Out-of-Pocket Costs for Colonoscopy After Noninvasive Colorectal Cancer Screening Among US Adults With Commercial and Medicare Insurance

This economic evaluation examines whether adult patients in the US who have commercial or Medicare insurance pay out-of-pocket costs associated with follow-up colonoscopy within 6 months of a noninvasive stool-based test.

Optimizing Positivity Thresholds for a Risk-Adapted Screening Strategy in Colorectal Cancer Screening

INTRODUCTION

Risk-adapted screening combining the Asia-Pacific Colorectal Screening score, fecal immunochemical test (FIT), and colonoscopy improved the yield of colorectal cancer screening than FIT. However, the optimal positivity thresholds of risk scoring and FIT of such a strategy warrant further investigation.

METHODS

We included 3,407 participants aged 50-74 years undergoing colonoscopy from a colorectal cancer screening trial. For the risk-adapted screening strategy, subjects were referred for subsequent colonoscopy or FIT according to their risk scores. Diagnostic performance was evaluated for FIT and the risk-adapted screening method with various positivity thresholds. Furthermore, a modeled screening cohort was established to compare the yield and cost using colonoscopy, FIT, and the risk-adapted screening method in a single round of screening.

RESULTS

Risk-adapted screening method had higher sensitivity for advanced neoplasm (AN) (27.6%-76.3% vs 13.8%-17.3%) but lower specificity (46.6%-90.8% vs 97.4%-98.8%) than FIT did. In a modeled screening cohort, FIT-based screening would be slightly affected because the threshold varied with a reduction of 76.0%-80.9% in AN detection and 82.0%-84.4% in cost when compared with colonoscopy. By contrast, adjusting the threshold of Asia-Pacific Colorectal Screening score from 3 to 5 points for risk-adapted screening varied from an increase of 12.6%-14.1% to a decrease of 55.6%-60.1% in AN detection, with the reduction of cost from 4.2%-5.3% rising to 66.4%-68.5%.

DISCUSSION

With an appropriate positivity threshold tailored to clinical practice, the risk-adapted screening could save colonoscopy resources and cost compared with the colonoscopy-only and FIT-only strategies.

Should colorectal cancer screening start at different ages for men and women? Cost-effectiveness analysis for a resource-constrained service

BACKGROUND

Men have a greater risk of colorectal cancer (CRC) than women, but population screening currently starts at the same age for both sexes.

AIM

This analysis investigates whether, in a resource-constrained setting, it would be more effective and cost-effective for men and women to start screening for CRC at different ages.

METHODS AND RESULTS

An economic modeling analysis was carried out using the Microsimulation Model in Cancer of the Bowel to compare sex-stratification against screening everyone from the same age, taking an English National Health Service perspective. Screening men from age 56 and women from age 60, rather than screening everyone from age 58 using a Fecal Immunochemical Test (FIT) threshold of 120 μg/g is expected to produce an additional 0.0004 QALYs for a cost of £0.55 per person at model start (Incremental Cost-effectiveness Ratio = £1392), and to reduce CRC cases and mortality by 25 and 19 per 100 000 people respectively, while using a similar amount of screening resources. Probabilistic sensitivity analysis indicates a 61% probability that sex-stratification is more cost-effective than screening everyone at age 58. Similar benefits of sex-stratification are found at other FIT thresholds, but become negligible if mean screening start age is reduced to 50.

CONCLUSION

Where resources are constrained and it is not feasible to screen everyone from the age of 50, starting screening earlier in men than women is likely to be more cost-effective and gain more health benefits overall than strategies where men and women start screening at the same age.

The Costs and Benefits of Risk Stratification for Colorectal Cancer Screening Based On Phenotypic and Genetic Risk: A Health Economic Analysis

Population-based screening for colorectal cancer is an effective and cost-effective way of reducing colorectal cancer incidence and mortality. Many genetic and phenotypic risk factors for colorectal cancer have been identified, leading to development of colorectal cancer risk scores with varying discrimination. However, these are not currently used by population screening programs. We performed an economic analysis to assess the cost-effectiveness, clinical outcomes, and resource impact of using risk-stratification based on phenotypic and genetic risk, taking a UK National Health Service perspective. Biennial fecal immunochemical test (FIT), starting at an age determined through risk-assessment at age 40, was compared with FIT screening starting at a fixed age for all individuals. Compared with inviting everyone from age 60, using a risk score with area under the receiver operating characteristic curve of 0.721 to determine FIT screening start age, produces 418 QALYs, costs £247,000, and results in 218 fewer colorectal cancer cases and 156 fewer colorectal cancer deaths per 100,000 people, with similar FIT screening invites. There is 96% probability that risk-stratification is cost-effective, with net monetary benefit (based on £20,000 per QALY threshold) estimated at £8.1 million per 100,000 people. The maximum that could be spent on risk-assessment and still be cost-effective is £114 per person. Lower benefits are produced with lower discrimination risk scores, lower mean screening start age, or higher FIT thresholds. Risk-stratified screening benefits men more than women. Using risk to determine FIT screening start age could improve the clinical outcomes and cost effectiveness of colorectal cancer screening without using significant additional screening resources. PREVENTION RELEVANCE: Colorectal cancer screening is essential for early detection and prevention of colorectal cancer, but implementation is often limited by resource constraints. This work shows that risk-stratification using genetic and phenotypic risk could improve the effectiveness and cost-effectiveness of screening programs, without using substantially more screening resources than are currently available.

Real-World Use of Colonoscopy in an Older Population: A Nationwide Standard Cohort Study Using a Common Data Model

BACKGROUNDS AND AIMS

Rapid population aging is considered to be a major factor in increased colonoscopy use in Korea. However, real-world use of colonoscopy in older populations is rarely evaluated using Korean databases.

METHODS

We conducted a retrospective, observational cohort study of individuals aged over 20 years between 2012 and 2017. We used the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. The use of diagnostic colonoscopy and colonoscopic polypectomy was evaluated, stratified by age group and sex.

RESULTS

During the study period, we captured data from the database on 240,406 patients who underwent diagnostic colonoscopy and 88,984 who underwent colonoscopic polypectomy. During the study period, use of diagnostic colonoscopy and colonoscopic polypectomy steadily increased, but both procedures were most significantly increased in the 65- to 85-year group compared to other age groups (p < 0.05). Average ages for both procedures significantly increased in the most recent 3 years (p < 0.05). Polypectomy rates for men plateaued in the 50- to 64-year age group, but rates for women steadily increased up to the 65- to 85-year group. Polypectomy rates were higher for men than for women in all index years.

CONCLUSIONS

The use of diagnostic colonoscopy and colonoscopic polypectomy significantly increased in the 65- to 85-year age group. Our findings suggest that more available colonoscopy resources should be allocated to older populations, considering the aging society in Asian countries.

Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People

OBJECTIVE

To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults.

PATIENTS AND METHODS

A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019.

RESULTS

With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy.

CONCLUSION

Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Screening for Colorectal Cancer

Colorectal cancer screening is essential to detect and remove premalignant lesions to prevent the development of colorectal cancer. Multiple screening modalities are available, including colonoscopy and stool-based testing. Colonoscopy remains the gold standard for detection and removal of premalignant colorectal lesions. Screening guidelines by the American Cancer Society now recommend initiating screening for all average-risk adults at 45 years old. Family history of colorectal cancer, other cancers, and advanced colon polyps are strong risk factors that must be considered in order to implement earlier testing. Epidemiologic studies continue to show disparities in colorectal cancer incidence and mortality and wide variability in screening rates.

Cost-effectiveness of surveillance with CT colonography after resection of colorectal cancer

OBJECTIVE

Surveillance following colorectal cancer (CRC) resection uses optical colonoscopy (OC) to detect intraluminal disease and CT to detect extracolonic recurrence. CT colonography (CTC) might be an efficient use of resources in this situation because it allows for intraluminal and extraluminal evaluations with one test.

