title: An economic evaluation of colorectal cancer screening in primary care practice.
abstract: BACKGROUND
  Recent colorectal cancer screening studies focus on optimizing adherence. This study evaluated the cost effectiveness of interventions using electronic health records (EHRs); automated mailings; and stepped support increases to improve 2-year colorectal cancer screening adherence.
  
  
  METHODS
  Analyses were based on a parallel-design, randomized trial in which three stepped interventions (EHR-linked mailings ["automated"]; automated plus telephone assistance ["assisted"]; or automated and assisted plus nurse navigation to testing completion or refusal [navigated"]) were compared to usual care. Data were from August 2008 to November 2011, with analyses performed during 2012-2013. Implementation resources were micro-costed; research and registry development costs were excluded. Incremental cost-effectiveness ratios (ICERs) were based on number of participants current for screening per guidelines over 2 years. Bootstrapping examined robustness of results.
  
  
  RESULTS
  Intervention delivery cost per participant current for screening ranged from $21 (automated) to $27 (navigated). Inclusion of induced testing costs (e.g., screening colonoscopy) lowered expenditures for automated (ICER=-$159) and assisted (ICER=-$36) relative to usual care over 2 years. Savings arose from increased fecal occult blood testing, substituting for more expensive colonoscopies in usual care. Results were broadly consistent across demographic subgroups. More intensive interventions were consistently likely to be cost effective relative to less intensive interventions, with willingness to pay values of $600-$1,200 for an additional person current for screening yielding ≥80% probability of cost effectiveness.
  
  
  CONCLUSIONS
  Two-year cost effectiveness of a stepped approach to colorectal cancer screening promotion based on EHR data is indicated, but longer-term cost effectiveness requires further study.
authors.affiliation: Kaiser Permanente Center for Health Research, Portland, Oregon. Electronic address: richard.meenan@kpchr.org.
authors.forename: Richard T
authors.initials: RT
authors.lastname: Meenan
authors.affiliation: Group Health Research Institute, Seattle, Washington.
authors.forename: Melissa L
authors.initials: ML
authors.lastname: Anderson
authors.affiliation: Group Health Research Institute, Seattle, Washington.
authors.forename: Jessica
authors.initials: J
authors.lastname: Chubak
authors.affiliation: University of Texas School of Public Health, Houston, Texas.
authors.forename: Sally W
authors.initials: SW
authors.lastname: Vernon
authors.affiliation: Group Health Research Institute, Seattle, Washington.
authors.forename: Sharon
authors.initials: S
authors.lastname: Fuller
authors.affiliation: Fred Hutchinson Cancer Research Center, Seattle, Washington.
authors.forename: Ching-Yun
authors.initials: CY
authors.lastname: Wang
authors.affiliation: Group Health Research Institute, Seattle, Washington.
authors.forename: Beverly B
authors.initials: BB
authors.lastname: Green
mesh_terms: D000368:Aged; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer / Q000191:economics*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008403:Mass Screening / Q000191:economics*; D008875:Middle Aged; D009780:Occult Blood; D011320:Primary Health Care; D017010:Reminder Systems