Trends and Projections in National United States Health Care Spending for Gastrointestinal Malignancies (1996-2030).

BACKGROUND & AIMS: The management of gastrointestinal (GI) cancers is associated with high health care spending. We estimated trends in United States (US) health care spending for patients with GI cancers between 1996 and 2016 and developed projections to 2030. METHODS: We used economic data, adjusted for inflation, developed by the Institute for Health Metrics and Evaluations for the Disease Expenditure Project. Corresponding US age-adjusted prevalence of GI cancers was estimated from the Global Burden of Diseases Study. Prevalence-adjusted temporal trends in the US health care spending in patients with GI cancers, stratified by cancer site, age, and setting of care, were estimated using joinpoint regression, expressed as annual percentage change (APC) with 95% confidence intervals (CIs). Autoregressive integrated moving average models were used to project spending to 2030. RESULTS: In 2016, total spending for GI cancers was primarily attributable to colorectal ($10.50 billion; 95% CI, $9.35-$11.70 billion) and pancreatic cancer ($2.55 billion; 95% CI, $2.23-$2.82 billion), and primarily for inpatient care (64.5%). Despite increased total spending, more recent per-patient spending for pancreatic (APC 2008-2016, -1.4%; 95% CI, -2.2% to -0.7%), gallbladder/biliary tract (APC 2010-2016, -4.3%; 95% CI, -4.8% to -3.8%), and gastric cancer (APC 2011-2016, -4.4%; 95% CI, -5.8% to -2.9%) decreased. Increasing price and intensity of care provision was the largest driver of higher expenditures. By 2030, it is projected more than $21 billion annually will be spent on GI cancer management. CONCLUSIONS: Total spending for GI cancers in the US is substantial and projected to increase. Expenditures are primarily driven by inpatient care for colorectal cancer, although per-capita spending trends differ by GI cancer type.

Validation of the Model of End-Stage Liver Disease for Liver Transplant Allocation in Alberta: Implications for Future Directions in Canada.

Background. Since 2002, the Model of End-Stage Liver Disease (MELD) has been used for allocation of liver transplants (LT) in the USA. In Canada, livers were allocated by the CanWAIT algorithm. The aim of this study was to compare the abilities of MELD, Child-Pugh (CP), and CanWAIT status to predict 3-month and 1-year mortality before LT in Canadian patients and to describe the use of MELD in Canada. Methods. Validation of MELD was performed in 320 patients listed for LT in Alberta (1998-2002). In October 2014, a survey of MELD use by Canadian LT centers was conducted. Results. Within 1 year of listing, 47 patients were removed from the waiting list (29 deaths, 18 too ill for LT). Using logistic regression, the MELD and CP were better than the CanWAIT at predicting 3-month (AUROC: 0.79, 0.78, and 0.59; p = 0.0002) and 1-year waitlist mortality (AUROC: 0.70, 0.70, and 0.55; p = 0.0023). Beginning in 2004, MELD began to be adopted by Canadian LT programs but its use was not standardized. Conclusions. Compared with the CanWAIT system, the MELD score was significantly better at predicting LT waitlist mortality. MELD-sodium (MELD-Na) has now been adopted for LT allocation in Canada.

Reactions to a targeted intervention to increase fecal occult blood testing among average-risk adults waiting for screening colonoscopy.

BACKGROUND: Increasing demand combined with limited capacity has resulted in long wait times for average-risk adults referred for screening colonoscopy for colorectal cancer. Management of patients on these growing wait lists is an emerging clinical issue. OBJECTIVE: To inform the content and design of a mailed targeted invitation for patients to undergo annual fecal occult blood testing (FOBT) while awaiting colonoscopy. METHODS: Focus groups (FGs) with average-risk patients on a wait list for screening colonoscopy at a high-throughput academic outpatient colonoscopy facility were conducted. During each FG session, feedback regarding a range of materials under consideration for the planned intervention was elicited using a semistructured facilitator guide. The FG sessions were recorded and transcribed verbatim, and analyzed using the constant comparative method to identify key themes. RESULTS: Findings from the three FGs (n=28) suggested that average risk patients on a wait list for screening colonoscopy would be receptive to a targeted intervention recommending they undergo FOBT while waiting. Participants indicated that the invitation to undergo FOBT was an important acknowledgement that they were on an actively managed list, and that a mechanism to ensure that they were correctly triaged while waiting was in place. Several specific suggestions to improve the design of the targeted intervention were obtained. CONCLUSIONS: Results of the present study provide useful information for developing effective strategies to manage average-risk individuals facing long wait times for screening colonoscopy.

