Cost-effectiveness of an early awareness campaign for colorectal cancer


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Cost-effectiveness of an early awareness campaign for colorectal cancer

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  • Used an existing model of CRC screening in England.The original model consists of two components: the first describes the natural history of CRC by representing the development of adenomas and their progression to CRC, and the second describes the effect of screening and surveillance.Mention calibration.
  • Say ICER<£20K
  • Suggest collecting data for 2 years (1 year before campaign and 1 year after campaign). Allow differentiation between seasonal variations and campaign effect.Report all data split into 5 /10 year age bands.
  • Cost-effectiveness of an early awareness campaign for colorectal cancer

    1. 1. Cost-effectiveness of an early awareness campaign for colorectal cancer Sophie Whyte 1, Sue Harnan 1, Paul Tappenden 1, Mark Sculpher 2, Seb Hinde 2, Claire Mckenna 2 Policy Research Unit in Economic Evaluation of Health and Care Intervention (EEPRU) 1 School of Health and Related Research (ScHARR), University of Sheffield 2 Centre for Health Economics, University of York Contact:
    2. 2. Early awareness campaigns • The primary aim of cancer awareness campaigns is earlier presentation of symptomatic cancers through improved public knowledge of the symptoms
    3. 3. Data from early awareness campaigns Data from the pilot early awareness campaign for colorectal cancer showed an increase in GP referrals for a short period following the campaign.
    4. 4. Awareness campaign efficacy Key questions: • Does this data mean the campaign ‘worked’? • Should it be repeated? To understand benefit of campaign need information on longer-term outcomes such as ‘change in cancer incidence or mortality’
    5. 5. • A campaign may also lead to increased numbers of GP attendances by the ‘worried well’ • Some critics assert that the campaigns will ‘undo years of work persuading patients with minor ailments to stay at home’.
    6. 6. Project Aim • Estimate cost effectiveness of an early awareness campaign using data from the colorectal cancer early awareness campaign piloted in the East of England and south west regions in January 2011. • The estimates provide an improved understanding of the benefits of such a campaign so can be used to inform policy decisions.
    7. 7. Potential effects of an early awareness campaign for colorectal cancer Public awareness of signs and symptoms Increase in awareness? Early Awareness campaign TV, radio, press, online, etc. GP consultations Increase? GP referrals for suspected CRC Increase? Cancer diagnoses Change in incidence/stage distribution? Diagnosis of other lower GI conditions Increase? Cancer mortality Decrease? CRC screening Increase in uptake? lives save d treatment costs consultation costs campaign costs referral costs screening costs
    8. 8. Scope of analysis The analysis captures: • the direct costs of the campaign, • the costs any additional GP consultations/appointments in secondary care resulting from the campaign • benefits of the campaign due to earlier diagnosis and any change in screening uptake.
    9. 9. Data from the pilot campaign used in the modelling Data observed from pilot campaign Base case assumption in model Scenario analyses GP attendances 700 increase over 3 month period (532 increase if diarrhoea included as a symptom) Equivalent to 60,000- 80,000 nationally. 70,000 more attendances nationally over 3 month period Assumed 50% ‘additional’& 50% ‘earlier’ Assumed 90% ‘additional’ & 10% ‘earlier’ GP referrals 1,956 increase in referrals over 5 month period (+28%) 17,519 additional referrals nationally Assumed 50% ‘additional’& 50% ‘earlier’ Assumed 90% ‘additional’ & 10% ‘earlier’ CRC incidence 7-11% increase in incidence for 1 month 10% increase in presentation rates for 1 month 5-20% magnitude 1-6 month duration CRC incidence stage distribution Numbers too small to draw any conclusions Campaign assumed to have the same proportional effect on presentation rates for each CRC stage. Short term increase in incidence only consists of Dukes stages C & D CRC screening uptake No significant change which could be attributed to the campaign Assume screening uptake unaffected by campaign Exploratory analysis undertaken Cost of running campaign £5 million £5 million -
    10. 10. Methods • Pilot data demonstrates short term impacts of the awareness campaign. • A mathematical model was used in combination with the pilot data to predict long term impacts of the campaign on cancer incidence, mortality and costs. • An existing mathematical model [1] was adapted (representing the CRC disease natural history, symptomatic presentation and the bowel cancer screening programme). [1] Re-appraisal of the options for colorectal cancer screening in England; Whyte S, Chilcott J, Halloran S, (Colorectal Disease, March 2012)
