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Keywords:

  • patient navigators;
  • colonoscopy;
  • cancer screening;
  • cost-effectiveness analysis;
  • cost-benefit analysis

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES

BACKGROUND:

Patient navigation can increase colorectal cancer screening rates. The net economic impact of a colonoscopy patient navigator program was evaluated in an urban public hospital setting.

METHODS:

Cost, cost-effectiveness, and cost-benefit analyses were performed of a colonoscopy patient navigation program at 3 urban public hospitals in the period from 2003 to 2007. Program effectiveness was assessed in a 2-group, pre- and post-program, nonrandomized evaluation, comparing program hospitals with comparison hospitals that served similar populations. Costs were assessed from the provider's perspective. Outcomes included colonoscopy volume, colonoscopy completion rate, program cost, incremental cost-effectiveness, and net monetary benefit.

RESULTS:

Patient navigation was associated with a 61% increase in average monthly colonoscopy volume at program hospitals, from 114 procedures to 184 procedures, compared with a 12% increase at comparison hospitals. Adjusted for other factors, the navigator program increased colonoscopy volume by 44 to 67 additional procedures per month. Average program cost varied from $50 to $300 per patient referred to a navigator. Incremental cost-effectiveness varied from $200 to $700 per additional colonoscopy. At 2 hospitals, net revenue associated with increased colonoscopy volume exceeded the program cost per additional colonoscopy, yielding a net financial benefit; at the third hospital, the program yielded a net cost. Variation between hospitals in the program's economic impact was primarily attributable to differences in personnel costs.

CONCLUSIONS:

Economic evaluation of this colonoscopy patient navigator program in an urban public hospital setting suggests that such programs can be a cost-effective use of limited resources and yield a net financial benefit for providers. Cancer 2012. © 2012 American Cancer Society.

Colorectal cancer is the third most common cancer and the third leading cause of cancer death in the United States. In 2010, there were approximately 140,000 new cases and more than 50,000 deaths due to colorectal cancer.1 Although screening colonoscopy, recommended for adults age 50 or older at average risk, can reduce the incidence of cancer through removal of precancerous polyps and improve outcomes through earlier tumor detection,2, 3 this disease continues to pose a substantial public health burden.

In 2003, the Commissioner of the New York City Department of Health and Mental Hygiene (NYC DOHMH) launched a colorectal cancer screening initiative, which included a colonoscopy patient navigator program, within selected public hospitals. Patient navigators are trained to guide individuals through complex clinical settings in order to assist with the scheduling, preparation, and completion of the procedure. Commonly cited barriers addressed by navigators include confusion and fear about the procedure and bowel preparation, and logistical challenges such as lack of health insurance, difficulty scheduling, and finding an escort home.4 For members of ethnic minority groups, patient navigators also assist in overcoming cultural and linguistic obstacles.5

Initial evaluations of the NYC DOHMH colonoscopy patient navigator program and a similar program implemented at 2 tertiary academic medical centers in New York City suggest that these programs can be effective in increasing the number of screening colonoscopies performed, increasing the probability of colonoscopy completion, increasing the number of precancerous colorectal polyps removed, and reducing the number of missed appointments for colonoscopy.6-8 Our objective was to evaluate the economic impact of the patient navigator program, specifically the cost, cost-effectiveness, and net financial benefit associated with the program implemented at 3 public hospitals.

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES

Patient Navigator Program

The NYC colonoscopy patient navigator program was implemented at 3 hospitals in 3 of the 5 boroughs of New York City. All study sites were part of the Health and Hospitals Corporation (HHC), a public corporation of New York City whose patients include many uninsured, low-income, and high-risk populations. The first demonstration site implemented the patient navigator intervention in May 2003, the second in October 2005, and the third in January 2006.

