Dataset Information

Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population.

ABSTRACT:

Background

The Centers for Medicare and Medicaid Services (CMS) considered whether to reimburse computed tomographic colonography (CTC) for colorectal cancer screening of Medicare enrollees. To help inform its decision, we evaluated the reimbursement rate at which CTC screening could be cost-effective compared with the colorectal cancer screening tests that are currently reimbursed by CMS and are included in most colorectal cancer screening guidelines, namely annual fecal occult blood test (FOBT), flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 5 years in conjunction with annual FOBT, and colonoscopy every 10 years.

Methods

We used three independently developed microsimulation models to assess the health outcomes and costs associated with CTC screening and with currently reimbursed colorectal cancer screening tests among the average-risk Medicare population. We assumed that CTC was performed every 5 years (using test characteristics from either a Department of Defense CTC study or the National CTC Trial) and that individuals with findings of 6 mm or larger were referred to colonoscopy. We computed incremental cost-effectiveness ratios for the currently reimbursed screening tests and calculated the maximum cost per scan (ie, the threshold cost) for the CTC strategy to lie on the efficient frontier. Sensitivity analyses were performed on key parameters and assumptions.

Results

Assuming perfect adherence with all tests, the undiscounted number life-years gained from CTC screening ranged from 143 to 178 per 1000 65-year-olds, which was slightly less than the number of life-years gained from 10-yearly colonoscopy (152-185 per 1000 65-year-olds) and comparable to that from 5-yearly sigmoidoscopy with annual FOBT (149-177 per 1000 65-year-olds). If CTC screening was reimbursed at $488 per scan (slightly less than the reimbursement for a colonoscopy without polypectomy), it would be the most costly strategy. CTC screening could be cost-effective at $108-$205 per scan, depending on the microsimulation model used. Sensitivity analyses showed that if relative adherence to CTC screening was 25% higher than adherence to other tests, it could be cost-effective if reimbursed at $488 per scan.

Conclusions

CTC could be a cost-effective option for colorectal cancer screening among Medicare enrollees if the reimbursement rate per scan is substantially less than that for colonoscopy or if a large proportion of otherwise unscreened persons were to undergo screening by CTC.

SUBMITTER: Knudsen AB

PROVIDER: S-EPMC2923219 | biostudies-literature | 2010 Aug

REPOSITORIES: biostudies-literature

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Publications

Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population.

Knudsen Amy B AB Lansdorp-Vogelaar Iris I Rutter Carolyn M CM Savarino James E JE van Ballegooijen Marjolein M Kuntz Karen M KM Zauber Ann G AG

Journal of the National Cancer Institute 20100727 16

<h4>Background</h4>The Centers for Medicare and Medicaid Services (CMS) considered whether to reimburse computed tomographic colonography (CTC) for colorectal cancer screening of Medicare enrollees. To help inform its decision, we evaluated the reimbursement rate at which CTC screening could be cost-effective compared with the colorectal cancer screening tests that are currently reimbursed by CMS and are included in most colorectal cancer screening guidelines, namely annual fecal occult blood te ...[more]

PMID: 20664028

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Project description:BackgroundConventional CTCS images the mid/lower chest for coronary artery disease (CAD). Because many CAD patients are also at risk for lung malignancy, CTCS often discovers incidental pulmonary nodules (IPN). CTCS excludes the upper chest, where malignancy is common. Full-chest CTCS (FCT) may be a cost-effective screening tool for IPN.MethodsA decision tree was created to compare a FCT to CTCS in a hypothetical patient cohort with suspected CAD. (Figure) The design compares the effects of missed cancers on CTCS with the cost of working up non-malignant nodules on FCT. The model was informed by results of the National Lung Screening Trial and literature review, including the rate of malignancy among patients receiving CTCS and the rate of malignancy in upper vs lower portions of the lung. The analysis outcomes are Quality-Adjusted Life Year (QALY) and incremental cost-effectiveness ratio (ICER), which is generally considered beneficial when <$50,000/QALY.ResultsLiterature review suggests that rate of IPNs in the upper portion of the lung varied from 47 to 76%. Our model assumed that IPNs occur in upper and lower portions of the lung with equal frequency. The model also assumes an equal malignancy potential in upper lung IPNs despite data that malignancy occurs 61–66% in upper lung fields.In the base case analysis, a FCT will lead to an increase of 0.03 QALYs comparing to conventional CTCS (14.54 vs 14.51 QALY, respectively), which translates into an QALY increase of 16?days. The associated incremental cost for FCT is $278 ($1027 vs $748, FCT vs CTCS respectively. The incremental cost-effectiveness ratio (ICER) is $10,289/QALY, suggesting significant benefit. Sensitivity analysis shows this benefit increases proportional to the rate of malignancy in upper lung fields.ConclusionConventional CTCS may be a missed opportunity to screen for upper lung field cancers in high risk patients. The ICER of FCT is better than screening for breast cancer screening (mammograms $80?k/QALY) and colon cancer (colonoscopy $6?k/QALY). Prospective studies are appropriate to define protocols for FCT.

Project description:BackgroundComputed tomography (CT) colonography's effectiveness, its associated patient advantages, and its potential role to increase colorectal cancer (CRC) screening rates have been demonstrated in previous research, but whether CT colonography has a cost advantage relative to optical colonoscopy for the commercially insured US population has not been assessed.ObjectiveTo compare the costs of CRC screening using CT colonography or optical colonoscopy for commercially insured people in the United States.MethodsUsing retrospective commercial healthcare claims data and peer-reviewed studies, we performed a simulated multiyear, matched-case comparison of the costs of CT and optical colonoscopies for CRC screening. We estimated commercial optical colonoscopy costs per screening based on the 2016 Truven Health MarketScan Commercial Database and ancillary services, such as bowel preparation, anesthesia, pathology, and complication costs. We developed 4 scenarios for CT colonography cost per screening using the ratio of commercial to Medicare fees, and calculated ancillary service and follow-up costs from payers' costs for these services when associated with optical colonoscopies. For comparison, we converted the costs per screening to the costs per screening year per person using real-world screening intervals that were obtained from peer-reviewed studies.ResultsIn 2016, the average optical colonoscopy screening cost for commercial payers was $2033 (N = 406,068), or $340 per screening year per person. With our highest-cost CT colonography scenario, CT colonography costs 22% less, or $265 per screening year, than optical colonoscopy, mostly because of the advantages for patients of no anesthesia and the greatly reduced use of pathology services.ConclusionsThe use of CT colonography for CRC testing offers effective screening, patient-centered advantages, and lower costs compared with optical colonoscopy, and may be particularly appealing to the currently unscreened population with commercial health insurance. If the availability of CT colonography expands to meet the increased demand for it, CT colonography could cost up to 50% less than optical colonoscopy per screening year.

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Dataset Information

Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population.

Background

Methods

Results

Conclusions

Publications

Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population.

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