Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening

Lee et al. BMC Gastroenterology 2011, 11:93 http://www.biomedcentral.com/1471-230X/11/93 RESEARCH ARTICLE Open Access Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening Jeffrey K Lee1, Erik J Groessl2,3, Theodore G Ganiats3 and Samuel B Ho1* Abstract Background: Colorectal cancer (CRC) screening rates are low in many areas and cost-effective interventions to promote CRC screening are needed. Recently in a randomized controlled trial, a mailed educational reminder increased CRC screening rates by 16.2% among U.S. Veterans. The aim of our study was to assess the costs and cost-effectiveness of a mailed educational reminder on fecal occult blood test (FOBT) adherence. Methods: In a blinded, randomized, controlled trial, 769 patients were randomly assigned to the usual care group (FOBT alone, n = 382) or the intervention group (FOBT plus a mailed reminder, n = 387). Ten days after picking up the FOBT cards, a 1-page reminder with information related to CRC screening was mailed to the intervention group. Primary outcome was number of returned FOBT cards after 6 months. The costs and incremental costeffectiveness ratio (ICER) of the intervention were assessed and calculated respectively. Sensitivity analyses were based on varying costs of labor and supplies. Results: At 6 months after card distribution, 64.6% patients in the intervention group returned FOBT cards compared with 48.4% in the control group (P < 0.001). The total cost of the intervention was $962 or $2.49 per patient, and the ICER was $15 per additional person screened for CRC. Sensitivity analysis based on a 10% cost variation was $13.50 to $16.50 per additional patient screened for CRC. Conclusions: A simple mailed educational reminder increases FOBT card return rate at a cost many health care systems can afford. Compared to other patient-directed interventions (telephone, letters from physicians, mailed reminders) for CRC screening, our intervention was more effective and cost-effective. Keywords: Cost-effectiveness, Reminder, Colorectal Cancer, Screening, FOBT Background Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the United States and a common cause of morbidity and mortality worldwide [1]. In 2008, about 148,000 new cases of CRC will be diagnosed, and about 50,000 people will die from this disease [2]. Several randomized controlled trials have shown evidence for the effectiveness of fecal occult blood testing (FOBT) in reducing CRC mortality by using samples from three successive stools [3,4]. In one randomized trial, annual FOBT followed by colonoscopy in those with a positive test reduced colorectal cancer mortality by 33% [5]. The impact of FOBT screening on * Correspondence: 1 Department of Medicine, VA San Diego Healthcare System and University of California, San Diego, 3350 La Jolla Village Drive, San Diego, California 92161, USA Full list of author information is available at the end of the article CRC incidence and mortality is likely due to the early detection and removal of precancerous adenomatous polyps and earlier stage cancers. National efforts have been made to increase awareness of CRC screening over the past several years. Recently, the United States Preventive Services Task Force (USPSTF) and National Comprehensive Cancer Network (NCCN) recommend all individuals aged 50 to 75 years, who are at average risk for CRC to use one of the following methods for CRC screening: an annual high sensitivity FOBT, a flexible sigmoidoscopy every 5 years, or a colonoscopy every 10 years [6,7]. Despite these recommendations and guidelines, CRC screening rates remain low. As of 2006, almost 50% of adults age 50 years or older were not up-to-date with CRC screening [2]. Numerous studies have shown that patient compliance in CRC screening programs and FOBT card return rates © 2011 Lee et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Lee et al. BMC Gastroenterology 2011, 11:93 http://www.biomedcentral.com/1471-230X/11/93 are suboptimal [8-11]. As a result, interest in cost-effective patient-directed interventions to promote CRC screening remains keen. Recently, we reported that a mailed educational reminder increased FOBT card return rate for CRC screening by 16.2% (P < 0.001) at a large Veteran Affairs (VA) medical center [12]. However, it is not known if our intervention was cost-effective, particularly in the context of other similar cancer screening promotion programs. Given the highly constrained resources for health promotion, it is essential for decision makers to require information on the costs and cost-effectiveness of the interventions. Although there have been several studies on the economics of cervical cancer and mammography screening promotion [13,14], few studies have evaluated the cost-effectiveness of patient or providerdirected interventions for CRC screening in average risk patients, especially in the VA population [15-20]. The primary aim of this study is to assess the costs and costeffectiveness of our mailed educational reminder on adherence with FOBT-type screening among the U.S. Veteran population. Methods Data for this study were collected in 2007 and analyses were conducted in 2008-2009. Detailed descriptions of the design, methods, primary, and secondary outcomes of the randomized controlled trial on using a mailed educational reminder to increase FOBT card return rates have been published [12]. Here we provide a brief summary of the clinical trial and analytic methods below Clinical Trial To test the effect of a mailed educational reminder on increasing FOBT card return rate for CRC screening, we conducted a double-blind, randomized controlled trial in a U.S. Veteran patient population. Patients meeting inclusion criteria (age ≥ 50, not up to date with CRC screening) were randomly assigned to receive either usual care or usual care with a mailed educational reminder (intervention), which was mailed 10 days after the patients received their FOBT cards from the laboratory. All patients were given 6 months to return the FOBT cards. Study Setting and Population We evaluated patients from three VA primary care clinics in San Diego and Vista, California between June 1 and September 9, 2007. The study included asymptomatic men and women age 50 years or older who agreed with screening and received FOBT card kits with a postage paid return envelope. Under usual care, primary care physicians (PCP) entered a computerized order for FOBT for CRC screening, and then patients Page 2 of 8 were instructed by their PCP to pick up FOBT cards from the laboratory and return them for analysis. Patients were excluded from this study if they were less than (...truncated)