全球肺癌筛查卫生经济学研究的系统评价

目的 了解全球肺癌筛查的卫生经济学评价研究进展,为我国相关研究和筛查工作开展提供参考。方法 系统检索PubMed、EMbase、The Cochrane Library、中国知网及万方数据知识服务平台自建库至2018年6月30日间肺癌筛查卫生经济学研究相关文献,摘录其经济学评价方法及结果等信息,并进行质量评价。成本统一货币单位后计算增量成本效果比（ICER）后计算与当年当地人均GDP比值。结果 共纳入23项研究（1项基于人群随机对照试验,20项完全基于模型评价）,整体质量较好;22项来自发达国家,11项筛查起始年龄为55岁,18项目标人群考虑了吸烟史;评价的筛查技术全部涉及低剂量螺旋CT（LDCT）,筛查频率以每年1次（17项）和终生1次（7项）居多。22项研究可获得与未筛查相比的ICER,其中17项研究报道的ICER低于3倍当年当地人均GDP。各有15项和7项研究可获得每年1次和终生1次的ICER,其中各有12项和7项支持其经济有效,且终生1次略优于每年1次;不同筛查起始年龄和吸烟包年的经济有效性优劣差异不明显。结论 发达国家多开展基于模型LDCT肺癌筛查卫生经济学评价,并结合年龄和吸烟史进行高危人群选择,初步提示该方案经济有效;可为证据有限的欠发达地区提供参考,但实施需结合当地卫生资源现状;预算有限时低频次LDCT筛查更佳,而筛查起始年龄和吸烟史等细节确定需结合人群特征进行精准评价。     

Cost-Effectiveness Analyses of Lung Cancer Screening Strategies Using Low-Dose Computed Tomography: a Systematic Review

Background

Lung cancer screening with low-dose computed tomography (LDCT) has been shown to deliver appreciable reductions in mortality in high-risk patients. However, in an era of constrained medical resources, the cost-effectiveness of such a program needs to be demonstrated.

Objective

The aim of this study was to systematically review the literature analyzing the cost-effectiveness of lung cancer screening using LDCT.

Methods

We searched MEDLINE, EMBASE, EBM Reviews—Health Technology Assessment, the National Health Service Economic Evaluation Database (NHS-EED), and the Cochrane Database of Systematic Reviews. Due to technological progress in CT, we limited our search to studies published between January 2000 and December 2014. Our search returned 393 unique results. After removing studies that did not meet our inclusion criteria, 13 studies remained. Costs are presented in 2014 US dollars (US$).

Results

The results from the economic evaluations identified in this review were varied. All identified studies reported outcomes using either additional survival (life-years gained) or quality-adjusted life-years (QALYs gained). Results ranged from US$18,452 to US$66,480 per LYG and US$27,756 to US$243,077 per QALY gained for repeated screening. The results of cost-effectiveness analyses were sensitive to several key model parameters, including the prevalence of lung cancer, cost of LDCT for screening, the proportion of lung cancer detected as localized disease, lead time bias, and, if included, the characteristics of a smoking cessation program.

Conclusions

The cost-effectiveness of a lung cancer screening program using LDCT remains to be conclusively resolved. It is expected that its cost-effectiveness will largely depend on identifying an appropriate group of high-risk subjects.

     

Cancer-Specific Mortality,All-Cause Mortality,and Overdiagnosis in Lung Cancer Screening Trials: A Meta-Analysis

