TableA.10 Cost effectiveness of GI services: summary of articles examined for surveillance programmes

AuthorsResearch setting and year of studyStudy designSample sizeTopic of documentResults and conclusionsComments
Renehan et al618UK NHS perspective but based on five studies from Finland, Denmark, Italy, Sweden, and Australia (2004)Modelling exercise based on the results of a previous meta-analysis of five RCTs performed by the authors1342 PatientsPatient follow-upBased on the five trials the life years gained were 0.73, and the adjusted net (extra) cost for each patient was £2479 and for each life year gained was £3402. NHS perspective. The main predictor of incremental cost effectiveness ratios was surveillance cost. Based on the available data and current costs, intensive follow-up after curative resection for colorectal cancer should be normal practiceLarge RCTs are needed to evaluate the efficacy of specific surveillance tools. These studies should include CEAs and quality of life assessments.Also, costs beyond the five years’ initial treatment need to be considered as a proportion of patients with recurrences undergoing salvage treatment will have delayed second recurrences. Also a societal perspective should be taken as travel and time off work might be relevant in cancer surveillance
Maule758UK (1994)Prospective cohort study1881 Patients (examined by nurses) and 730 (examined by physiciansScreening of colorectal cancer by nurse endoscopistsNurses can carry out screening by flexible sigmoidoscopy as accurately and safely as experienced gastroenterologistsThe paper did not include a proper economic evaluation.
Mathew et al778UK (England) (2000–02)Case series study2382 PatientsThis study aimed to identify the percentage of patients aged <45 who undergo flexible sigmoidoscopy for rectal bleeding and compare the incidence of colorectal cancers and polyps above and below this ageThe incidence of colorectal cancers and adenomatous polyps in patients aged <45 years with rectal bleeding is very lowThere is no real economic analysis
Atkin622UK (1998)ReviewNAFlexible sigmoidoscopy as mass screening toolFlexible sigmoidoscopy as mass screening tool No economics evaluation. The authors simply hypothesise that FS screening “would cost only marginally more than is currently spent on treating the disease” and describe a continuing trial set up to test that hypothesis. Nothing in here about cost for case detected (cf FOB test, RS, etc) or cost for each life year gainedThe economic analysis of the study is flawed
Pignone et al619USA, UK, and others (1993–2001)Systematic reviewTo assess cost effectiveness of colorectal cancer screening for the US Preventive Services Task ForceSeven articles were identified. Compared with no screening, cost effectiveness ratios for screening with any of the commonly considered methods were generally between $10 000 and $ 25 000 for each life year saved. No one strategy was consistently found to be the most effective or to have the best ICER. Currently available models provided insufficient evidence to determine optimal starting and stopping ages for screening.No studies considered patient time cost associated with attendance for screening, diagnostic, or surveillance procedures or for treatment of cancer
Smith et al573UK (1997)Postal questionnaires to clinicians (members of the society of gastroenterology)152To determine the practices that clinicians employ in the management of Barrett’s oesophagus in the UKWide disparity in surveillance for Barrett’s oesophagus.A recent UK study quoted £120 for each examination (£80 for endoscopy with £40 for historical assessment), giving a cost of about £49 000 per each detected cancerNo proper economic analysis. A prospective trial is needed to determine whether screening is beneficial
Mason et al614UK (2002)Markov model extrapolating results of an RCTn = 8407 in an RCTPopulation screening for gastric cancer using H pylori testing and eradicationCost difference overall favoured intervention group but did not reach statistical significance. Cost difference was statistically significant for men. For women there was no difference.Modelling estimated that population screening/eradication for population of one million 45 year olds would save £6m and 1300 life years. Cost for each life year saved was £14 200, which is good value for moneyVery useful subject to usual caveats about modelling, but the “base case” (producing figures in the previous column) was conservative—that is, a lower limit of 95% CI for cost savings and only 10% efficacy of H pylori eradication in reducing mortality from distal gastric cancer and peptic ulcer disease
Duncan616UK (1992)Case study9 PatientsThe importance of identifying self induced diarrhoea by self administration of laxativesFor eight patients in whom the diagnosis was unsuspected, an average of £2807 (range £60–10 709) was spent on investigations, which would have been avoided had an early laxative screening been performed. In comparison, the cost of performing a laxative screen on all patients presenting with diarrhoea can be estimated at £600 for each laxative abuser identified (assuming a prevalence of 4% and a laxative screen cost of £24).The economic analysis is not fully described
Roderick et al779UK (2002)A discrete event simulation modelNATo evaluate the cost effectiveness of population screening for H pyloriThe cost/life years saved (LYS) at age of 40 was £5860 at a discount of 6%. The outcomes were sensitive to H pylori prevalence, the degree of opportunistic eradication, the discount rate, the efficacy of eradication on gastric cancer risk, the risk of complicated peptic ulcer disease and gastric cancer associated with H pylori infection, and the duration of follow-up. In sensitivity analysis the cost/LYS rarely exceeded £20 000 over an 80 year follow-up, but did for shorter periods.Two critical determinants of cost effectiveness are time horizon and discount rate. Screening does not become cost effective for several decades, which largely reflects the long duration between the age of screening and the incidence of gastric cancer. A lower discount rate for benefits makes screening appear more cost effectiveA very good study