Lashner B A, Silverstein M D
Department of Medicine, University of Chicago Medical Center.
Am J Gastroenterol. 1990 Sep;85(9):1088-95.
We performed a decision analysis to evaluate cost per cancer detected, cost per neoplasm detected, and cost per treatable lesion of two common diagnostic strategies, barium enema-proctoscopy or colonoscopy as the first diagnostic test, for patients with fecal occult blood loss. The prevalence of polyps, cancer, and angiodysplasia, and the colonoscopy success rate were obtained from consecutive colonoscopy records. Costs were estimated from hospital charges; sensitivity and specificity of barium enema and colonoscopy were obtained from the literature. For treatable lesions (cancer, polyps, and angiodysplasia), the colonoscopy first strategy had a higher sensitivity (80% vs. 57%) and a higher specificity (95% vs. 80%) than the barium enema first strategy. Cost effectiveness measures were similar for the two strategies. Colonoscopy as the first diagnostic test had a lower cost per treatable lesion ($2,319 vs. $2,895) and a lower cost per neoplasm detected ($2,694 vs. $2,896), whereas the barium enema first strategy had a lower cost per cancer detected ($10,050 vs. $10,297). The lower cost per treatable lesion of the colonoscopy first strategy was not affected by changes in the prevalence of lesions, test characteristics, costs of tests, or colonoscopy success rate over clinically relevant ranges. The higher cost of colonoscopy was offset by its greater sensitivity and its capacity for biopsy and therapy. Therefore, since the cost per treatable lesion is lower and the sensitivity, specificity, and predictive value is superior, colonoscopy is recommended as the preferred initial test in evaluating a patient with fecal occult blood loss.
我们进行了一项决策分析，以评估两种常见诊断策略（以钡剂灌肠 - 直肠镜检查或结肠镜检查作为首次诊断测试）对粪便潜血患者每检测到一例癌症、每检测到一例肿瘤以及每一个可治疗病变的成本。息肉、癌症和血管发育异常的患病率以及结肠镜检查成功率来自连续的结肠镜检查记录。成本根据医院收费估算；钡剂灌肠和结肠镜检查的敏感性和特异性来自文献。对于可治疗病变（癌症、息肉和血管发育异常），先进行结肠镜检查的策略比先进行钡剂灌肠的策略具有更高的敏感性（80%对57%）和更高的特异性（95%对80%）。两种策略的成本效益指标相似。作为首次诊断测试，结肠镜检查每一个可治疗病变的成本更低（2319美元对2895美元），每检测到一例肿瘤的成本更低（2694美元对2896美元），而先进行钡剂灌肠的策略每检测到一例癌症的成本更低（10050美元对10297美元）。先进行结肠镜检查的策略每一个可治疗病变的较低成本不受病变患病率、检测特征、检测成本或结肠镜检查成功率在临床相关范围内变化的影响。结肠镜检查较高的成本被其更高的敏感性以及活检和治疗能力所抵消。因此，由于每一个可治疗病变的成本更低，且敏感性、特异性和预测价值更高，所以建议将结肠镜检查作为评估粪便潜血患者的首选初始检查。