PURPOSEBenefit of lung cancer screening using low-dose computed tomography (LDCT) in reducing lung cancer–specific and all-cause mortality is unclear. We undertook a meta-analysis to assess its associations with outcomes.METHODSWe searched the literature and previous systematic reviews to identify randomized controlled trials comparing LDCT screening with usual care or chest radiography. We performed meta-analysis using a random effects model. The primary outcomes were lung cancer–specific mortality, all-cause mortality, and the cumulative incidence ratio of lung cancer between screened and unscreened groups as a measure of overdiagnosis.RESULTSMeta-analysis was based on 8 trials with 90,475 patients that had a low risk of bias. There was a significant reduction in lung cancer–specific mortality with LDCT screening (relative risk = 0.81; 95% CI, 0.74-0.89); the estimated absolute risk reduction was 0.4% (number needed to screen = 250). The reduction in all-cause mortality was not statistically significant (relative risk = 0.96; 95% CI, 0.92-1.01), but the absolute reduction was consistent with that for lung cancer–specific mortality (0.34%; number needed to screen = 294). In the studies with the longest duration of follow-up, the incidence of lung cancer was 25% higher in the screened group, corresponding to a 20% rate of overdiagnosis.CONCLUSIONSThis meta-analysis showing a significant reduction in lung cancer–specific mortality, albeit with a tradeoff of likely overdiagnosis, supports recommendations to screen individuals at elevated risk for lung cancer with LDCT.Key words: lung cancer, cancer screening, mass screening, low-dose computed tomography, overdiagnosis, public health, preventive medicine, health services     

Cost-Effectiveness of Baseline Low-Dose Computed Tomography Screening for Lung Cancer: The Israeli Experience

ObjectiveReduced mortality with low-dose computed tomography (LDCT) lung cancer screening was demonstrated in a large randomized controlled study of high-risk individuals. Cost-effectiveness must be assessed before routine LDCT screening is considered. We aimed to evaluate the cost-effectiveness of LDCT lung cancer screening in Israel.MethodsA decision analytic framework was used to evaluate the decision to screen or not screen from the health system perspective. The screening arm included 842 moderate-to-heavy smokers aged 45 years or older, screened at Hadassah-Hebrew University Medical Center from 1998 to 2004. In the usual-care arm, stage distribution and stage-specific life expectancy were obtained from the Israel National Cancer Registry data for 1994 to 2006. Lifetime stage-specific costs were estimated from medical records of patients diagnosed and treated at Hadassah Medical Center in the period 2003 to 2004. The analysis considered possible biases—lead time, overdiagnosis, and self-selection. Cost per quality-adjusted-life-year (QALY) gained by screening was estimated.ResultsBase-case incremental cost per QALY gained was $1464 (2011 prices). Extensive sensitivity analysis affirmed the low cost per QALY gained. The cost per QALY gained is lower than $10,000 with probability 0.937 and is lower than $20,000 with probability 0.978.ConclusionsOur analysis suggests that baseline LDCT lung cancer screening in Israel presents a good value for the money and should be considered for inclusion in the National List of Health Services financed publicly.     

Development of a quality framework for models of cervical screening and its application to evaluations of the cost-effectiveness of HPV vaccination in developed countries

BackgroundHPV vaccination has now been introduced in most developed countries, but this has occurred in the context of established cervical cancer screening mechanisms which provide population-level protection against the most common HPV-related cancer. Therefore, estimating the cost-effectiveness of HPV vaccination to further reduce HPV-related disease depends in large part on the estimation of the effectiveness of the cervical screening ‘background’. The aim of this study was to systematically review and assess methods for simulating cervical screening in decision analytic models used for evaluation of HPV vaccination.MethodsExisting quality frameworks for economic models were extended to develop a specific quality framework for models of cervical screening. This involved domains for model structure, parameterisation (data sources) and validation (consistency). A systematic review of economic evaluations of HPV vaccination was then conducted, and assessment of cervical screening model components was then performed via application of the new quality framework.ResultsGenerally, models took into account population-level cervical screening participation, but were inconsistent in their approach to modelling abnormal smear management, diagnostic evaluation and treatment of precancerous disease. There was also considerable variability in the accuracy of modelling clinical pathways and the scope of validation performed for screening-related outcomes, with focus directed towards cervical cancer targets. Only a few models comprehensively validated against observed pre-cancerous abnormalities.ConclusionModels of HPV vaccination in developed countries can be improved by further attention to the ‘background’ modelling of secondary protection via cervical screening. The quality framework developed for this review can be used to inform future HPV vaccination evaluations, including evaluations of the cost-effectiveness of male vaccination and next generation HPV vaccines, and to assess models used to evaluate new cervical screening technologies and recommendations.     

