An Economic Evaluation of Colorectal Cancer Screening in Primary Care Practice


      Recent colorectal cancer screening studies focus on optimizing adherence. This study evaluated the cost effectiveness of interventions using electronic health records (EHRs); automated mailings; and stepped support increases to improve 2-year colorectal cancer screening adherence.


      Analyses were based on a parallel-design, randomized trial in which three stepped interventions (EHR-linked mailings [“automated”]; automated plus telephone assistance [“assisted”]; or automated and assisted plus nurse navigation to testing completion or refusal [navigated”]) were compared to usual care. Data were from August 2008 to November 2011, with analyses performed during 2012–2013. Implementation resources were micro-costed; research and registry development costs were excluded. Incremental cost-effectiveness ratios (ICERs) were based on number of participants current for screening per guidelines over 2 years. Bootstrapping examined robustness of results.


      Intervention delivery cost per participant current for screening ranged from $21 (automated) to $27 (navigated). Inclusion of induced testing costs (e.g., screening colonoscopy) lowered expenditures for automated (ICER=–$159) and assisted (ICER=–$36) relative to usual care over 2 years. Savings arose from increased fecal occult blood testing, substituting for more expensive colonoscopies in usual care. Results were broadly consistent across demographic subgroups. More intensive interventions were consistently likely to be cost effective relative to less intensive interventions, with willingness to pay values of $600–$1,200 for an additional person current for screening yielding ≥80% probability of cost effectiveness.


      Two-year cost effectiveness of a stepped approach to colorectal cancer screening promotion based on EHR data is indicated, but longer-term cost effectiveness requires further study.
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        • U.S. Preventive Services Task Force
        Screening for colorectal cancer: U.S. Preventive Services Task Force recommendation statement.
        Ann Intern Med. 2008; 149: 627-637
      1. Howlader N, Noone AM, Krapcho M, et al, eds. SEER Cancer Statistics Review, 1975-2011. Bethesda, MD: National Cancer Institute.

        • Whitlock E.P.
        • Lin J.S.
        • Liles E.
        • Beil T.L.
        • 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
        • Zauber A.G.
        • Lansdorp-Vogelaar I.
        • Knudsen A.B.
        • Wilschut J.
        • van Ballegooijen M.
        • Kuntz K.M.
        Evaluating test strategies for colorectal cancer screening: a decision analysis for the U.S. Preventive Services Task Force.
        Ann Intern Med. 2008; 149: 659-669
        • CDC
        Vital signs: colorectal cancer screening test use—United States, 2012.
        Morb Mortal Wkly Rep. 2013; 62: 881-888
        • Shapiro J.A.
        • Klabunde C.N.
        • Thompson T.D.
        • Nadel M.R.
        • Seeff L.C.
        • White A.
        Patterns of colorectal cancer test use, including CT colonography, in the 2010 National Health Interview Survey.
        Cancer Epidemiol Biomarkers Prev. 2012; 21: 895-904
        • Shankaran V.
        • Luu T.H.
        • Nonzee N.
        • et al.
        Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening.
        J Clin Oncol. 2009; 27: 5370-5375
        • Sequist T.D.
        • Franz C.
        • Ayanian J.Z.
        Cost-effectiveness of patient mailings to promote colorectal cancer screening.
        Med Care. 2010; 48: 553-557
      2. CDC. 2014. Guide to Community Preventive Services.

        • Green B.B.
        • Wang C.Y.
        • Horner K.
        • et al.
        Systems of support to increase colorectal cancer screening and follow-up rates (SOS): design, challenges, and baseline characteristics of trial participants.
        Contemp Clin Trials. 2010; 31: 589-603
        • Green B.B.
        • Wang C.Y.
        • Anderson M.L.
        • et al.
        An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial.
        Ann Intern Med. 2013; 158: 301-311
        • Green B.B.
        • Bogart A.
        • Chubak J.
        • et al.
        Nonparticipation in a population-based trial to increase colorectal cancer screening.
        Am J Prev Med. 2012; 42: 390-397
        • Hoch J.S.
        • Briggs A.H.
        • Willan A.R.
        Something old, something new, something borrowed, something blue: a framework for the marriage of health econometrics and cost-effectiveness analysis.
        Health Econ. 2002; 11: 415-430
        • Fenwick E.
        • Byford S.
        A guide to cost-effectiveness acceptability curves.
        Br J Psychiatry. 2005; 187: 106-108
        • Hoch J.S.
        • Rockx M.A.
        • Krahn A.D.
        Using the net benefit framework to construct cost-effectiveness acceptability curves: an example using data from a trial of external loop recorders versus Holter monitoring for ambulatory monitoring of “community acquired” syncope.
        BMC Health Serv Res. 2006; 6: 68
        • Centre for Health Economics
        Regression Methods for Health Economic Evaluation Workshop Session Guide.
        University of York, York, UK2010
        • Frick K.D.
        Micro-costing quantity data collection methods.
        Med Care. 2009; 47 (7): S76-S81
        • Lansdorp-Vogelaar I.
        • Knudsen A.B.
        • Brenner H.
        Cost-effectiveness of colorectal cancer screening.
        Epidemiol Rev. 2011; 33: 88-100
        • Smith D.H.
        • Feldstein A.C.
        • Perrin N.
        • et al.
        Automated telephone calls to enhance colorectal cancer screening: economic analysis.
        Am J Manag Care. 2012; 18: 691-699
        • Lairson D.R.
        • Dicarlo M.
        • Deshmuk A.A.
        • et al.
        Cost-effectiveness of a standard intervention versus a navigated intervention on colorectal cancer screening use in primary care.
        Cancer. 2014; 120: 1042-1049
        • Lairson D.R.
        • DiCarlo M.
        • Myers R.E.
        • et al.
        Cost-effectiveness of targeted and tailored interventions on colorectal cancer screening use.
        Cancer. 2008; 112: 779-788
        • Misra S.
        • Lairson D.R.
        • Chan W.
        • et al.
        Cost effectiveness of interventions to promote screening for colorectal cancer: a randomized trial.
        J Prev Med Public Health. 2011; 44: 101-110
        • Wolf M.S.
        • Fitzner K.A.
        • Powell E.F.
        • et al.
        Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening among Veterans.
        J Clin Oncol. 2005; 23: 8877-8883
        • Davis T.C.
        • Arnold C.L.
        • Bennett C.L.
        • et al.
        Strategies to improve repeat fecal occult blood testing cancer screening.
        Cancer Epidemiol Biomarkers Prev. 2014; 23: 134-143
        • Lansdorp-Vogelaar I.
        • Kuntz K.M.
        • Knudsen A.B.
        • van Ballegooijen M.
        • Zauber A.G.
        • Jemal A.
        Contribution of screening and survival differences to racial disparities in colorectal cancer rates.
        Cancer Epidemiol Biomarkers Prev. 2012; 21: 728-736
        • Goede S.L.
        • van Roon A.H.
        • Reijerink J.C.
        • et al.
        Cost-effectiveness of one versus two sample faecal immunochemical testing for colorectal cancer screening.
        Gut. 2013; 62: 727-734
        • Wilschut J.A.
        • Hol L.
        • Dekker E.
        • et al.
        Cost-effectiveness analysis of a quantitative immunochemical test for colorectal cancer screening.
        Gastroenterology. 2011; 141: 1648-1655