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Published on: August 1, 2019
Initial evaluation of rectal bleeding in young persons: a cost-effectiveness analysis
James D Lewis1, Alphonso Brown, A Russell Localio
1Center for Clinical Epidemiology and Biostatistics, Blockley Hall, 9th Floor, 423 Guardian Drive, Philadelphia, PA 19104-6021, USA.
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.
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