Quality of life in long term survivors of colorectal cancer

OBJECTIVES: We aimed to determine the quality of life (QOL) for long term survivors of colorectal cancer. METHODS: Persons with colorectal cancer who had survived at least 5 yr from diagnosis were recruited from a local cancer registry to answer questions about general QOL and colon cancer-specific issues. Before the general survey, focus group interviews with long term survivors were conducted to select survey questions from a pool of general and cancer-specific QOL questionnaires. The survey included the Health Utilities Index, the Center for Epidemiological Studies Depression Scale, and questions from the Short Form 36 and Functional Assessment of Cancer Therapy-Colorectal Cancer. After permission was obtained from their primary physicians, long term survivors from the registry were mailed invitation letters, then telephoned. Those agreeing were mailed self-administered questionnaires with stamped return envelopes. RESULTS: Two hundred twenty-seven respondents (average age = 74 yr, 46% female) completed the survey. Survivors reported a relatively uniform and high QOL, irrespective of stage at diagnosis and time from diagnosis. Non-cancer related comorbid conditions and low income status had more influence on overall QOL than initial stage of colorectal cancer or time since diagnosis. Compared to age-matched populations, long term survivors reported higher overall QOL, but had higher rates of depression. Sixteen percent reported three or more bowel movements a day; 49% reported chronic recurrent diarrhea. CONCLUSIONS: Those who achieve long term remission from colorectal cancer may experience a relatively high QOL, although physical symptoms such as diarrhea and depressive symptoms remain a problem.     

What is the most cost-effective strategy to screen for second primary colorectal cancers in male cancer survivors in Korea？

AIM： To identify a cost-effective strategy of second primary colorectal cancer （CRC） screening for cancer survivors in Korea using a decision-analytic model. METHODS： A Markov model estimated the clinical and economic consequences of a simulated 50-year- old male cancer survivors＇ cohort, and we compared the results of eight screening strategies： no screening, fecal occult blood test （FOBT） annually, FOBT every 2 years, sigmoidoscopy every 5 years, double contrast barium enema every 5 years, and colonoscopy every 10 years （COL10）, every 5 years （COL5）, and every 3 years （COL3）. We included only direct medical costs, and our main outcome measures were discounted lifetime costs, life expectancy, and incremental cost- effectiveness ratio （ICER）. RESULTS： In the base-case analysis, the non-dominat- ed strategies in cancer survivors were COL5, and COL3. The ICER for COL3 in cancer survivors was $5593/life- year saved （LYS）, and did not exceed $10000/LYS in one-way sensitivity analyses. If the risk of CRC in can- cer survivors is at least two times higher than that in the general population, COL5 had an ICER of less than $10500/LYS among both good and poor prognosis of index cancer. If the age of cancer survivors starting CRC screening was decreased to 40 years, the ICER of COL5 was tess than $7400/LYS regardless of screening compliance. CONCLUSION： Our study suggests that more strict and frequent recommendations for colonoscopy such as COL5 and COL3 could be considered as economically reasonable second primary CRC screening strategies for Korean male cancer survivors.     

The medical care cost of childhood and adolescent cancer in Manitoba, 1990-1995

The main purpose of this study is to estimate the medical care costs of childhood and adolescent cancer in Manitoba, and to determine the elements that influence these costs. Retrospective chart reviews were done to obtain all the information. A total of 118 childhood (age 0-14 years) and 41 adolescent (age 15-19 years) cancer patients were included. For childhood cancer, in-patient hospitalizations accounted for 59% of the total cost, followed by bone marrow transplant (BMT) (9%), medications (8%), laboratory investigations (7%) and physician fees (7%). For adolescent cancer, in-patient hospitalization accounted for 37% of the total cost, followed by bone marrow transplant (BMT) (25%), physicians' fees (11%), medications (9%) and laboratory investigations (7%). Overall, the average cost for the first, second and third year following diagnosis was $50,902 (median 35,708), $13,939 (4,127) and $6,769 (2,565) respectively for childhood cancer patients, and $57,354 (24,192), $16,888 (3,267) and $3,436 (3,267) respectively for adolescent cancer patients. Further work involving long-term data linkage of medical charts with hospital and clinic financial billing codes is needed to provide more accurate estimates of the costs of childhood and adolescent cancer care.     

