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

James D. Lewis, MD, MSCE; Alphonso Brown, MD; A. Russell Localio, JD, MS; and J. Sanford Schwartz, MD
[+] Article and Author Information

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.


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.


Ann Intern Med. 2002;136(2):99-110. doi:10.7326/0003-4819-136-2-200201150-00007
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Colorectal cancer is the third most common cause of cancer-related death in men and women (1). The incidence increases with increasing age, and before 40 years of age, the risk for colorectal cancer is low (2). The disease can be effectively prevented by endoscopic removal of precancerous adenomatous polyps (3). After invasive cancer develops, mortality from colorectal cancer increases with advancing cancer stage at diagnosis (1). Most medical professional societies recommend routine screening with fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, or barium enema beginning at 50 years of age for average-risk patients and 40 years of age for persons at increased risk (1).

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Figure 2.
Cost-effectiveness of strategies for the evaluation of rectal bleeding in the base-case analysis.

The figure includes the discounted lifetime cost and expected survival per patient for each of the alternative strategies examined. Incremental cost-effectiveness ratios are equal to the slope of the line between any two points and can be calculated from the data at the bottom of the figure. No evaluation offered the shortest life expectancy, and a strategy of flexible sigmoidoscopy plus barium enema offered the greatest life expectancy. All strategies using anoscopy followed by further evaluation if needed resulted in reduced life expectancy compared with all strategies in which all patients undergo evaluation of the colon with endoscopy or barium enema.

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Figure 3.
Multiway probabilistic sensitivity analysis comparing flexible sigmoidoscopy in all patients with a strategy of anoscopy followed by flexible sigmoidoscopy if anal disease is not identified on anoscopy.

The multiway analysis allowed all probability variables to vary simultaneously across the full range of values examined. The plotted values represent the incremental cost-effectiveness ratio from 1000 trials. The ellipse shows the middle 95th percentile of this distribution (from the 2.5th to the 97.5th percentiles). The mean incremental cost-effectiveness ratio (±SD) was $11 461 ± $14 773 per year of life saved. Only 2.5% of the values exceeded $52 158 per year of life gained.

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Figure 1.
Overview of the Markov model.Top.Bottom.

The alternative diagnostic strategies. Patients with rectal bleeding undergo no evaluation, undergo anoscopy, or undergo a diagnostic test. Patients undergoing anoscopy are referred for further diagnostic testing only if no lesions are identified on anoscopy. All patients with colitis eventually undergo colonoscopy. The circled “M” notations represent Markov nodes in the computer program. The potential consequences of colonoscopy. Patients with detected adenomas or who survive cancer therapy enter surveillance programs. Undetected adenomas may remain as adenomas or may advance to cancer. Adenomas and cancers may also be detected at the time of colorectal cancer screening.

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Summary for Patients

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

The summary below is from the full report titled “Initial Evaluation of Rectal Bleeding in Young Persons: A Cost- Effectiveness Analysis.” It is in the 15 January 2002 issue of Annals of Internal Medicine (volume 136, pages 99-110). The authors are JD Lewis, A Brown, AR Localio, and JS Schwartz.

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