The full-time patient navigators at each program site were lay health educators who received intensive initial training in a 1-week program orientation and subsequent ongoing training. They were recruited from within the respective hospital systems or the surrounding communities, which have predominantly minority populations. At each program site, key activities of the patient navigators included reminding patients to arrive at scheduled appointments, reviewing bowel preparation procedures and general colonoscopy information, addressing patient concerns about the procedure, and linking patients with financial services. All patients with an appointment for colonoscopy were identified in clinic schedules. Navigators contacted patients in advance of their scheduled colonoscopy appointment. A very small fraction of patients (<5%) were missed for administrative or logistical reasons. The navigators interacted with patients in person and by telephone. This study of the patient navigator program was reviewed and deemed exempt by the Biomedical Research Alliance of New York Institutional Review Board and by the DOHMH Institutional Review Board.

Data Sources

Data were obtained from DOHMH and HHC records, including patient navigator logs, hospital medical and administrative records, and program databases that tracked patient colonoscopy appointments and completion rates. The number of colonoscopies performed, polyps removed, and cancers diagnosed were identified in HHC records for the 3 program hospitals and for 3 HHC comparison hospitals that did not implement the navigator program but served similar patient populations. Information about navigator program costs, including personnel time and salaries, was obtained from interviews with hospital administrators, medical personnel, and program staff at each site.

Economic Analysis

Program Cost Analysis

The primary endpoint of the program cost analysis was cost per patient referred to the navigator program, estimated by summing the total costs of all components of the patient navigator program and dividing the total by the number of patients referred to the program. All economic analyses were conducted from the perspective of DOHMH and HHC, and costs were estimated separately for each program site. Personnel costs included salary for the portion of time relevant individuals dedicated to the navigator program and fringe benefits calculated at 40% of salary, based on estimates reported by each hospital in 2006. Salary ranges for program personnel were used to calculate low, high, and midpoint estimates of annual program costs. The only nonpersonnel cost at any site was the monthly cost of pagers for program personnel at 1 hospital during the study period. Three estimates of the monthly patient referral rate were assessed: average referrals for the entire program period, average referrals in the first 12 months of the program, and average referrals in the last 12 months.

Cost-Effectiveness Analysis

Program effectiveness was estimated using a 2-group (program versus comparison), pre- and post-program analysis and multivariable statistical methods to assess the program's impact on total colonoscopy volume and on the probability of colonoscopy completion, controlling for potential confounders. Of the 8 HHC hospitals that had not implemented the navigator program during the study period, the 3 comparison hospitals were selected because they were the most similar to the program hospitals with respect to patient demographic and socioeconomic characteristics (Table 1).

Table 1. Characteristics of Colonoscopy Patients at Program and Comparison Hospitalsa
CharacteristicProgram Hospitals (n = 25,481)Comparison Hospitals (n = 18,845)
  • a

    Values are given as percentage of colonoscopy patients.

Sex  
 Male39.738.7
 Female60.361.3
Race/ethnicity  
 White3.94.2
 Black16.440.8
 Hispanic70.841.6
 Asian6.310.3
 Other6.43.2
Age  
 <5012.114.9
 50-6460.058.8
 ≥6527.926.3
Education  
 >50% in ZIP code graduated high school30.714.2
 >50% in ZIP code did not graduate high school69.385.8
Health insurance status  
 Insured83.278.3
 Uninsured16.821.7
Colonoscopy indication  
 Screening68.168.3
 Surveillance4.35.7
 Diagnostic27.626.0

For program hospitals, the pre-program period was defined as the 12 months prior to program implementation, and the post-program period included the month of program implementation through June 2007. For the 3 comparison hospitals, the pre-program period was defined as calendar year 2005, and the post-program period included 2006 and the first half of 2007.

The impact of the navigator program on monthly colonoscopy volume was estimated in a multivariable linear regression analysis with random and fixed effects. The regression model produced hospital-specific estimates of the mean change in colonoscopy volume, comparing program hospitals with comparison hospitals, controlling for average monthly volume in the pre-program period. Estimates were adjusted for the number of physicians performing colonoscopy, the number of navigators, and the proportion of patients navigated at each site, as well as other interventions that coincided with the patient navigator program at 1 or more sites. These interventions included a Direct Endoscopy Referral System, which allowed primary care providers to medically clear patients and refer them directly for colonoscopy, and increases in capacity associated with expansion of endoscopy suites, acquisition of additional equipment, and hiring of additional staff.