Lifetime costs of colon and rectal cancer management in Canada

Colorectal cancer is the second leading cause of cancer-related mortality among Canadians. We derived the direct health care costs associated with the lifetime management of an estimated 16,856 patients with a diagnosis of colon and rectal cancer in Canada in 2000. Information on diagnostic approaches, treatment algorithms, follow-up and care at disease progression was obtained from various databases and was integrated into Statistics Canada's Population Health Model (POHEM) to estimate lifetime costs. The average lifetime cost (in Canadian dollars) of managing patients with colorectal cancer ranged from $20,319 per case for TNM stage I colon cancer to $39,182 per case for stage III rectal cancer. The total lifetime treatment cost for the cohort of patients in 2000 was estimated to be over $333 million for colon and $187 million for rectal cancer. Hospitalization represented 65% and 61% of the lifetime costs of colon and rectal cancer respectively. Disease costing models can be important policy- relevant tools to assist in resource allocation. Our results highlight the importance of performing preoperative tests and staging in an ambulatory care setting, where possible, to achieve optimal cost efficiencies. Similarly, terminal care might be delivered more efficiently in the home environment or in palliative care units.     

Modeling the lifetime costs of rheumatoid arthritis.

OBJECTIVE: To develop an analytical approach for estimating the lifetime costs of rheumatoid arthritis (RA) using existing population based cross sectional data, and to use this estimate to describe the potential cost-effectiveness of bone marrow transplantation for RA. METHODS: Estimates of arthritis related costs (direct, indirect, and nonmedical) and mortality were obtained from previously assembled population based cohorts. A mathematical model was designed defining 25 hypothetical ratios (RA/NA) representing the proportionate excess cost of RA each year for the 25 years following a diagnosis of RA. Using age and sex-specific cost estimates, we then simulated a vector of 25 ratios 1000 times. Each age and sex-specific randomly generated variable was converted to an estimated dollar amount (in 1995 dollars US) of excess cost attributable to RA. All dollar amounts were discounted by 3% per year. Finally, each vector of 25 discounted dollar amounts was summed to yield an estimate of the total excess medical costs in 1995 dollars for the first 25 years of a person's lifetime following a diagnosis of RA. Because not every one of these hypothetical individuals would be expected to live all 25 years, we used the standardized mortality ratio for an individual with RA (from our inception cohort) and multiplied it by the age-specific 1990 mortality rates for Minnesota whites to estimate how many of the 1000 randomly generated hypothetical individuals could be expected to die during each of the 25 years. For these, the summation of estimated cost was truncated at the death year. This process yielded, for each age and sex, a sample of 1000 sums of 25 (or fewer) excess costs all in terms of 1995 dollars that correspond to the excess cost during the first 25 years after an RA diagnosis, adjusted for differential survival among patients with RA compared to nonarthritic controls. The distribution of these sums thus represented a distribution of the 1995 dollars that could be saved if RA could be "cured" soon after incidence. RESULTS: Our simulation analyses indicated that the median lifetime incremental costs of RA range roughly from ,$61,000 to $ 122,000. Incremental costs were higher for younger individuals compared to older individuals and were consistent over all percentiles and age groups. No systematic relationship between the incremental costs of females with RA compared to males was identified. CONCLUSION: These data suggest that interventions such as autologous bone marrow transplantation, which has recently been estimated to cost roughly $60,000, may be cost saving if they eliminate the downstream incremental costs of RA.     

