|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 25, No 33 (November 20), 2007: pp. 5248-5253 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.13.4098 Costs and Cost-Effectiveness of a Low-Intensity Patient-Directed Intervention to Promote Colorectal Cancer Screening
From the Veterans Affairs Chicago Healthcare System; Veterans Affairs Midwest Center for Health Services and Policy Research; Feinberg School of Medicine, Division of Hematology/Oncology and Division of Geriatric Medicine; Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL; and Department of Internal Medicine, Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver, CO Address reprint requests to Charles L. Bennett, MD, PhD, MPP, Division of Hematology/Oncology, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Olson Pavilion Suite 8250, Chicago, IL 60611; e-mail: cbenne{at}northwestern.edu
Purpose Colorectal cancer (CRC) screening is the most underused evidence-based cancer screening test in the United States. Few studies have reported the cost-effectiveness of CRC screening promotional efforts. In a recent randomized controlled trial, a patient-directed intervention for average-risk patients who had been referred for screening colonoscopy led to a 12% increase in CRC screening rates. The objective of this secondary analysis is to assess the cost-effectiveness of this intervention. Patients and Methods Patients in the intervention arm received a customized mailed brochure that included a reminder to schedule a screening colonoscopy and general information about CRC, the importance of CRC screening, and how to prepare for the procedure. The end point was completion of screening colonoscopy. The costs and incremental cost-effectiveness ratio of this patient-directed intervention were derived. Sensitivity analyses were based on varying the costs of labor and supplies. Results Rates of CRC screening for the intervention (n = 386 patients) versus control (n = 395) arms were 71% and 59%, respectively (P = .001). The total cost of the intervention was $1,927 and the incremental cost-effectiveness ratio was $43 per additional patient screened ($38 to $47 in a sensitivity analysis). Conclusion An intervention based on mailing a customized brochure to patients who were referred for a screening colonoscopy improved CRC screening rates at a university-based general medicine clinic. This intervention was comparable in effectiveness and cost-effectiveness to a similar recently reported low-intensity patient-directed CRC screening intervention, and markedly more affordable and cost-effective than a previously reported physician-directed CRC screening promotion intervention.
Of all cancer screening tests, colonoscopy is among the most efficacious in terms of saving lives through early detection and removal of precancerous polyps.1 Colorectal cancer (CRC) screening with either an annual fecal occult blood test, barium enema every 5 years, or colonoscopy every 10 years is recommended for average-risk individuals who are age  50 years.2 However, national CRC screening rates are less than 45%, much lower than the national cancer screening rates reported for prostate, cervical, and breast cancers.1 Interventions designed to improve adherence to cancer screening recommendations can occur at various levels: community (outreach activities, educational fairs), individual patients (mailings, telephone calls), health care providers (feedback reports, debriefing sessions), or clinic infrastructure (flagged charts, computerized prompts).3 A number of studies have evaluated patient-directed cancer screening interventions, primarily related to breast and cervical cancer screening. A high-intensity patient-directed intervention consisting of mailing a tailored barrier-specific letter and a follow-up motivational telephone call from a staff person was effective, with a 20% increase in breast and cervical cancer screening rates, but less cost-effective (incremental costs of $818 per extra woman screened).4 Another high-intensity patient-directed intervention involving periodic barrier-specific telephone counseling during a 3-year period for former mammography users (who had subsequently become noncompliant with screening) was associated with a 9% increase in screening adherence, but a similarly high incremental cost ($726 per extra woman screened).5 In contrast, in three studies based on low-intensity patient-directed screening interventions through telephone prompts or mailed reminders, breast and cervical cancer screening rates improved by 7% to 41%, with incremental costs between $3 and $52 per extra women screened.6-8 To our knowledge, to date only one study has reported the cost-effectiveness of a low-intensity patient-directed intervention designed to improve rates of CRC screening9 (M. Pignone, personal communication, June 2007). In this recently completed study, patients received a mailed packet that included a letter from their physicians describing the need for screening, information about how to directly obtain screening, a brief survey, and an opportunity to request a decision aid about screening options. Reminder letters were sent subsequently at 1 and 2 months. This intervention resulted in a 9% increase in CRC screening rates, with an incremental cost-effectiveness ratio (ICER) of $15 per extra patient screened (M. Pignone, personal communication, June, 2007).9 The second study entailed a three-arm intervention, with the lowest intensity arm consisting of a mailed informational packet; a 13% increase in CRC screening was seen, but the ICER of $319 per extra patient screened was much less favorable.9a In contrast, a high-intensity physician-directed intervention consisting of quarterly report cards and feedback sessions resulted in a 9% improvement in CRC screening rates with an ICER of $978 per extra patient screened.10 In 2006, one of our coauthors (T.D.) reported that a low-intensity patient-directed screening intervention consisting of a mailed reminder and informational brochure customized with the patient's and physician's name was clinically effective.11 In that study, a 12% improvement in CRC screening rates was observed among patients in two general internal medicine clinics at the University of Colorado Health Sciences Center (Denver, CO) who had been referred, but who had not yet scheduled, a screening colonoscopy examination. However, it is not known if the intervention was cost-effective, particularly in the context of other similar cancer screening promotion programs. For this intervention to be considered for use in other settings, information about effectiveness, costs, and cost-effectiveness is needed.12 The objective of this study was to evaluate the costs and cost-effectiveness of this low-intensity patient-directed CRC screening effort.
