Initial Evaluation of Rectal Bleeding in Young Persons: A Cost-Effectiveness Analysis

  1. James D. Lewis, MD, MSCE;
  2. Alphonso Brown, MD;
  3. A. Russell Localio, JD, MS; and
  4. J. Sanford Schwartz, MD
  1. From Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Cancer Center, Leonard Davis Institute of Health Economics, and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

    Abstract

    Background: Evaluation of rectal bleeding in young patients is a frequent diagnostic challenge.

    Objective: To determine the relative cost-effectiveness of alternative diagnostic strategies for young patients with rectal bleeding.

    Design: Cost-effectiveness analysis using a Markov model.

    Data Sources: Probability estimates were based on published medical literature. Cost estimates were based on Medicare reimbursement rates and published medical literature.

    Target Population: Persons 25 to 45 years of age with otherwise asymptomatic rectal bleeding.

    Time Horizon: The patient's lifetime.

    Perspective: Modified societal perspective.

    Interventions: Diagnostic strategies included no evaluation, colonoscopy, flexible sigmoidoscopy, barium enema, anoscopy, or any feasible combination of these procedures.

    Outcome Measures: Life expectancy and costs.

    Results of Base-Case Analysis: For 35-year-old patients, the no-evaluation strategy yielded the least life expectancy. The incremental cost-effectiveness of flexible sigmoidoscopy compared with no evaluation or with any strategy incorporating anoscopy (followed by further evaluation if no anal disease was found on anoscopy) was less than $5300 per year of life gained. A strategy of flexible sigmoidoscopy plus barium enema yielded the greatest life expectancy, with an incremental cost of $23 918 per additional life-year gained compared with flexible sigmoidoscopy alone.

    Results of Sensitivity Analysis: As patient age at presentation of rectal bleeding increased, evaluation of the entire colon became more cost-effective. The incremental cost-effectiveness of flexible sigmoidoscopy plus barium enema compared with colonoscopy was sensitive to estimates of the sensitivity of the tests. In a probabilistic sensitivity analysis comparing flexible sigmoidoscopy with anoscopy followed by flexible sigmoidoscopy if needed, the middle 95th percentile of the distribution of the incremental cost-effectiveness ratios ranged from flexible sigmoidoscopy yielding an increased life expectancy at reduced cost to $52 158 per year of life gained (mean, $11 461 per year of life saved).

    Conclusions: Evaluation of the colon of persons 25 to 45 years of age with otherwise asymptomatic rectal bleeding increases the life expectancy at a cost comparable to that of colon cancer screening.

    Article and Author Information

    • Grant Support: Dr. Lewis was supported in part by grant 1-K08-DK02589-0 from the National Institutes of Health.

    • Requests for Single Reprints: James D. Lewis, MD, MSCE, Center for Clinical Epidemiology and Biostatistics, Blockley Hall, 9th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021.

    • Current Author Addresses: Dr. Lewis: Center for Clinical Epidemiology and Biostatistics, Blockley Hall, 9th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021.

    • Dr. Brown: Division of Gastroenterology, University of North Carolina, 729-A Burnett–Womack Building, Chapel Hill, NC 27599.

    • Dr. Schwartz: Blockley Hall, Suite 1120, 423 Guardian Drive, Philadelphia, PA 19104-6021.

    • Mr. Localio: Center for Clinical Epidemiology and Biostatistics, Blockley Hall, 6th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021.

    • Author Contributions: Conception and design: J.D. Lewis, A. Brown, J.S. Schwartz

    • Analysis and interpretation of the data: J.D. Lewis, A. Brown, A.R. Localio, J.S. Schwartz.

    • Drafting of the article: J.D. Lewis, A. Brown, A.R. Localio.

    • Critical revision of the article for important intellectual content: J.D. Lewis, A. Brown, A.R. Localio, J.S. Schwartz.

    • Final approval of the article: J.D. Lewis, A. Brown, A.R. Localio, J.S. Schwartz.

    • Provision of study materials or patients: J.D. Lewis, A. Brown.

    • Statistical expertise: J.D. Lewis, A.R. Localio.

    • Collection and assembly of data: J.D. Lewis, A. Brown.

    Summary for Patients

    • Summaries for Patients:Initial Evaluation of Rectal Bleeding in Young Persons: A Cost-Effectiveness Analysis Ann Intern Med January 15, 2002 136:I30
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    1. Ann Intern Med January 15, 2002 vol. 136 no. 2 99-110
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