title: Initial evaluation of rectal bleeding in young persons: a cost-effectiveness analysis.
abstract: 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.
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Blockley Hall, 9th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
authors.forename: James D
authors.initials: JD
authors.lastname: Lewis
authors.forename: Alphonso
authors.initials: A
authors.lastname: Brown
authors.forename: A Russell
authors.initials: AR
authors.lastname: Localio
authors.forename: J Sanford
authors.initials: JS
authors.lastname: Schwartz
mesh_terms: 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
chemical_list: D001466:Barium Sulfate