The program's impact on the probability of colonoscopy completion was estimated using multivariable logistic regression, with patient referred for colonoscopy serving as the unit of analysis. The model generated a pooled estimate of impact for all program hospitals, adjusted for patient sex, race (white, black, Hispanic, Asian, or other), health insurance status (insured or uninsured), colonoscopy indication (screening, diagnostic, or surveillance), and ZIP code–level educational attainment (percent of residents who graduated from high school) from the 2000 US Census.

Using the 2 measures of program effectiveness, incremental cost-effectiveness was expressed in 2 ways: cost per additional colonoscopy (based on the volume model) and cost per additional colonoscopy completed (based on the completion model). Cost-effectiveness ratios were estimated separately for each of the 3 program sites.

Cost-Benefit Analysis

For the program cost-benefit analysis, estimates of program benefit were based on the colonoscopy volume model of program effectiveness. The cost-benefit analysis was conducted from the perspective of the hospital and included program costs, colonoscopy costs and colonoscopy revenues. In the base case, colonoscopy revenue was based on Medicare reimbursement rates. We used a weighted average of reimbursement rates for all relevant colonoscopy billing codes based on the distribution of codes reported in a microcosting study of colonoscopies performed at a university hospital and a Veterans Affairs medical center.9 In sensitivity analysis, we evaluated a range of reimbursement rates, reflecting values 20% greater and 20% less than the base-case estimate. The lower rate approximated average colonoscopy reimbursement paid by 1 large local Medicaid managed care plan. All procedures were assumed to occur in a hospital setting, and we assumed an average procedure cost of $461 per colonoscopy, based on a published estimate adjusted to 2007 US dollars.9

Two primary endpoints were estimated for the cost-benefit analysis: the net financial benefit (or cost) of the program, and the benefit:cost ratio. The first metric was calculated in Equation 1:

  • equation image(1)

and the second metric was calculated in Equation 2:

  • equation image(2)

where NFB is net financial benefit per additional colonoscopy, AR is average reimbursement per colonoscopy, AC is average cost per colonoscopy, and PC is average program cost per additional colonoscopy attributable to the navigator program.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES

Program Cost

Using the midpoint of salary ranges for program personnel, annual program costs varied from $104,868 at Hospital C to $373,606 at Hospital B (Table 2). Average monthly costs were $8739 at Hospital C, $9685 at Hospital A, and $31,134 at Hospital B. Costs per patient referred to a navigator, estimated using the average monthly patient count over the entire program duration, were $74 at Hospital A, $51 at Hospital C and $287 at Hospital B. Within each program site, use of alternative estimates of the average referral rate (ie, from first 12 months or last 12 months) did not have a substantial impact on the cost per patient referred to a navigator.

Table 2. Program Cost by Site
CostsHospital AHospital BHospital C
  • a

    Cost per patient referred to navigator program using average monthly program referrals for the duration of the program.

Annual cost$116,221$373,606$104,868
Monthly average cost$9685$31,134$8739
Cost per patient, monthly averagea$74$287$51
Cost per patient, first 12 months$61$328$59
Cost per patient, last 12 months$93$379$45

The average monthly program costs at Hospital B were more than 3.5 times greater than those at Hospital A and more than 5.5 times greater than those at Hospital C. The substantially higher monthly costs at Hospital B were primarily attributable to costs of program personnel other than the navigators. The navigation programs at Hospitals A and C each had the equivalent of more than 2 full-time employees, including 2 full-time navigators, part-time administrative and nursing staff, and a service chief who contributed 2% to 8% of his time. In contrast, Hospital B had the equivalent of more than 5 full-time employees, including 2 full-time navigators, a program coordinator, a program assistant, a half-time nurse, a half-time clerk, as well as 2 service chiefs and a medical director who dedicated 10% to 25% of their time to the program. The programs at Hospitals A and C did not use a program coordinator or assistant, and they did not have as much physician involvement.