Screening for lung cancer: A systematic review and meta-analysis

ObjectivesTo examine evidence on benefits and harms of screening average to high-risk adults for lung cancer using chest radiology (CXR), sputum cytology (SC) and low-dose computed tomography (LDCT).MethodsThis systematic review was conducted to provide up to date evidence for Canadian Task Force on Preventive Health Care (CTFPHC) lung cancer screening guidelines. Four databases were searched to March 31, 2015 along with utilizing a previous Cochrane review search. Randomized trials reporting benefits were included; any design was included for harms. Meta-analyses were performed if possible. PROSPERO #CRD42014009984.ResultsThirty-four studies were included. For lung cancer mortality there was no benefit of CXR screening, with or without SC. Pooled results from three small trials comparing LDCT to usual care found no significant benefits for lung cancer mortality. One large high quality trial showed statistically significant reductions of 20% in lung cancer mortality over a follow-up of 6.5 years, for LDCT compared with CXR. LDCT screening was associated with: overdiagnosis of 10.99–25.83%; 11.18 deaths and 52.03 patients with major complications per 1000 undergoing invasive follow-up procedures; median estimate for false positives of 25.53% for baseline/once-only screening and 23.28% for multiple rounds; and 9.74 and 5.28 individuals per 1000 screened, with benign conditions underwent minor and major invasive follow-up procedures.ConclusionThe evidence does not support CXR screening with or without sputum cytology for lung cancer. High quality evidence showed that in selected high-risk individuals, LDCT screening significantly reduced lung cancer mortality and all-cause mortality. However, for its implementation at a population level, the current evidence warrants the development of standardized practices for screening with LDCT and follow-up invasive testing to maximize accuracy and reduce potential associated harms.     

Panel discussion on the application of MCDA tools

Background

Due to its epidemiological relevance, several studies have been performed to assess the cost-effectiveness of diagnostic tests and treatments in colorectal cancer (CRC) patients.

Objective

We reviewed economic evaluations on diagnosis of inherited CRC-syndromes and genetic tests for the detection of mutations associated with response to therapeutics.

Methods

A systematic literature review was performed by searching the main literature databases for relevant papers on the field, published in the last 5 years.

Results

20 studies were included in the final analysis: 14 investigating the cost-effectiveness of hereditary-CRC screening; 5 evaluating the cost-effectiveness of KRAS mutation assessment before treatment; and 1 study analysing the cost-effectiveness of genetic tests for early-stage CRC patients prognosis. Overall, we found that: (a) screening strategies among CRC patients were more effective than no screening; (b) all the evaluated interventions were cost-saving for certain willingness-to-pay (WTP) threshold; and (c) all new CRC patients diagnosed at age 70 or below should be screened. Regarding patients treatment, we found that KRAS testing is economically sustainable only if anticipated in patients with non-metastatic CRC (mCRC), while becoming unsustainable, due to an incremental cost-effectiveness ratio (ICER) beyond the levels of WTP-threshold, in all others evaluated scenarios.

Conclusions

The poor evidence in the field, combined to the number of assumptions done to perform the models, lead us to a high level of uncertainty on the cost-effectiveness of genetic evaluations in CRC, suggesting that major research is required in order to assess the best combination among detection tests, type of genetic test screening and targeted-therapy.

