Initial evaluation of rectal bleeding in young persons: a cost-effectiveness analysis.
BACKGROUND
Evaluation of rectal bleeding in young patients is a frequent diagnostic challenge.


OBJECTIVE
To determine the relative cost-effectiveness of alternative diagnostic strategies for young patients with rectal bleeding.


METHODS
Cost-effectiveness analysis using a Markov model.


METHODS
Probability estimates were based on published medical literature. Cost estimates were based on Medicare reimbursement rates and published medical literature.


METHODS
Persons 25 to 45 years of age with otherwise asymptomatic rectal bleeding.


METHODS
The patient's lifetime.


CONCLUSIONS
Modified societal perspective.


METHODS
Diagnostic strategies included no evaluation, colonoscopy, flexible sigmoidoscopy, barium enema, anoscopy, or any feasible combination of these procedures.


METHODS
Life expectancy and costs.


RESULTS
For 35-year-old patients, the no-evaluation strategy yielded the least life expectancy. The incremental cost-effectiveness of flexible sigmoidoscopy compared with no evaluation or with any strategy incorporating anoscopy (followed by further evaluation if no anal disease was found on anoscopy) was less than $5300 per year of life gained. A strategy of flexible sigmoidoscopy plus barium enema yielded the greatest life expectancy, with an incremental cost of $23 918 per additional life-year gained compared with flexible sigmoidoscopy alone.


RESULTS
As patient age at presentation of rectal bleeding increased, evaluation of the entire colon became more cost-effective. The incremental cost-effectiveness of flexible sigmoidoscopy plus barium enema compared with colonoscopy was sensitive to estimates of the sensitivity of the tests. In a probabilistic sensitivity analysis comparing flexible sigmoidoscopy with anoscopy followed by flexible sigmoidoscopy if needed, the middle 95th percentile of the distribution of the incremental cost-effectiveness ratios ranged from flexible sigmoidoscopy yielding an increased life expectancy at reduced cost to $52 158 per year of life gained (mean, $11 461 per year of life saved).


CONCLUSIONS
Evaluation of the colon of persons 25 to 45 years of age with otherwise asymptomatic rectal bleeding increases the life expectancy at a cost comparable to that of colon cancer screening.
Lewis
James D
JD
Center for Clinical Epidemiology and Biostatistics, Blockley Hall, 9th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
Brown
Alphonso
A
Localio
A Russell
AR
Schwartz
J Sanford
JS
D000328:Adult; D000367:Age Factors; D001003:Anal Canal; D001466:Barium Sulfate; D003113:Colonoscopy / Q000191:economics; D015179:Colorectal Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000191:economics; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D016099:Endoscopy, Gastrointestinal / Q000191:economics*; D004733:Enema / Q000191:economics*; D006471:Gastrointestinal Hemorrhage / Q000191:economics / Q000209:etiology*; D006801:Humans; D008017:Life Expectancy; D008390:Markov Chains; D008875:Middle Aged; D012002:Rectal Diseases / Q000191:economics / Q000209:etiology*; D012680:Sensitivity and Specificity; D012812:Sigmoidoscopy / Q000191:economics
D001466:Barium Sulfate