analyzed. Cost-effectiveness is defined as the cost per life-year saved or as the cost per quality-adjusted life-year saved. Finding a large cost-effectiveness disparity between chemical controls and health care intervention, we raise the question of whether chemical regulations cost society too much. We point out the limitations of this study and propose a way to improve the incorporation of morbidity effects in cost-effectiveness analysis.

The limited incorporation of economic analyses in clinical practice guidelines

BACKGROUND

Because there is increasing concern that economic data are not used in the clinical guideline development process, our objective was to evaluate the extent to which economic analyses are incorporated in guideline development.

METHODS

We searched medline and HealthSTAR databases to identify English-language clinical practice guidelines (1996-1999) and economic analyses (1990-1998). Additional guidelines were obtained from The National Guidelines Clearinghouse Internet site available at http://www.guideline.gov. Eligible guidelines met the Institute of Medicine definition and addressed a topic included in an economic analysis. Eligible economic analyses assessed interventions addressed in a guideline and predated the guideline by 1 or more years. Economic analyses were defined as incorporated in guideline development if 1) the economic analysis or the results were mentioned in the text or 2) listed as a reference. The quality of economic analyses was assessed using a structured scoring system.

RESULTS

Using guidelines as the unit of analysis, 9 of 35 (26%) incorporated at least 1 economic analysis of above-average quality in the text and 11 of 35 (31%) incorporated at least 1 in the references. Using economic analyses as the unit of analysis, 63 economic analyses of above-average quality had opportunities for incorporation in 198 instances across the 35 guidelines. Economic analyses were incorporated in the text in 13 of 198 instances (7%) and in the references in 18 of 198 instances (9%).

CONCLUSIONS

Rigorous economic analyses may be infrequently incorporated in the development of clinical practice guidelines. A systematic approach to guideline development should be used to ensure the consideration of economic analyses so that recommendations from guidelines may impact both the quality of care and the efficient allocation of resources.

Age-related cancer detection rate and costs for one cancer detected in one screening by immunochemical fecal occult blood test

PURPOSE

This study was performed to assess, from the aspects of screening efficiency and cost-effectiveness, the optimal lower limit of age in immunochemical occult blood screening for colorectal cancer.

METHODS

Seven thousand four hundred asymptomatic individuals were the subjects of this study. They gave samples for an immunochemical fecal occult blood test (OC-Hemodia), and colonoscopy was performed during a medical checkup. They were divided into three groups according to their ages: younger (40-49), middle (50-59), and older (60+) groups. The detection rate for colorectal cancer and the average costs to detect one patient with colorectal cancer were evaluated among the three groups.

RESULTS

The detection rate for colorectal cancer and the average costs to detect one cancer patient were calculated as 0.3 percent and $6024 for the younger group, 1.6 percent and $1425 for the middle group, and 1.7 percent and $1410 for the older group, respectively. The cancer detection rate was significantly different between the younger and middle groups (P < 0.05) and between the younger and older groups (P < 0.05).

CONCLUSIONS

This analysis suggests that the subjects aged less than 50 have some disadvantage when carrying out the immunochemical fecal occult blood test, OC-Hemodia for colorectal cancer screening, from the aspects of screening efficiency and cost-effectiveness.

Cost-effectiveness of colorectal cancer screening

PURPOSE

To determine the most cost-effective colorectal cancer screening strategy costing less than $100,000 per life-year saved and to determine how available strategies compare with each other.

MATERIALS AND METHODS

Standardized methods were used to calculate incremental cost-effectiveness ratios (ICERs) from published estimates of cost and effectiveness of colorectal cancer screening strategies, and the direction and magnitude of any effect on the ratio from parameter estimate adjustments based on literature values were estimated.

RESULTS

Strategies in which double-contrast barium enema examination was performed emerged as optimal from all studies included. In average-risk individuals, screening with double-contrast barium enema examination every 3 years, or every 5 years with annual fecal occult blood testing, had an ICER of less than $55,600 per life-year saved. However, double-contrast barium enema examination screening every 3 years plus annual fecal occult blood testing had an ICER of more than $100,000 per life-year saved. Colonoscopic screening had an ICER of more than $100,000 per life-year saved, was dominated by other screening strategies, and offered less benefit than did double-contrast barium enema examination screening.

CONCLUSION

Double-contrast barium enema examination can be a cost-effective component of colorectal cancer screening, but further modeling efforts are necessary.

