Abstract
Three studies report estimates of the cost and effectiveness of alternate strategies for screening the average-risk Australian population for colorectal cancer. The options considered are faecal occult blood testing, double contrast barium enema, sigmoidoscopy and colonoscopy. At present, there is no consensus over which screening method is optimal by the economic criterion. Also, the existing studies report a mixture of average and incremental cost-effectiveness ratios derived from data collected between 1994 and 2002. We suggest average cost-effectiveness ratios are not useful for decision-making and illustrate how they differ from the preferred incremental cost-effectiveness ratio. We then update the cost data reported in the three studies to 2002 prices and calculate incremental cost-effectiveness ratios where not previously available. Our re-analysis of one study contradicts the conclusions drawn by the authors, who had only calculated average cost-effectiveness ratios. In particular, we find their recommendation of population screening with colonoscopy would cause, annually, between 33 and 1,322 years of life to be lost and between $M17 and $M87 to be wasted. Based on updated cost data and the incremental analysis, our findings indicate that population screening using biennial faecal occult blood testing ($39,459 per life-year gained), annual faecal occult blood testing ($30,556 per life-year gained) and colonoscopy ($26,587 per life-year gained) are cost-effective. Hence, the decision over which method of screening is optimal remains ambiguous across the three studies. We recommend policy-makers choose the study they believe produces the most accurate estimates of cost and health effect, identify their willingness to pay for health benefits and consider other issues relevant to the decision.
Highlights
In 1996, Salkeld et al [1] found that screening the average-risk Australian population for colorectal cancer using a faecal occult blood test (FOBT), compared to existing practice, would cost $24,660 per life-year gained (LYG)
Australia and New Zealand Health Policy 2005, 2:10 http://www.anzhealthpolicy.com/content/2/1/10 per life-year gained between £1,371–£5,685 and the analysis of the Danish trial data [5] suggest a cost per life-year gained between 17,000–42,000DKK
In 1997, he asked whether the time had come to use colonoscopy for population screening in Australia [8]
Summary
In 1996, Salkeld et al [1] found that screening the average-risk Australian population for colorectal cancer using a faecal occult blood test (FOBT), compared to existing practice, would cost $24,660 per life-year gained (LYG). We have four objectives in this paper: first, to demonstrate why incremental, not average, cost-effectiveness ratios should be used for decision-making; second, to update the cost data reported by Salkeld et al [1], Bolin et al [10] and O'Leary et al [17] to 2002 Australian dollar prices; third, to calculate incremental cost-effectiveness ratios from the Bolin data; and fourth, to discuss the results of our re-analysis, comparing the outcomes from the three previous studies This will provide readers with an up-todate and appropriate assessment of the existing cost-effectiveness data for population-based CRC screening programmes in Australia. The incremental cost-effectiveness ratio derived from the Salkeld data, in 2002 prices, for FOBT, is $30,556 per LYG, and the 2002 incremental cost-effectiveness ratios These results define the screening options that are preferred (ie, not dominated), by the measure of cost-effectiveness, for population-based CRC screening in Australia. The decision over which to choose depends on additional factors that we discuss
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