Fisher Judith A, Fikry Christopher, Troxel Andrea B
Department of Family Practice and Community Medicine, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA.
Cancer Epidemiol Biomarkers Prev. 2006 Jan;15(1):108-13. doi: 10.1158/1055-9965.EPI-05-0198.
Through medical decision making, physicians in the U.S. influence the spending of >$1.3 trillion or 15% of the gross domestic product. U.S. physicians are challenged to identify areas of clinical practice to improve while cutting cost and increasing access. Primary screening for colorectal cancer is a good example to illustrate this point.
To apply a population-based method of medical decision making in the area of primary screening for colorectal cancer in order to illustrate a reduction in health care costs while increasing access and maintaining quality of care.
We used a combination of (a) census population data, (b) National Cancer Institute Survey data on screening rates, and (c) charge data to estimate the current costs of colorectal cancer screening. We also estimated cost and capacity increases that would occur under various other screening scenarios. These included all currently screened subjects receiving annual fecal occult blood testing (FOBT), all currently unscreened individuals undergoing either colonoscopy every decade or annual FOBT, and all eligible subjects undergoing annual FOBT.
Cost and access differences between current screening activity and other potential scenarios compliant with guidelines.
Screening for colorectal cancer with yearly, six-window, rehydrated FOBT for all normal-risk individuals over the age of 50 has the potential to screen 3,813,095 more Americans for colon cancer yearly than are currently being screened, while costing $8.7 billion less per decade than what is currently being spent on screening a fraction of the population. Looking into the future, it is possible to increase screening rates from 50% to 100%, while saving almost $10 billion per decade by using FOBT for all eligible Americans. In practice, some proportion of these benefits would be realized as the calculations assume a 100% patient compliance rate.
Considering a population-based approach and the balance among quality, accessibility, and cost parameters, we recommend primary screening for colorectal cancer to be based on yearly six-window, rehydrated FOBT. Colonoscopy due to cost and access issues should be relegated to secondary screening and case finding.
通过医疗决策，美国医生影响着超过1.3万亿美元的支出，占国内生产总值的15%。美国医生面临着识别临床实践中需要改进的领域的挑战，同时还要削减成本并增加医疗服务可及性。结直肠癌的初级筛查就是一个很好的例子来说明这一点。
在结直肠癌初级筛查领域应用基于人群的医疗决策方法，以说明在增加医疗服务可及性并维持医疗质量的同时降低医疗成本。
我们结合了（a）人口普查数据、（b）美国国立癌症研究所关于筛查率的调查数据以及（c）收费数据来估计结直肠癌筛查的当前成本。我们还估计了在各种其他筛查方案下会出现的成本和能力增加情况。这些方案包括所有目前接受筛查的受试者每年进行粪便潜血试验（FOBT），所有目前未接受筛查的个体每十年进行一次结肠镜检查或每年进行FOBT，以及所有符合条件的受试者每年进行FOBT。
当前筛查活动与其他符合指南的潜在方案之间的成本和可及性差异。
对所有50岁以上正常风险个体每年进行六窗口复水FOBT筛查结直肠癌，每年有可能比目前多筛查3,813,095名美国人患结肠癌的情况，同时每十年花费比目前用于筛查部分人群的费用少87亿美元。展望未来，通过对所有符合条件的美国人使用FOBT，有可能将筛查率从50%提高到100%，同时每十年节省近100亿美元。在实际中，由于计算假设患者依从率为100%，这些益处的一部分将得以实现。
考虑到基于人群的方法以及质量、可及性和成本参数之间的平衡，我们建议结直肠癌的初级筛查应基于每年六窗口复水FOBT。由于成本和可及性问题，结肠镜检查应作为二级筛查和病例发现手段。
