- Top of page
- MATERIALS AND METHODS
- FUNDING SUPPORT
- CONFLICT OF INTEREST DISCLOSURES
Estimates indicate that there will be 142,820 new cases and 50,830 deaths from colorectal cancer (CRC) in 2013. CRC screening can detect colorectal adenoma, a precursor to CRC. The American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF) encourage screening in adults who are aged ≥50 years, asymptomatic, and at average risk for CRC.
Colonoscopy every 10 years and annual stool blood testing (SBT) are the most frequently performed CRC screening strategies. Although US rates of CRC screening are increasing, they lag behind those for breast and cervical cancer screening. Healthy People 2020 called for greater than 70% CRC screening rates. To achieve sustainable high CRC screening rates, primary care providers need to implement cost-effective behavioral interventions. Whereas mailed contacts and reminders have a modest impact on CRC screening rates, personally tailored patient programs may achieve greater gains.
Few studies have evaluated the cost-effectiveness of CRC screening promotion strategies.[7, 8] Estimates for CRC promotion range from $11 to $978 per additional individual screened.[9, 10] The former estimate was for a low-cost intervention directed toward disadvantaged populations in primary care clinics, whereas the higher cost was for a sophisticated tracking system in the Veterans Administration Health System. Elsewhere, we reported on the cost-effectiveness of targeted and tailored behavioral outreach interventions to increase CRC screening within an urban family practice in Philadelphia. Our estimates of the mean intervention cost in that project ranged from $42 to $200.11
Here, we present findings from a randomized trial designed to test the cost-effectiveness of a standard intervention (SI) and a tailored navigation intervention (TNI) on CRC screening use among patients in the Christiana Care Health System (CCHS). CCHS provides health care to approximately 66% of the Delaware population. The system includes 2 acute care hospitals with over 42,000 inpatient admissions and more than 125,000 annual emergency department visits and a network of primary care practices in family medicine, internal medicine, pediatrics, and obstetrics/gynecology. We recently reported the research design and screening outcomes of SI and TNI compared with usual care (control).
Interventions that help patients address barriers to screening and help providers deliver the screening message increase CRC screening adherence.[13-17] The population outreach strategies used in this randomized trial and the detailed screening outcome and cost data provide information for decision-makers' assessment of CRC prevention methods.
- Top of page
- MATERIALS AND METHODS
- FUNDING SUPPORT
- CONFLICT OF INTEREST DISCLOSURES
Randomized trials of CRC screening navigation have focused on primary care patients who attended scheduled office visit and received a referral for screening colonoscopy. Navigators who followed “in-office” provider screening referrals achieved patient adherence rates up to 54% to 66%, which was significantly higher than controls at 13%.[30, 31] Navigation studies have also used medical records to recruit patients outside the office visit and have achieved screening rates from 27% to 41%.[32-34] The current study, in which patients were identified from an EMR, reflects comparable navigation effects.
For this study, we selected patients in CCHS practices who were noncompliant with CRC screening at baseline. From data on patients who were adherent at baseline, we estimated that the baseline screening rate in the practices was about 44%. Thus, approximately 56% of screening-eligible patients in the practices were nonadherent. In this segment of the patient population, a 33% screening rate in the SI group and a 38% screening rate among TNI participants was achieved among the patients who were nonadherent at baseline. When the SI and TNI study group screenees were added to those who were adherent with screening at baseline, the estimated overall screening rate was between 71% and 73%, which is similar to the Healthy People 2020 goals.
