P1181 - Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population

Award: Presidential Poster Award

Award: Presidential Poster Award

Jordan J. Karlitz, MD, FACG¹, Mark Fendrick, MD², Jay Bhatt, DO³, Gloria D. Coronado, PhD⁴, Sushanth Jeyakumar, MSc⁵, Nate Smith, PhD⁵, Marcus Plescia, MD⁶, Durado Brooks, MD⁷, Paul Limburg, MD⁸, David Lieberman, MD^9
1Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO; ²University of Michigan, Ann Arbor, MI; ³Chicago School of Public Health, Chicago, IL; ⁴Kaiser Permanente Center for Health Research, Portland, OR; ⁵Maple Health Group, New York, NY; ⁶Association of State and Territorial Health Officials, Atlanta, GA; ⁷Exact Sciences Laboratories, LLC, Madison, WI; ⁸Mayo Clinic, Rochester, MN; ⁹Oregon Health & Science University, Portland, OR

Introduction: Outreach, including patient navigation, has been shown to increase the uptake of colorectal cancer (CRC) screening in underserved populations. This analysis evaluates the cost-effectiveness of triennial multi-target stool DNA (mt-sDNA), where each test includes centralized patient navigation support, versus outreach, with or without a mailed annual fecal immunochemical test (FIT), in a simulated Medicaid population.

Methods: A microsimulation model was used to estimate the incremental cost-effectiveness ratio using quality-adjusted life years (QALY), direct costs and clinical outcomes in a cohort of Medicaid beneficiaries aged 50 – 64 over a lifetime time horizon. For annual FIT screening, we modeled two outreach scenarios: a mailed letter encouraging CRC screening completion along with instructions about how to obtain a FIT test (with no actual FIT test provided); and outreach via a mailed letter encouraging CRC screening completion along with a FIT test. The base case model explored scenarios of either 100% adherence or real-world reported adherence (51.3% for mt-sDNA, 21.1% for outreach with FIT and 12.3% for outreach without FIT) with or without real-world adherence for follow-up colonoscopy (66.7% for all). Costs and outcomes were discounted at 3.0%.

Results: When 100% adherence is assumed for both the screening test and follow-up colonoscopy, outreach with or without FIT results in higher incidence reduction and higher mortality reduction compared to mt-sDNA (Table 1); mt-sDNA also cost more and was less effective compared to outreach with or without FIT at 100% adherence to both screening tests and follow-up colonoscopy (Figure 1). When real-world adherence rates were considered for screening strategies (with 100% adherence for follow-up colonoscopy), mt-sDNA resulted in the greatest reduction in incidence and mortality from CRC compared to outreach with or without FIT for incidence and mortality (Table 1); mt-sDNA was also cost-effective versus outreach with and without FIT ($32,150/QALY and $22,707/QALY, respectively) (Figure 1). mt-sDNA remained cost-effective versus FIT, with or without outreach, under real-world adherence rates for follow-up colonoscopy (Figure 1).

Discussion: Patient outreach/navigation interventions and associated real-world adherence rates to screening tests should be considered when evaluating the cost effectiveness of CRC screening strategies in underserved populations.


Figure: Figure 1. Incremental cost-effectiveness plane (A) mt-sDNA versus outreach + FIT (B) mt-sDNA versus outreach alone

COL: colonoscopy; CRC: colorectal cancer; CX: complication; FIT: fecal immunochemical test; LYG: life years gained; mt-sDNA: multi-target stool DNA; a Per 1,000 patients b Lifetime costs include colonoscopy costs, screening costs (stool-based screening costs and follow-up / symptom / surveillance colonoscopies, as relevant), cost of complications, cost of program and cost of CRC).
Analysis	Screening strategy	Number of screening testsa	Total number of COLsa	LYGa	Total costsb	Total QALYs	Incidence reduction	Mortality reduction
100% adherence screening test 100% follow-up colonoscopy	None	0	80	0.00	$3,091	15.100	0%	0%
	mt-sDNA	3,904	1,032	228.1	$4,111	15.174	46.2%	51.0%
	Outreach + FIT	10,594	1,107	251.1	$2,991	15.182	51.9%	57.0%
	Outreach alone	10,594	1,107	251.1	$2,440	15.182	51.9%	57.0%
Real-world adherence screening test 100% follow-up colonoscopy	None	0	80	0.00	$3,093	15.100	0%	0%
	mt-sDNA	3,205	894	203.5	$3,837	15.166	41.5%	45.8%
	Outreach + FIT	2,755	425	112.5	$2,872	15.136	21.1%	24.6%
	Outreach alone	1,660	290	73.2	$2,862	15.123	13.3%	15.7%
Real-world adherence screening test Real-world follow-up colonoscopy	None	0	80	0.00	$3,097	15.100	0%	0%
	mt-sDNA	3,163	611	132.8	$4,030	15.143	27.3%	30.0%
	Outreach + FIT	2,772	301	76.3	$3,013	15.123	13.9%	16.5%
	Outreach alone	1,653	215	48.4	$2,951	15.115	8.8%	10.2%

