Expanding CRC screening: Understanding the options and the costs to providers

1. Expanding CRC screening: Understanding the options and the costs to providers Paul Brown Kelly Kohler University of North Carolina

2. Two types of studies 1. Effectiveness/Cost effectiveness • Addresses the question Should we screen for CRC and, if so, with what modality? • Example: • 2002 review of colorectal cancer screening • Cost effective • $10,000 to $25,000 per life year gain • Conclusion • Colorectal cancer screening with FOBT should be undertaken

3. 2. Micro-level costing study • Addresses the question How should we screen and what does it cost to screen? • Focus on screening process • Recruitment, testing, relaying results, etc

4. CRC Screening Program Overview Registry, EHRs, media ads, awareness campaigns Reminder letters, phone calls, Dr visits, etc. Phone calls, follow-up appointments, endoscopy referrals, case manager FOBT, colonoscopy, etc.

5. Costing study • Question is not “Should we screen”? • Question is “Should we increase our current efforts?” • Relevant to the providers in the US • Most already doing some type of screening • Question • What will it cost us to increase our efforts? • What will the benefit be?

6. Issues • Not looking at the total cost • Interested in marginal (additional) cost • Actual expenditures not needed • Not an ‘audit’ of expenditures • Identify resources • Unit costs • Overheads • “What cost could other providers expect to incur?” • Sensitivity analysis • Explore robustness of results to assumptions or areas of uncertainty

7. Example – Colorectal cancer screening (Lewis et al, 2008) • Issue: • People not coming in for regular CRC screening • Context • Hospital clinic with records of patients • Can access records, identify who is not up-to-date • Intervention • Send letter signed by provider • Include decision aid (video tape) • Follow up phone calls to schedule appointment

8. Effectiveness • 137 patients • identified from database as being eligible but not current for screening • Sent materials • 97 followed up with phone call • 55 contacted • Final numbers screened • 20/137 intervention (15%) • 4/100 control group (4%)

9. Is the program “worth it?” • Is the program effective? • Yes • Improved screening rates is good • Will the clinic continue with the program? • “Will the clinic be willing to pay for the program?”

10. Cost of program

11. Is the program “worth it?” • Society • $206 per person screened • Look at benefit of having an additional person screened • Prob of getting preventing CR • Cost and benefit from getting CRC • Etc. • Organization • Unlikely to realize long term benefits • Net Revenue will depend upon • Effectiveness • Reimbursement • Etc.

12. Net revenue – Each program

13. Comparing programs

14. Motivation for costing study • “How much will it cost to expand screening beyond our current efforts?” • “What do the results depend upon? Confidence?” • Break-even/sensitivity analysis • Level of effectiveness that need to be reached • Level of reimbursement, • Etc.

15. Break even analysis

16. Motivation for costing study • If hospital medical directors care about costs… • Can help overcome financial barrier • Profits or budgets?