Colorectal cancer screening for average-risk North Americans: an economic evaluation.

BACKGROUND: Colorectal cancer (CRC) fulfills the World Health Organization criteria for mass screening, but screening uptake is low in most countries. CRC screening is resource intensive, and it is unclear if an optimal strategy exists. The objective of this study was to perform an economic evaluation of CRC screening in average risk North American individuals considering all relevant screening modalities and current CRC treatment costs. METHODS AND FINDINGS: An incremental cost-utility analysis using a Markov model was performed comparing guaiac-based fecal occult blood test (FOBT) or fecal immunochemical test (FIT) annually, fecal DNA every 3 years, flexible sigmoidoscopy or computed tomographic colonography every 5 years, and colonoscopy every 10 years. All strategies were also compared to a no screening natural history arm. Given that different FIT assays and collection methods have been previously tested, three distinct FIT testing strategies were considered, on the basis of studies that have reported "low," "mid," and "high" test performance characteristics for detecting adenomas and CRC. Adenoma and CRC prevalence rates were based on a recent systematic review whereas screening adherence, test performance, and CRC treatment costs were based on publicly available data. The outcome measures included lifetime costs, number of cancers, cancer-related deaths, quality-adjusted life-years gained, and incremental cost-utility ratios. Sensitivity and scenario analyses were performed. Annual FIT, assuming mid-range testing characteristics, was more effective and less costly compared to all strategies (including no screening) except FIT-high. Among the lifetimes of 100,000 average-risk patients, the number of cancers could be reduced from 4,857 to 1,393 [corrected] and the number of CRC deaths from 1,782 [corrected] to 457, while saving CAN$68 per person. Although screening patients with FIT became more expensive than a strategy of no screening when the test performance of FIT was reduced, or the cost of managing CRC was lowered (e.g., for jurisdictions that do not fund expensive biologic chemotherapeutic regimens), CRC screening with FIT remained economically attractive. CONCLUSIONS: CRC screening with FIT reduces the risk of CRC and CRC-related deaths, and lowers health care costs in comparison to no screening and to other existing screening strategies. Health policy decision makers should consider prioritizing funding for CRC screening using FIT.

Nonmedical costs of colorectal cancer screening using CT colonography.

PURPOSE: Nonmedical costs are important because they may influence screening uptake and the results of cost-effectiveness analyses of colorectal cancer (CRC) screening. Although the nonmedical costs of CRC screening are known for fecal occult blood testing, flexible sigmoidoscopy, and colonoscopy, they are unknown for CT colonography (CTC). The purpose of this study was to determine the nonmedical costs of CTC. METHODS: Four hundred eighty-one consecutive individuals presenting for CRC screening using CTC were approached at a radiology clinic in Calgary, Alberta, Canada, to participate in the study. Of these, 197 agreed to have a questionnaire mailed to them. Subjects completed the questionnaire, including items on time off work, both for the subject and any accompanying caregiver; travel details; and direct out-of-pocket expenses. Time costs were valued at government of Canada wage rates. Travel costs included estimated costs for travel by car and actual parking costs and taxi and public transportation fares. Car user's costs were calculated using a Canadian Automobile Association estimate of motoring costs per kilometer. Costs are reported in 2010 Canadian dollars. RESULTS: One hundred thirty-two subjects returned the questionnaire (mean age, 57 years; 65% men; 67% employed). Ten subjects traveled >200 km for their CTC. The nonmedical costs (subject with or without caregiver) for the 122 subjects who resided within 200 km of the clinic averaged $101. CONCLUSIONS: The nonmedical costs of CRC screening using CTC are significant but lower than those of colonoscopy. Patients should be aware of these differential costs, and they should be incorporated into economic analyses of CRC screening.

Assessment of endoscopic training of general surgery residents in a North American health region.