Potential costs of flexible sigmoidoscopy-based colorectal cancer screening

BACKGROUND & AIMS: Increasing evidence shows that periodic screening by flexible sigmoidoscopy with appropriate referral of patients with adenomas to colonoscopy could substantially decrease colorectal cancer mortality rates. Estimates of the complete cost of such screening are needed. The aim of this study was to estimate the annual costs of periodic screening of Americans 50 years and older by flexible sigmoidoscopy with referral of subjects with adenomas to colonoscopy. METHODS: Cost analysis of flexible sigmoidoscopy, followed by colonoscopy as warranted, in U.S. population cohorts reaching age 50 each year from 1995 to 2010 was performed. Total yearly costs of repeat screening and surveillance examinations at American Cancer Society- recommended and other intervals were determined. RESULTS: With screening and surveillance intervals of 3 years, annual costs for the cohort of individuals turning 50 in 1995 would increase to $553 million by 2010. Annual costs for the entire population 50 years of age and older could increase by 2010 to nearly $20 billion. CONCLUSIONS: The cost of flexible sigmoidoscopy-based screening for colorectal cancer could vary as much as threefold depending on the protocol chosen. (Gastroenterology 1996 Dec;111(6):1411-7)     

Cost effectiveness of colorectal cancer screening in the elderly

OBJECTIVE: To assess the cost effectiveness of a periodic program of colorectal cancer screening in the elderly. DESIGN: A model was constructed of four strategies for the periodic screening of persons 65 to 85 years of age. The effect of each strategy on life expectancy and health care costs was estimated under assumptions that were uniformly unfavorable to screening. Cost and added years of life were discounted at 5% per year. Cost per year of life gained from screening was calculated for each screening strategy. DATA SOURCES: Assumptions used in the model were based on a review of pertinent studies; those studies with results more unfavorable to screening were given more weight. Strengths and weaknesses of studies are discussed. MAIN RESULTS: A program of annual fecal occult blood testing (FOBT) in the elderly would detect at least 17% of the expected cases of cancer and could cost $35,000 per year of life saved. Screening schedules that include periodic sigmoidoscopy would prevent more cases of cancer but could cost between $43,000 and $47,000 per year of life gained. These estimates are based on uncertain assumptions, but results were not extremely sensitive to further relaxation of the values of the most uncertain assumptions. In no case did the cost per year of life gained from annual FOBT exceed $55,000 or did the cost per year of life gained from FOBT with sigmoidoscopy every 5 years exceed $61,000. CONCLUSIONS: Although colorectal cancer screening is costly in the aggregate, its potential medical benefits make it a reasonably cost-effective preventive intervention for the elderly.     

Cost comparison of predictive genetic testing versus conventional clinical screening for familial adenomatous polyposis

BACKGROUND: Mutations of the APC gene cause familial adenomatous polyposis (FAP), a hereditary colorectal cancer predisposition syndrome. AIMS: To conduct a cost comparison analysis of predictive genetic testing versus conventional clinical screening for individuals at risk of inheriting FAP, using the perspective of a third party payer. METHODS: All direct health care costs for both screening strategies were measured according to time and motion, and the expected costs evaluated using a decision analysis model. RESULTS: The baseline analysis predicted that screening a prototype FAP family would cost $4975/ pound3109 by molecular testing and $8031/ pound5019 by clinical screening strategy, when family members were monitored with the same frequency of clinical surveillance (every two to three years). Sensitivity analyses revealed that the genetic testing approach is cost saving for key variables including the kindred size, the age of screening onset, and the cost of mutation identification in a proband. However, if the APC mutation carriers were monitored at an increased (annual) frequency, the cost of the genetic screening strategy increased to $7483/ pound4677 and was especially sensitive to variability in age of onset of screening, family size, and cost of genetic testing of at risk relatives. CONCLUSIONS: In FAP kindreds, a predictive genetic testing strategy costs less than conventional clinical screening, provided that the frequency of surveillance is identical using either strategy. An additional significant benefit is the elimination of unnecessary colonic examinations for those family members found to be non-carriers.     

A decision analysis of surveillance for colorectal cancer in ulcerative colitis

BACKGROUND: Patients with long standing, extensive ulcerative colitis have an increased risk of developing colorectal cancer. AIMS: To assess the feasibility of surveillance colonoscopy in preventing death from colorectal cancer. PATIENTS: A hypothetical cohort of patients with chronic ulcerative colitis. METHODS: The benefits of life years saved were weighted against the costs of biannual colonoscopy and proctocolectomy, and the terminal care of patients dying from colorectal cancer. Two separate Markov processes were modelled to compare the cost-benefit relation in patients with or without surveillance. The cumulative probability of developing colorectal cancer served as a threshold to determine which of the two management strategies is associated with a larger net benefit. RESULTS: If the cumulative probability of colorectal cancer exceeds a threshold value of 27%, surveillance becomes more beneficial than no surveillance. The threshold is only slightly smaller than the actual cumulative cancer rate of 30%. Variations of the assumptions built into the model can raise the threshold above or lower it far below the actual rate. If several of the assumptions are varied jointly, even small changes can lead to extreme threshold values. CONCLUSIONS: It is not possible to prove that frequent colonoscopies scheduled at regular intervals are an effective means to manage the increased risk of colorectal cancer associated with ulcerative colitis.     