Patient enrollment occurred at two general medicine clinics located at the University of Colorado Health Sciences Center between February and November 2005. Each week, a research assistant reviewed the colonoscopy referral forms completed in the general internal medicine clinics; patient eligibility was determined by an asymptomatic screening check box marked by the primary care physician (PCP) on the referral form and subsequently verified by review of recent clinic notes in the medical record. Data on patients who met the eligibility criteria were entered, unsorted, into an Excel (Microsoft Corp, Redmond, WA) database along with the sex of the referring PCP. Using a random-number generator, the research assistant then randomly and sequentially assigned each of the patients to a usual care (control) group versus an intervention group consisting of usual care plus the mailed brochure. Immediately after recording the study group assignments, the research assistant prepared and mailed the brochures via the US mail. The brochure included the name of the patient's PCP in the introductory paragraph. On the brochure, simplified drawings of the large intestines and a colonoscope were provided. Text written at an eighth-grade level included the following information: the similar lifetime risk for CRC for men and women at average risk; the concept of cancer prevention (finding and removal of benign polyps that might develop into cancer), as well as the early detection of cancer; the typically asymptomatic nature of polyps and early-stage cancer; how screening may help prevent death; a description of colonoscopy, including the use of conscious sedation to minimize discomfort; and alternative screening to colonoscopy (fecal occult blood testing and flexible sigmoidoscopy). The brochure concluded with a statement encouraging patients to call the endoscopy laboratory to schedule a colonoscopy or to call their PCPs to obtain additional information (telephone numbers were provided). There was also a brief mention of the frequent use of the bathroom after consumption of the liquid preparation the night before the procedure. All brochures were mailed within 10 days of the referral date. If the post office returned a brochure as undeliverable, no additional mailings were sent, but the patient data were retained in the sample for an intention-to-treat analysis. Patients receiving more than one referral during the study period were retained in the sample, but were counted as not adhering in relation to their original referrals. Subsequent referrals for these patients were ignored.11
Calculation of Costs
Assumptions for the Economic Model
Calculation of the Cost-Effectiveness Ratio
The study enrolled 386 patients onto the intervention arm who received the mailed educational brochure and 395 patients onto the control arm who did not receive the mailed brochure (Fig 1). All patients were at average risk for CRC and had been referred for direct access colonoscopy. The majority of the patients were covered by private health insurance, Medicare, or the university health plan. Approximately 60% of the patients were female. At 4 months after the referral, rates of CRC screening (effectiveness) in the intervention and control arms were 71% and 59%, respectively (P = .001). The total cost of the patient-directed intervention (ie, development and mailing of educational brochures to each patient) was $1,927 and the cost per patient in the intervention group was $5 (Table 1). The ICER of the patient-directed mailed brochure intervention was $43 per additional person screened (Table 2). Sensitivity estimates based on a 10% variation around the cost inputs indicated that the estimated cost per additional patient screened for CRC ranged from $38 to $47. Across various subgroups of patients, the intervention retained a similar ICER ($27 to $100 per additional person screened; Table 2).
