title: Program-specific cost-effectiveness analysis: breast cancer screening policies for a safety-net program.
abstract: BACKGROUND
  Every Woman Counts (EWC), a California breast cancer screening program, faced challenging budget cutbacks and policy choices.
  
  
  METHODS
  A microsimulation model evaluated costs, outcomes, and cost-effectiveness of EWC program mammography policy options on coverage for digital mammography (which has a higher cost than film mammography but recent legislation allowed reimbursement at the lower film rate); screening eligibility age; and screening frequency. Model inputs were based on analyses of program claims data linked to California Cancer Registry data, Surveillance, Epidemiology, and End Results data, and the Medi-Cal literature. Outcomes included number of procedures, cancers, cancer deaths, costs, and incremental cost per life-year.
  
  
  RESULTS
  Projected model outcomes matched program data closely. With restrictions on the number of clients screened, strategies starting screening at age 40 years were dominated (not cost-effective). This finding was highly robust in sensitivity analyses. Compared with no screening, biennial film mammography for women aged 50 to 64 years was projected to reduce 15-year breast cancer mortality by nearly 7.8% at $18,999 per additional life-year, annual film mammography was $106,428 per additional life-year, and digital mammography $180,333 per additional life-year. This more effective, more expensive strategy was projected to reduce breast cancer mortality by 8.6%. Under equal mammography reimbursement, biennial digital mammography beginning at age 50 years was projected to decrease 15-year breast cancer mortality by 8.6% at an incremental cost per additional life-year of $17,050.
  
  
  CONCLUSIONS
  For the EWC program, biennial screening mammography starting at age 50 years was the most cost-effective strategy. The impact of digital mammography on life expectancy was small. Program-specific cost-effectiveness analysis can be completed in a policy-relevant time frame to assist policymakers faced with difficult program choices.
authors.affiliation: Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA. Electronic address: jamelnikow@ucdavis.edu.
authors.forename: Joy
authors.initials: J
authors.lastname: Melnikow
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Tancredi
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Yang
authors.forename: Dominique
authors.initials: D
authors.lastname: Ritley
authors.forename: Yun
authors.initials: Y
authors.lastname: Jiang
authors.forename: Christina
authors.initials: C
authors.lastname: Slee
authors.forename: Svetlana
authors.initials: S
authors.lastname: Popova
authors.forename: Phillip
authors.initials: P
authors.lastname: Rylett
authors.forename: Kirsten
authors.initials: K
authors.lastname: Knutson
authors.forename: Sherie
authors.initials: S
authors.lastname: Smalley
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000175:diagnosis*; D002140:California; D003362:Cost-Benefit Analysis; D005260:Female; D006291:Health Policy; D006297:Health Services Accessibility; D006801:Humans; D008403:Mass Screening / Q000191:economics* / Q000379:methods; D008875:Middle Aged; D008962:Models, Theoretical; D011203:Poverty; D012680:Sensitivity and Specificity
keywords: breast cancer screening; cost-effectiveness analysis; health policy; safety net programs