At what age should a one-time only colonoscopy for screening of colorectal cancer be performed?

OBJECTIVE: To determine at what age the only screening colonoscopy during lifetime should be performed to achieve the highest yield. METHODS: Medical decision analysis to calculate the loss in life years associated with mortality from colorectal cancer at different ages. RESULTS: The expected loss in life years from colorectal cancer is highest between the ages 70 to 80 years, with a peak occurring at age 75. The length of protection provided by colonoscopy plus polypectomy is estimated to last 5-10 years after the procedure. A screening colonoscopy at age 65 would, thus, protect a subject from age 65 until age 70 or 75 years. Similarly, a screening colonoscopy at age 70 would protect the subject from age 70 until age 75 or 80 years. CONCLUSIONS: The highest yield in life years by preventing death from colorectal cancer is achieved if the only colonoscopy per lifetime is scheduled between the ages of 65 and 70 years.     

Costs of Acid-Related Disorders to a Health Maintenance Organization

BACKGROUND: Little is known about the economic impact of the acid-related disorders (ARDs), which include dyspepsia, gastritis, gastroesophageal reflux disease (GERD), and peptic ulcer disease (PUD), in managed care patient populations.OBJECTIVES: To describe the prevalence of medically attended ARDs, and their direct medical costs from the perspective of a large health maintenance organization (HMO).METHODS: A total of 1,550 ARDs subjects (age ≥18 years), were randomly sampled from outpatient diagnosis and pharmacy databases of the Kaiser Permanente Medical Care Program of Northern California and verified by chart review. Five age- and gender-matched controls were identified per subject. One-year prevalence, excess annual costs, and initial 6-month costs for incident cases were estimated using the HMO cost accounting system.RESULTS: Total ARDs prevalence (5.8%) increases with advancing age. GERD is the most common ARD (2.9% overall prevalence). Annual per person attributable costs were $1,183, $471, and $431 respectively for PUD, GERD, and gastritis/dyspepsia. Excess inpatient costs for PUD explain its higher costs. Outpatient costs were somewhat higher for GERD ($279) than for PUD or gastritis/dyspepsia. Pharmacy costs were relatively low for each condition, in part because many patients were treated with generic cimetidine. Total annual HMO expenditures for ARDs were $59.4 million, with 40.6%, 36.8%, and 22.6% respectively for GERD, PUD, and gastritis/dyspepsia.CONCLUSIONS: Acid-related disorders, particularly GERD and PUD, contribute substantially to the direct costs of medical care in this managed care population.     

The impact of colorectal cancer screening on life expectancy

METHODS: The purpose of this study was to assess the effect of screening for colorectal cancer on life expectancy and estimate the number of colonoscopies needed per life year saved. The declining exponential approximation of life expectancy was used to calculate the effect of colorectal cancer screening on expected remaining lifetime. The annual number of deaths from colorectal cancer and the size of the population were obtained from the vital statistics of the United States. Published reports were consulted to determine the decrease in mortality from colorectal cancer achieved by fecal occult blood testing, screening sigmoidoscopy or colonoscopy. A Markov chain analysis was used to determine the endoscopic resources required to screen and survey the entire population of U.S. residents age 50 years until death or age 85 years. RESULTS: Colorectal cancer decreases the life expectancy of U.S. residents aged 50 to 54 years by 292 days and those aged 70 to 74 years by 70 days. Screening with fecal occult blood tests extends expected lifetime of the 2 age groups by 51 and 12 days, respectively, whereas screening with sigmoidoscopy leads to increases of 86 and 21 days. Colonoscopic screening increases expected lifetime by 170 and 41 days, respectively. The number of colonoscopies needed to save 1 year of expected life ranges from 2.9 to 6.0, depending on the type of screening regimen used. CONCLUSIONS: The extension of life through screening colonoscopy is two or three times longer than the extension achieved through flexible sigmoidoscopy or fecal occult blood test, respectively. Although a large number of colonoscopies are required to screen the U.S. population, relatively few colonoscopies need to be invested per year of life expectancy saved.     