BACKGROUND: Ensuring competency of trainees is a challenge for residency programs. The American Society for Gastrointestinal Endoscopy (ASGE) recommends that a minimum of 130 EGDs and 140 colonoscopies be performed to assess competency. OBJECTIVE: We assessed the number of endoscopies performed by surgery and gastroenterology residents during their training. Endoscopy patterns were also assessed for staff gastroenterology specialists and general surgeons in Alberta, Canada. DESIGN: Physician billing data were used to determine endoscopic practice patterns, and the number of endoscopies performed by gastroenterology fellows and surgery residents were obtained. SETTING: Major teaching hospital. MAIN OUTCOME MEASUREMENT: Procedure numbers. RESULTS: In large cities, the number of colonoscopies performed by gastroenterologists increased ( approximately 2-fold) over the study period (there was minimal change in endoscopy numbers by surgeons). In contrast, in smaller communities, EGDs and colonoscopies by surgeons increased about 2-fold (from approximately 4065 to 7288) and about 4-fold (from approximately 1909 to approximately 7629), respectively (with only a minimal increase in colonoscopies ( approximately 3000), by gastroenterologists. During training, gastroenterology fellows performed significantly more procedures (EGDs, 29 +/- 5.6 by surgery residents vs 363.9 +/- 12.7 by gastroenterology fellows; colonoscopies, 91 +/- 14.2 by surgery residents vs 247.8 +/- 21.6 by gastroenterology fellows). LIMITATION: All training data are from a single teaching center. CONCLUSIONS: All gastroenterology fellows, but none of the surgery residents, achieved the minimum number of endoscopic procedures recommended by the ASGE to assess competency. These data suggest that we must reexamine our training programs and/or our methods for evaluating endoscopic competence.

Nonmedical costs of colorectal cancer screening with the fecal occult blood test and colonoscopy.

BACKGROUND & AIMS: The nonmedical costs of colorectal cancer screening are unknown. However, they might influence screening uptake and impact the cost-effectiveness of colorectal cancer screening modalities. METHODS: Consecutive individuals presenting for colorectal cancer screening in the Calgary Health Region were recruited from 4 community laboratory collection sites (fecal occult blood test) and 2 endoscopy units (colonoscopy). Subjects completed a questionnaire including items on time off work for the subject and any accompanying caregiver, travel details, and direct out-of-pocket expenses (bowel prep). Time costs were valued at Government of Canada wage rates. Travel costs included estimated costs for travel by car and actual parking costs and taxi and public transportation fares. Car users' costs were calculated by using a Canadian Automobile Association estimate of motoring costs per kilometer. Costs are in 2006 Canadian dollars. RESULTS: The final sample included 604 subjects who underwent fecal occult blood test (mean age, 62 years; 51% male; 43% employed) and 723 who underwent colonoscopy (mean age, 56; 49% male; 66% employed). Eighty percent of colonoscopy subjects required an accompanying caregiver, compared with only 5% for fecal occult blood test. The nonmedical costs (subject +/- caregiver) averaged $308 for colonoscopy and $36 for fecal occult blood test. CONCLUSIONS: The nonmedical costs of colorectal cancer screening are substantial, especially for colonoscopy. However, the costs are similar with repeated fecal occult blood tests. These costs might be one factor accounting for low colorectal cancer screening uptake rates. Nonmedical costs should be incorporated into economic analyses of colorectal cancer screening.

Population-based analysis of practices and costs of surveillance for colonic dysplasia in patients with primary sclerosing cholangitis and colitis.

BACKGROUND: Patients with primary sclerosing cholangitis (PSC) and colitis are at risk of developing dysplasia and colorectal cancer (CRC). Consequently, annual surveillance colonoscopy with random biopsies is recommended. The aims of the present study were (1) to determine the incidence of dysplasia or CRC, (2) to assess surveillance practices, and (3) to assess the costs associated with surveillance of PSC patients. METHODS: A population-based study was conducted between 2000 and 2004 to identify all patients with a diagnosis of PSC using regional databases. Colonic histopathology reports of PSC patients with colitis were reviewed to determine the frequency of surveillance colonoscopies performed between 2000 and 2005, the number of biopsies retrieved, and the presence of CRC or dysplasia. The cost of annual surveillance colonoscopy with 33 random biopsies to detect 1 additional case of dysplasia was calculated from a local costs database. RESULTS: Forty-five PSC patients with ulcerative colitis or Crohn's disease were identified. Five patients (11.1%) were diagnosed with low-grade dysplasia (n = 2), dysplasia-associated lesion or mass (n = 2), or CRC (n = 1) during the 5-year follow-up period for an incidence rate of 3.1 events per 100 person-years (95% confidence interval: 1.0-7.2/100 person-years). Two of these lesions were detected through surveillance and 3 because of symptomatic presentation. Only 36% (56) of the expected number of surveillance colonoscopies were performed. The median number of biopsies collected was 27 (IQR: 19-33). The cost of surveillance to detect 1 additional case of dysplasia was USD 26,495. CONCLUSION: Despite a high rate of colorectal dysplasia or CRC among PSC patients, surveillance was suboptimal.