DESIGN

We developed a simulation model to compare lifetime costs and benefits for a cohort of patients with resected CRC. Standard of care involved annual CT for 3 years and OC for years 1, 4 and every 5 years thereafter. For the CTC-based strategy, we replace CT+OC at year 1 with CTC. Patients with lesions greater than 6 mm detected by CTC underwent OC. Detection of an adenoma 10 mm or larger was followed by OC at 1 year, then every 3 years thereafter. Test characteristics and costs for CTC were derived from a clinical study. Medicare costs were used for cancer care costs as well as alternative test costs. We discounted costs and effects at 3% per year.

RESULTS

For persons with resected stage III CRC, the standard-of-care strategy was more costly (US$293) and effective (2.6 averted CRC cases and 1.1 averted cancer deaths per 1000) than the CTC-based strategy, with an incremental cost-effectiveness ratio of US$55 500 per quality-adjusted life-year gained. Our analysis was most sensitive to the sensitivity of CTC for detecting polyps 10 mm or larger and assumptions about disease progression.

CONCLUSION

In a simulation model, we found that replacing the standard-of-care approach to postdiagnostic surveillance with a CTC-based strategy is not an efficient use of resources in most situations.

Reference-Based Benefits for Colonoscopy and Arthroscopy: Large Differences in Patient Payments Across Procedures but Similar Behavioral Responses

This study examines how reference-based benefits (RBB) affect patient out-of-pocket payments across outpatient procedures. The California Public Employees' Retirement System (CalPERS) implemented RBB asymmetrically for outpatient procedures in 2012, only applying RBB to outpatient procedures performed in a hospital outpatient department (HOPD), and not applying RBB to outpatient procedures performed in a lower cost ambulatory surgery center. Using claims data (2009-2013) on arthroscopy and colonoscopy services, we found that for colonoscopy, CalPERS patients paid an average of 63.9% (p < .01) more for HOPDs than ambulatory surgery centers in 2012. For arthroscopy, no statistically different cost sharing was found on average. However, high-priced HOPDs were 17.3% and 17.9% less likely to be chosen by CalPERS patients in 2012 for colonoscopy and arthroscopy, respectively. These magnitudes increased in 2013 to 25.2% and 24.2% less, respectively. Overall, responsiveness to RBB with regard to the most expensive HOPDs was similar despite varying cost sharing by procedure.

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.

Evaluating the effects of a risk-adapted screening program for familial colorectal cancer in individuals between 25 and 50 years of age: study protocol for the prospective population-based intervention study FARKOR

BACKGROUND

Colorectal cancer (CRC) is the second most common malignant disease and the second most common cause of cancer death in Germany. Official CRC screening starts at age 50. As there is evidence that individuals with a family history of CRC have an increased risk of developing CRC before age 50, there are recommendations to start screening for this group earlier. This study aims to evaluate the clinical and economic effects of a risk-adapted screening program for CRC in individuals between 25 and 50 years of age with potentially increased familial CRC risk.

METHODS

FARKOR (Familiäres Risiko für das Kolorektale Karzinom) is a population-based prospective intervention study. All members of cooperating statutory health insurance companies between 25 and 50 years of age living in a model region in Germany (federal state of Bavaria, 3.5 million inhabitants in this age group) can participate in the program between October 2018 and March 2020. Recruitment takes place through physicians and through a public campaign. Additionally, insurances contact recently diagnosed CRC patients in order to encourage their relatives to participate in the program. Physicians assess a participant's familial history of CRC using a short questionnaire. All participants with a family history of CRC are invited to a shared decision making process to decide on further screening options consisting of either undergoing an immunological test for fecal occult blood or colonoscopy. Comprehensive data collection based on self-reported lifestyle information, medical documentation and health administrative databases accompanies the screening program. Longterm benefits, harms and the cost-effectiveness of the risk-adapted CRC screening program will be assessed by decision analytic modeling.

DISCUSSION

The data collected in this study will add important pieces of information that are still missing in the evaluation of the effects and the cost-effectiveness of a risk-adapted CRC screening strategy for individuals under 50 years of age.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS-IDDRKS00015097.

Fecal Transplants by Colonoscopy and Capsules Are Cost-Effective Strategies for Treating Recurrent Clostridioides difficile Infection

BACKGROUND

Recurrent Clostridioides difficile infections (CDIs) occur frequently and pose a substantial economic burden on the US healthcare system. The landscape for the treatment of CDI is evolving.

AIM

To elucidate the most cost-effective strategy for managing recurrent CDI.

METHODS

A decision tree analysis was created from a modified third-party payer's perspective to compare the cost-effectiveness of five strategies for patients experiencing their first CDI recurrence: oral vancomycin, fidaxomicin, fecal microbiota transplant (FMT) via colonoscopy, FMT via oral capsules, and a one-time infusion of bezlotoxumab with vancomycin. Effectiveness measures were quality-adjusted life years (QALY). A willingness-to-pay (WTP) threshold of $100,000 per QALY was set. One-way and probabilistic sensitivity analyses were performed.

RESULTS

Base-case analysis showed that FMT via colonoscopy was associated with the lowest cost at $5250 and that FMT via capsules was also a cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of $31205/QALY. Sensitivity analyses demonstrated that FMT delivered by oral capsules and colonoscopy was comparable cost-effective modalities. At its current cost and effectiveness, bezlotoxumab was not a cost-effective strategy.

CONCLUSIONS

FMT via oral capsules and colonoscopy is both cost-effective strategies to treat the first recurrence of CDI. Further real-world economic studies are needed to understand the cost-effectiveness of all available strategies.

Improving Australian National Bowel Cancer Screening Program outcomes through increased participation and cost-effective investment

BACKGROUND

The Australian National Bowel Cancer Screening Program (NBCSP) provides biennial immunochemical faecal occult blood test (iFOBT) screening for people aged 50-74 years. Previous work has quantified the number of colorectal cancer (CRC) deaths prevented by the NBCSP and has shown that it is cost-effective. With a 40% screening participation rate, the NBCSP is currently underutilised and could be improved by increasing program participation, but the maximum appropriate level of spending on effective interventions to increase adherence has not yet been quantified.

OBJECTIVES

To estimate (i) reductions in CRC cases and deaths for 2020-2040 attributable to, and (ii) the threshold for cost-effective investment (TCEI) in, effective future interventions to improve participation in the NBCSP.

METHODS

A comprehensive microsimulation model, Policy1-Bowel, was used to simulate CRC natural history and screening in Australia, considering currently reported NBCSP adherence rates, i.e. iFOBT participation (∼40%) and diagnostic colonoscopy assessment rates (∼70%). Australian residents aged 40-74 were modelled. We evaluated three scenarios: (1) diagnostic colonoscopy assessment increasing to 90%; (2) iFOBT screening participation increasing to 60% by 2020, 70% by 2030 with diagnostic assessment rates of 90%; and (3) iFOBT screening increasing to 90% by 2020 with diagnostic assessment rates of 90%. In each scenario, we estimated CRC incidence and mortality, colonoscopies, costs, and TCEI given indicative willingness-to-pay thresholds of AUD$10,000-$30,000/LYS.

RESULTS

By 2040, age-standardised CRC incidence and mortality rates could be reduced from 46.2 and 13.5 per 100,000 persons, respectively, if current participation rates continued, to (1) 44.0 and 12.7, (2) 36.8 and 8.8, and (3) 31.9 and 6.5. In Scenario 2, 23,000 lives would be saved from 2020-2040 vs current participation rates. The estimated scenario-specific TCEI (Australian dollars or AUD$/year) to invest in interventions to increase participation, given a conservative willingness-to-pay threshold of AUD$10,000/LYS, was (1) AUD$14.9M, (2) AUD$72.0M, and (3) AUD$76.5M.

CONCLUSION

Significant investment in evidence-based interventions could be used to improve NBCSP adherence and help realise the program's potential. Such interventions might include mass media campaigns to increase program participation, educational or awareness interventions for practitioners, and/or interventions resulting in improvements in referral pathways. Any set of interventions which achieves at least 70% iFOBT screening participation and a 90% diagnostic assessment rate while costing under AUD$72 million annually would be highly cost-effective (<AUD$10,000/LYS) and save 23,000 additional lives from 2020-2040.