Lifetime health and economic consequences of obesity.

BACKGROUND: Obesity is an established risk factor for several chronic diseases. The lifetime health and economic consequences of obesity for individual patients have not been documented. OBJECTIVE: To estimate the lifetime health and economic consequences of obesity. METHODS: We developed a dynamic model of the relationship between body mass index and the risks and associated costs of 5 obesity-related diseases: hypertension, hypercholesterolemia, type 2 diabetes mellitus, coronary heart disease, and stroke. The model was estimated using data from the Third National Health and Nutrition Examination Survey, the Framingham Heart Study, and other secondary sources. We used this model to estimate (1) risks of hypertension, hypercholesterolemia, and type 2 diabetes mellitus at future ages; (2) lifetime risks of coronary heart disease and stroke; (3) life expectancy; and (4) expected lifetime medical care costs of these 5 diseases for men and women aged 35 to 64 years with body mass indexes of 22.5, 27.5, 32.5, and 37.5 kg/m2 (nonobese and mildly, moderately, and severely obese, respectively). RESULTS: Disease risks and costs increase substantially with increased body mass index. The risk of hypertension for moderately obese 45- to 54-year-old men, for example, is roughly 2-fold higher than for their nonobese peers (38.1% vs 17.7%), whereas the risk of type 2 diabetes mellitus is almost 3-fold higher (8.1% vs 3.0%). Lifetime risks of coronary heart disease and stroke are similarly elevated (41.8% vs 34.9% and 16.2% vs 13.9%, respectively), whereas life expectancy is reduced by 1 year (26.5 vs 27.5 years). Total discounted lifetime medical care costs for the treatment of these 5 diseases are estimated to differ by $10,000 ($29,600 vs $19,600). Similar results were obtained for women. CONCLUSIONS: The lifetime health and economic consequences of obesity are substantial and suggest that efforts to prevent or reduce this problem might yield significant benefits.     

Cost benefits of hemoccult screening for colorectal carcinoma

Hemoccult screening for colorectal carcinoma was begun in 1979 at the Kaiser Permanente Medical Center, Oakland, California, as part of a program for periodic health examinations. A concomitant cost-benefit analysis was conducted to determine the long-term medical care costs and survival benefits of this procedure. Of 14,041 patients 45 years of age mailed hemoccult slides, 10,255 (70.3%) returned them at the time of their examination. One hundred twelve (1.1%) were positive, and 12 colorectal carcinomas were detected. Additionally, 13 patients with one or more polyps 1 cm and 45 patients with other gastrointestinal sources of blood were found. Of the screened cases of colorectal carcinoma, 50% were in Dukes' stage A compared with 25% found in this stage in our institution in 1974, when screening was not done. Five-year Dukes' stage-specific medical care costs and mortality rates were developed from the 1974 cases and were then applied to the screened cases of colorectal cancer. A savings in medical care costs of $14,685 and a projected increase of 22 years in life expectancy was found.This research was supported by the Community Service Program of Kaiser Foundation Hospitals. The study protocol was approved in December 1978, by our Northern California Regional Institutional Review Board.     

Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer

BACKGROUND: Substantial variability in the use of colon surveillance among colorectal cancer survivors has been reported. This study sought to examine trends in the use of colon surveillance among patients who have had colorectal cancer and to investigate factors associated with utilization. METHODS: Health maintenance organization enrollees with a diagnosis of local or regional colon or rectal cancer between January 1993 and December 1999 were studied. Receipt of a colon examination by colonoscopy or by flexible sigmoidoscopy, together with barium contrast radiography of the colon was determined from automated clinical records, and rates of colon surveillance were estimated by using survival analysis. RESULTS: A total of 1002 patients with a diagnosis of colorectal cancer met inclusion criteria for the study. Colon examinations were performed in 61% of patients within 18 months of diagnosis and in 80% of patients within 5 years of diagnosis. The median time from diagnosis to first colon surveillance examination (14 months) was unchanged over the study period, but the interval between first and second surveillance examinations increased by 17 months (p<0.001). Patients over 80 years of age (relative risk=0.32; 95% CI[0.22, 0.45]) and those with rectal cancer (relative risk=0.80; 95% CI[0.66, 0.97]) were less likely to undergo surveillance. Higher socioeconomic status (relative risk=1.29; 95% CI[1.03, 1.61]) and being married (relative risk=1.27; 95% CI[1.05, 1.53]) were associated with greater utilization. There was lower utilization among African American patients (relative risk=0.70; p=0.14) and increased utilization among other minorities (relative risk=1.47; p=0.06). CONCLUSIONS: There is substantial variability in the use of colon examination for surveillance in patients with a history of colorectal cancer, and clinical and sociodemographic factors appear to influence the likelihood of surveillance.     

Age, costs of acute and long-term care and proximity to death: evidence for 1987-88 and 1994-95 in British Columbia

BACKGROUND: the consequences of ageing populations for health care costs have become a concern for governments and health care funders in most countries. However, there is increasing evidence that costs are more closely related to proximity to death than to age. This means that projections using age-specific costs will exaggerate the impact of ageing. Previous studies of the relationship of age, proximity to death and costs have been restricted to acute medical care. OBJECTIVE: to assess the effects of age and proximity to death on costs of both acute medical care and nursing and social care, and to assess if this relationship was stable in a time of rapid change in health care expenditure. DESIGN AND METHODS: we compared all decedents in the chosen age categories for the years 1987-88 and 1994-95 with all survivors in the same age groups. We measured use of health and social care for each individual using the British Columbia linked data, and costs of care assessed by multiplying the number of services by the unit cost of each service. SETTING: the Province of British Columbia. SUBJECTS: all decedents in 1987-88 and 1994-95 in British Columbia in the chosen age groups, and all survivors in the same age groups. RESULTS: costs of acute care rise with age, but the proximity to death is a more important factor in determining costs. The additional costs of dying fall with age. In contrast, costs of nursing and social care rise with age, but additional costs for those who are dying increase with age. Similar patterns were found for the two cohorts. CONCLUSIONS: age is less important than proximity to death as a predictor of costs. However, the pattern of social and nursing care costs is different from that for acute medical care. In planning services it is important to take into account the relatively larger impact of ageing on social and nursing care than on acute care.     

Cost‐effectiveness analysis of voglibose for prevention of type 2 diabetes mellitus in Japanese patients with impaired glucose tolerance

Aims/Introduction: The objective of this study was to estimate the cost‐effectiveness of administering voglibose, in addition to standard care of diet and exercise, compared with standard care alone for high‐risk Japanese patients with impaired glucose tolerance. Materials and Methods: A Markov model was constructed to estimate the long‐term prognosis of individuals with impaired glucose tolerance, in terms of expected medical costs and life expectancy. Transition probabilities were derived from the results of a clinical trial of voglibose, as well as the epidemiological information. Effectiveness was evaluated by life expectancy and only direct costs were considered. The future costs and effectiveness were discounted by 3% per year. Results: Estimated expected lifetime costs for the voglibose administration group and the standard care group was JPY718,724 ($US7598) and JPY1,365,405 ($US14,433), respectively, with voglibose administration resulting in saving of JPY646,681 ($US6836). Estimated life expectancy was 18.672 and 18.073 years, respectively, with life expectancy prolonged by 0.599 years when voglibose was administered together with the standard care. Conclusions: In order to prevent type 2 diabetes among Japanese patients with impaired glucose tolerance, voglibose with standard care resulted in cost‐saving, as well as prolongation of life expectancy, compared with standard care alone. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2010.0052.x, 2010)     

Colonoscopic surveillance after polypectomy: considerations of cost effectiveness.