Evaluation of the optimum cut-off point in immunochemical occult blood testing in screening for colorectal cancer

This study was carried out to assess, from the aspects of cost-effectiveness and diagnostic validity, the optimum cut-off point for immunochemical occult blood testing using a 2-day method as a means of screening for colorectal cancer. Four thousand, two hundred and sixty asymptomatic individuals were subjects of this study. They gave samples for an immunochemical fecal occult blood test, and colonoscopy was carried out during a medical check-up. For evaluation of the optimum cut-off point, three cut-off levels of fecal haemoglobin, 50, 150 and 300 ng/ml, were used. A total of 27 patients with colorectal cancer were diagnosed. The average costs to detect one patient with colorectal cancer and the sensitivity and specificity of these three cut-off points of fecal haemoglobin were evaluated. The average costs for the detection of one cancer case were calculated as $2870.45 for cut-off level of 50 ng/ml, $2492.98 for that of 150 ng/ml and $3329.09 for that of 300 ng/ml, respectively. The sensitivity and specificity were calculated as 89 and 94% for the 50 ng/ml cut-off level, 81% and 96% for the 150 ng/ml cut-off level and 56 and 97% for the 300 ng/ml cut-off level, respectively, indicating a significant difference in the sensitivity between the 50 and 300 ng/ml levels (P<0.05), as well as between the 150 and 300 ng/ml levels (P<0.05), and a significant difference in the specificity between the 50 and 300 ng/ml levels (P<0.05). However, no significant difference was observed in the specificity between the 50 and 150 ng/ml levels. The findings show that 150 ng/ml of fecal haemoglobin is the optimal cut-off point when carrying out the OC-Hemodia test as a means of screening for colorectal cancer.

Cost-effectiveness analysis of dopamine agonists in the treatment of Parkinson's disease in Japan

BACKGROUND

Dopamine agonists such as bromocriptine or pergolide are often used in Japan to treat Parkinson's disease. Dopamine agonists are relatively expensive drugs; economic evaluations are required.

OBJECTIVE

To evaluate the cost effectiveness of dopamine agonists for the treatment of Parkinson's disease in Japan.

DESIGN AND SETTING

We used a Markov model to simulate the course of Parkinson's disease and to compare the cost effectiveness of dopamine agonists added to levodopa with that of levodopa alone in Japan. The model assumed that 60-year-old men with Parkinson's disease in Hoehn-Yahr (HY) stages 2 to 5 using levodopa were administered dopamine agonists or continued on levodopa alone. The incremental cost effectiveness of dopamine agonists used for 10 years was then estimated.

STUDY PERSPECTIVE

Societal.

MAIN OUTCOME MEASURES AND RESULTS

In the patients in HY stage 2, the incremental cost effectiveness of dopamine agonists was 18,610,000 to 19,320,000 yen per quality-adjusted life-year (QALY) [$US 172,300 to $US 178,900/QALY; 1998 values] . In patients in HY stage 3 or higher, the use of dopamine agonists was dominant over levodopa alone mainly due to reduced cost for care. In sensitivity analyses, costs and effectiveness of dopamine agonists significantly influenced the results. The use of a generic formulation of bromocriptine was dominant over levodopa alone even in the patients with HY stage 2 disease.

CONCLUSIONS

Dopamine agonists appear to be cost effective in advanced Parkinson's disease, although their use is sensitive to the costs and effectiveness of dopamine agonists. If factors discouraging the prescription of generic drugs in Japan were removed, the treatment of Parkinson's disease would become more cost effective.

Effectiveness and economic impact of screening for colorectal cancer by mass fecal occult blood testing

OBJECTIVES

Fecal occult blood testing has been shown to reduce mortality from colorectal cancer in large randomized, controlled trials conducted in the United States, Denmark, and the United Kingdom, and mathematical simulation modeling found it to be cost-effective relative to other health care services. Before making a concerted effort to implement mass fecal occult blood testing based on this evidence alone, however, we considered it prudent to critically re-evaluate the effectiveness and economic impact of screening in the US population as a whole.

METHODS

To assess the effectiveness of screening, we projected published outcomes from each of the three large randomized controlled trials of fecal occult blood testing to the US population, as if each clinical trial had been done in the population as a whole. We then determined the resource costs of detection and treatment that would be associated with the outcomes predicted from each trial.