Cost-effectiveness and budget impact analyses of colorectal cancer screenings in a low- and middle-income country: example from Thailand

Objectives: Colorectal cancer (CRC) screening programs have been reported to be cost-effective in many high-income countries. However, there was no such study in low- and middle-income countries. This study aimed to evaluate cost-effectiveness and budget impact of CRC screening modalities for average-risk persons in Thailand.Methods: A decision tree coupled with a Markov model was used to estimate lifetime costs and health benefits of fecal immunochemical test (FIT) and colonoscopy using a societal perspective. The input parameters were obtained from a CRC screening project at a Thai tertiary care hospital, Thai health care costs and databases, and systematic literature review. Results were reported as incremental cost-effectiveness ratios (ICERs) in 2017 US Dollars (USD) per quality-adjusted life year (QALY) gained. Sensitivity analyses were performed to assess the influence of parameter uncertainty. Finally, budget impact analysis was conducted.Results: At the Thai ceiling threshold of societal willingness-to-pay of 4,706 USD, the screening colonoscopy every 10 years and annual FIT, starting at age 50, was cost-effective, as compared to no screening resulting in 15.09 and 15.00 QALYs with the ICERs of 600.20 and 509.84 USD/QALY gained, respectively. Colonoscopy every 10 years and annual FIT could prevent 17.9% and 5.7% of early stage cancer and 27.8% and 9.2% of late stage cancer per 100,000 screening over lifetime when compared to no screening, respectively. The colonoscopy screening was cost-effective with the ICER of 646.53 USD/QALY gained when compared to FIT. The probabilities of being cost-effective for the colonoscopy and FIT were 75% and 25%, respectively. Budget impact analysis showed the colonoscopy screening required an 8-times higher budget than FIT.Conclusions: Colonoscopy offers the best value for money of CRC screenings in Thailand. Annual FIT is potentially feasible since it requires less resources. Our findings can be used as part of evidence for informing policy decision making.Key points for decision makersThere was a lack of cost-effective study of colorectal cancer screening programs in low- and middle-income countries.This study evaluated lifetime health outcomes and costs, and the cost-effectiveness of colorectal screening options for average-risk persons in Thailand.Colonoscopy screening every 10 years is cost-effective with high probability of being cost-effective as compared with annual fecal immunochemical test.Screening by annual fecal immunochemical test is more feasible in terms of human resource and budgetary burden.Colorectal screening programs provides an opportunity for early diagnosis and treatments to prevent advance colorectal stages and avoid higher consequent costs.This study contributes a new evidence-based knowledge for Thailand and can be used to support policy decision making process.

Faecal immunochemical tests (FIT) versus colonoscopy for surveillance after screening and polypectomy: a diagnostic accuracy and cost-effectiveness study

OBJECTIVE

The English Bowel Cancer Screening Programme (BCSP) recommends 3 yearly colonoscopy surveillance for patients at intermediate risk of colorectal cancer (CRC) postpolypectomy (those with three to four small adenomas or one ≥10 mm). We investigated whether faecal immunochemical tests (FITs) could reduce surveillance burden on patients and endoscopy services.

DESIGN

Intermediate-risk patients (60-72 years) recommended 3 yearly surveillance were recruited within the BCSP (January 2012-December 2013). FITs were offered at 1, 2 and 3 years postpolypectomy. Invitees consenting and returning a year 1 FIT were included. Participants testing positive (haemoglobin ≥40 µg/g) at years one or two were offered colonoscopy early; all others were offered colonoscopy at 3 years. Diagnostic accuracy for CRC and advanced adenomas (AAs) was estimated considering multiple tests and thresholds. We calculated incremental costs per additional AA and CRC detected by colonoscopy versus FIT surveillance.

RESULTS

74% (5938/8009) of invitees were included in our study having participated at year 1. Of these, 97% returned FITs at years 2 and 3. Three-year cumulative positivity was 13% at the 40 µg/g haemoglobin threshold and 29% at 10 µg/g. 29 participants were diagnosed with CRC and 446 with AAs. Three-year programme sensitivities for CRC and AAs were, respectively, 59% and 33% at 40 µg/g, and 72% and 57% at 10 µg/g. Incremental costs per additional AA and CRC detected by colonoscopy versus FIT (40 µg/g) surveillance were £7354 and £180 778, respectively.

CONCLUSIONS

Replacing 3 yearly colonoscopy surveillance in intermediate-risk patients with annual FIT could reduce colonoscopies by 71%, significantly cut costs but could miss 30%-40% of CRCs and 40%-70% of AAs.

TRIAL REGISTRATION NUMBER

ISRCTN18040196; Results.

Changes in screening colonoscopy following Medicare reimbursement and cost-sharing changes

OBJECTIVES

To compare existing algorithms for classifying screening vs diagnostic colonoscopies and to quantify the increase in screening colonoscopy rates when Medicare began reimbursement in 2001 and when the Affordable Care Act (ACA) eliminated cost-sharing.

DATA SOURCES

Twenty percent random sample of fee-for-service (FFS) Medicare claims, 2000-2012.

STUDY DESIGN

Using recent administrative codes as tarnished gold standards, we examined the sensitivity and specificity of five published algorithms for classifying colonoscopies and calculated annual screening colonoscopy rates. We estimated the change in rates after Medicare began reimbursement and used difference-in-differences analysis to estimate the effects of eliminating cost-sharing by comparing states with and without a mandate to cover screening colonoscopy prior to the ACA.

FINDINGS

Model-based algorithms have higher sensitivity (0.53-0.99) than expert-based algorithms (0.35-0.39), but lower specificity (0.43-0.65 vs 0.79-0.88). All algorithms detected increases in screening from both Medicare's reimbursement change (range: 24-93/10 000) and the 2011 cost-sharing change (range: 1.1-34/10 000). Difference-in-difference estimates of the ACA's effect varied from 51 to 155 tests per 10 000 depending on the algorithm.

CONCLUSIONS

Screening colonoscopy rates increased after eliminating cost-sharing in 2011, but the increase's size varied depending on the algorithm used to classify the indication. Improvements are needed in Medicare coding for screening.

Implementing a small media intervention to increase colorectal cancer screening in primary care clinics

Colorectal cancer (CRC) is one of the most common cancers in the USA. In 2017, an estimated 135,420 people were diagnosed with CRC and 50,260 people died from CRC. Several screening modalities are recommended by the United States Preventive Services Task Force (USPSTF), including annual stool tests that are usually completed at home and under-used compared with colonoscopy despite stated patient preferences for an alternative to colonoscopy. The Community Preventive Services Task Force recommends use of small media interventions (SMIs) to increase CRC screening and calls for a greater understanding of its independent impact on screening participation. This study tested whether a SMI increased the likelihood of participant return of a USPSTF recommended Fecal Immunochemical Test (FIT). In total, 804 individuals participated in a two-group, prospective randomized controlled trial. Descriptive statistics with chi-square tests compared differences in participant characteristics and return rates. Multivariable log-binomial modeling estimated combined effects of patient characteristics with FIT return rates. No differences in return rates were observed overall or by participant characteristics other than the year of enrollment. A multivariable model controlling for all covariates, found gender, insurance type, and regular place for healthcare to be significantly associated with return rates. Receipt of the SMI did not independently increase overall return rates but it may have improved the ease of completing the FIT by some participants, particularly women, those with insurance, and those with a regular place for healthcare.

Low-cost, high-resolution imaging for detecting cervical precancer in medically-underserved areas of Texas

OBJECTIVE

Cervical cancer rates in the United States have declined since the 1940's, however, cervical cancer incidence remains elevated in medically-underserved areas, especially in the Rio Grande Valley (RGV) along the Texas-Mexico border. High-resolution microendoscopy (HRME) is a low-cost, in vivo imaging technique that can identify high-grade precancerous cervical lesions (CIN2+) at the point-of-care. The goal of this study was to evaluate the performance of HRME in medically-underserved areas in Texas, comparing results to a tertiary academic medical center.

