Monday, April 21
Grant Miller: Managerial Incentives in Public Service Delivery
Ladabaum, U., C.L. Chopra, G. Huang, J.M. Scheiman, Michael Chernew, and A. Mark Fendrick. 2001. "Aspirin as an Adjunct to Screening for Prevention of Sporadic Colorectal Cancer: A Cost-Effectiveness Analysis." Annals of Internal Medicine, 135(9): 769-781.
Background: Aspirin may decrease colorectal cancer incidence, but its role as an adjunct to or substitute for screening has not been evaluated.
Objective: To examine the potential cost-effectiveness of aspirin chemoprophylaxis in relation to screening.
Design: Markov model.
Data Sources: Literature on colorectal cancer epidemiology, screening, costs, and aspirin chemoprevention (1980–1999).
Target Population: General U.S. population.
Time Horizon: 50 to 80 years of age.
Perspective: Third-party payer.
Intervention: Aspirin therapy in patients screened with sigmoidoscopy every 5 years and fecal occult blood testing every year (FS/FOBT) or colonoscopy every 10 years (COLO).
Outcome Measures: Discounted cost per life-year gained.
Results of Base-Case Analysis: When a 30% reduction in colorectal cancer risk was assumed, aspirin increased costs and decreased life-years because of related complications as an adjunct to FS/FOBT and cost $149 161 per life-year gained as an adjunct to COLO. In patients already taking aspirin, screening with FS/FOBT or COLO cost less than $31 000 per life-year gained.
Results of Sensitivity Analysis: Cost-effectiveness estimates depended highly on the magnitude of colorectal cancer risk reduction with aspirin, aspirin-related complication rates, and the screening adherence rate in the population. However, when the model’s inputs were varied over wide ranges, aspirin chemoprophylaxis remained generally non–cost-effective for patients who adhere to screening.
Conclusions: In patients undergoing colorectal cancer screening, aspirin use should not be based on potential chemoprevention. Aspirin chemoprophylaxis alone cannot be considered a substitute for colorectal cancer screening. Public policy should focus on improving screening adherence, even in patients who are already taking aspirin.