Cost-Effectiveness Analysis of Four Simulated Colorectal Cancer Screening Interventions, North Carolina

Abstract

Introduction Colorectal cancer (CRC) screening rates are suboptimal, particularlyamong the uninsured and the under-insured and among ruraland African American populations. Little guidance is available forstate-level decision makers to use to prioritize investment in evidence-based interventions to improve their population’s health. Theobjective of this study was to demonstrate use of a simulationmodel that incorporates synthetic census data and claims-basedstatistical models to project screening behavior in North Carolina.MethodsWe used individual-based modeling to simulate and compare interventioncosts and results under 4 evidence-based and stakeholder-informed intervention scenarios for a 10-year intervention window,from January 1, 2014, through December 31, 2023. We comparedthe proportion of people living in North Carolina who wereaged 50 to 75 years at some point during the window (that is, ageeligiblefor screening) who were up to date with CRC screeningrecommendations across intervention scenarios, both overall andamong groups with documented disparities in receipt of screening. We estimated that the costs of the 4 intervention scenarios consideredwould range from $1.6 million to $3.75 million. Our modelshowed that mailed reminders for Medicaid enrollees, mass mediacampaigns targeting African Americans, and colonoscopyvouchers for the uninsured reduced disparities in receipt of screeningby 2023, but produced only small increases in overall screeningrates (0.2–0.5 percentage-point increases in the percentage ofage-eligible adults who were up to date with CRC screening recommendations).Increased screenings ranged from 41,709 additionallife-years up to date with screening for the voucher interventionto 145,821 for the mass media intervention. Remindersmailed to Medicaid enrollees and the mass media campaign forAfrican Americans were the most cost-effective interventions,with costs per additional life-year up to date with screening of $25or less. The intervention expanding the number of endoscopy facilitiescost more than the other 3 interventions and was less effectivein increasing CRC screening.ConclusionCost-effective CRC screening interventions targeting observeddisparities are available, but substantial investment (more than$3.75 million) and additional approaches beyond those consideredhere are required to realize greater increases population-wide