To our knowledge, this is the third study to assess the costs and cost-effectiveness of a randomized controlled trial designed to improve CRC screening rates, and the second study specifically to assess a patient-directed intervention for CRC screening. The study was conducted among asymptomatic average-risk patients who had received a referral for a screening colonoscopy. This intervention resulted in a 12% increase in the percentage of patients who completed the referral process and actually had a screening colonoscopy. The incremental cost of the screening promotion intervention was $43 per extra person screened for CRC. Our economic analysis can first be considered in the context of other interventions to improve CRC screening (Table 3). Our findings for effectiveness and cost-effectiveness are similar to those reported for an analogous patient-directed CRC screening promotion intervention conducted at the University of North Carolina (Chapel Hill, NC) primary care practice setting (9% improvement in CRC screening rates; $15 per extra person screened), but more favorable than a comparable patient-directed screening promotion conducted at the University of Texas (Houston, TX; 13% improvement in colorectal cancer screening; $319 per extra patient screening; M. Pignone, personal communication, June, 2007).9 In the latter randomized study, increasingly intensive patient-directed interventions resulted in even higher ICERs, with the most unfavorable ICER of $5,843 resulting from the addition of a reminder telephone call to a tailored mailing.9a A recently reported labor-intensive, provider-directed intervention that included quarterly report cards of the CRC screening rates for individual physicians' patient panels was markedly less cost-effective ($978 per additional patient screened), though similarly effective (9% improvement in CRC screening rates).10 A recent pilot study combining patient-directed mailings with physician-directed health literacy training to more effectively communicate the importance of CRC screening resulted in a 16% increase in CRC screening adherence, with an ICER of $106 per additional patient screened.16
This economic analysis can also be considered in the context of costs reported for other patient-directed cancer screening promotion efforts, primarily for breast or cervical cancer (Table 3). The cost per patient of our intervention was within the range of costs per patient reported for other low-intensity patient-directed interventions ($5 v $1 to $15), as was the ICER of our intervention ($43 v $3 to $52 per extra person screened). Aside from two high-intensity patient-directed interventions and one low-intensity patient-directed intervention (with ICERs of $5,843, $818, $726, and $319 per additional patient screened, respectively), the majority of low-intensity patient-directed screening promotion interventions seemed to be clinically effective as well as cost-effective across a wide spectrum of patient populations. Cost-effectiveness studies traditionally have examined costs from a public health perspective where the goal is to increase screening adherence to save lives.12,14 In our study, referral for colonoscopy is associated with a cost of generating and processing referrals at $10 per referral; a broader perspective of the implications of this intervention include revenue generation for the health care system resulting from a higher rate of colonoscopy completion. In other words, the opportunity costs associated with generating and processing referrals and sending customized patient brochures are rewarded by substantial fee-for-service revenue (in the original study, 65% of all patients) related to completing a colonoscopy. On a larger scale, this could represent a substantial return on investment. Some limitations of our study should be noted. First, the findings are based on an urban general internal medicine clinic population consisting primarily of individuals who are privately insured or covered by Medicare. The patient populations described in the comparison cancer screening promotion studies mentioned in this article are not uniform; several of the studies are conducted in low-income, uninsured, and disadvantaged patient populations. Second, different cost methodologies have been used to evaluate the cost-effectiveness of cancer screening promotion efforts across the various studies. In conclusion, an intervention that included mailing of customized information brochures resulted in a 12% improvement in adherence to CRC screening recommendations. The costs and ICER associated with this cancer screening promotional intervention are similar to those reported for an analogous patient-directed cancer screening intervention, and markedly more cost-effective in comparison to a physician-directed CRC screening promotion intervention. The cost per extra patient screened is a useful piece of information that should be included in future studies of cancer screening promotion interventions.
The author(s) indicated no potential conflicts of interest.