    11. 11. CRC=colorectal cancer, LR=low risk,HR=highrisk Normal Epithelium LR adenomas HR adenomas Dukes’A CRC Dukes’B CRC Dukes’C CRC Stage DCRC Dead(CRC) Dukes’A CRC clinical Dukes’C CRC clinical Stage DCRCclinical Dukes’ B CRCclinical Dead(non-CRC) Transitionestimatedwithinmodel calibration Transitionestimateddirectly from mortality data CRC natural history model CRC screening pathways Invited to screening Screening test completed Donot attend screening Donot attend follow up Noadenomas Positivescreening result–refer to follow up(colonoscopy) Negativescreening testresult/ LR adenomas found Returnto general screening population LR adenomas HR adenomas CRC CRCtreatment Attendfollow up Surveillance(annual/ 3-yearlycolonoscopy) Model structure
    12. 12. Modelling methodology • Four rates relating to symptomatic or chance presentation with Dukes’ A-D CRC. Baseline presentation rates reflect the England population from years 2004 to 2006 i.e. before screening commenced. • The four transition probabilities are increased to result in an increase in incidence which matches the observed increase seen in the pilot campaign. • Assumption: campaign causes a temporary change in the transition probabilities and that subsequently these probabilities will return to their pre-campaign values. • No data available on stage distribution of incidence. -> Assume that the extra incidence due to the awareness campaign has the usual CRC stage distribution.
    13. 13. Results-Effectiveness The campaign causes: Dukes’ stage A-C CRC presenting symptomatically Stage D CRC presenting symptomatically. CRC presenting symptomatically. Screen/surveillance detected CRC CRC specific deaths QALYs.
    14. 14. Results-Costs Overall the campaign lead to increase in NHS costs Campaign running cost Screening costs (caused by a decrease in positives at screening since more CRC presents symptomatically) CRC treatment costs (1) CRC is presenting at younger ages which are associated with higher treatment costs. (2) A shift of cases from stage D to Dukes’ C and Dukes’ C CRC is associated with higher treatment costs than Dukes’ D. Costs associated with increased GP consultations and referrals (account for only a small proportion of total costs and are considerably less than the cost of the campaign itself)
    15. 15. Model predictions CRC incidence - symptomatic presentation Dukes Stage A 26 B 52 C 33 D -92 CRC incidence - symptomatic presentation TOTAL 20 CRC incidence screen/surveillance detected Dukes Stage A -0 B -1 C -2 D -2 CRC incidence - screening/surveillance detected TOTAL -5 CRC-specific deaths -66 Deaths with undiagnosed CRC -14 Total costs related to screening (discounted) 3,407-£ Cancer management (inc. pathology) costs (discounted) 94,443£ Cost of additional GP consultations/referrals (discounted) 855,716£ Cost of awareness campaign (discounted) 4,499,995£ Total cost (discounted) 5,446,745£ Total life years gained (discounted) 622 Total QALYs gained (discounted) 404 ICER 13,496£ NMB 2,624,770£ Model predictions for the current population of England evaluated over a lifetime: Change compared to 'No awareness campaign' For a CRC awareness campaign resulting in a 10% increase in presentation rates for a period of one month
    16. 16. Modelling uncertainty in change in presentation rates due to campaign: duration and magnitude 0% 5% 10% 15% 20% 0 1 2 3 4 5 6 Increase in symptomatic presentation rate (%) Duration of increase in symptomatic presentation rate (months) Number of CRC deaths prevented 800-900 700-800 600-700 500-600 400-500 300-400 200-300 100-200 0-100 base case= 66 deaths prevented
    17. 17. 0.05 0.1 0.15 0.2 1 2 3 4 5 6 Increase in symptomatic presentation rate (%) Duration of increase in symptomatic presentation rate (months) ICER 25000-30000 20000-25000 15000-20000 10000-15000 5000-10000 0-5000 base case= ICER=£13K per QALY Modelling uncertainty in change in presentation rates due to campaign: duration and magnitude
    18. 18. Priorities for future research Co-ordinate and maximise the evaluation and dissemination of efforts that have already been made to increase cancer awareness. • comparison with non-intervention regions • clear reporting of completeness of data and potential data limitations Information of importance for future modelling studies: • duration of effect of campaign • effect of campaign on CRC incidence • effect of campaign on emergency presentation rates • effect of campaign by age • differential diagnoses costs associated with emergency presentation versus two-week wait referrals • rates of diagnosis of other lower GI conditions with similar symptoms to CRC.