     

Cost-Effectiveness of Targeted Genetic Testing for Breast and Ovarian Cancer: A Systematic Review

BackgroundTargeted genetic testing is a tool to identify women at increased risk of gynaecological cancer.ObjectiveThis systematic review evaluates the results and quality of cost-effectiveness modeling studies that assessed targeted genetic-based screen-and-treat strategies to prevent breast and ovarian cancer.MethodsUsing MEDLINE and databases of the Centre for Reviews and Dissemination, we searched for health economic modeling evaluations of targeted genetic-based screen-and-treat strategies to prevent inheritable breast and ovarian cancer (until August 2020). The incremental cost-effectiveness ratios (ICERs) were compared. Methodological variations were addressed by evaluating the model conceptualizations, the modeling techniques, parameter estimation and uncertainty, and transparency and validation of the models. Additionally, the reporting quality of each study was assessed.ResultsEighteen studies met our inclusion criteria. From a payer perspective, the ICERs of (1) BRCA screening for high-risk women without cancer ranged from dominating the no test strategy to an ICER of $21 700/quality-adjusted life years (QALY). In studies that evaluated (2) BRCA cascade screening (ie, screening of women with cancer plus their unaffected relatives) compared with no test, the ICERs were between $6500/QALY and $50 200/QALY. Compared with BRCA alone, (3) multigene testing in women without cancer had an ICER of $51 800/QALY (one study), while for (4) multigene-cascade screening the ICERs were $15 600/QALY, $56.500/QALY, and $69 600/QALY for women in the United Kingdom, Norway, and the United States, respectively (2 studies). More recently published studies showed a higher methodological and reporting quality.ConclusionsTargeted BRCA or multiple gene screening is likely to be cost-effective. Methodological variations could be decreased by the development of a reference model, which may serve as a tool for validation of present and future cost-effectiveness models.     

Should we screen for occupational lung cancer with low-dose computed tomography?

OBJECTIVE: The objective of this study was to assess the potential value of screening for occupational lung cancer through the use of low-dose computed tomography (LDCT). METHODS: A literature review of Medline was conducted to assess: 1) screening studies of occupational lung cancer that used LDCT; 2) screening studies of nonoccupational lung cancer that used LDCT; and 3) position papers of medical professional societies and nongovernmental health organizations that have addressed the value of screening for lung cancer with LDCT. RESULTS: No screening studies of occupational lung cancer with LDCT were uncovered; however, numerous observational and population-based studies have addressed the value of screening for lung cancer among cigarette smokers. Results of these studies are difficult to interpret in light of numerous biases associated with these types of studies. No randomized, controlled studies on screening for lung cancer have been published at this time. No professional, governmental, or nonprofit health organization recommends screening asymptomatic people at risk of lung cancer with LDCT at this time. CONCLUSION: In the absence of randomized, controlled studies that can address biases commonly encountered in observational and population-based studies, it is unclear whether LDCT reduces mortality from lung cancer. The National Cancer Institute is sponsoring a randomized, controlled study of over 50,000 current and former smokers with the results expected in 2009.     

肺癌筛查的卫生经济学评价研究

目的:对肺癌筛查进行成本一效果分析,评价肺癌筛查的经济性。方法:构建肺癌筛查决策树模型,对肺癌筛查及不筛查两种策略进行投入产出分析,评价两种策略的成本与健康产出,并进行增量成本一效果分析,判断肺癌筛查策略的经济性。结果:肺癌筛查策略与不筛查策略相比,每多获得1个寿命年的成本为93 153元。结论:根据WHO推荐阈值,在人群中实施肺癌筛查是具有成本一效果的,应在人群中积极推广肺癌筛查。     

Systematic review of rotavirus vaccination cost-effectiveness in high income settings utilising dynamic transmission modelling techniques

