Meenan Richard T, Anderson Melissa L, Chubak Jessica, Vernon Sally W, Fuller Sharon, Wang Ching-Yun, Green Beverly B
Kaiser Permanente Center for Health Research, Portland, Oregon.
Group Health Research Institute, Seattle, Washington.
Am J Prev Med. 2015 Jun;48(6):714-21. doi: 10.1016/j.amepre.2014.12.016.
Recent colorectal cancer screening studies focus on optimizing adherence. This study evaluated the cost effectiveness of interventions using electronic health records (EHRs); automated mailings; and stepped support increases to improve 2-year colorectal cancer screening adherence.
Analyses were based on a parallel-design, randomized trial in which three stepped interventions (EHR-linked mailings ["automated"]; automated plus telephone assistance ["assisted"]; or automated and assisted plus nurse navigation to testing completion or refusal [navigated"]) were compared to usual care. Data were from August 2008 to November 2011, with analyses performed during 2012-2013. Implementation resources were micro-costed; research and registry development costs were excluded. Incremental cost-effectiveness ratios (ICERs) were based on number of participants current for screening per guidelines over 2 years. Bootstrapping examined robustness of results.
Intervention delivery cost per participant current for screening ranged from $21 (automated) to $27 (navigated). Inclusion of induced testing costs (e.g., screening colonoscopy) lowered expenditures for automated (ICER=-$159) and assisted (ICER=-$36) relative to usual care over 2 years. Savings arose from increased fecal occult blood testing, substituting for more expensive colonoscopies in usual care. Results were broadly consistent across demographic subgroups. More intensive interventions were consistently likely to be cost effective relative to less intensive interventions, with willingness to pay values of $600-$1,200 for an additional person current for screening yielding ≥80% probability of cost effectiveness.
Two-year cost effectiveness of a stepped approach to colorectal cancer screening promotion based on EHR data is indicated, but longer-term cost effectiveness requires further study.
近期的结直肠癌筛查研究聚焦于优化筛查依从性。本研究评估了利用电子健康记录（EHR）、自动邮件发送以及逐步增加支持措施以提高两年期结直肠癌筛查依从性的干预措施的成本效益。
分析基于一项平行设计的随机试验，其中将三种逐步干预措施（与EHR关联的邮件发送["自动"]；自动邮件发送加电话协助["协助"]；或自动邮件发送、协助加护士引导直至完成检查或拒绝检查["引导"]）与常规护理进行比较。数据收集时间为2008年8月至2011年11月，分析在2012 - 2013年期间进行。实施资源按微观成本计算；研究和登记系统开发成本被排除在外。增量成本效益比（ICER）基于两年内按照指南进行筛查的参与者人数。自抽样法检验了结果的稳健性。
每名参与筛查的参与者的干预实施成本从21美元（自动）到27美元（引导）不等。纳入诱导检测成本（如筛查结肠镜检查）后，相对于常规护理，自动干预（ICER = - 159美元）和协助干预（ICER = - 36美元）在两年内的支出有所降低。粪便潜血检测增加带来了节省，取代了常规护理中更昂贵的结肠镜检查。结果在各人口亚组中大致一致。与强度较低的干预措施相比，强度更大的干预措施始终更有可能具有成本效益，对于每增加一名进行筛查的人，支付意愿值为600 - 1200美元时，成本效益的概率≥80%。
基于EHR数据的逐步推进结直肠癌筛查方法在两年内具有成本效益，但长期成本效益需要进一步研究。
