From the Journals

CRC: Mailing fecal test kits appears cost effective, boosts screening



Mailing fecal immunochemical testing (FIT) kits with colorectal cancer (CRC) screening reminders appears cost effective and may boost screening rates across a variety of payers and providers, according to investigators.

Cost savings, when compared with mailing reminders alone, would be greatest from a Medicaid and state government perspective, reported lead author Stephanie B. Wheeler, PhD, MPH, of the University of North Carolina at Chapel Hill and colleagues.

“As payers and providers endeavor to increase the proportion of age-eligible adults who are up to date with CRC screening, according to the National Colorectal Cancer Roundtable target of 80% screened, understanding the comparative value of mailed FIT-based programs in low-income populations is urgently needed,” the investigators wrote in Cancer.

To address this need, Dr. Wheeler and colleagues coupled a randomized clinical trial with a cost-effectiveness analysis.

The trial involved 2,144 North Carolina Medicaid enrollees between 52 and 64 years of age who were overdue for CRC screening. Participants were randomly assigned to receive either a mailed reminder with an FIT kit or a mailed reminder alone. Those who received the reminder alone were provided with information about how to get an FIT kit or undergo screening colonoscopy.

The screening rate was significantly higher in the combination mailer group than it was the reminder-only group, at 21.1% versus 12.3% (P less than .01). Based on data from previous research, the investigators estimated that a number of participants also underwent colonoscopy screenings because of the reminders; this resulted in an estimated 23.3% screening rate among those who received an FIT kit, compared with 15.8% among those who received a reminder alone.

For cost analysis, these rates were entered into a model involving 35,000 Medicaid enrollees. Annual costs were compared from two perspectives: Medicaid/state and health clinic/facility, the latter of which included primary care providers, integrated health care systems, county health departments, and federally qualified health centers. The model incorporated a number of costs, such as those associated with equipment, mailing supplies, FIT kits, colonoscopy screenings, and personnel.

From a Medicaid/state perspective, the estimated total population screening cost of mailing both an FIT kit and reminder was $1.40 million, compared with $1.45 million for a reminder alone. This translated to a total cost per person screened of $172 for the combination mailer versus $262 for the reminder alone.

“Notably, compared with the reminder-only alternative, the reminder + FIT alternative was cost-saving or dominant from this perspective because it yielded more screenings at lower cost,” the investigators wrote.

The cost analysis from a health clinic/facility perspective was more nuanced.

While the estimated total population screening cost of a combination mailer was more than the reminder alone ($927,000 vs. $624,000), sending test kits led to screening of 2,598 additional individuals (8,131 vs. 5,533). The incremental cost-effectiveness ratio (ICER) for the combination mailer was $116 per person screened.

“This ICER fell within the range of what decision makers typically would be willing to pay for an additional person screened for CRC, previously shown to include ICERs as high as several hundred dollars or more,” the investigators noted.

According to Beverly B. Green, MD, MPH, of Kaiser Permanente Washington, Seattle, and Richard T. Meenan, PhD, MPH, of Kaiser Permanente Northwest, Portland, Oregon, who wrote a simultaneously published editorial, the study “suggests that direct FIT mailing can be highly cost effective if not cost saving within the Medicaid population, similar to tobacco-cessation programs or diabetes prevention programs in the same context of a Medicaid population.”

Still, practical details need to be resolved prior to real-world application, they added.

“[T]he analysis by Wheeler et al. raises an important question: Who should pay for mailed FIT screening programs?”

The answer, they suggested, may be health plans, since prevention of CRC could mitigate greater costs of care down the line. Further motivation could come from a program such as the Medicare 5-star program, which rewards higher screening rates with bonuses such as longer enrollment periods and higher payments, according to Dr. Green and Dr. Meenan.

“Unsurprisingly, Medicare CRC screening rates have been steadily increasing and now are approaching 80%,” they noted, “whereas Medicaid CRC screening rates remain low.”

The study was supported by the University of North Carolina, the Cancer Prevention and Control Research Network, the Centers for Disease Control and Prevention, and the National Cancer Institute. Dr. Wheeler reported grant funding from Pfizer.

SOURCE: Wheeler SB et al. Cancer. 2020 Jul 20. doi: 10.1002/cncr.32992.

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