RESULTS

More than 1 million colorectal cancers could be expected to arise over 10 yr in the cohort of US residents eligible to enter a screening program in 1997, and trial outcomes indicate that > or = 60% of these cancers would be fatal. If the 60-67% compliance rate of the population-based randomized controlled trials were achieved, a fecal occult blood testing program would detect 30% of known colorectal cancers and save 100,000 lives over 10 yr. Screening would incur total costs of $3-4 billion over 10 yr, or $2,500 per life-year saved.

CONCLUSIONS

Mass fecal occult blood testing is cost-effective, and, although not inexpensive, many would consider the total cost acceptable. Even with a concerted effort to achieve compliance, however, the effectiveness of fecal occult blood testing would be limited to saving the lives of < or = 15% of those who otherwise would die from their cancer in the first 10 yr after beginning mass screening. The limitations of fecal occult blood testing suggest the need to further evaluate the role of endoscopy in screening, and to develop more effective, noninvasive screening tools.

Screening for colorectal cancer: current status in Japan

PURPOSE

Screening for colorectal cancer using a guaiac-based fecal occult blood, or Hemoccult, test has been demonstrated to reduce colorectal cancer mortality. However, the magnitude of effectiveness is relatively low because of poor sensitivity of the Hemoccult test. The immunochemical fecal occult blood test has been shown to be much more sensitive than the Hemoccult test in detecting preclinical colorectal cancer in an asymptomatic population. The purpose of this article is to discuss the validity of the immunochemical fecal occult blood test and the efficacy of a population-based screening program using the test.

METHODS

Relevant articles were primarily identified through MEDLINE search. Review was focused on the studies of population screening programs with the immunochemical fecal occult blood test.

RESULTS

Sensitivities for colorectal cancer calculated in the same population were reported to be 67 to 89 percent and only 33 to 37 percent for the immunochemical test and Hemoccult test, respectively. Case-control studies and other observational studies showed that screening programs using the immunochemical fecal occult blood test by hemagglutination reaction would reduce the risk of dying of colorectal cancer by 60 percent or more for those screened annually compared with those unscreened. It was also shown that a screening strategy using the immunochemical fecal occult blood test had the best cost-effectiveness ratio among the methods available. Nearly 5 million persons are currently screened per year in Japan, yielding 0.15 to 0.2 percent colorectal cancer cases among persons with positive fecal occult blood test results.

CONCLUSIONS

These results strongly suggest that a screening program with immunochemical fecal occult blood test has promising advantages in terms of effectiveness over programs with the Hemoccult test. More stress is warranted on introduction of immunochemical fecal occult blood testing as a screening test in place of the guaiac fecal occult blood test.

Screening for colorectal cancer

Colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer deaths in the United States. Fortunately, both the incidence and mortality associated with the disease have declined during the past 2 decades. This is likely due, at least in part, to improved efforts at screening and more aggressive removal of adenomatous polyps. However, colorectal cancer screening is still generally underutilized. This article reviews the current status and future outlook for colorectal cancer screening, including a discussion of risk factors for the disease, its anatomic distribution, proposed mechanisms of development from adenomatous polyps, rationale for screening, and screening options. Published literature concerning the cost-effectiveness of colorectal cancer screening is also summarized. The article concludes with a discussion of the emerging consensus regarding the importance of and approaches to screening.

A cost-effective analysis of the optimum number of stool specimens collected for immunochemical occult blood screening for colorectal cancer

This study was carried out to assess, from the viewpoint of cost-effectiveness, the optimum number of faecal specimens to collect for use in immunochemical occult blood testing as a means of screening for colorectal cancer. 3300 asymptomatic individuals were subjects of this study. They gave samples for an immunochemical faecal occult blood test, monohaem and colonoscopy was carried out during a medical check-up. For evaluation of the optimum number of sampling specimens, the results of the first day of sampling, those of the first and second days, and those of samples taken for 3 consecutive days were considered as the single-day method, the 2-day method and the 3-day method respectively. The average cost to detect 1 patient with colorectal cancer, the detection rate and the false-positive rate of these three faecal sample collection methods were evaluated. The average costs for one cancer case detected were calculated as $3,630.68 for the single-day method, $3,350.65 for the 2-day method and $4,136.36 for the 3-day method, respectively. The detection rate and the false-positive rate were calculated as 47 and 3.5% for the single-day method, 82 and 4.7% for the 2-day method and 88 and 5.3% for the 3-day method, respectively. This detection rate was significantly different between the single- and the 2-day methods, as well as between the single- and the 3-day methods (P<0. 05). No significant differences in the false-positive rate amongst the three testing methods were observed. This analysis suggests that a 2-day faecal collection method is recommended for immunochemical occult blood screening by Monohaem from the aspects of cost-effectiveness and diagnostic accuracy.

