title: Cost-Effectiveness Analysis of Four Simulated Colorectal Cancer Screening Interventions, North Carolina.
abstract: Colorectal cancer (CRC) screening rates are suboptimal, particularly among the uninsured and the under-insured and among rural and African American populations. Little guidance is available for state-level decision makers to use to prioritize investment in evidence-based interventions to improve their population's health. The objective of this study was to demonstrate use of a simulation model that incorporates synthetic census data and claims-based statistical models to project screening behavior in North Carolina.
  
  
  
  We used individual-based modeling to simulate and compare intervention costs and results under 4 evidence-based and stakeholder-informed intervention scenarios for a 10-year intervention window, from January 1, 2014, through December 31, 2023. We compared the proportion of people living in North Carolina who were aged 50 to 75 years at some point during the window (that is, age-eligible for screening) who were up to date with CRC screening recommendations across intervention scenarios, both overall and among groups with documented disparities in receipt of screening.
  
  
  
  We estimated that the costs of the 4 intervention scenarios considered would range from $1.6 million to $3.75 million. Our model showed that mailed reminders for Medicaid enrollees, mass media campaigns targeting African Americans, and colonoscopy vouchers for the uninsured reduced disparities in receipt of screening by 2023, but produced only small increases in overall screening rates (0.2-0.5 percentage-point increases in the percentage of age-eligible adults who were up to date with CRC screening recommendations). Increased screenings ranged from 41,709 additional life-years up to date with screening for the voucher intervention to 145,821 for the mass media intervention. Reminders mailed to Medicaid enrollees and the mass media campaign for African Americans were the most cost-effective interventions, with costs per additional life-year up to date with screening of $25 or less. The intervention expanding the number of endoscopy facilities cost more than the other 3 interventions and was less effective in increasing CRC screening.
  
  
  
  Cost-effective CRC screening interventions targeting observed disparities are available, but substantial investment (more than $3.75 million) and additional approaches beyond those considered here are required to realize greater increases population-wide.
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg, Campus Box 7411, Chapel Hill, NC 27599. Email: klich@unc.edu.
authors.forename: Kristen
authors.initials: K
authors.lastname: Hassmiller Lich
authors.affiliation: Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina.
authors.forename: David A
authors.initials: DA
authors.lastname: Cornejo
authors.affiliation: Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina.
authors.forename: Maria E
authors.initials: ME
authors.lastname: Mayorga
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Michael
authors.initials: M
authors.lastname: Pignone
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Florence K L
authors.initials: FK
authors.lastname: Tangka
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Lisa C
authors.initials: LC
authors.lastname: Richardson
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Tzy-Mey
authors.initials: TM
authors.lastname: Kuo
authors.affiliation: Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill North Carolina.
authors.forename: Anne-Marie
authors.initials: AM
authors.lastname: Meyer
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Ingrid J
authors.initials: IJ
authors.lastname: Hall
authors.affiliation: Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Judith Lee
authors.initials: JL
authors.lastname: Smith
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Todd A
authors.initials: TA
authors.lastname: Durham
authors.affiliation: Renaissance Computing Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Chall
authors.affiliation: Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Trisha M
authors.initials: TM
authors.lastname: Crutchfield
authors.affiliation: Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.|Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
authors.forename: Stephanie B
authors.initials: SB
authors.lastname: Wheeler
mesh_terms: D000368:Aged; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000453:epidemiology*; D003198:Computer Simulation; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000191:economics / Q000379:methods; D008875:Middle Aged; D009657:North Carolina; D012307:Risk Factors