METHODS

HRME was evaluated in five different outpatient clinical settings, two in Houston and three in the RGV, with medical providers of varying skill and training. Colposcopy, followed by HRME imaging, was performed on eligible women. The sensitivity and specificity of traditional colposcopy and colposcopy followed by HRME to detect CIN2+ were compared and HRME image quality was evaluated.

RESULTS

174 women (227 cervical sites) were included in the final analysis, with 12% (11% of cervical sites) diagnosed with CIN2+ on histopathology. On a per-site basis, a colposcopic impression of low-grade precancer or greater had a sensitivity of 84% and a specificity of 45% to detect CIN2+. While there was no significant difference in sensitivity (76%, p = 0.62), the specificity when using HRME was significantly higher than that of traditional colposcopy (56%, p = 0.01). There was no significant difference in HRME image quality between clinical sites (p = 0.77) or medical providers (p = 0.33).

CONCLUSIONS

HRME imaging increased the specificity for detecting CIN2+ when compared to traditional colposcopy. HRME image quality remained consistent across different clinical settings.

Cost-Effectiveness and National Effects of Initiating Colorectal Cancer Screening for Average-Risk Persons at Age 45 Years Instead of 50 Years

BACKGROUND & AIMS

The American Cancer Society has recommended initiating colorectal cancer (CRC) screening at age 45 years instead of 50 years. We estimated the cost effectiveness and national effects of adopting this recommendation.

METHODS

We compared screening strategies and alternative resource allocations in a validated Markov model. We based national projections on screening participation rates by age and census data.

RESULTS

Screening colonoscopy initiation at age 45 years instead of 50 years in 1000 persons averted 4 CRCs and 2 CRC deaths, gained 14 quality-adjusted life-years (QALYs), cost $33,900/QALY gained, and required 758 additional colonoscopies. These 758 colonoscopies could instead be used to screen 231 currently unscreened 55-year-old persons or 342 currently unscreened 65-year-old persons, through age 75 years. These alternatives averted 13-14 CRC cases and 6-7 CRC deaths and gained 27-28 discounted QALYs while saving $163,700-$445,800. Improving colonoscopy completion rates after abnormal results from a fecal immunochemical test yielded greater benefits and savings. Initiation of fecal immunochemical testing at age 45 years instead of 50 years cost $7700/QALY gained. Shifting current age-specific screening rates to 5 years earlier could avert 29,400 CRC cases and 11,100 CRC deaths over the next 5 years but would require 10.7 million additional colonoscopies and cost an incremental $10.4 billion. Improving screening rates to 80% in persons who are 50-75 years old would avert nearly 3-fold more CRC deaths at one third the incremental cost.

CONCLUSIONS

In a Markov model analysis, we found that starting CRC screening at age 45 years is likely to be cost effective. However, greater benefit, at lower cost, could be achieved by increasing participation rates for unscreened older and higher-risk persons.

Feasibility and economic assessment of chromocolonoscopy for detection of proximal serrated neoplasia within a population-based colorectal cancer screening programme (CONSCOP): an open-label, randomised controlled non-inferiority trial

BACKGROUND

Most post-colonoscopy interval colorectal cancers are proximal; serrated polyps are often precursors to these cancers and are considered difficult to detect. We assessed the safety, feasibility, and economic effect of chromocolonoscopy on detection of proximal serrated neoplasia.

METHODS

We did an open-label, multicentre, randomised, controlled non-inferiority trial including patients from Bowel Screening Wales centres. Participants who tested positive for faecal occult blood and who were eligible for and considered fit to have colonoscopy (patients with known cases of polyposis syndromes, Lynch syndrome, and chronic inflammatory disease were excluded) were randomly assigned (1:1; with the use of minimisation, stratified by centre with an 80:20 random element) to either standard white light colonoscopy (standard group) or chromocolonoscopy (indigo carmine dye [0·2%]; chromocolonoscopy group) using a secure, internet-based, computerised, randomisation system that used centralised, dynamic allocation. Participants were followed up for 1 year and data from index colonoscopies and associated clearance procedures were analysed. All proximal polyps were reviewed by an expert pathologist panel. The main outcome on which power was based was time taken to perform the colonoscopy procedure, defined as from the time when the scope was inserted to withdrawal from the anus, assessed in the per-protocol population. The non-inferiority margin was 15 min. This trial is complete and is registered with ClinicalTrials.gov, number NCT01972451.

FINDINGS

Between Nov 20, 2014, and June 16, 2016, 741 (72%) of 1031 patients screened were eligible and consented: 360 were randomly assigned to white light colonoscopy and 381 to chromocolonoscopy. In the chromocolonoscopy group, the procedure took a mean of 36·8 min (SD 15·0), compared with a mean of 30·6 min (13·7) in the standard group (mean difference 6·3 min [95% CI 4·2-8·4] longer with chromocolonoscopy than in the standard group). The mean difference was within the prespecified non-inferiority margin. Detection rates for proximal serrated lesions were significantly higher in the chromocolonoscopy group than in the control group (45 [12%] of 381 patients vs 23 [6%] of 360 patients; odds ratio 1·96 [95% CI 1·16-3·32]; p=0·012). Serious adverse events (four cases of postpolypectomy bleeding [two in each group], and one case of anxiety and hyperventilation [in the chromocolonoscopy group]), colonoscopy quality measures, comfort scores, and sedation were similar between groups.

INTERPRETATION

Chromocolonoscopy is feasible within a population-based colorectal cancer screening programme, is safe, and has significantly increased detection of proximal serrated neoplasia and other polyp types compared with standard colonoscopy. Larger randomised trials of chromocolonoscopy, powered for improved detection of significant serrated polyps and for longer-term follow-up to investigate the effect on reduction of interval cancers within screening populations, are warranted.

FUNDING

Health and Care Research Wales (RfPPB-1021).

Reference pricing: The case of screening colonoscopies

We study the introduction of reference pricing to the California Public Employees' Retirement System. Reference pricing changes the relative price of using a hospital versus an ambulatory surgery center (ASC) for patients receiving a colonoscopy, leading to as good as random variation in patients' use of ASCs. We find a 10 percentage point increase in the share of patients using an ASC, leading to a $2300 to $1700 reduction in prices paid for patients who switch to ASCs. Our results suggest that the use of ASCs has a causal effect on prices paid and has no negative effect on patient health outcomes.

A cost-effectiveness analysis of a colorectal cancer screening program in safety net clinics

STOP CRC is a cluster-randomized pragmatic study of a colorectal cancer (CRC) screening program within eight federally-qualified health centers (FQHCs) in Oregon and California promoting fecal immunochemical testing (FIT) with appropriate colonoscopy follow-up. Results are presented of a cost-effectiveness analysis of STOP CRC. Organization staff completed activity-based costing spreadsheets, assigning labor hours by intervention activity and job-specific wage rates. Non-labor costs were from study data. Data were collected over February 2014-February 2016; analyses were performed in 2016-2017. Incremental cost-effectiveness ratios (ICERs) using completed FITs adjusted for number of screening-eligible patients (SEPs), as the effectiveness measure were calculated overall and by organization. Intervention delivery costs totaled $305 K across eight organizations (range: $10.2 K-$110 K). Overall delivery cost per SEP was $14.43 (range: $10.37-$19.10). The largest cost category across organizations was implementation, specifically mailing preparation. The overall ICER was $483 per SEP-adjusted completed FIT (range: $96-$1021 among organizations with positive effectiveness). Lagged data accounting for implementation delay produced comparable results. The costs of colonoscopies following abnormal FITs decreased the overall ICER to S409 because usual care clinics generated more such colonoscopies than intervention clinics. Using lagged data, follow-up colonoscopies increase the ICER by 4.3% to $460. Results indicate the complex implications for cost-effectiveness of implementing standard CRC screening within a pragmatic setting involving FQHCs with varied patient populations, clinical structures, and resources. Performance variation across organizations emphasizes the need for future evaluations that inform the introduction of efficient CRC screening to underserved populations.