PurposeThis systematic review presents cost-effectiveness studies of rotavirus vaccination in high-income settings based on dynamic transmission modelling to inform policy decisions about implementing rotavirus vaccination programmes.MethodsWe searched CEA Registry, MEDLINE, Embase, Health Technology Assessment Database, Scopus, and the National Health Service Economic Evaluation Database for studies published since 2002. Full economic evaluation studies based on dynamic transmission models, focusing on high-income countries, live oral rotavirus vaccine and children ≤ 5 years of age were eligible for inclusion. Included studies were appraised for quality and risk of bias using the Consensus on Health Economic Criteria (CHEC) list and the Philips checklist. The review protocol was prospectively registered with PROSPERO (CRD42020208406).ResultsA total of four economic evaluations were identified. Study settings included England and Wales, France, Norway, and the United States. All studies compared either pentavalent or monovalent rotavirus vaccines to no intervention. All studies were cost-utility analyses that reported incremental cost per quality-adjusted life year (QALY) gained. Included studies consistently concluded that rotavirus vaccination is cost-effective compared with no vaccination relative to the respective country’s willingness to pay threshold when herd protection benefits are incorporated in the modelling framework.ConclusionsRotavirus vaccination was found to be cost-effective in all identified studies that used dynamic transmission models in high-income settings where child mortality rates due to rotavirus gastroenteritis are close to zero. Previous systematic reviews of economic evaluations considered mostly static models and had less conclusive findings than the current study. This review suggests that modelling choices influence cost-effectiveness results for rotavirus vaccination. Specifically, the review suggests that dynamic transmission models are more likely to account for the full impact of rotavirus vaccination than static models in cost-effectiveness analyses.     

Biennial screening mammography is cost effective in healthy women aged over 65 years

QuestionWhat is the cost-effectiveness of screening mammography in women over 65 years old?Study designSystematic review with narrative synthesis.Main resultsTen studies, out of 115 identified, met inclusion criteria. Studies had similar cost-effectiveness findings; extending biennial screening to ages 75–80 years cost, on average, $34,000–$88,000 per life year gained compared with stopping screening at age 65 (adjusted to 2002 US dollars). Two studies found breast cancer screening less effective at reducing mortality in women with significant comorbidities (dementia, congestive heart failure, or hypertension), thus reducing the cost-effectiveness of screening in this population. No study fully adjusted for potential harms of screening.Authors’ conclusionsIn women aged over 65 years without serious comorbidity, biennial breast cancer screening reduces mortality at reasonable costs.     

Cost-Effectiveness of RAS Genetic Testing Strategies in Patients With Metastatic Colorectal Cancer: A Systematic Review

BackgroundMonoclonal antibodies against epidermal growth factor receptor (EGFR) have proved beneficial for the treatment of metastatic colorectal cancer (mCRC), particularly when combined with predictive biomarkers of response. International guidelines recommend anti-EGFR therapy only for RAS (NRAS, KRAS) wild-type tumors because tumors with RAS mutations are unlikely to benefit.ObjectivesWe aimed to review the cost-effectiveness of RAS testing in mCRC patients before anti-EGFR therapy and to assess how well economic evaluations adhere to guidelines.MethodsA systematic review of full economic evaluations comparing RAS testing with no testing was performed for articles published in English between 2000 and 2018. Study quality was assessed using the Quality of Health Economic Studies scale, and the British Medical Journal and the Philips checklists.ResultsSix economic evaluations (2 cost-effectiveness analyses, 2 cost-utility analyses, and 2 combined cost-effectiveness and cost-utility analyses) were included. All studies were of good quality and adopted the perspective of the healthcare system/payer; accordingly, only direct medical costs were considered. Four studies presented testing strategies with a favorable incremental cost-effectiveness ratio under the National Institute for Clinical Excellence (£20 000-£30 000/QALY) and the US ($50 000-$100 000/QALY) thresholds.ConclusionsTesting mCRC patients for RAS status and administering EGFR inhibitors only to patients with RAS wild-type tumors is a more cost-effective strategy than treating all patients without testing. The treatment of mCRC is becoming more personalized, which is essential to avoid inappropriate therapy and unnecessarily high healthcare costs. Future economic assessments should take into account other parameters that reflect the real world (eg, NRAS mutation analysis, toxicity of biological agents, genetic test sensitivity and specificity).     

