The evaluation of rectal bleeding in adults: A cost-effectiveness analysis comparing four diagnostic strategies

Elizabeth Allen, Christina Nicolaidis, Mark Helfand

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

BACKGROUND: Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown. OBJECTIVE: To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding. DESIGN: Cost-effectiveness analysis using a Markov decision model. DATA SOURCES: Systematic review of the literature. Medicare reimbursement data. Surveillance, Epidemiology, and End Results (SEER) Cancer Registry. TARGET POPULATION: Patients over age 40 with otherwise asymptomatic rectal bleeding. TIME HORIZON: The patient's lifetime. PERSPECTIVE: Modified societal perspective. INTERVENTIONS: Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy. OUTCOME MEASURES: Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was $5,480 per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy. RESULTS OF SENSITIVITY ANALYSES: The cost of colonoscopy was reduced to $1,686 per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7%, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above $34,000. CONCLUSIONS: Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.

Original languageEnglish (US)
Pages (from-to)81-90
Number of pages10
JournalJournal of General Internal Medicine
Volume20
Issue number1
DOIs
StatePublished - Jan 2005

Fingerprint

Colonoscopy
Cost-Benefit Analysis
Sigmoidoscopy
Quality-Adjusted Life Years
Watchful Waiting
Hemorrhage
Costs and Cost Analysis
Medicare
Polyps
Life Expectancy
Registries
Primary Health Care
Epidemiology
Air
Neoplasms

Keywords

  • Colorectal cancer
  • Cost-effectiveness analysis
  • Diagnosis
  • Hematochezia
  • Rectal bleeding

ASJC Scopus subject areas

  • Internal Medicine

Cite this

The evaluation of rectal bleeding in adults : A cost-effectiveness analysis comparing four diagnostic strategies. / Allen, Elizabeth; Nicolaidis, Christina; Helfand, Mark.

In: Journal of General Internal Medicine, Vol. 20, No. 1, 01.2005, p. 81-90.

Research output: Contribution to journalArticle

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abstract = "BACKGROUND: Though primary care patients commonly present with rectal bleeding, the optimal evaluation strategy remains unknown. OBJECTIVE: To compare the cost-effectiveness of four diagnostic strategies in the evaluation of rectal bleeding. DESIGN: Cost-effectiveness analysis using a Markov decision model. DATA SOURCES: Systematic review of the literature. Medicare reimbursement data. Surveillance, Epidemiology, and End Results (SEER) Cancer Registry. TARGET POPULATION: Patients over age 40 with otherwise asymptomatic rectal bleeding. TIME HORIZON: The patient's lifetime. PERSPECTIVE: Modified societal perspective. INTERVENTIONS: Watchful waiting, flexible sigmoidoscopy, flexible sigmoidoscopy followed by air contrast barium enema (FS+ACBE), and colonoscopy. OUTCOME MEASURES: Incremental cost-effectiveness ratio. RESULTS OF BASE-CASE ANALYSIS: The incremental cost-effectiveness ratio for colonoscopy compared with flexible sigmoidoscopy was $5,480 per quality-adjusted year of life saved (QALY). Watchful waiting and FS+ACBE were more expensive and less effective than colonoscopy. RESULTS OF SENSITIVITY ANALYSES: The cost of colonoscopy was reduced to $1,686 per QALY when age at entry was changed to 45. Watchful waiting became the least expensive strategy when community procedure charges replaced Medicare costs, when age at entry was maximized to 80, or when the prevalence of polyps was lowered to 7{\%}, but the remaining strategies provided greater life expectancy at relatively low cost. The strategy of FS+ACBE remained more expensive and less effective in all analyses. In the remaining sensitivity analyses, the incremental cost-effectiveness of colonoscopy compared with flexible sigmoidoscopy never rose above $34,000. CONCLUSIONS: Colonoscopy is a cost-effective method to evaluate otherwise asymptomatic rectal bleeding, with a low cost per QALY compared to other strategies.",
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