Program Cost-Effectiveness

From the pre-program to post-program study periods, monthly colonoscopy volume increased both in program hospitals and comparison hospitals. However, the 61% relative increase in average volume at the program hospitals, from 114 procedures per month to 184, exceeded the 12% relative increase in the comparison hospitals, from 193 procedures per month to 213. Controlling for the number of navigators, the number of physicians, the presence or absence of a Direct Endoscopy Referral System, and the proportion of patients navigated, the estimated impact of the navigator program on monthly colonoscopy volume was 44 additional procedures at Hospital A, 48 at Hospital B, and 67 at Hospital C (P < .0001 for each estimate). Using these estimates of effectiveness, the program cost per additional colonoscopy was $220 at Hospital A, $708 at Hospital B, and $199 at Hospital C (Table 3).

Table 3. Program Cost-Effectiveness by Sitea
Cost-EffectivenessHospital AHospital BHospital C
  • a

    Program effectiveness estimated from separate analyses of program impact on monthly colonoscopy volume and on the probability of colonoscopy completion. Both models estimated using a 2-group (program vs comparison), pre- and post-program analytic design. Estimates of program impact on volume were site-specific; estimates of impact on colonoscopy completion were pooled across sites.

Colonoscopy volume model   
 Monthly average cost$9685$31,134$8739
 Additional colonoscopies per month444867
 Cost per additional colonoscopy$220$708$199
Colonoscopy completion model   
 Average cost per patient$74$287$51
 Increased probability of completion0.20.20.2
 Cost per additional colonoscopy completed$369$1434$254

In the pre-program period, the rate of colonoscopy completion was 75% in program hospitals and 85% in comparison hospitals. In adjusted analysis, the navigator program was associated with an increase in the probability of colonoscopy completion of approximately 20 percentage points (P < .0001). Using this pooled estimate of program effectiveness for all sites, the cost per additional colonoscopy completed was $369 at Hospital A, $1434 at Hospital B, and $254 at Hospital C.

Net Financial Impact

Using our base-case estimate of average colonoscopy reimbursement ($697), at both Hospital A and Hospital C, the net revenue associated with each colonoscopy exceeded the program cost per additional colonoscopy, resulting in a net financial benefit and a benefit:cost ratio > 1.0 (Table 4). At Hospital B, the program cost per additional colonoscopy exceeded the net revenue per procedure, yielding a net financial cost and a benefit:cost ratio < 1.0.

Table 4. Net Financial Impacta
ImpactHospital AHospital BHospital C
  • a

    Program benefit based on change in monthly colonoscopy volume.

Program cost per additional colonoscopy$220$708$199
Net revenue per additional colonoscopy$236$243$243
Net benefit per additional colonoscopy$16$(464)$45
Benefit:cost ratio1.10.31.2

At all 3 sites, the program yielded a net monetary cost when we assumed that colonoscopy was reimbursed at 80% of the Medicare reimbursement rate ($419). Independent of the cost of the navigator program, colonoscopy procedure cost exceeded reimbursement per procedure when this lower estimate of reimbursement was used. In this scenario, the navigator program was effective in increasing colonoscopy volume, but a hospital would lose money on every procedure performed.

DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES

In the urban public hospital settings evaluated in this study, a colonoscopy patient navigator program was associated with increases in colonoscopy volume and in the likelihood of colonoscopy completion. The cost-effectiveness of the program varied from about $200 to $700 per additional colonoscopy, with variation between sites primarily attributable to differences in the time and salaries of program personnel. The program was associated with a net monetary benefit of about $45 per additional colonoscopy at the lowest cost site and a net cost of $464 per additional colonoscopy at the highest cost site.

