Determination of the appropriateness of an indication for colonoscopy has been advanced as a means to help rationalize the use of endoscopic resources.
However, the efficacy and cost effectiveness of the current guidelines used to select patients for colonoscopy are largely unknown.
Dr Cesare Hassan and colleagues from Italy assessed the clinical and economic impact of American Society for Gastrointestinal Endoscopy, and the European Panel on the appropriateness of Gastrointestinal Endoscopy appropriateness guidelines.
The team evaluated the effectiveness of these guidelines in selecting patients who are referred for colonoscopy, in relation to colorectal cancer detection.
The team constructed a decision-analysis model to compare colonoscopy strategies for ‘appropriate’ indications with those for which colonoscopy is deemed ‘inappropriate’ or ‘generally not indicated’.
A 50% cancer upstaging was modeled to simulate cancer progression for patients not referred for colonoscopy.
|Cost-effectiveness ratios for colonoscopies was $6154 per life-year gained|
|Clinical Gastroenterology & Hepatology |
Colorectal cancer prevalence was estimated using a pooled data analysis based on a systematic review of the literature.
The research team estimated costs of colonoscopy and cancer care from Medicare reimbursement data.
The number of colonoscopies needed to detect one case of cancer, and to prevent one cancer-related death were computed.
In addition the team computed incremental cost-effectiveness ratios according to appropriateness categories, in a simulated population of patients that were 60 years of age and referred for colonoscopy.
The researchers found that the numbers of appropriate and inappropriate colonoscopies that needed to be performed to detect one patient with cancer were 18 and 93, respectively.
Similarly, the team noted that 115 and 617 colonoscopies would be needed, respectively, to prevent one colorectal cancer-related death.
The incremental cost-effectiveness ratios for appropriate and inappropriate colonoscopies, compared with a policy of not referring patients to colonoscopy, was $6154 and $31,807 per life-year gained, respectively.
In a sensitivity analysis, only a reduction from the baseline value of 1% to 0.2% was associated with an incremental cost-effectiveness ratios for inappropriate colonoscopy higher than $150,000.
Dr Hassan’s team concluded, “Current guidelines regarding the appropriateness of colonoscopy are relatively inefficient in excluding a clinically meaningful colorectal cancer risk for patients in whom colonoscopy is generally not indicated.”
“This raises serious concerns about their applicability to clinical practice.”