Positive cost effectiveness of early diagnosis of colorectal cancer

BACKGROUND

Studies examining interventional screening have lacked accurate data, because costs of hospital infrastructure, nursing and disinfection have not been included. We compared all costs of different strategies for screening, including colonoscopy, to provide a rational basis for decisions in early diagnosis. The costs, although based on Australian data, are probably applicable to all developed countries.

METHODS

Comprehensive cost data from Australian private day endoscopy centres, public and private hospitals, physicians, anaesthetists and pathologists were used to assess medical and infrastructure hospital costs for various methods of screening. The data were processed using the Office of Technology Assessment colorectal cancer screening model.

RESULTS

Annual or triennial faecal occult blood tests (FOBT; Hemoccult(®) ) are cost-effective, particularly with assumed 10-year dwell times (the time taken for an adenoma to become a cancer), the costs per year of life saved being $US 26 015 and $US 24 756, respectively. Colonoscopy at 5- or 10-year intervals is also cost-effective with similar dwell times, and colonoscopy every 10 years with a cost of $27 159 per year saved is comparable to annual or triennial FOBT. Double contrast barium enema at either 3- or 5-year intervals is cost-effective, but ideally should be combined with an annual FOBT, reducing the cost effectiveness of these options. FOBT also is ideally combined with flexible sigmoidoscopy; an annual FOBT and 5-yearly flexible sigmoidoscopy is cost-effective with both 5- and 10-year dwell times, though less than FOBT or colonoscopy. A once-only colonoscopy at age 50 is not cost-effective.

CONCLUSIONS

Annual or triennial FOBT, double contrast barium enema (DCBE) 3 and 5 and colonoscopy 5 and 10 are all cost-effective. There is less value in combining FOBT and flexible sigmoidoscopy, or flexible sigmoidoscopy alone. Physicians therefore have the option of offering individuals a range of cost-effective screening strategies, including colonoscopy.

Active detection of chronic obstructive pulmonary disease and asthma in the general population. Results and economic consequences of the DIMCA program

The aim of this prospective study was to detect subjects in the general population with objective signs of chronic obstructive pulmonary disease (COPD) or asthma at an early stage. This was done by means of a two-stage protocol involving screening and a subsequent 2-yr monitoring of all subjects with positive results of screening. The study was done in 10 general practices located in the eastern part of the Netherlands. A random sample was taken from the general population aged 25 to 70 yr. All known COPD and asthma patients were excluded. A total of 1,749 subjects met the inclusion criteria: 1,155 subjects (66%) agreed to participate in the screening stage of the study. A total of 604 subjects (52.3%) showed symptoms or objective signs of COPD or asthma during the screening and were considered "positive." Of those with positive screening results, 384 subjects (64%) agreed to participate in the second, 2-yr monitoring stage of the study. The costs involved in detection were calculated for three different scenarios, as follows: (1) The detection of subjects with persistently decreased lung function or an increased level of bronchial hyperresponsiveness (BHR) during 6 mo of monitoring; (2) Scenario 1 plus the detection of subjects with a rapid decline in lung function with signs of BHR during 12 mo of monitoring; (3) Scenario 2 plus the detection of subjects with a moderate increase in the decline in lung function or signs of BHR during 24 mo of monitoring. The costs of lung function assessments, organization, transportation, and patient time were included. The costs were converted to United States dollars on the basis of purchasing power (1 United States dollar = 2.08 Netherlands guilders). During the second stage, 252 subjects were detected with objective signs of COPD or asthma at an early stage. Smoking status as a screening criterion was neither sensitive nor specific. Because there was no evidence of biased recruitment or selection during the program, the proportions of subjects found to have objective signs of COPD or asthma at an early stage could be extrapolated to the general population. Of the general population, 7.7% showed persistently reduced lung function or increased BHR. Another 12.5 % of the general population showed a rapid decline in lung function (> 80 ml/yr) in combination with signs of BHR, and a further 19.4% of the general population showed mild objective signs of COPD or asthma. The average costs per detected case varied from US$953 (Scenario 1) to US$469 (Scenario 3). In conclusion, detection of COPD or asthma at an early stage by means of a two-stage protocol was feasible at relatively little expense in comparison with other mass screening programs. Persistently decreased lung function or a rapid decline in lung function (Scenario 2) was observed in approximately 20% of the general adult population.