Of the 3 program sites included in this evaluation, the site with the highest costs (Hospital B) was the first to implement the patient navigator program. This site's substantially greater personnel costs were likely related to its pioneering role in the program, with more staff and higher paid staff initially involved in program planning and administration. All of these personnel might not have been necessary for ongoing program operation, but the hospital chose to maintain program staffing at its original level. The staffing arrangements at the 2 other sites suggest that a similar impact on colonoscopy volume and appointment completion can be achieved at a lower cost. Program costs were lower at Hospital A and Hospital C, and the program was sufficiently effective to yield a net financial benefit.

In the cost-benefit analysis presented here, conducted from the perspective of the hospital, net financial outcomes were a function of 3 factors: navigator program cost, reimbursement associated with increased colonoscopy volume, and the cost of performing these additional procedures. We did not explicitly consider the economic value of reducing missed colonoscopy appointments. Instead, the analysis implicitly assumed that endoscopy suites and personnel did not sit idle when a scheduled patient failed to show. If resources cannot be immediately reassigned when appointments are missed, then our analysis may underestimate the economic benefit of the program, because an increase in the colonoscopy completion rate would be associated with financial savings from a reduction in missed appointments.

Despite enthusiasm for patient navigation programs, particularly those that facilitate cancer screening, diagnosis, and treatment, evidence of their efficacy and cost-effectiveness is relatively limited. A recent review identified 16 studies that reported outcomes of cancer-related patient navigation programs.10 Six of the studies involved programs designed to improve cancer screening rates, and 3 studies specifically addressed colorectal cancer screening.8, 11, 12 Although patient navigation was associated with an increase in colonoscopy completion rates, the review authors noted that methodologic limitations precluded a definitive determination of program efficacy. More importantly, of all 16 studies reviewed, none included an analysis of program cost-effectiveness.

A more recent study found an increase in colorectal cancer screening rates, including colonoscopy specifically, among low-income adults who were randomized to a patient navigator program in an urban primary care setting in Massachusetts.13 Although that program was not identical to the patient navigator program evaluated here, based on the authors' projections of program cost ($75,000 per year) and the difference in colonoscopy use associated with the program in a 9-month period (20.8% of 409 adults randomized to the intervention versus 9.6% of 814 controls), the cost-effectiveness of the Massachusetts patient navigator program would be more than $8000 per additional patient screened with colonoscopy.

The scope of economic evaluation in our study was limited to the proximal endpoint of cost per additional colonoscopy. Ultimately, the benefit of increased screening derives from its impact on the more distant outcomes of morbidity and mortality due to colorectal cancer. Several investigators have used decision-analytic methods to estimate the long-term outcomes of colon cancer screening.14 Five studies simulating the experience of adults aged 50 to 85 years who were at average risk of colorectal cancer found that screening colonoscopy every 10 years was associated with a cost of $10,000 to $20,000 per life-year gained (given in 2000 US dollars).15-19 In these models, adherence with screening varied from 50% to 100%. By increasing colonoscopy volume and completion rates, the patient navigator program evaluated here can be viewed as increasing adherence with screening recommendations in the population served by the program. One decision-analytic simulation showed that enhancing the rate of colonoscopy screening adherence from 50% to 80% increased the average number of life-years gained by more than 30%, and increasing the screening adherence rate from 50% to 100% increased life-years gained by more than 60%.20 Thus, by increasing adherence, colonoscopy patient navigation likely has a beneficial impact on long-term health outcomes.

Following standard methods of cost-effectiveness analysis, we did not analyze the financial cost of lost productivity associated with colorectal cancer.21 However, the economic value of reducing productivity losses due to morbidity and premature mortality may be quite substantial. One recent estimate suggests that every death due to colorectal cancer is associated with more than $210,000 in lost productivity.22 Of the $142 billion projected value of lost productivity due to all cancer deaths in 2010, colorectal cancer deaths account for $12 billion or 9% of these economic losses. Colorectal cancer mortality is second only to lung cancer mortality in contributing to the value of lost productivity associated with all cancer deaths.

