Rationale and Objectives
To compare differences in Medicare costs 1 year after initial computed tomographic colonography (CTC) or initial optical colonoscopy (OC).
Materials and Methods
We performed a retrospective cohort study of asymptomatic Medicare outpatients aged ≥66 years who received initial CTC ( n = 531) or OC ( n = 17,593) between January 2007 and December 2008; initial OC patients were matched on county of residence and year of screening. Outcomes included differences in total inpatient and outpatient Medicare costs 1 year after initial CTC or OC and differences in outpatient testing of potential findings in the colon, abdomen, pelvis, and lungs.
Results
Higher adjusted costs per patient were revealed in the year after initial CTC compared to initial OC for outpatient testing related to potential colonic ($50; 95% confidence interval [CI], $12–$88; P = .010) and extracolonic findings ($64; 95% CI, $23–$106; P = .002). However, there were no differences in adjusted total costs per patient in the year after either modality ($2065; 95% CI, $1672–$5803; P = .28). Similarly, adjusted costs did not differ between cohorts for inpatient ($267; 95% CI, $1017–$1550; P = .68) or outpatient care ($2828; 95% CI, $311–$5966; P = .08).
Conclusions
Despite higher adjusted costs of outpatient testing potentially related to colonic and extracolonic findings among asymptomatic elderly patients 1 year after initial CTC compared to OC, we found no differences in adjusted total, inpatient, or outpatient costs between cohorts. Although Medicare does not cover screening CTC, our results suggest that these modalities generate comparable downstream costs to payers.
Computerized tomographic colonography (CTC) is an accurate and safe alternative to traditional or optical colonoscopy (OC) for colorectal cancer screening . CTC has the potential to reach the 40%–50% of the unscreened US population because patient preference and medical conditions have limited the uptake of OC in this population . However, in March 2009, the Centers for Medicare and Medicaid Services (CMS) decided against coverage for screening CTC among asymptomatic individuals. This decision was based, in part, on the scarcity of observed data regarding differences in outcomes and costs between patients who receive CTC and OC, in particular, differences related to follow-up testing of colonic and extracolonic findings on CTC . Current estimates of testing rates and costs related to the follow-up of colonic and extracolonic findings are derived from chart review. Moreover, these studies have not included control groups of patients who receive OC or who have no additional findings at the time of CTC to assess the incremental costs of these findings. Thus, our objective was to compare total, inpatient, and outpatient Medicare costs among asymptomatic elderly patients in the year after either initial CTC or OC (ie, screening population) between January 2007 and December 2008, in other words, the two years preceding the CMS decision about coverage for screening CTC. We additionally examined differences in costs attributable to testing plausibly related to colonic or extracolonic findings because of the impact of these findings on CTC.
Methods
Design Overview
We performed a retrospective cohort study using 100% Medicare fee-for-service claims files. All Medicare beneficiaries aged ≥66 years in the United States who received CTC between January 2007 and December 2008 were evaluated; an age cutoff of 66 years was selected to adjust for care in the preceding year. The CTC cohort was compared to a group of patients who received OC, randomly matched by county of residence and year of screening. CTC was not covered for routine screening during this time interval and was performed predominantly among patients at risk for OC due to existing medical conditions. Therefore, we approximated the screening population by selecting asymptomatic patients, defined as patients with no symptoms of colorectal cancer, and patients undergoing initial OC or CTC, defined as no CTC or OC in the preceding year. Claims were used to identify total, outpatient, and inpatient Medicare costs and testing and costs potentially related to outpatient colonic and extracolonic follow-up. We focused on costs to Medicare rather than costs to the patient (eg, copayment), the physician or the facility. Nearly, all potentially clinically significant colonic and extracolonic findings are evaluated within 1 year of detection . Therefore, we followed all patients for 1-year window from the date of either procedure.