Cost-effectiveness of computerized tomographic colonography versus colonoscopy for colorectal cancer screening.

BACKGROUND: Computerized tomographic (CT) colonography is a potential alternative to colonoscopy for colorectal cancer screening. Its main advantage, a better safety profile, may be offset by its limitations: lower sensitivity, need for colonoscopy in cases where results are positive, and expense. METHODS: We performed an economic evaluation, using decision analysis, to compare CT colonography with colonoscopy for colorectal cancer screening in patients over 50 years of age. Three-year outcomes included number of colonoscopies, perforations and adenomas removed; deaths from perforation and from colorectal cancer from missed adenomas; and direct health care costs. The expected prevalence of adenomas, test performance characteristics of CT colonography and colonoscopy, and probability of colonoscopy complications and cancer from missed adenomas were derived from the literature. Costs were determined in detail locally. RESULTS: Using the base-case assumptions, a strategy of CT colonography for colorectal cancer screening would cost 2.27 million dollars extra per 100,000 patients screened; 3.78 perforation-related deaths would be avoided, but 4.11 extra deaths would occur from missed adenomas. Because screening with CT colonography would cost more and result in more deaths overall compared with colonoscopy, the latter remained the dominant strategy. Our results were sensitive to CT colonography's test performance characteristics, the malignant risk of missed adenomas, the risk of perforation and related death, the procedural costs and differences in screening adherence. INTERPRETATION: At present, CT colonography cannot be recommended as a primary means of population-based colorectal cancer screening in Canada.

Patterns of use of endoscopic retrograde cholangiopancreatography in a Canadian province.

BACKGROUND: Data on current endoscopic retrograde cholangiopancreatography (ERCP) practice patterns drawn from large population-based samples are limited. METHODS: Patterns of ERCP use were determined using billing records for ERCP, sphincterotomy, stone extraction or stent placement performed between April 1, 1994 and March 31, 2002 in Alberta from a population-based administrative database. Age-sex adjusted rates (per 1000 population) were calculated using the 1991 Canadian population as the standard. RESULTS: The eight-year average ERCP rate was 0.98 without evidence of an increasing or decreasing trend over time. The ERCP rate was 0.85 in men and 1.12 in women. Significant regional variation in ERCP rates was seen, ranging from a low of 0.64 to a high of 1.27. The proportion of procedures that were therapeutic increased from 33% in 1994 to 70% in 2001. The likelihood of a procedure being considered therapeutic varied with the age and sex of the patient as well as the health region in which the procedure was performed. CONCLUSIONS: The ERCP rate remained relatively stable over an eight-year time period, but the proportion of procedures that were therapeutic increased dramatically. Important regional variation in ERCP rates and therapeutic procedures exists.

Complementary and alternative medicine use by Canadian patients with inflammatory bowel disease: results from a national survey.

OBJECTIVE: Previous studies of complementary and alternative medicine (CAM) use by patients with inflammatory bowel disease (IBD) have relied on samples from specialty clinics. The aim of this study was to determine the prevalence of use and perceived outcomes of CAM in a large, diverse IBD population. METHODS: A postal survey of the members of the Crohn's and Colitis Foundation of Canada gathered data on demographic, disease, and conventional IBD treatment characteristics, and on the use and perceived effects of CAM. Respondents were characterized as not using CAM, as past or present users of CAM for their IBD, or as present users of CAM for other reasons. Comparisons between groups were made with the chi(2) test. RESULTS: The final sample included 2847 IBD patients. Current or past use of CAM for IBD was reported by 1332 patients, of whom 666 continued their use of CAM. Use was lowest in the eastern provinces and highest in the west. Only 15% had used CAM before their IBD diagnosis. Herbal therapies were the most commonly used (41% of CAM users). Improvements in sense of well-being, IBD symptoms, and sense of control over the disease were the most commonly reported benefits. Only 16% of prior CAM users reported any adverse effect of CAM use. A complementary practitioner was consulted by 34%. During the previous year, 46% had spend more than $250 on CAM. CONCLUSIONS: Use of CAM by IBD patients is very common. Most of these patients attribute significant benefits to their CAM use. Few report significant adverse events.