Limitations of our study should be noted. The nonrandomized design of the program evaluation yielded measures of program effectiveness, rather than efficacy. Although program hospitals and comparison hospitals served similar populations, and we used multivariable statistical methods to control for selection bias, there may be some residual confounding in our estimates, although the likely direction of such bias is not obvious. The racial and ethnic composition of colonoscopy patients at program and comparison hospitals was not identical, and colonoscopy patients at program hospitals came from neighborhoods with more high school graduates. Both groups of hospitals were located in New York City, limiting potential bias due to local secular trends in cancer screening. However, the generalizability of our findings to nonpublic hospitals and hospitals in other cities and regions is uncertain. It is notable that the program was both effective and cost-effective in an urban public hospital system serving a population composed predominantly of low-income racial and ethnic minorities, among whom the burdens of colorectal cancer morbidity and mortality are greater compared with their white peers.23 Finally, navigator program and colonoscopy costs and reimbursement amounts are from 2006. Although adjustment for inflation would increase the absolute values of these items if reported in more recent year dollars, the relative values of these items would likely be similar. The relative input prices and technologies associated with patient navigation and screening colonoscopy have not changed substantially in the past 6 years.

The colonoscopy patient navigator program studied here was effective in increasing colonoscopy volume and rates of colonoscopy completion, at a cost of $200 to $700 per additional colonoscopy. From the perspective of a hospital or other provider, the return on investment in a colonoscopy patient navigator program depends on several factors, most importantly the program cost, procedure cost, and reimbursement. If colonoscopy reimbursement exceeds the procedure cost by an amount greater than the cost of the navigator program per additional colonoscopy (ie, the cost-effectiveness ratio), then the program generates a net monetary benefit. In this case, net revenue associated with each additional colonoscopy exceeds the cost to achieve that additional colonoscopy. Alternatively, if colonoscopy reimbursement exceeds procedure cost, but by an amount less than program cost per additional colonoscopy, then the navigator program generates a net monetary cost. Even if the navigator program is effective and cost-effective relative to other similar interventions, if procedure cost exceeds reimbursement, then the provider loses money on every colonoscopy.

Colorectal cancer screening rates have increased in the past decade, both nationwide and in New York City. By 2007, 62% of eligible New York City residents had received a colonoscopy, compared with 42% in 2003,24 and similar trends have been observed across the country.25 Despite these advances, nationally at least two-thirds of Americans aged 50 years and older have not had a screening colonoscopy.26 As the population ages, the number of adults eligible for colonoscopy will grow substantially. Patient navigation programs, in conjunction with other efforts, may improve colonoscopy rates. Our results suggest that such programs are economically feasible and can yield a financial benefit to providers.

Acknowledgements

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES

We thank Dr. Shadi Chamany, Dr. James Hadler, and Dr. Lynn Silver for helpful comments on a prior version of the manuscript.

FUNDING SOURCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES

This study was supported by a grant from the New York Community Trust.

CONFLICT OF INTEREST DISCLOSURE

The authors made no disclosure.

