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Original Investigation |

The Appropriateness of More Intensive Colonoscopy Screening Than Recommended in Medicare Beneficiaries:  A Modeling Study ONLINE FIRST

Frank van Hees, MSc1; Ann G. Zauber, PhD2; Carrie N. Klabunde, PhD3; S. Luuk Goede, MSc1; Iris Lansdorp-Vogelaar, PhD1; Marjolein van Ballegooijen, MD, PhD1
[+] Author Affiliations
1Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
2Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
3Health Services and Economics Branch, Applied Research Program, National Cancer Institute, Bethesda, Maryland
JAMA Intern Med. Published online August 18, 2014. doi:10.1001/jamainternmed.2014.3889
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Importance  Many Medicare beneficiaries undergo more intensive colonoscopy screening than recommended. Whether this is favorable for beneficiaries and efficient from a societal perspective is uncertain.

Objective  To determine whether more intensive colonoscopy screening than recommended is favorable for Medicare beneficiaries (ie, whether it results in a net health benefit) and whether it is efficient from a societal perspective (ie, whether the net health benefit justifies the additional resources required).

Design, Setting, and Participants  Microsimulation modeling study of 65-year-old Medicare beneficiaries at average risk for colorectal cancer (CRC) and with an average life expectancy who underwent a screening colonoscopy at 55 years with negative results.

Interventions  Colonoscopy screening as recommended by guidelines (ie, at 65 and 75 years) vs scenarios with a shorter screening interval (5 or 3 instead of 10 years) or in which screening was continued to 85 or 95 years.

Main Outcomes and Measures  Quality-adjusted life-years (QALYs) gained (measure of net health benefit); additional colonoscopies required per additional QALY gained and additional costs per additional QALY gained (measures of efficiency).

Results  Screening previously screened Medicare beneficiaries more intensively than recommended resulted in only small increases in CRC deaths prevented and life-years gained. In comparison, the increases in colonoscopies performed and colonoscopy-related complications experienced were large. As a result, all scenarios of more intensive screening than recommended resulted in a loss of QALYs, rather than a gain (ie, a net harm). The only exception was shortening the screening interval from 10 to 5 years, which resulted in 0.7 QALYs gained per 1000 beneficiaries. However, this scenario was inefficient because it required no less than 909 additional colonoscopies and an additional $711 000 per additional QALY gained. Results in previously unscreened beneficiaries were slightly less unfavorable, but conclusions were identical.

Conclusions and Relevance  Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often it is also unfavorable for those being screened. This study provides evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.

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Figure 1.
Model Inputs: Age-Specific Risks for Complications Associated With Colonoscopies With Polypectomy

Derived by performing additional statistical analyses on Medicare data used in a study by Warren et al16 (eAppendix 2 in the Supplement). Only complications necessitating hospitalization or an emergency department visit were considered.

aPerforations, gastrointestinal bleeding, or complications necessitating transfusions; risk per colonoscopy = 1/[exp(9.27953 − 0.06105 × Age) + 1] − 1/[exp(10.78719 − 0.06105 × Age) + 1].

bParalytic ileus, nausea and vomiting, dehydration, abdominal pain; risk per colonoscopy = 1/[exp(8.81404 − 0.05903 × Age) + 1] − 1/[exp(9.61197 − 0.05903 × Age) + 1].

cMyocardial infarction or angina, arrhythmias, congestive heart failure, cardiac or respiratory arrest, syncope, hypotension, or shock; risk per colonoscopy = 1/[exp(9.09053 − 0.07056 × Age) + 1] − 1/[exp(9.38297 − 0.07056 × Age)+1].

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Figure 2.
Increases in Benefits, Burden, and Harms Associated With More Intensive Colonoscopy Screening Than Recommended in Medicare Beneficiaries With a Negative Screening Colonoscopy Result at 55 Years

A-D, Benefits; E and F, burden and harms. Numbers are per 1000 beneficiaries and undiscounted. CRC indicates colorectal cancer; LY, life-year.

aFor each scenario, the distribution of additional LYs with CRC care prevented over the different phases of care and stages of CRC is given in eAppendix 3 in the Supplement.

bOnly complications necessitating hospitalization or an emergency department visit were considered.

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