title: Cutting cost and increasing access to colorectal cancer screening: another approach to following the guidelines.
abstract: BACKGROUND
  Through medical decision making, physicians in the U.S. influence the spending of >$1.3 trillion or 15% of the gross domestic product. U.S. physicians are challenged to identify areas of clinical practice to improve while cutting cost and increasing access. Primary screening for colorectal cancer is a good example to illustrate this point.
  
  
  OBJECTIVE
  To apply a population-based method of medical decision making in the area of primary screening for colorectal cancer in order to illustrate a reduction in health care costs while increasing access and maintaining quality of care.
  
  
  METHODS
  We used a combination of (a) census population data, (b) National Cancer Institute Survey data on screening rates, and (c) charge data to estimate the current costs of colorectal cancer screening. We also estimated cost and capacity increases that would occur under various other screening scenarios. These included all currently screened subjects receiving annual fecal occult blood testing (FOBT), all currently unscreened individuals undergoing either colonoscopy every decade or annual FOBT, and all eligible subjects undergoing annual FOBT.
  
  
  METHODS
  Cost and access differences between current screening activity and other potential scenarios compliant with guidelines.
  
  
  RESULTS
  Screening for colorectal cancer with yearly, six-window, rehydrated FOBT for all normal-risk individuals over the age of 50 has the potential to screen 3,813,095 more Americans for colon cancer yearly than are currently being screened, while costing $8.7 billion less per decade than what is currently being spent on screening a fraction of the population. Looking into the future, it is possible to increase screening rates from 50% to 100%, while saving almost $10 billion per decade by using FOBT for all eligible Americans. In practice, some proportion of these benefits would be realized as the calculations assume a 100% patient compliance rate.
  
  
  CONCLUSIONS
  Considering a population-based approach and the balance among quality, accessibility, and cost parameters, we recommend primary screening for colorectal cancer to be based on yearly six-window, rehydrated FOBT. Colonoscopy due to cost and access issues should be relegated to secondary screening and case finding.
authors.affiliation: Department of Family Practice and Community Medicine, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA. Judith.Fisher@uphs.upenn.edu
authors.forename: Judith A
authors.initials: JA
authors.lastname: Fisher
authors.forename: Christopher
authors.initials: C
authors.lastname: Fikry
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Troxel
mesh_terms: D003113:Colonoscopy / Q000191:economics; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000191:economics; D003362:Cost-Benefit Analysis; D019983:Guideline Adherence / Q000191:economics*; D006801:Humans; D008403:Mass Screening / Q000191:economics* / Q000379:methods; D009780:Occult Blood; D010349:Patient Compliance; D017410:Practice Guidelines as Topic; D012680:Sensitivity and Specificity; D012812:Sigmoidoscopy / Q000191:economics