In an earlier economic evaluation of a CRC intervention in a large, diverse patient population in Philadelphia, individuals were mailed a targeted screening invitation letter, SBT cards, an information booklet, and a reminder letter. In that study, the screening rate in the control group was 33%. The cost per additional individual screened was $319 comparing the standard mailed intervention with usual care, and the tailored intervention was less effective and more costly. Adding a reminder telephone call from a trained health educator to the tailored intervention increased the screening rate, but at a very high incremental cost. The current study, which was conducted in Delaware, provided access to screening on the basis of expressed screening test preference and encouraged screening through a tailored navigation call keyed to the individual's preferred screening test. Shankaran and colleagues provided a mailed brochure that was customized to the individual's name and sex to patients who had received a colonoscopy screening referral from their physician. The mailing included a reminder to schedule a screening colonoscopy, general CRC screening information, material about the importance of screening, and instructions on how to prepare for a colonoscopy. The control group had a screening rate of 59%, and those in the intervention group had a 12% increase in screening. The ICER was $43 per additional individual screened, and the intervention cost only $5 per patient. Chirikos et al reported results from a study of primary care clinics serving disadvantaged populations ages 50 to 75 years in which the baseline screening rate was 12%. The primary intervention included a clinician reminder of cancer screening tests due and the division of office responsibilities to ensure follow through on tests ordered. The cost per additional individual screened was $11.53 from the societal perspective. Wolf et al reported on a clinic-based Veterans Administration screening promotion program for individuals aged ≥50 years who were not compliant with screening guidelines and attended a physician visit. The baseline screening rate was 32%. The intervention included a provider workshop on CRC screening plus feedback on individual and group-specific rates. The cost per additional individual screened was $978 from a payer perspective. These cost results are similar to our findings, which included costs for planning, training staff, recruiting participants, and implementation.
We excluded the cost of participant recruitment for the control group, because this research cost is not relevant to decisions regarding the implementation of similar, future CRC screening-promotion programs. However, program managers need to recruit the target group to implement the interventions. The recruitment costs would be the same for each intervention and, thus, would not affect their relative cost-effectiveness. Recruitment costs represent from 30% up to 40% of the total cost, even in highly organized health care settings.[36, 37] Nevertheless, our average cost estimates may be an upper bound because of the higher costs associated with a research project, the small scale of the target groups, and the lack of a sophisticated EMR system to identify patient screening status.
Elsewhere, we have reported that exposure to a mailed intervention was associated with race-related disparity in CRC screening adherence that favored whites. The inclusion of a relatively small proportion of nonwhite participants limits the generalizability of findings from our current study. Nonetheless, secondary analyses performed in the current study indicated that the TNI effect was substantially greater among nonwhites (SI rate, 28%; TNI rate, 42%) compared with whites (SI rate, 39%; TNI, 43%), attenuating the screening disparity. This finding suggests that the impact and cost-effectiveness of interventions intended to encourage screening may vary according to race. Future cost-effectiveness studies that consider race may be useful. Exogenous factors may have influenced the results. The state of Delaware initiated an aggressive CRC screening promotion program, and participating primary care practices engaged in various CRC screening initiatives during the study period. We assume that these initiatives had little impact on study group differences, but they may have had a modest effect on overall screening rates. Cost information is subject to the limitations of staff time input recall, overhead cost rate assumptions, inflation from delivery of the interventions in the context of a research project, and the higher costs associated with learning a new program. It would be preferable to collect time data prospectively to avoid recall errors. We caution reliance on the absolute cost estimates, although we have confidence in the relative costs of the interventions.
Adjusting investigator salaries to the levels paid to the administrators and primary care physicians who are likely to be implementing these interventions in the “real world” yields lower cost estimates for the interventions: the SI costs would decrease to $165 per participant, and the TNI costs would decrease to $275. Real-world applications should reduce costs further by using existing experienced staff, EMRs, and a larger scale of operations. It is likely that a medical assistant and a registered nurse could handle management, which would decrease average costs by $2.07 for SI and $14.68 for TNI.
In a secondary analysis (data not shown), we examined the TNI subgroups according to their preference for particular screening tests. Participants who had equal preference for SBT and colonoscopy screening were provided information and navigation for both tests, whereas those who had a screening test preference were provided information and navigation only for the preferred test. Average costs were about the same in these subgroups, but the screening rate was 0.5 in the group with equal preference compared with 0.375 in the group with a preference. The higher screening rate in the TNI subgroup with equal preference may be because they were provided information about and access to both screening modalities. This reduced the ICER to a level ($912) just above the ICER for the SI program, potentially increasing the economic attractiveness of the more effective TNI program, minus the tailoring.
Considering the cost-effectiveness acceptability along with outcomes from a randomized trial allows for a more complete evaluation of intervention effects. The economic evaluation estimates the costs and effects of the alternative interventions and the uncertainty around those estimates. Decision-makers need to consider the uncertainties, along with their willingness to pay, cost structure, and level of planning and training required to implement the interventions, to determine whether the extra resources required for navigation would be worth the investment. Decision-makers may explore ways of decreasing the costs of identifying eligible individuals and delivering tailored navigation contacts, making tailored navigation a more feasible option. In either case, the interventions are effective in increasing the screening rates above the level attained with usual care.