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Model Simulation With Cost-effectiveness Analysis

Cesare Hassan, MD; Perry Pickhardt, MD; Andrea Laghi, MD; Daniel Kim, MD; Angelo Zullo, MD; Franco Iafrate, MD; Lorenzo Di Giulio, MD; Sergio Morini, MD

Arch Intern Med. 2008;168(7):696-705.

Background  In addition to detecting colorectal neoplasia, abdominal computed tomography (CT) with colonography technique (CTC) can also detect unsuspected extracolonic cancers and abdominal aortic aneurysms (AAA).The efficacy and cost-effectiveness of this combined abdominal CT screening strategy are unknown.

Methods  A computerized Markov model was constructed to simulate the occurrence of colorectal neoplasia, extracolonic malignant neoplasm, and AAA in a hypothetical cohort of 100 000 subjects from the United States who were 50 years of age. Simulated screening with CTC, using a 6-mm polyp size threshold for reporting, was compared with a competing model of optical colonoscopy (OC), both without and with abdominal ultrasonography for AAA detection (OC-US strategy).

Results  In the simulated population, CTC was the dominant screening strategy, gaining an additional 1458 and 462 life-years compared with the OC and OC-US strategies and being less costly, with a savings of $266 and $449 per person, respectively. The additional gains for CTC were largely due to a decrease in AAA-related deaths, whereas the modeled benefit from extracolonic cancer downstaging was a relatively minor factor. At sensitivity analysis, OC-US became more cost-effective only when the CTC sensitivity for large polyps dropped to 61% or when broad variations of costs were simulated, such as an increase in CTC cost from $814 to $1300 or a decrease in OC cost from $1100 to $500.With the OC-US approach, suboptimal compliance had a strong negative influence on efficacy and cost-effectiveness. The estimated mortality from CT-induced cancer was less than estimated colonoscopy-related mortality (8 vs 22 deaths), both of which were minor compared with the positive benefit from screening.

Conclusion  When detection of extracolonic findings such as AAA and extracolonic cancer are considered in addition to colorectal neoplasia in our model simulation, CT colonography is a dominant screening strategy (ie, more clinically effective and more cost-effective) over both colonoscopy and colonoscopy with 1-time ultrasonography.

Author Affiliations: Gastroenterology and Digestive Endoscopy Unit, "Nuovo Regina Margherita"Hospital, Rome, Italy (Drs Hassan, Zullo, and Morini); Department of Radiology, University of Wisconsin Medical School, Madison (Drs Pickhardt and Kim); Department of Radiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland (Dr Pickhardt); Department of Radiological Sciences, University "Polo Pontino," Rome (Drs Laghi and Iafrate); and Department of Vascular Surgery, University of Rome "Tor Vergata," Rome (Dr Di Giulio).

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