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More intensive colonoscopy screening yielded little benefit among Medicare beneficiaries
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Medicare beneficiaries who undergo more intensive colonoscopy screening than the guideline-recommended schedule only derive a slight benefit in colorectal cancer-specific survival and life-years gained, according to results of a modeling study.
“Screening Medicare beneficiaries more intensively than recommended is not only inefficient from a societal perspective; often, it is also unfavorable for those being screened,” Frank van Hees, MSc, of the department of public health at Erasmus University Medical Center in Rotterdam, the Netherlands, and colleagues wrote. “This study provides strong evidence and a clear rationale for clinicians and policy makers to actively discourage this practice.”
Van Hees and colleagues used a microsimulation model to determine whether more intensive colonoscopy screening than recommended conferred a health benefit among 65-year-old Medicare beneficiaries who demonstrated average life expectancies and an average risk for colorectal cancer. The researchers also assessed whether the net health benefit justified the additional resources required.
All beneficiaries underwent a screening colonoscopy at age 55 years with negative results.
The model compared the approach recommended by current guidelines — screening at age 65 and 75 years — with scenarios in which screening was extended to age 85 years and age 95 years. They also evaluated scenarios in which screening intervals were reduced to every 5 years or every 3 years instead of every 10 years.
Results showed current guideline recommendations prevented 14.1 cases of colorectal cancer and 7.7 deaths while leading to 63.1 life-years gained per 1,000 beneficiaries compared with no screening. The life-years gained translated to a mean of 23 days per beneficiary.
Reducing screening intervals from every 10 years to every 5 years prevented an additional 1.7 colorectal cancer cases and an additional 0.6 colorectal cancer deaths while leading to an additional 5.8 life-years gained per 1,000 beneficiaries. The life-years gained translated to a mean 2.1 days per beneficiary.
Guideline-recommended screening prevented 37.5 life-years with colorectal cancer care per 1,000 beneficiaries. To achieve this benefit, 2,131 colonoscopies had to be performed, resulting in 8.3 complications.
Reducing the screening interval to every 5 years prevented 10.9 additional life-years with colorectal cancer care per 1,000 beneficiaries. To achieve this benefit, an additional 783 colonoscopies had to be performed, resulting in an additional 1.3 complications.
Cary P. Gross
When researchers evaluated the effects of continuing screening to age 85 years, results showed that approach resulted in fewer additional colorectal cancer cases prevented (0.2), fewer colorectal cancer deaths (0.3) and fewer life-years gained (1.2) per 1,000 beneficiaries. The life-years gained translated to a mean 0.4 days per beneficiary. To achieve this benefit, an additional 369 additional colonoscopies had to be performed, resulting in an additional 2.4 complications.
Continuation of screening to age 95 years or further reducing the screening interval to 3 years yielded even smaller increases in screening-related benefits relative to the increased harms, researchers wrote.
“For years, receipt of cancer screening has been a core element used to assess quality of care, to address the concern of under-screening,” Cary P. Gross, MD, associate professor of internal medicine at Yale School of Medicine and director of the Cancer Outcomes, Public Policy and Effectiveness Research Center at Yale Cancer Center, wrote in an accompanying editorial. “In a marked departure from this focus on increasing screening use, the National Committee for Quality Assurance has recently released proposed overuse measures for inclusion in their HEDIS 2015 measurement set: colorectal cancer screening in adults 86 years or older and prostate-specific antigen screening among men 70 years or older.
“It truly will be a new era when providers will be evaluated, in part, by their ability to refrain from ordering cancer screening tests for some of their patients,” Gross wrote. “We are moving toward a time when prevention efforts will be more evidence based, more effective and patient centered. What could be more wonderful than that?”
For more information:
- Gross CP. JAMA Intern Med. 2014; doi:10.1001/jamainternmed.2014.3901.
- van Hees F. JAMA Intern Med. 2014;doi:10.1001/jamainternmed.2014.3889.
Disclosure: The study was supported by grants from the NIH.