Cost-Effectiveness of Lung Cancer Screening Using Low-Dose Computed Tomography Based on Start Age and Interval in China: Modeling Study

BackgroundLung cancer is the most commonly diagnosed cancer and the leading cause of cancer-related death in China. The effectiveness of screening for lung cancer has been reported to reduce lung cancer–specific and overall mortality, although the cost-effectiveness, optimal start age, and screening interval remain unclear.ObjectiveThis study aimed to assess the cost-effectiveness of lung cancer screening among heavy smokers in China by incorporating start age and screening interval.MethodsA Markov state-transition model was used to assess the cost-effectiveness of a lung cancer screening program in China. The evaluated screening strategies were based on a screening start age of 50-74 years and a screening interval of once or annually. Transition probabilities were obtained from the literature and validated, while cost parameters were derived from databases of local medical insurance bureaus. A societal perspective was adopted. The outputs of the model included costs, quality-adjusted life years (QALYs), and lung cancer–specific mortality, with future costs and outcomes discounted by 5%. A currency exchange rate of 1 CNY=0.1557 USD is applicable. The incremental cost-effectiveness ratio (ICER) was calculated for different screening strategies relative to nonscreening.ResultsThe proposed model suggested that screening led to a gain of 0.001-0.042 QALYs per person as compared with the findings in the nonscreening cohort. Meanwhile, one-time and annual screenings were associated with reductions in lung cancer–related mortality of 0.004%-1.171% and 6.189%-15.819%, respectively. The ICER ranged from 119,974.08 to 614,167.75 CNY per QALY gained relative to nonscreening. Using the World Health Organization threshold of 212,676 CNY per QALY gained, annual screening from a start age of 55 years and one-time screening from the age of 65 years can be considered as cost-effective in China. Deterministic and probabilistic sensitivity analyses were conducted.ConclusionsThis economic evaluation revealed that a population-based lung cancer screening program in China for heavy smokers using low-dose computed tomography was cost-effective for annual screening of smokers aged 55-74 years and one-time screening of those aged 65-74 years. Moreover, annual lung cancer screening should be promoted in China to realize the benefits of a guideline-recommended screening program.     

我国乳腺癌筛查卫生经济学研究的系统评价

目的 了解我国大陆地区乳腺癌筛查的卫生经济学评价进展。方法 系统检索PubMed、中国知网、万方数据知识服务平台和维普网1995年1月至2015年12月收录文献,对纳入研究基本信息、人群项目参与率及检出率、模型研究方法学、经济学评价方法及结果等信息进行摘录和比较,采用卫生经济学评价报告规范（CHEERS）评价报告质量（总分24分）。结果 共检索356篇文献,最终纳入13篇,均发表于近4年（2012-2015年）,其中11篇基于人群、3篇基于模型研究。筛查起始年龄为18～45岁,终止年龄均≥59岁;筛查技术包括临床检查、超声和钼靶单一或联合筛查。有7篇报道了研究角度,其中为政府等服务提供方5篇,社会角度2篇;仅有5篇研究进行了成本和（或）效果贴现。11篇成本-效果分析中,有9篇提供了评价指标检出1例乳腺癌的成本,为5.0～229.3（M=14.5）万元。以质量调整生命年（QALY）或伤残调整生命年（DALY）为指标的成本-效用分析仅4篇,相应增量成本效果比（ICER）为0.3万元～27.1万元（2015年我国人均GDP为4.9万元）。13篇文献平均得分14.5（9.5～21.0）分,总分24分,其中研究角度、贴现率、ICER及不确定性等维度得分较低。结论 我国大陆地区乳腺癌筛查的经济学研究尚处于起步阶段,尤其是模型研究;各研究间方法及结果可比性一般,报告质量有待加强。应从社会角度全面核算成本后对筛查项目开展以QALY或DALY为指标的成本-效用分析。     

A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies

ObjectivesMany economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data.MethodsWe conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies.ResultsThe review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial.ConclusionsAlthough many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.     