How robust are reference pricing studies on outpatient medical procedures? Three different preprocessing techniques applied to difference-in differences

The evaluation of policies that are not randomly assigned on outcomes generated by nonlinear data generating processes often requires modeling assumptions for which there is little theoretical guidance. This paper revisits previously published difference-in-differences results of an important example, the introduction of reference pricing to common outpatient procedures, to assess the robustness of the estimated impacts by using different matching, and reweighting techniques to preprocess the data. These techniques improve covariate balance and reduce model dependence. Specifically, we examine the robustness of the effect of reference pricing on patient site-of-care choice, total expenditures, and complication rates. We apply three preprocessing methods: propensity score reweighting, exact matching, and genetic matching. Propensity score reweighting is a technique for achieving covariate balance but does not balance higher-order moments and may lead to bias and inefficiency in estimating treatment effects in the context of nonlinear data generating processes. In contrast, exact matching and genetic matching are designed to balance higher-order moments. We find that although the use of the preprocessing techniques is a valuable robustness check showing that some results are sensitive to the method used, the three approaches generally yield results that do not statistically differ from the published results.

Role of surveillance imaging and endoscopy in colorectal cancer follow-up: Quality over quantity?

Colorectal cancer (CRC) is a prevalent disease and represents a major cause of morbidity and mortality in the developed world. Intensive post-treatment surveillance is routinely recommended by major expert groups for early stage (II and III) CRC survivors because previous meta-analyses showed a modest, but significant survival benefit. This practice has been recently challenged based on data emerging from several large phase III randomized trials that demonstrated a lack of survival benefit from intensive surveillance strategies. In addition, findings from cost-effectiveness analyses of such an approach are inconsistent. Data on real-world practice, specifically adherence to these follow-up guidelines, are also limited. The debate is especially controversial in resected stage IV patients where there are currently no clear guidelines for follow-up. In an era of personalized medicine, there may be a shift towards a more risk-adapted approach to better define the optimal follow-up strategy. In this article, we review the evidence and highlight the role of surveillance in CRC survivors.

Faecal immunochemical tests versus colonoscopy for post-polypectomy surveillance: an accuracy, acceptability and economic study

BACKGROUND

In the UK, patients with one or two adenomas, of which at least one is ≥ 10 mm in size, or three or four small adenomas, are deemed to be at intermediate risk of colorectal cancer (CRC) and referred for surveillance colonoscopy 3 years post polypectomy. However, colonoscopy is costly, can cause discomfort and carries a small risk of complications.

OBJECTIVES

To determine whether or not annual faecal immunochemical tests (FITs) are effective, acceptable and cost saving compared with colonoscopy surveillance for detecting CRC and advanced adenomas (AAs).

DESIGN

Diagnostic accuracy study with health psychology assessment and economic evaluation.

SETTING

Participants were recruited from 30 January 2012 to 30 December 2013 within the Bowel Cancer Screening Programme in England.

PARTICIPANTS

Men and women, aged 60-72 years, deemed to be at intermediate risk of CRC following adenoma removal after a positive guaiac faecal occult blood test were invited to participate. Invitees who consented and returned an analysable FIT were included.

INTERVENTION

We offered participants quantitative FITs at 1, 2 and 3 years post polypectomy. Participants testing positive with any FIT were referred for colonoscopy and not offered further FITs. Participants testing negative were offered colonoscopy at 3 years post polypectomy. Acceptibility of FIT was assessed using discussion groups, questionnaires and interviews.

MAIN OUTCOME MEASURES

The primary outcome was 3-year sensitivity of an annual FIT versus colonoscopy at 3 years for detecting advanced colorectal neoplasia (ACN) (CRC and/or AA). Secondary outcomes included participants' surveillance preferences, and the incremental costs and cost-effectiveness of FIT versus colonoscopy surveillance.

RESULTS

Of 8008 invitees, 5946 (74.3%) consented and returned a round 1 FIT. FIT uptake in rounds 2 and 3 was 97.2% and 96.9%, respectively. With a threshold of 40 µg of haemoglobin (Hb)/g faeces (hereafter referred to as µg/g), positivity was 5.8% in round 1, declining to 4.1% in round 3. Over three rounds, 69.2% (18/26) of participants with CRC, 34.3% (152/443) with AAs and 35.6% (165/463) with ACN tested positive at 40 µg/g. Sensitivity for CRC and AAs increased, whereas specificity decreased, with lower thresholds and multiple rounds. At 40 µg/g, sensitivity and specificity of the first FIT for CRC were 30.8% and 93.9%, respectively. The programme sensitivity and specificity of three rounds at 10 µg/g were 84.6% and 70.8%, respectively. Participants' preferred surveillance strategy was 3-yearly colonoscopy plus annual FITs (57.9%), followed by annual FITs with colonoscopy in positive cases (31.5%). FIT with colonoscopy in positive cases was cheaper than 3-yearly colonoscopy (£2,633,382), varying from £485,236 (40 µg/g) to £956,602 (10 µg/g). Over 3 years, FIT surveillance could miss 291 AAs and eight CRCs using a threshold of 40 µg/g, or 189 AAs and four CRCs using a threshold of 10 µg/g.

CONCLUSIONS

Annual low-threshold FIT with colonoscopy in positive cases achieved high sensitivity for CRC and would be cost saving compared with 3-yearly colonoscopy. However, at higher thresholds, this strategy could miss 15-30% of CRCs and 40-70% of AAs. Most participants preferred annual FITs plus 3-yearly colonoscopy. Further research is needed to define a clear role for FITs in surveillance.

FUTURE WORK

Evaluate the impact of ACN missed by FITs on quality-adjusted life-years.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN18040196.

FUNDING

National Institute for Health Research (NIHR) Health Technology Assessment programme, NIHR Imperial Biomedical Research Centre and the Bobby Moore Fund for Cancer Research UK. MAST Group Ltd provided FIT kits.

Combined endo-laparoscopic surgery (CELS) for benign colon polyps: a single institution cost analysis

BACKGROUND

Endoscopic removal of benign colon polyps is not always possible, even with advanced endoscopic techniques. Segmental colectomy has been the traditional therapy but is associated with an increased risk of complications and may be unnecessary since fewer than 20% of these polyps harbor malignancy. Combined endo-laparoscopic surgery (CELS) has emerged as an alternative method to address these polyps. While feasibility, safety, and improved short-term patient outcomes have been demonstrated, there has never been an evaluation of cost comparing these two approaches within a single institution.

METHODS

In this observational cohort study, we compared short-term outcomes and costs of 11 patients who underwent CELS for right colon polyps with 11 patients who underwent a laparoscopic right colectomy between April 2014 and November 2017. The cost analysis covered the perioperative period from operating room to hospital discharge.

RESULTS

A total of 11 patients underwent an attempted CELS procedure for right colon polyps with a success rate of 90% (10/11). The median length of stay (LOS) for CELS patients was 1 day. LOS for patients who underwent a laparoscopic right colectomy at TMC was 3.82 days. The median OR time for CELS was 166.73 (± 57.88) min, compared to 204.73 (± 51.49) min for a laparoscopic right colectomy. The calculated total cost for a CELS patient was $5523.29, compared to $12,626.33 for a laparoscopic right colectomy, for a cost-savings of $7103.04 per patient.

CONCLUSIONS

CELS procedures are associated with good short-term outcomes and are performed at a lower cost compared to traditional laparoscopic colectomy, with the most significant cost saver being shorter hospital LOS. This is the first study to directly compare the cost of CELS to traditional laparoscopic colectomy in the surgical management of benign colon polyps within a single institution.

Effects of the ACA on Preventive Care Disparities

BACKGROUND

The Affordable Care Act (ACA) requires non-grandfathered private insurance plans, starting with plan years on or after September 23rd, 2010, to provide certain preventive care services without any cost sharing in the form of deductibles, copayments or co-insurance. This requirement may affect racial and ethnic disparities in preventive care as it provides the largest copay reduction in preventive care.

OBJECTIVES

We ask whether the ACA's free preventive care benefits are associated with a reduction in racial and ethnic disparities in the utilization of four preventive services: cholesterol screenings, colonoscopies, mammograms, and Pap smears.