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. Acknowledgements
  7. FUNDING SOURCES
  8. REFERENCES
  • 1
    American Cancer Society. Cancer Facts & Figures 2010. Atlanta, GA: American Cancer Society; 2010.
  • 2
    Levin B, Lieberman DA, McFarland B, et al; American Cancer Society Colorectal Cancer Advisory Group; US Multi-Society Task Force; American College of Radiology Colon Cancer Committee. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008; 134: 1570-1595.
  • 3
    Whitlock EP, Lin JS, Liles E, Beil TL, Fu R. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008; 149: 638-658.
  • 4
    Denberg TD, Melhado TV, Coombes JM, et al. Predictors of nonadherence to screening colonoscopy. J Gen Intern Med. 2005; 20: 989-995.
  • 5
    Christie J, Nassisi D, Wilets I, et al. Assessing endoscopic colorectal screening adherence in an emergency department population. J Natl Med Assoc. 2006; 98: 1095-1101.
  • 6
    Chen L, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol. 2008; 6: 443-450.
  • 7
    Lebwohl B, Neugut AI, Stavsky E, et al. Effect of a patient navigator program on the volume and quality of colonoscopy. J Clin Gastroenterol. 2011; 45: e47-e53.
  • 8
    Nash D, Azeez S, Vlahov D, Schori M. Evaluation of an intervention to increase screening colonoscopy in an urban public hospital setting. J Urban Health. 2006; 83: 231-243.
  • 9
    Henry SG, Ness RM, Stiles RA, Shintani AK, Dittus RS. A cost analysis of colonoscopy using microcosting and time-and-motion techniques. J Gen Intern Med. 2007; 22: 1415-1421.
  • 10
    Wells KJ, Battaglia TA, Dudley DJ, et al; Patient Navigation Research Program. Patient navigation: state of the art or is it science? Cancer. 2008; 113: 1999-2010.
  • 11
    Freeman HP, Muth BJ, Kerner JF. Expanding access to cancer screening and clinical follow-up among the medically underserved. Cancer Pract. 1995; 3: 19-30.
  • 12
    Jandorf L, Gutierrez Y, Lopez J, Christie J, Itzkowitz SH. Use of a patient navigator to increase colorectal cancer screening in an urban neighborhood health clinic. J Urban Health. 2005; 82: 216-224.
  • 13
    Percac-Lima S, Grant RW, Green AR, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med. 2009; 24: 211-217.
  • 14
    Pignone M, Saha S, Hoerger T, Mandelblatt J. Cost-effectiveness analyses of colorectal cancer screening: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2002; 137: 96-104.
  • 15
    Frazier AL, Colditz GA, Fuchs CS, Kuntz KM. Cost-effectiveness of screening for colorectal cancer in the general population. JAMA. 2000; 284: 1954-1961.
  • 16
    Khandker RK, Dulski JD, Kilpatrick JB, Ellis RP, Mitchell JB, Baine WB. A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guidelines for average-risk adults. Int J Technol Assess Health Care. 2000; 16: 799-810.
  • 17
    Sonnenberg A, Delco F, Inadomi JM. Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med. 2000; 133: 573-584.
  • 18
    Vijan S, Hwang EW, Hofer TP, Hayward RA. Which colon cancer screening test? A comparison of costs, effectiveness, and compliance. Am J Med. 2001; 111: 593-601.
  • 19
    Wagner J, Tunis S, Brown M, Ching A, Almeida R. Cost-effectiveness of colorectal cancer screening in average-risk adults. In: Young G, Rozen P, Levin B, editors. Prevention and Early Detection of Colorectal Cancer. London, UK: Saunders; 1996: 321-356.
  • 20
    Zauber AG, Knudsen AB, Rutter CM, et al. Cost-Effectiveness of CT Colonography to Screen for Colorectal Cancer. Technology Assessment Report. Project ID: CTCC0608. Rockville, MD: Agency for Healthcare Research and Quality; 2009.
  • 21
    Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-Effectiveness in Health and Medicine. New York, NY: Oxford University Press; 1996.
  • 22
    Bradley CJ, Yabroff KR, Dahman B, Feuer EJ, Mariotto A, Brown ML. Productivity costs of cancer mortality in the United States: 2000-2020. J Natl Cancer Inst. 2008; 100: 1763-1770.
  • 23
    Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin. 2008; 58: 71-96.
  • 24
    Richards CA, Kerker BD, Thorpe L, et al. Increased screening colonoscopy rates and reduced racial disparities in the New York Citywide campaign: an urban model. Am J Gastroenterol. 2011; 106: 1880-1886.
  • 25
    American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2010. Atlanta, GA: American Cancer Society; 2010.
  • 26
    Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey. Atlanta, GA: US Department of Health and Human Services, CDC; 2008.