Economic Evaluations of Remote Patient Monitoring for Chronic Disease: A Systematic Review

ObjectivesThis study aimed to systematically review and summarize economic evaluations of noninvasive remote patient monitoring (RPM) for chronic diseases compared with usual care.MethodsA systematic literature search identified economic evaluations of RPM for chronic diseases, compared with usual care. Searches of PubMed, Embase, CINAHL, and EconLit using keyword synonyms for RPM and economics identified articles published from up until September 2021. Title, abstract, and full-text reviews were conducted. Data extraction of study characteristics and health economic findings was performed. Article reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist.ResultsThis review demonstrated that the cost-effectiveness of RPM was dependent on clinical context, capital investment, organizational processes, and willingness to pay in each specific setting. RPM was found to be highly cost-effective for hypertension and may be cost-effective for heart failure and chronic obstructive pulmonary disease. There were few studies that investigated RPM for diabetes or other chronic diseases. Studies were of high reporting quality, with an average Consolidated Health Economic Evaluation Reporting Standards score of 81%. Of the final 34 included studies, most were conducted from the healthcare system perspective. Eighteen studies used cost-utility analysis, 4 used cost-effectiveness analysis, 2 combined cost-utility analysis and a cost-effectiveness analysis, 1 used cost-consequence analysis, 1 used cost-benefit analysis, and 8 used cost-minimization analysis.ConclusionsRPM was highly cost-effective for hypertension and may achieve greater long-term cost savings from the prevention of high-cost health events. For chronic obstructive pulmonary disease and heart failure, cost-effectiveness findings differed according to disease severity and there was limited economic evidence for diabetes interventions.     

Offering Lung Cancer Screening to High-Risk Medicare Beneficiaries Saves Lives and Is Cost-Effective: An Actuarial Analysis

Background

By a wide margin, lung cancer is the most significant cause of cancer death in the United States and worldwide. The incidence of lung cancer increases with age, and Medicare beneficiaries are often at increased risk. Because of its demonstrated effectiveness in reducing mortality, lung cancer screening with low-dose computed tomography (LDCT) imaging will be covered without cost-sharing starting January 1, 2015, by nongrandfathered commercial plans. Medicare is considering coverage for lung cancer screening.

Objective

To estimate the cost and cost-effectiveness (ie, cost per life-year saved) of LDCT lung cancer screening of the Medicare population at high risk for lung cancer.

Methods

Medicare costs, enrollment, and demographics were used for this study; they were derived from the 2012 Centers for Medicare & Medicaid Services (CMS) beneficiary files and were forecast to 2014 based on CMS and US Census Bureau projections. Standard life and health actuarial techniques were used to calculate the cost and cost-effectiveness of lung cancer screening. The cost, incidence rates, mortality rates, and other parameters chosen by the authors were taken from actual Medicare data, and the modeled screenings are consistent with Medicare processes and procedures.

Results

Approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately 3 years. Based on our analysis, the average annual cost of LDCT lung cancer screening in Medicare is estimated to be $241 per person screened. LDCT screening for lung cancer in Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years is low cost, at approximately $1 per member per month. This assumes that 50% of these patients were screened. Such screening is also highly cost-effective, at <$19,000 per life-year saved.