METHODS

We use a data set of over 6000 individuals from the 2009, 2010, and 2013 Medical Expenditure Panel Surveys (MEPS). We restrict our data set only to individuals who are old enough to be eligible for each preventive service. Our difference-in-differences logistic regression model classifies privately insured Hispanics, African Americans, and Asians as the treatment groups and 2013 as the after-policy year. Our control group consists of non-Hispanic whites on Medicaid as this program already covered preventive care services for free or at a low cost before the ACA.

RESULTS

After controlling for income, education, marital status, preferred interview language, self-reported health status, employment, having a usual source of care, age and gender, we find that the ACA is associated with increases in the probability of the median, privately insured Hispanic person to get a colonoscopy by 3.6% and a mammogram by 3.1%, compared to a non-Hispanic white person on Medicaid. Similarly, we find that the median, privately insured African American person's probability of receiving these two preventive services improved by 2.3 and 2.4% compared to a non-Hispanic white person on Medicaid. We do not find any significant improvements for any racial or ethnic group for cholesterol screenings or Pap smears. Furthermore, our results do not indicate any significant changes for Asians compared to non-Hispanic whites in utilizing the four preventive services. These reductions in racial/ethnic disparities are robust to reconfigurations of time periods, previous diagnosis, and residential status.

CONCLUSIONS

Early effects of the ACA's provision of free preventive care are significant for Hispanics and African Americans. Further research is needed for the later years as more individuals became aware of these benefits.

Willingness to pay for colorectal cancer screening in Guangzhou

AIM

To measure the willingness to pay for colorectal cancer screening in Guangzhou, and to identify those factors associated with it.

METHODS

A face-to-face questionnaire survey for pre-screening population from free and non-free colonoscopy districts was used to collect information on demographic characteristics, health behaviours, the intention of the cancer screenings and willingness to pay for colorectal cancer screening. A total of 1243 participants who took part in the pre-screening for colorectal cancer in Guangzhou were collected in the study. Categorical data were compared using the χ2 test to analyse significant differences. Non-conditional logistic regression and multi-class logistic regression were also performed for multivariate analysis and to estimate the odds ratios.

RESULTS

The percentage of participants willing to pay for colorectal cancer screening was 91.7%. "Unnecessary" was the dominant reason that participants gave for their unwillingness, accounting for 63.1%. Of those who were willing to pay, 29.2%, 20.7%, 14.8%, 13.0% and 22.4% of participants were willing to pay less than \100, \100-\199, \200-299, \300-\399 and more than \400, respectively. Non-logistic regression analysis showed that respondents who were male, had a high level of education, were from the family with more children/older to raise, and accepted colorectal cancer screening were willing to pay for this screening. Multi-class logistic regression analysis showed that respondents with higher annual household income per capita, from government and private enterprises, government agency/institution and peasants, and less family medical expenditure were willing to pay more.

CONCLUSION

Willingness to pay for colorectal cancer screening in Guangzhou is high, but the amount of willing to pay is not much.

Firm responses to targeted consumer incentives: Evidence from reference pricing for surgical services

This paper examines how health care providers respond to a reference pricing insurance program that increases consumer cost sharing when consumers choose high-priced surgical providers. We use geographic variation in the population covered by the program to estimate supply-side responses. We find limited evidence of market segmentation and price reductions for providers with baseline prices above the reference price. Finally, approximately 75% of the reduction in provider prices is in the form of a positive externality that benefits a population not subject to the program.

The Association Between Provider Price and Complication Rates for Outpatient Surgical Services

BACKGROUND

Wide variations exist in price and quality for health-care services, but the link between price and quality remains uncertain.

OBJECTIVE

This paper used claims data from a large commercially insured population to assess the association between both procedure- and provider-level prices and complication rates for three common outpatient surgical services.

DESIGN

This is a retrospective cohort study.

SETTING

The study used medical claims data from commercial health plans between 2009 and 2013 for three outpatient surgical services-joint arthroscopy, cataract surgery, and colonoscopy.

MAIN MEASURES

For each procedure, price was assessed as the sum of patient, employer, and insurer spending. Complications were identified using existing algorithms specific to each service. Multivariate regressions were used to risk-adjust prices and complication rates. Provider-level price and complication rates were compared by calculating standardized differences that compared provider risk-adjusted price and complication rates with other providers within the same geographic market. The association between provider-level risk-adjusted price and complication rates was estimated using a linear regression.

KEY RESULTS

Across the three services, there was an inverse association between both procedure- and provider-level prices and complication rates. For joint arthroscopy, cataract surgery, and colonoscopy, a one standard deviation increase in procedure-level price was associated with 1.06 (95% CI 1.05-1.08), 1.14 (95% CI 1.11-1.16), and 1.07 (95% CI 1.06-1.07) odds increases in the rate of procedural complications, respectively. A one standard deviation increase in risk-adjusted provider price was associated with 0.09 (95% CI 0.07 to 0.11), 0.02 (95% CI 0.003 to 0.05), and 0.32 (95% CI 0.29 to 0.34) standard deviation increases in the rate of provider risk-adjusted complication rates, respectively.

LIMITATIONS

Results may be due to unobserved factors. Only three surgical services were examined, and the results may not generalize to other services and procedures. Quality measurements did not include patient satisfaction or experience measures.

CONCLUSIONS

For three common outpatient surgical services, procedure- and provider-level prices are associated with modest increased rates of complication rates.

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.

Cost analysis of colorectal cancer screening with CT colonography in Italy

OBJECTIVE

Unit costs of screening CT colonography (CTC) can be useful for cost-effectiveness analyses and for health care decision-making. We evaluated the unit costs of CTC as a primary screening test for colorectal cancer in the setting of a randomized trial in Italy.

METHODS

Data were collected within the randomized SAVE trial. Subjects were invited to screening CTC by mail and requested to have a pre-examination consultation. CTCs were performed with 64- and 128-slice CT scanners after reduced or full bowel preparation. Activity-based costing was used to determine unit costs per-process, per-participant to screening CTC, and per-subject with advanced neoplasia.

RESULTS

Among 5242 subjects invited to undergo screening CTC, 1312 had pre-examination consultation and 1286 ultimately underwent CTC. Among 129 subjects with a positive CTC, 126 underwent assessment colonoscopy and 67 were ultimately diagnosed with advanced neoplasia (i.e., cancer or advanced adenoma). Cost per-participant of the entire screening CTC pathway was €196.80. Average cost per-participant for the screening invitation process was €17.04 and €9.45 for the pre-examination consultation process. Average cost per-participant of the CTC execution and reading process was €146.08 and of the diagnostic assessment colonoscopy process was €24.23. Average cost per-subject with advanced neoplasia was €3777.30.

CONCLUSIONS

Cost of screening CTC was €196.80 per-participant. Our data suggest that the more relevant cost of screening CTC, amenable of intervention, is related to CTC execution and reading process.

Value Of Waiving Coinsurance For Colorectal Cancer Screening In Medicare Beneficiaries

Financial barriers to colorectal cancer screening persist despite the Affordable Care Act (ACA). Medicare beneficiaries may face 20 percent coinsurance for a screening colonoscopy when the procedure includes the removal of polyps or follows a positive fecal screening test. Using an established microsimulation model, we estimated that waiving this coinsurance would result in 1.7 fewer colorectal cancer deaths (a decrease of 13 percent) and $17,000 higher colorectal cancer-related costs (an increase of 0.6 percent) for the Centers for Medicare and Medicaid Services per 1,000 sixty-five-year-olds, assuming a 10-percentage-point increase in the rates of first colonoscopy screening, follow-up, and surveillance. If the rates did not change, waiving coinsurance would increase total costs by $51,000 (1.9 percent) per 1,000 sixty-five-year-olds. Estimated screening benefits were comparable when fecal testing was assumed to be the primary screening method. Moreover, waiving coinsurance would be cost-effective if the screening rate increased by 0.6 percentage points, assuming a willingness-to-pay threshold of $50,000 per quality-adjusted life-year gained. Thus, the waiver is likely to have a favorable balance of health and cost impact.

