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  • March 2009

    Cost-Benefit Analysis of CT Colonography in Screening for Colorectal Cancer

    American Journal of Roentgenology | Perry Pickhardt et al.


    CT Colonography to Screen for Colorectal Cancer and Aortic Aneurysm in the Medicare Population: Cost-Effectiveness Analysis


    Pickhardt, Perry; Hassan, Cesare; Laghi, Andrea; and Kim, David


    American Journal of Roentgenology, May 2009


    A recent study published in Cancer showed that fewer than 25% of average-risk Medicare beneficiaries undergo complete screening for colorectal cancer. Although Medicare currently covers a variety of colorectal cancer screening procedures – optical colonoscopy, flexible sigmoidoscopy, barium enema, and annual fecal occult blood testing – the program does not offer reimbursement for computed tomography (CT) colonography. In addition to being less invasive, CT colonography is also more patient-friendly in that it does not require sedation, pain control or recovery time. As a result, many experts feel a broader implementation of CT colonography might greatly increase the rate at which patients, particularly older patients, adhere to screening recommendations. This issue is of grave importance, as complications due to colorectal cancer can largely be prevented with routine screening, yet the disease remains the second-leading cause of cancer deaths in the United States.

    Unfortunately, in February, 2009, the Center for Medicare and Medicaid Services decided that the data recommending CT colonography be covered by Medicare was “inadequate.” The organization cited a particular lack of data regarding the cost-effectiveness of CT colonography.

    In this study, Pickardt et al set out to prove not only that CT colonography is cost-effective; it is also clinically efficacious. Researchers utilized a Markov model to simulate the development of colorectal cancer and abdominal aortic aneurysms (AAA) in a hypothetical cohort of 100,000 American adults over the age of 65. Screening with CT colonography at five and ten-year intervals was compared with optical colonoscopy every ten years, as well as with no screening at all. Clinical efficacy was measured in terms of life-years gained through the prevention or downstaging of a disease, while an incremental cost-effectiveness ratio (ICER) was determined by dividing the difference in costs (between two procedures) by the difference in life expectancy. An ICER of $50,000 was determined as the threshold at which a procedure was deemed either cost-efficient or cost-inefficient. Costs were determined using existing Medicare reimbursement information converted to 2008 US dollars.

    According to Pickhardt et al, “Out current study has addressed [the] perceived data gap by showing that CT colonography…is both a highly cost-effective and clinically efficacious screening strategy for the Medicare population.” Five-year and ten-year CT colonography screening strategies had an ICER of $6,088 and $1,251, respectively, when compared to no screening, placing them well within the cost-effectiveness range established in the study’s parameters. The five and ten-year CT colonography strategies had an ICER of $23,234 and $2,144, respectively, when compared to the ten-year optical colonoscopy strategy. When the cost of screening for AAA (which may simultaneously be screened for with CT colonography, but not optical colonoscopy) was included, CT colonography emerged as the most cost-effective screening procedure in the study. Researchers went on to say, “We believe that CT colonography should be implemented as soon as possible because it has met or has exceeded the key benchmarks achived by optical colonoscopy and the other currently approved screening options.”

    Of note: These cost-effectiveness ratios are particularly impressive, as researchers performed statistical analyses assuming CT colonography and optical colonoscopy to be of similar cost; yet at the institution in which the study was conducted, optical colonoscopy costs 3-5 times more than CT colonography, on average.

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