Conclusion

If all eligible Medicare beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014. LDCT screening is a low-cost and cost-effective strategy that fits well within the standard Medicare benefit, including its claims payment and quality monitoring.Lung cancer is a lethal disease that claims the lives of more people in the United States annually than the next 4 most lethal cancers combined, which are, in order, colon, breast, pancreas, and prostate cancers.1,2 In the United States, an estimated 224,210 people will be diagnosed with lung cancer, and an estimated 159,260 people will die of the disease in 2014.3 The incidence of lung cancer increases with age,4 and the risk increases with the cumulative effects of past smoking. Millions of Medicare beneficiaries are at significant risk.5On December 31, 2013, lung cancer screening using low-dose computed tomography (LDCT) was rated as a level “B” recommendation by the US Preventive Services Task Force (USPSTF),6 a panel of independent experts convened by the Agency for Healthcare Research and Quality to evaluate the strength of evidence and the balance of benefits and harms of preventive services.7 The USPSTF recommendation applies to people aged 55 to 80 years with a history of heavy smoking.6 LDCT is an imaging technology that enables 3-dimensional visualization of internal body structures, including the lungs, using low doses of radiation.Under the Affordable Care Act, the “B” recommendation means that LDCT lung cancer screening must be covered without cost-sharing by qualified health plans starting January 1, 2015.6,8 Qualified health plans include commercial insurance and self-insured benefit plans, with the exclusion of grandfathered plans. Several private insurers have initiated LDCT screening coverage in advance of the 2015 requirement.9 Furthermore, versions of the USPSTF recommendations have been adopted essentially by every major academic body with an interest in lung cancer, including the National Comprehensive Cancer Network, American Association for Thoracic Surgery, American College of Radiology, Society of Thoracic Surgeons, International Association for the Study of Lung Cancer, American College of Chest Physicians, and the American Cancer Society.Medicare has begun a national coverage analysis to determine whether LDCT lung cancer screening meets its criteria for coverage, which includes whether screening is reasonable and necessary for early detection, whether the service has an “A” or a “B” recommendation by the USPSTF, and whether screening is appropriate for Medicare beneficiaries.High doses of radiation can be harmful. LDCT can be performed at very low doses of <0.7 mSv per procedure10 by comparison, the annual natural background radiation in New York City (sea level) is 3 mSv. LDCT technology refinements and protocol optimization have translated into patient benefits, supporting the detection of ever-smaller lung cancers, reducing the rate of surgical procedures, and providing higher cure rates.11–14Advances in LDCT technology, promising results from nonrandomized trials,14 and unchanged survival statistics over the previous 30 years, led to the implementation of the National Lung Screening Trial (NLST), the most expensive and one of the largest randomized screening trials ever sponsored by the National Cancer Institute.13 The trial of 53,454 people aged 55 to 74 years at high risk for lung cancer was conducted to determine whether LDCT screening could reduce mortality from lung cancer. Participants in this 2-arm US study received 3 annual screenings with either an LDCT or a chest x-ray. Based on the study protocol, the trial was stopped when findings demonstrated a relative reduction of 20% in lung cancer mortality in the LDCT arm versus the chest x-ray arm.13Observational data and epidemiologic arguments for breast cancer also suggest that additional rounds of screening would reduce lung cancer mortality by much more than 20%.15–22 Other large studies have shown that computed tomography (CT) screening is associated with a high proportion (much higher than 70%) of the lung cancer diagnoses being early stage15–17,21 compared with 15% in the national data.23 Long-term survival rates of approximately 80% have been reported for patients with lung cancer who are diagnosed by CT screening12,15,16 compared with a 16.8% 5-year survival rate from the national data.23

KEY POINTS

• ▸ Lung cancer is the leading cause of cancer death in the United States and worldwide.
• ▸ Because the risk increases with age and with a history of smoking, some Medicare beneficiaries are at high risk for this type of cancer.
• ▸ Low-dose computed tomography (LDCT) has been shown to reduce mortality from lung cancer by more than 20%.
• ▸ Under healthcare reform, LDCT must be covered without cost-sharing by nongrandfathered commercial health plans beginning in 2015.
• ▸ Based on this new analysis, LDCT screening of high-risk Medicare beneficiaries is cost-effective and will cost approximately $1 per member per month.
• ▸ The average annual cost of such a screening policy is estimated to be $241 for a Medicare beneficiary screened.
• ▸ Given all causes of mortality, without screening, Medicare patients newly diagnosed with lung cancer have an average of 3 years life expectancy.
• ▸ With screening, these patients would have an additional 4 years of additional life expectancy incremental to the life expectancy without screening.
• ▸ If all eligible beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014.

One of the coauthors of this article was the lead author of an actuarial analysis of LDCT lung cancer screening for the commercially insured population.24 This report used similar methodology, types of structures, and data to examine lung cancer screening for the Medicare program. The Medicare program faces significant budget limitations, and any new coverage benefit will face scrutiny regarding its costs and benefits.The purpose of the present study was to estimate the hypothetical 2014 costs and benefits associated with the responsible implementation of widespread lung cancer screening in the high-risk US population covered by Medicare.