Active Choice and Financial Incentives to Increase Rates of Screening Colonoscopy-A Randomized Controlled Trial

Behavioral economic approaches could increase uptake for colorectal cancer screening. We performed a randomized controlled trial of 2245 employees to determine whether an email containing a phone number for scheduling (control), an email with the active choice to opt in or opt out (active choice), or the active choice email plus a $100 incentive (financial incentive) increased colonoscopy completion within 3 months. Higher proportions of participants in the financial incentive group underwent screening (3.7%) than in the control (1.6%) or active choice groups (1.5%) (P = .01 and P < .01). We found no difference in uptake of screening between the active choice and control groups (P = .88). The $100 conditional incentive modestly but significantly increased colonoscopy use. ClinicalTrials.gov no: NCT02660671.

Colorectal cancer screening: An updated review of the available options

Colorectal cancer (CRC) is a significant cause of morbidity and mortality worldwide. However, colon cancer incidence and mortality is declining over the past decade owing to adoption of effective screening programs. Nevertheless, in some parts of the world, CRC incidence and mortality remain on the rise, likely due to factors including “westernized” diet, lifestyle, and lack of health-care infrastructure and resources. Participation and adherence to different national screening programs remain obstacles limiting the achievement of screening goals. Different modalities are available ranging from stool based tests to radiology and endoscopy with varying sensitivity and specificity. However, the availability of these tests is limited to areas with high economic resources. Recently, FDA approved a blood-based test (Epi procolon^®) for CRC screening. This blood based test may serve to increase the participation and adherence rates. Hence, leading to increase in colon cancer detection and prevention. This article will discuss various CRC screening tests with a particular focus on the data regarding the new approved blood test. Finally, we will propose an algorithm for a simple cost-effective CRC screening program.

New endoscopes and add-on devices to improve colonoscopy performance

Colonoscopy is the gold standard for colorectal cancer prevention; however, it is still an imperfect modality. Precancerous lesions can be lost during screening examinations, thus increasing the risk of interval cancer. A variety of factors either patient-, or endoscopist dependent or even the procedure itself may contribute to loss of lesions. Sophisticated modalities including advanced technology endoscopes and add-on devices have been developed in an effort to eliminate colonoscopy's drawbacks and maximize its ability to detect potentially culprit polyps. Novel colonoscopes aim to widen the field of view. They incorporate more than one cameras enabling simultaneous image transmission. In that way the field of view can expand up to 330°. On the other hand a plethora of add-on devices attachable on the standard colonoscope promise to detect lesions in the proximal aspect of colonic folds either by offering a retrograde view of the lumen or by straightening the haustral folds during withdrawal. In this minireview we discuss how these recent advances affect colonoscopy performance by improving its quality indicators (cecal intubation rate, adenoma detection rate) and other metrics (polyp detection rate, adenomas per colonoscopy, polyp/adenoma miss rate) associated with examination's outcomes.

Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening

We assess annual costs of screening provision activities implemented by 23 of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) grantees and report differences in costs between colonoscopy and FOBT/FIT-based screening programs. We analysed annual cost data for the first three years of the CRCCP (July 2009-June 2011) for each screening provision activity and categorized them into clinical and non-clinical screening provision activities. The largest cost components for both colonoscopy and FOBT/FIT-based programs were screening and diagnostic services, program management, and data collection and tracking. During the first 3 years of the CRCCP, the average annual clinical cost for screening and diagnostic services per person served was $1150 for colonoscopy programs, compared to $304 for FIT/FOBT-based programs. Overall, FOBT/FIT-based programs appear to have slightly higher non-clinical costs per person served (average $1018; median $838) than colonoscopy programs (average $980; median $686). Colonoscopy-based CRCCP programs have higher clinical costs than FOBT/FIT-based programs during the 3-year study timeframe (translating into fewer people screened). Non-clinical costs for both approaches are similar and substantial. Future studies of the cost-effectiveness of colorectal cancer screening initiatives should consider both clinical and non-clinical costs.

Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies

Many studies have documented barriers to colorectal cancer screenings. However, there is lack of comprehensive information on the time and costs borne by low-income patients and the persons accompanying the patient (caregiver) for colonoscopies in the United States. We surveyed patients in three health clinics in Philadelphia retrospectively who had undergone free colonoscopies in the previous 18-month period. Participants were asked questions about time and out-of-pockets expenses for themselves and their caregivers. Even when colonoscopies were free to the patient through Colorectal Cancer Control Program funded by the Centers for Disease Control and Prevention, the patient and caregivers still incurred costs in relation to preparing for, undergoing, and recovering from a colonoscopy. These costs can be substantial and may account for some of the low colorectal cancer screening rates especially among the low-income populations. Patients' and caregivers' costs need to be considered when designing and implementing colorectal cancer control programs.

Budget Impact Analysis of Against Colorectal Cancer In Our Neighborhoods (ACCION): A Successful Community-Based Colorectal Cancer Screening Program for a Medically Underserved Minority Population

OBJECTIVES

Given the uncertain cost of delivering community-based cancer screening programs, we developed a Markov simulation model to project the budget impact of implementing a comprehensive colorectal cancer (CRC) prevention program compared with the status quo.

METHODS

The study modeled the impacts on the costs of clinical services, materials, and staff expenditures for recruitment, education, fecal immunochemical testing (FIT), colonoscopy, follow-up, navigation, and initial treatment. We used data from the Against Colorectal Cancer In Our Neighborhoods comprehensive CRC prevention program implemented in El Paso, Texas, since 2012. We projected the 3-year financial consequences of the presence and absence of the CRC prevention program for a hypothetical population cohort of 10,000 Hispanic medically underserved individuals.

RESULTS

The intervention cohort experienced a 23.4% higher test completion rate for CRC prevention, 8 additional CRC diagnoses, and 84 adenomas. The incremental 3-year cost was $1.74 million compared with the status quo. The program cost per person was $261 compared with $86 for the status quo. The costs were sensitive to the proportion of high-risk participants and the frequency of colonoscopy screening and diagnostic procedures.

CONCLUSIONS

The budget impact mainly derived from colonoscopy-related costs incurred for the high-risk group. The effectiveness of FIT to detect CRC was critically dependent on follow-up after positive FIT. Community cancer prevention programs need reliable estimates of the cost of CRC screening promotion and the added budget impact of screening with colonoscopy.

Early Adoption of a Multitarget Stool DNA Test for Colorectal Cancer Screening

OBJECTIVES

To characterize early adoption of a novel multitarget stool DNA (MT-sDNA) screening test for colorectal cancer (CRC) screening and to test the hypothesis that adoption differs by demographic characteristics and prior CRC screening behavior and proceeds predictably over time.

PATIENTS AND METHODS

We used the Rochester Epidemiology Project research infrastructure to assess the use of the MT-sDNA screening test in adults aged 50 to 75 years living in Olmsted County, Minnesota, in 2014 and identified 27,147 individuals eligible or due for screening colonoscopy from November 1, 2014, through November 30, 2015. We used electronic Current Procedure Terminology and Health Care Common Procedure codes to evaluate early adoption of the MT-sDNA screening test in this population and to test whether early adoption varies by age, sex, race, and prior CRC screening behavior.

RESULTS

Overall, 2193 (8.1%) and 974 (3.6%) individuals were screened by colonoscopy and MT-sDNA, respectively. Age, sex, race, and prior CRC screening behavior were significantly and independently associated with MT-sDNA screening use compared with colonoscopy use after adjustment for all other variables (P<.05 for all). The rates of adoption of MT-sDNA screening increased over time and were highest in those aged 50 to 54 years, women, whites, and those who had a history of screening. The use of the MT-sDNA screening test varied predictably by insurance coverage. The rates of colonoscopy decreased over time, whereas overall CRC screening rates remained steady.

CONCLUSION

The results of the present study are generally consistent with predictions derived from prior research and the diffusion of innovation framework, pointing to increasing use of the new screening test over time and early adoption by younger patients, women, whites, and those with prior CRC screening.