Table: Table 1. Clinical and cost outcomes


Disclosures:
Jordan Karlitz: Exact Sciences – Consultant. Gastro Girl – Advisory Committee/Board Member, Stockholder/Ownership Interest (excluding diversified mutual funds). GI OnDEMAND – Advisory Committee/Board Member, Stockholder/Ownership Interest (excluding diversified mutual funds).
Mark Fendrick: AbbVie – Consultant. AHRQ – Grant/Research Support. AJMC – Other Financial or Material Support, Co-editor. Amgen – Consultant. Arnold Ventures – Grant/Research Support. Bayer – Consultant. Boehringer-Ingelheim – Grant/Research Support. Centivo – Consultant. Community Oncology Association – Consultant. Covered California – Consultant. EmblemHealth – Consultant. Exact Sciences – Consultant. Freedman Health – Consultant. Gary and Mary West Health Policy Center – Grant/Research Support. GRAIL – Consultant. Harvard University – Consultant. Health & Wellness Innovations – Consultant, Stockholder/Ownership Interest (excluding diversified mutual funds). Health at Scale Technologies – Consultant, Stockholder/Ownership Interest (excluding diversified mutual funds). HealthCorum – Consultant. Hygieia – Consultant. MEDCAC – Other Financial or Material Support, Member. MedZed – Consultant. Mercer – Consultant. Merck – Consultant. Montana Health Cooperative – Consultant. National Pharmaceutical Council – Grant/Research Support. Pair Team – Consultant, Stockholder/Ownership Interest (excluding diversified mutual funds). PCORI – Grant/Research Support. Penguin Pay – Consultant. Phathom Pharmaceuticals – Consultant. PhRMA – Grant/Research Support. Risalto – Consultant. Risk International – Consultant. RWJ Foundation – Grant/Research Support. Sempre Health – Consultant, Stockholder/Ownership Interest (excluding diversified mutual funds). State of Michigan/CMS – Grant/Research Support. State of Minnesota – Consultant. US Department of Defense – Consultant. V-BID Health, LLC – Other Financial or Material Support, Partner. Virginia Center for Health Innovation – Consultant. Wellth – Consultant, Stockholder/Ownership Interest (excluding diversified mutual funds). Wildflower Health – Consultant. Yale-New Haven Health System – Consultant. Zansors – Consultant, Stockholder/Ownership Interest (excluding diversified mutual funds).
Jay Bhatt: Exact Sciences – Consultant. JDB Strategies – Other Financial or Material Support, Founder/Principal.
Gloria D. Coronado: Exact Sciences – Consultant. Guardant Health – Consultant.
Sushanth Jeyakumar indicated no relevant financial relationships.
Nate Smith indicated no relevant financial relationships.
Marcus Plescia indicated no relevant financial relationships.
Durado Brooks: Exact Sciences – Employee, Stockholder/Ownership Interest (excluding diversified mutual funds).
Paul Limburg: Exact Sciences – Other Financial or Material Support, PL services as Chief Medical Officer for Screening at Exact Sciences through a contracted services agreement with the Mayo Clinic; PL and Mayo Clinic have contractual rights to receive royalties through this agreement..
David Lieberman: ColoWrap – Advisory Committee/Board Member. Freenome – Advisory Committee/Board Member. Genescopy – Advisory Committee/Board Member.


Jordan J. Karlitz, MD, FACG¹, Mark Fendrick, MD², Jay Bhatt, DO³, Gloria D. Coronado, PhD⁴, Sushanth Jeyakumar, MSc⁵, Nate Smith, PhD⁵, Marcus Plescia, MD⁶, Durado Brooks, MD⁷, Paul Limburg, MD⁸, David Lieberman, MD⁹. P1181 - Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.