Setting and Participants
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Outcomes and Follow-up Costs
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Covariates
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Statistical Analysis
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Results
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Table 1
Patient Characteristics
Characteristic Initial CTC ( n = 531) Initial OC ( n = 17,593)P Value Demographic characteristics Gender Females 320 (60.3) 1,0493 (59.6) .770 Age (years) 66–74 315 (59.3) 12,189 (69.3) <.001 75–84 182 (34.3) 4986 (28.3) >85 34 (6.4) 418 (2.4) Race White 504 (94.9) 15,211 (86.5) <.001 Black 16 (3.0) 1277 (7.3) Other 11 (2.1) 1105 (6.3) Common elixhauser comorbidities Coronary artery disease 34 (6.4) 474 (2.7) <.001 Hypertension 55 (10.4) 1299 (7.4) .01 Chronic lung disease 20 (3.8) 314 (1.8) .001 Diabetes mellitus w/o complications 16 (3.0) 384 (2.2) .200 Hypothyroidism 14 (2.6) 246 (1.4) .02 Fluid and electrolyte disorders 13 (2.4) 413 (2.3) .880 Deficiency anemia 15 (2.8) 244 (1.4) .006 Socioeconomic characteristics Mean % of persons with college-level education by county of residence 32.43 (±11.3) 30.25 (±11.0) <.001 Mean household income by county of residence $51,796.34 (±$12,889.5) $50,615.20 (±$12,933.7) 0.04 Health care access Mean total Medicare Part A and B reimbursements by county of residence (2010) $8876.95 (±$1486.7) $9035.00 (±$1466.0) .014 Metropolitan/rural Rural 86 (16.2) 2566 (14.7) .320 Metropolitan 444 (83.8) 14,928 (85.3) Census region Northeast 101 (19.3) 3670 (21.1) .490 Midwest 117 (22.4) 3550 (20.4) South 184 (35.2) 6390 (36.7) West 121 (23.1) 3805 (21.8)
CTC, computed tomographic colonography; OC, optical colonoscopy.
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Table 2
Unadjusted Median Total Costs in the Year Before or After Colorectal Evaluation by Type of Colorectal Evaluation (95% CI)
Time Period and Type of Colorectal Evaluation Total (95% CI) Difference_P_ Value ∗ 12 Months before CTC first line $1826 ($1592–$2076) $589 <.0001 OC first line $1237 ($1208–$1267) 12 Months after CTC first line $2264 ($2000–$2558) $764 <.0001 OC first line $1500 ($1466–$1531)
CI, confidence interval; CTC, computed tomographic colonography; OC, optical colonoscopy.
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Table 3
Adjusted Total, Inpatient and Outpatient Costs by Type of Colorectal Evaluation (95% CI) ∗
Care Setting Adjusted Costs Difference_P_ Value Total CTC first line $16,355 ($5661 to $27,048) $2065 (−$1672 to $5803) .280 OC first line $14,289 ($5369 to $23,209) Inpatient CTC first line $3117 ($1725 to $4509) $267 (−$1017 to $1550) .680 OC first line $2850 ($2254 to $3447) Outpatient Overall CTC first line $20,646 ($5688 to $32,603) $2828 (−$311 to $5966) .080 OC first line $17,818 ($7665 to $27,971) Evaluation CTC first line $10,637 ($4386 to $16,888) $1319 (−$100 to $2739) .070 OC first line $9317 ($3879 to $17,456) Anesthesiology CTC first line $58 ($45 to $71) $9 (−$5 to $22) .200 OC first line $49 ($47 to $51) Surgery CTC first line $1022 ($729 to $1314) $75 (−$119 to $270) .450 OC first line $946 ($736 to $1157) Radiology CTC first line $15,570 (−$11,421 to $42,561) $1433 (−$2545 to $5411) .480 OC first line $14,137 (−$10,264 to $38,539) Pathology CTC first line $5119 ($1539 to $8699) $667 (−$89 to $1423) .080 OC first line $4452 ($1362 to $7542) Medicine CTC first line $183,954 (−$45,651 to $413,559) $12,921 (−$20,355 to $46,197) .480 OC first line $171,033 (−$42,274 to $384,341)
CI, confidence interval; CTC, computed tomographic colonography; OC, optical colonoscopy.
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Table 4
Adjusted outpatient Colonic and Extracolonic Costs by Type of Colorectal Evaluation (95% CI) ∗
Type of Testing and of Colorectal Evaluation Adjusted Costs Difference_P_ Value Outpatient colonic testing CTC first line $71 ($33–$109) $50 ($12–$88) .010 OC first line $21 ($19–$24) Outpatient extracolonic testing CTC first line $182 ($139–$225) $64 ($23–$106) .002 OC first line $118 ($107–$128)
CI, confidence interval; CTC, computed tomographic colonography; OC, optical colonoscopy.
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Discussion
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Supplementary Data
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Supplementary Table 1
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