The clinical effectiveness of different surveillance strategies to prevent colorectal cancer in people with intermediate-grade colorectal adenomas: a retrospective cohort analysis, and psychological and economic evaluations

BACKGROUND

The UK guideline recommends 3-yearly surveillance for patients with intermediate-risk (IR) adenomas. No study has examined whether or not this group has heterogeneity in surveillance needs.

OBJECTIVES

To examine the effect of surveillance on colorectal cancer (CRC) incidence; assess heterogeneity in risk; and identify the optimum frequency of surveillance, the psychological impact of surveillance, and the cost-effectiveness of alternative follow-up strategies.

DESIGN

Retrospective multicentre cohort study.

SETTING

Routine endoscopy and pathology data from 17 UK hospitals (n = 11,944), and a screening data set comprising three pooled cohorts (n = 2352), followed up using cancer registries.

SUBJECTS

Patients with IR adenoma(s) (three or four small adenomas or one or two large adenomas).

PRIMARY OUTCOMES

Advanced adenoma (AA) and CRC detected at follow-up visits, and CRC incidence after baseline and first follow-up.

METHODS

The effects of surveillance on long-term CRC incidence and of interval length on findings at follow-up were examined using proportional hazards and logistic regression, adjusting for patient, procedural and polyp characteristics. Lower-intermediate-risk (LIR) subgroups and higher-intermediate-risk (HIR) subgroups were defined, based on predictors of CRC risk. A model-based cost-utility analysis compared 13 surveillance strategies. Between-group analyses of variance were used to test for differences in bowel cancer worry between screening outcome groups (n = 35,700). A limitation of using routine hospital data is the potential for missed examinations and underestimation of the effect of interval and surveillance.

RESULTS

In the hospital data set, 168 CRCs occurred during 81,442 person-years (pys) of follow-up [206 per 100,000 pys, 95% confidence interval (CI) 177 to 240 pys]. One surveillance significantly lowered CRC incidence, both overall [hazard ratio (HR) 0.51, 95% CI 0.34 to 0.77] and in the HIR subgroup (n = 9265; HR 0.50, 95% CI 0.34 to 0.76). In the LIR subgroup (n = 2679) the benefit of surveillance was less clear (HR 0.62, 95% CI 0.16 to 2.43). Additional surveillance lowered CRC risk in the HIR subgroup by a further 15% (HR 0.36, 95% CI 0.20 to 0.62). The odds of detecting AA and CRC at first follow-up (FUV1) increased by 18% [odds ratio (OR) 1.18, 95% CI 1.12 to 1.24] and 32% (OR 1.32, 95% CI 1.20 to 1.46) per year increase in interval, respectively, and the odds of advanced neoplasia at second follow-up increased by 22% (OR 1.22, 95% CI 1.09 to 1.36), after adjustment. Detection rates of AA and CRC remained below 10% and 1%, respectively, with intervals to 3 years. In the screening data set, 32 CRCs occurred during 25,745 pys of follow-up (124 per 100,000 pys, 95% CI 88 to 176 pys). One follow-up conferred a significant 73% reduction in CRC incidence (HR 0.27, 95% CI 0.10 to 0.71). Owing to the small number of end points in this data set, no other outcome was significant. Although post-screening bowel cancer worry was higher in people who were offered surveillance, worry was due to polyp detection rather than surveillance. The economic evaluation, using data from the hospital data set, suggested that 3-yearly colonoscopic surveillance without an age cut-off would produce the greatest health gain.

CONCLUSIONS

A single surveillance benefited all IR patients by lowering their CRC risk. We identified a higher-risk subgroup that benefited from further surveillance, and a lower-risk subgroup that may require only one follow-up. A surveillance interval of 3 years seems suitable for most IR patients. These findings should be validated in other studies to confirm whether or not one surveillance visit provides adequate protection for the lower-risk subgroup of intermediate-risk patients.

STUDY REGISTRATION

Current Controlled Trials ISRCTN15213649.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy

Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.

Cost Effectiveness of Screening Colonoscopy Depends on Adequate Bowel Preparation Rates - A Modeling Study

Background

Inadequate bowel preparation during screening colonoscopy necessitates repeating colonoscopy. Studies suggest inadequate bowel preparation rates of 20–60%. This increases the cost of colonoscopy for our society.

Aim

The aim of this study is to determine the impact of inadequate bowel preparation rate on the cost effectiveness of colonoscopy compared to other screening strategies for colorectal cancer (CRC).

Methods

A microsimulation model of CRC screening strategies for the general population at average risk for CRC. The strategies include fecal immunochemistry test (FIT) every year, colonoscopy every ten years, sigmoidoscopy every five years, or stool DNA test every 3 years. The screening could be performed at private practice offices, outpatient hospitals, and ambulatory surgical centers.

Results

At the current assumed inadequate bowel preparation rate of 25%, the cost of colonoscopy as a screening strategy is above society’s willingness to pay (<$50,000/QALY). Threshold analysis demonstrated that an inadequate bowel preparation rate of 13% or less is necessary before colonoscopy is considered more cost effective than FIT. At inadequate bowel preparation rates of 25%, colonoscopy is still more cost effective compared to sigmoidoscopy and stool DNA test. Sensitivity analysis of all inputs adjusted by ±10% showed incremental cost effectiveness ratio values were influenced most by the specificity, adherence, and sensitivity of FIT and colonoscopy.

Conclusions

Screening colonoscopy is not a cost effective strategy when compared with fecal immunochemical test, as long as the inadequate bowel preparation rate is greater than 13%.

Economic value of narrow band imaging versus white light endoscopy for the characterization of diminutive polyps in the colon: systematic literature review and cost-consequence model

AIMS

To demonstrate the economic implication of adopting narrow-band imaging (NBI) for the characterization of diminutive polyps in the colon from an English payer perspective.

MATERIALS AND METHODS

A decision-tree model was undertaken to perform a cost-consequence and budget impact analysis from the NHS England perspective in the UK, over a 7-year time horizon. Clinical inputs came from the published literature (both randomized controlled trials and meta-analyses) identified through a systematic literature review, and cost inputs came from national list prices and unpublished internal market data. Deterministic sensitivity analysis (DSA) was conducted on the budget impact results to assess their robustness.

RESULTS

Optical diagnosis with NBI offered cost savings vs white light endoscopy (WLE) over 7 years due to reductions in histological exams, resections, and associated adverse events, while having minimal impact on health outcomes. Budget impact analysis demonstrated annual cost savings of £141 192 057 over 7 years, with histological exams being the biggest cost driver. DSA showed these results to be robust, but most sensitive to the cost of tariff with and without biopsy, and the cost of histological exam. Break-even analysis to explore how changing the unit cost and number of biopsies per patient would change the budget impact found NBI consistently offered net savings, even if the cost of biopsy was £0.

LIMITATIONS

Although every effort was made to ensure robustness of results, as with any model, there were some limitations including a lack of published data for certain clinical inputs and potential variation between model inputs and real-life cost and market share values.

CONCLUSIONS

Optical diagnosis with NBI was found to be equally effective compared with the standard of care (WLE), while potentially enabling cost savings from the NHS England perspective.

Adenomas as a risk factor in familial colorectal cancer: implications for screening and surveillance in the UK

Colorectal cancer (CRC) develops from normal epithelium, through dysplastic adenoma to invasive carcinoma. In addition to familial adenomatous polyposis and Lynch syndrome, approximately 10-35% of CRCs are familial in nature. CRC screening and surveillance programmes are based on an understanding of the natural history of polyps and rely on the ability to remove premalignant lesions endoscopically before they are capable of developing invasion. There are, however, significant differences in these guidelines between the UK and the USA in relation to the weight attributed to a family history of polyps. Here, using publicly available national data sets, we show that these differences in guidelines unexpectedly generate inadequate screening recommendations for second-degree relatives of patients with CRC in the UK. We validate our simple mathematical modelling of the clinical problem on a regional data set as well as previously published study data to demonstrate the correct interpretation. We further discuss the implications of a family history of adenoma formation in the current climate of the Bowel Cancer Screening Programme and suggest a re-evaluation of the UK guidelines in the light of this developing issue.