What's new in colorectal cancer screening?

There is now good evidence from case control studies and randomized controlled trials that screening average-risk subjects for colorectal cancer using faecal occult blood tests reduces mortality. There is limited data indicating that screening sigmoidoscopy can also achieve this. There is no evidence yet that screening by colonoscopy or double contrast barium enema can reduce mortality. Calculations of cost-effectiveness suggest that all of the above strategies should be economically worthwhile but there is no convincing evidence to suggest that one strategy is markedly more cost-effective than the others. Further data on several aspects of screening are required before any decisions are made on which form(s) of screening should be offered nationwide.

Review article: faecal occult blood testing for colorectal cancer

Major health organizations recommend colorectal cancer screening using faecal occult blood tests, sigmoidoscopy or both for patients 50 years of age or older who are at average risk for colorectal cancer. However, no specific recommendations have been made regarding choice of test from among the tests currently or soon to be available. Therefore, to aid clinicians in rationally choosing a particular test for faecal occult blood, published data are reviewed regarding the performance characteristics, strengths and weaknesses of the various faecal occult blood tests. New studies suggest that immunochemical tests (e.g. HemeSelect) or a combination of sensitive guaiac tests and immunochemical tests (e.g. Hemoccult Sensa and HemeSelect) are the most sensitive, specific tests for detecting colorectal carcinoma and colorectal polyps > or =1 cm.

An assessment of the use of costs and quality of life as outcomes in endoscopic research

BACKGROUND

Costs and quality of life are increasingly important study outcomes. We quantitatively and qualitatively assessed their use in recent endoscopic research.

METHODS

All Medline-retrieved 1985 to 1995 published gastrointestinal endoscopic research using cost and/or quality of life as outcomes were analyzed.

RESULTS

Sixty-eight (1.2%) of an estimated 5568 publications discussed costs and/or quality of life as endoscopic outcomes (24 quality of life, 37 cost-effectiveness, 7 cost-benefit). Their use did not increase with time. Cost or quality of life was infrequently a primary study outcome. Twenty of 24 (83%) quality of life papers used an objective scale. However, of these, 15 of 20 (75%) used symptom indexes, performance scales, or other nonvalidated quality of life instruments. Two of 24 (8%) evaluated quality of life in nonmalignant disease. Eight of 40 (20%) papers claimed endoscopy was cost-effective, with no evidence of formal cost assessment. Ten of 32 (31%) substituted charges for costs. Of 21 papers reporting cost data, 4 (19%) specified cost type (e.g., direct vs other), 6 (29%) specified cost perspective, and 9 (43%) reported sensitivity analysis. Sixteen of 27 (59%) cost-effectiveness papers did not correlate costs with changes in a health outcome.

CONCLUSIONS

The overall cost and quality of life assessment in endoscopic research has been limited and must be improved. Accurate cost and quality of life assessment will require cooperation between gastroenterologists and experts in these fields.

Screening for colorectal cancer by immunochemical fecal occult blood testing

Screening for colorectal cancer using the conventional Hemoccult test has been shown to reduce mortality associated with cancer by 33% through a randomized controlled trial. However, the magnitude of effectiveness is small in terms of cost-effectiveness. The recently developed immunochemical fecal occult blood test (IFOBT) provides a potential replacement for the Hemoccult test as a screening test, due to its superior performance characteristics such as higher sensitivity shown in preliminary studies and the fact that it does not require any dietary restriction. The IFOBT method is reviewed, especially in relation to its specificity. In known colorectal cancer subjects, IFOBTs have shown both higher sensitivity and specificity than the Hemoccult test. Similarly, IFOBT has demonstrated a higher sensitivity than Hemoccult for colorectal cancer in an asymptomatic population. A nationwide screening program in Japan has demonstrated the feasibility of this approach for large population screening. However, the positivity rate varied according to the conditions at each screening facility. Therefore, technical factors that influence the positivity rate of IFOBTs in the screening program are discussed. Case-control studies have strongly suggested that screening using IFOBT would reduce mortality from colorectal cancer by 60% or more. Several observational studies have provided support for this estimate. The feasibility and effectiveness of population-based screening by IFOBT are discussed.