Conception and design: Veena Shankaran, June M. McKoy, Neal Dandade, Narissa Nonzee, Charles L. Bennett, Tom D. Denberg Administrative support: June M. McKoy, Neal Dandade, Narissa Nonzee, Cara A. Tigue Provision of study materials or patients: Charles L. Bennett, Tom D. Denberg Collection and assembly of data: Veena Shankaran, June M. McKoy, Neal Dandade, Narissa Nonzee, Cara A. Tigue, Charles L. Bennett, Tom D. Denberg Data analysis and interpretation: Veena Shankaran, June M. McKoy, Neal Dandade, Narissa Nonzee, Cara A. Tigue, Charles L. Bennett, Tom D. Denberg Manuscript writing: Veena Shankaran, June M. McKoy, Neal Dandade, Narissa Nonzee, Cara A. Tigue, Charles L. Bennett, Tom D. Denberg Final approval of manuscript: Veena Shankaran, June M. McKoy, Neal Dandade, Narissa Nonzee, Cara A. Tigue, Charles L. Bennett, Tom D. Denberg
Supported in part by American Cancer Society Grant No. MRSG-06-081-01-CPPB (T.D.D.) and by National Cancer Institute Grants No. 1R01CA 102713-01 and P 30 CA60553 (C.L.B., J.M.M.) Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. American Cancer Society: Cancer Facts and Figures 2007. American Cancer Society, 2007. http://www.cancer.org/downloads/STT/CAFF2007PWSecured.pdf 2. NCCN Practice Guidelines in Oncology. 2007. v. 1.2007. http://www.nccn.org/professionals/physician_gls/PDF/colorectal_screening.pdf 3. Meissner HI, Smith RA, Rimer BK, et al: Promoting cancer screening: Learning from experience. Cancer 101: 1107-1117, 2004 (suppl 5)[Medline] 4. Lynch FL, Whitlock EP, Valanis BG, et al: Cost-effectiveness of a tailored intervention to increase screening in HMO women overdue for Pap test and mammography services. Prev Med 38: 403-411, 2004[CrossRef][Medline] 5. Costanza ME, Stoddard AM, Luckmann R, et al: Promoting mammography: Results of a randomized trial of telephone counseling and a medical practice intervention. Am J Prev Med 19: 39-46, 2000[CrossRef][Medline] 6. Lantz PM, Stencil D, Lippert MT, et al: Implementation issues and costs associated with a proven strategy for increasing breast and cervical cancer screening among low income women. J Public Health Manag Pract 2: 54-59, 1996[Medline] 7. Mohler PJ: Enhancing compliance with screening mammography recommendations: A clinical trial in a primary care office. Fam Med 27: 117-121, 1995[Medline] 8. Saywell RM Jr, Champion VL, Skinner CS, et al: A cost-effectiveness comparison of three tailored interventions to increase mammography screening. J Womens Health (Larchmt) 13: 909-918, 2004[CrossRef][Medline] 9. Brenner AT, Lewis C, Griffith JM, et al: Effectiveness of a mailed intervention to increase colorectal cancer screening in an academic primary care practice: A controlled trial. J Gen Intern Med 22: 1-276, 2007 (suppl 1)[Medline] 9. Lairson DR, DiCarlo M, Myers RE, et al: Cost-effectiveness of targeted and tailored interventions on colorectal cancer screening use. Cancer (in press) 10. Wolf MS, Fitzner KA, Powell EF, et al: Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening among Veterans. J Clin Oncol 23: 8877-8883, 2005 11. Denberg TD, Coombes JM, Byers TE, et al: Effect of a mailed brochure on appointment-keeping for screening colonoscopy: A randomized trial. Ann Intern Med 145: 895-900, 2006 12. Andersen MR, Urban N, Ramsey S, et al: Examining the cost-effectiveness of cancer screening promotion. Cancer 101: 1229-1238, 2004 (suppl 5)[CrossRef][Medline] 13. Chirikos TN, Christman LK, Hunter S, et al: Cost-effectiveness of an intervention to increase cancer screening in primary care settings. Prev Med 39: 230-238, 2004[CrossRef][Medline] 14. Russell LB, Gold MR, Siegel JE, et al: The role of cost-effectiveness analysis in health and medicine. JAMA 276: 1172-1177, 1996 15. Roetzheim RG, Christman LK, Jacobsen PB, et al: A randomized controlled trial to increase cancer screening among attendees of community health centers. Ann Fam Med 2: 294-300, 2004 16. Khankari K: Improving colorectal cancer screening among the medically underserved: A pilot study within a federally qualified health center. J Gen Intern Med 22: 1410-1414, 2007[CrossRef][Medline] Submitted July 6, 2007; accepted August 17, 2007.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
TOP
ABSTRACT
INTRODUCTION