OBJECTIVE: To assess the cost effectiveness of the current recommendation that persons who have had an adenomatous colon polyp removed have periodic colonoscopic surveillance at fixed and regular intervals. DESIGN: Cost-effectiveness analysis using data from the medical literature in a simulation model to estimate the costs of and the risk for perforation associated with periodic colonoscopic surveillance for a 50-year-old man followed for 30 years. MAIN RESULTS: A program of colonoscopy every 3 years would incur cumulatively a 1.4% risk for colon perforation, a 0.11% risk for perforation-related death, and direct physician costs of $2071 for colonoscopy (discounted at 5%). If a 50-year-old man's cumulative remaining risk for death from cancer is 2.5% after the removal of a single small adenoma and if effectiveness of colonoscopic surveillance every 3 years is 100%, then one death from cancer could be prevented by doing 283 colonoscopies, incurring 0.6 perforations, 0.04 perforation-related deaths, and direct physician costs of $82,000. If surveillance were 50% effective and the cumulative remaining risk for death from cancer were 1.25%--a plausible scenario--1131 colonoscopies would be required to prevent one death from cancer, incurring 2.3 perforations, 0.17 perforation-related deaths, and physician costs of $331,000. CONCLUSIONS: The cost effectiveness of colonoscopic surveillance is very sensitive to estimates of the cumulative remaining risk for death from cancer after polypectomy as well as to surveillance efficacy. For persons whose remaining risk for death from cancer may be low, such as persons with a single small adenoma, recommendations for colonoscopic surveillance at fixed and regular intervals may be excessively costly.     

Clinical course and costs of care for Crohn's disease: Markov model analysis of a population-based cohort.

BACKGROUND & AIMS: Crohn's disease results in substantial morbidity and high use of health services. The aim of this study was to describe the lifetime clinical course and costs of Crohn's disease in a 24-year population-based inception cohort of patients with Crohn's disease in Olmsted County, Minnesota. METHODS: Disease states were defined by medical and surgical treatment. A Markov model analysis calculated time in each disease state and present value of excess lifetime costs in comparison with an age- and sex-matched cohort. RESULTS: For a representative patient, projected lifetime costs were $39,906 per patient using median charges and $125,404 using mean charges. There were 29.1 years (63% of total) without medications. There were 12.7 years (27%) on aminosalicylate therapy, generating $11,467 (29%) in charges, and 3.2 years (7%) on corticosteroid or immunosuppressive therapy, generating $5147 (13%) in charges. Surgery generated $17,526 (44%) in charges. CONCLUSIONS: Most of the clinical course is spent in remission, either medical or surgical. Aminosalicylate therapy accounts for 29% of the costs of care. Surgery has the highest charges but the longest remissions. Treatment strategies that induce remission in mild disease and maintain remission with lower-cost maintenance therapy will have the largest effect on patient outcomes and costs.     

The outcomes and costs of acute myeloid leukemia among the elderly

BACKGROUND: The incidence of acute myeloid leukemia (AML) among the elderly can be expected to grow as the population continues to age. However, data on current treatment practices and costs for this form of cancer are sparse. METHODS: We used a retrospective inception cohort design and data from a linkage between 11 Surveillance, Epidemiology, and End Results cancer registries and Medicare administrative claims. We evaluated survival, use of health care resources, use of chemotherapy, and Medicare payments among adults 65 years and older with an initial diagnosis of AML between January 1, 1991, and December 31, 1996. RESULTS: A total of 2657 elderly patients with AML and complete Medicare claims data were identified. The prognosis for these patients was poor, with median survival estimated to be 2 months and a 2-year survival rate of 6%. Mean +/- SE total Medicare payments were $41,594 +/- $870 (in 1998 US dollars), 84% of which was attributed to inpatient payments. In the 2 years after the AML diagnosis, 790 patients (30%) underwent chemotherapy treatment. These patients had costs almost 3 times higher than those of other patients, and their median survival was 6 months longer. The use of hospice care was rare (17% of patients). CONCLUSIONS: Among the elderly, AML is associated with a poor prognosis and substantial costs during the relatively few remaining months of life. Moreover, most patients do not receive active treatment with chemotherapy or hospice services. Further work is needed to characterize this disease and the patient-related factors that influence treatment decisions and associated health outcomes.