Cost-effectiveness analysis of screening by faecal occult blood testing for colorectal cancer in Australia

The incremental costs and effects of annual faecal occult blood test screening in Australia were modelled for a hypothetical cohort of 1000 persons offered screening or not offered screening. Incremental costs and effects were estimated as the differences in direct health care costs (Australian costs) and years of life remaining between the annual-screen group and the control (no screen) group, based on the published results of the Minnesota randomised controlled trial. The cost per life year saved was $24,660. The greatest source of variability in the cost-effectiveness ratio is the effectiveness of screening. The 95 percent confidence interval for cumulative mortality in the annual-screen group is 3.86 to 7.9 per 1000, assuming the control rate is fixed at 8.83 per 1000. With this confidence interval, the cost per life year saved ranges from $12,695 to $67,848. The cost-effectiveness ratio increases to $48,000 if no mortality benefit is assumed beyond the end of the trial follow-up period, 13 years. The results are sensitive to the cost of colonoscopy (at $400 per colonoscopy, the cost per life year saved is $12,319) and the false-positive rate. The cost-effectiveness of colorectal cancer screening is comparable with that of other screening programs but further evidence is needed on the efficacy of screening. Whether the benefits of colorectal cancer screening outweigh the harm and costs needs to be more certain before more resources are committed to mass screening. Health policy planners should initiate planning for Australian pilot projects in the event that the efficacy of screening is confirmed by two current studies.

Economic evaluation in gastrointestinal disease

Safety and efficacy are not the only parameters of interest in the choice of medical technology--costs are playing an increasingly important role. There is growing interest in 'value for money', which can be assessed economically by comparing the costs and consequences of alternative courses of action. A number of different economic evaluation methods may be used: cost-minimization (only costs examined with no consideration given to consequences); cost-effectiveness (in which a unidimensional clinical outcome is assessed, for example, life-years gained); cost-utility (multidimensional outcomes measured, for example quantity and quality of life); and cost-benefit (where outcome is considered in monetary terms). Ulcer disease offers several examples of how economic evaluation can be used to address issues related to efficiency and value for money in healthcare. In a study of reflux oesophagitis, omeprazole was shown to be more cost-effective than ranitidine in a 12-week treatment study. With omeprazole the costs were lower and the effectiveness better than with the H2-receptor antagonist. In a later study the cost-effectiveness of omeprazole and ranitidine are compared for both intermittent and maintenance treatment in reflux oesophagitis. Using a Markov chain approach, Swedish cost data and studying a time period of 12 months, it found that omeprazole is both more effective in providing healthy days and less costly than ranitidine for both treatment strategies. The comparison between intermittent treatment and maintenance treatment with omeprazole shows that the latter is more effective but also more costly. It is concluded that the relative cost-effectiveness of omeprazole maintenance treatment increases with the risk of relapse when off treatment, the severity of symptoms following relapse, and the value of healthy days, i.e. days free from reflux oesophagitis. A model analysis comparing Helicobacter pylori eradication with conventional treatments in patients with duodenal ulcer disease has shown H. pylori eradication to be cost-effective when compared with either episodic therapy using omeprazole or maintenance therapy with ranitidine. The study used a Markov chain approach, and included the cost of treatment, in Swedish crowns, in a Swedish primary care setting over a period of 5 years. In the analysis, patients receiving conventional therapy were initially healed with omeprazole, 20-40 mg once daily. Following healing patients were either treated with further courses of omeprazole upon relapse or were given maintenance treatment with ranitidine, 150 mg once daily. The patients who were assigned to the H. pylori eradication therapy group were initially given an H. pylori test. Those patients who proved positive for the bacterium received omeprazole, 20 mg twice daily, plus amoxicillin, 2000 mg daily in divided doses, for 2 weeks, followed by omeprazole, 20 mg once daily, for a further 2 weeks to ensure healing. Patients who were H. pylori-negative were assigned to receive either episodic or maintenance therapy as described above. The model assumption applied in the H. pylori eradication group was that, following successful healing and H. pylori eradication, virtually all patients were cured and experienced no relapse during the following 5 years. by contrast, almost all the patients assigned to episodic therapy relapsed, and during maintenance therapy with H2-receptor antagonists, most patients experienced at least one relapse. Although H. pylori eradication resulted in initial higher costs than the alternative strategies, it reduced the risk of recurrence and for most patients there were no future costs. The investment therefore paid off within a relatively short period of time. Even when unfavourable assumptions were made, such as an H. pylori eradication rate of only 50%, the H. pylori eradication strategy had a pay-off period of less than 1.3 years compared with maintenance treatment, and 3 years compared with episodic