Kosten des Kolonkarzinom Screenings in der Schweiz

Transkript

1 Kosten des Kolonkarzinom Screenings in der Schweiz Thomas D. Szucs University of Zurich Prevention paradox 1

2 Disease conceptually Disease prevalence, according to ACS, ATS, AHA, UICC, ASCO, ESMO, NCI Observed Disease Tip of the Iceberg Undiagnosed Disease True disease Reservoir Pseudodisease 2

3 Pseudo disease = lesion that becomes known only as a result of screening; it would not be discovered otherwise 2 Types: Cases that would never progress to symptomatic stage cases that would progress, but are interrupted by death from unrelated causes Balancing harm, benefit and affordability Acceptability and accessability of screening, e.g. convenience, publicity, information Definition of the eligible group, e.g. changing age range or frequency of testing Changing the numbers of people defined positive or at high risk by the screening test, e.g. by more tests, by double or treble reding, or by changing the cut-offs Changing the number of positive or high risk people diagnosed with the disease, e.g. multiple investigations or changing the cut-off value used to distinguish people with the disease from those who do not have it 3

4 Affordability 2 dimensions Burden Economic direct costs Indirect costs Non- Economic Years of life lost Quality of life Pretium doloris Years of life lost (YLL) from deaths at different ages to quantify benefits of screening according to age YLL=age-specific death rate from disease x average life expectancy at age Age at which deaths from disease result in largest number of YLL is age at which screening is most effective Example: YLL from breast cancer at age 50 = 169 year /10000 [5.5 deaths/10000 woman aged 50 per year x life expectancy for 50 year old woman, 30.7 years] 4

5 Estimation of potential reduction in YLL due to screening Use published estimates of relative risks of mortality in screened persons compared to unscreened Examples: Breast cancer: RR=0.69 [age>50]; RR=0.81 [age<50] Cervical cancer: RR=0.09 CRC: RR=0.75 Annual number of years of life lost resulting from deaths in persons at each year of age from breast, cervical, colorectal and prostate cancer. Solid lines show total number YLL, interrupted lines the YLL up to the age of 80 (Law 1999) 5

6 Law 1999 Law

7 The Lucky Hit proportion FOBT result Colonic neoplasm Present Absent Bleeding Not bleeding Positive a LH b Negative Total c a + LH + c d b + d 7

8 Lucky hit proportion for 4 neoplasms Type of neoplasm Proportion of lucky hits Small adenoma (<1cm) Large adenoma (>1 cm) Early cancer Bleeding neoplasm rate, % Falsepositive rate =1% Falsepositive rate =2% Falsepositive rate =3% Advanced cancer Ramsuhoff, JAMA 1990 Economics 8

9 The economic consequences of screening itself Effects on incidence and mortality Effects on the delivery of health care 9

10 Number needed to screen (NNS) Mortality Risk reduction NNS + Control (%) Screened (%) Relative (%) Absolute* (%) * Control mortality x relative risk reduction; divided by absolute risk reduction Primary prevention of cancer of the breast and colon by screening Rembold BMJ

11 Comparison of number needed to screen in primary prevention Anzahl entdeckte Fälle und Kosten durch Testung auf okkultes Blut Anzahl Tests Entdeckte Fälle Kosten $ 1 Durchschnittskosten $ Guaiac Test bei Patienten plus Röntgen Doppelkontrast Untersuchung bei positiven Fällen 2 Gesamtkosten dividiert durch richtig positive Fälle Neuhauser und Lewicki (1975) 11

12 Inkrementale entdeckte Fälle und inkrementale Kosten sequentieller Guaiac Tests Anzahl Tests Inkrementale Inkrementale Grenzkosten $ Fälle Kosten $ Neuhauser und Lewicki (1975)) Reverse engineering on basis of per year investment Law

13 Overview available health economic models Wagner Frazier Khandker Vijan Loeve Ness Year Age range Single % cancers from adenoma Cancer sojourn time from early to late, years Discount rate, % Perforation rate COL, % Mortality rate Effectiveness of CRC screening Cancers prevented (%) Mortality reduction (%) Life years gained FOBT Q COL Q FS Q Szucs TD, own calculations 13

14 Model assumptions Population size Incidence w/o screening 34 Cost screening instrument CHF/unit FOBT Q1 20 COL Q FS Q5 200 Cost-effectiveness of CRC screening Total Costs (CHF) LE (Years) CHF/LYG ICER CHF/LYG FOBT Q1 198'000 1'759' dominant COL Q10 67'393'333 1'760' '523 FS Q5 18'147'000 1'758' '618 No screening 3'400'000 1'755' Szucs TD, own calculations 14

15 Cost-effectiveness of CRC screening - 1 Cost-effectiveness of CRC screening

16 Kosten-Effektivität im Vergleich (CH-Studien) CHF / gerettetes Lebensjahr ' PROVE IT LIPID 4-S CARE CRC-S PREVENT EUROPA ASCOT HPV-I+S CAPRIE WOSCOPS MSP v OS Mamma Kosten pro gerettetes Lebensjahr nicht-medizinischer Massnahmen US$ pro gerettetes Lebensjahr Tengs TO, Risk Analysis 1995 Umweltschutz Prävention Transportsicherheit Chlorierung Trinkwasser 2. Sekundärpräven tion 3. Airbags 4. Kindersitze im Fonds 5. Bodenbeleuchtu ng Notausgang Flugzeug 6. Primärpräventio n 7. Erste Hilfe Kurs Autolernfahrer 8. Verbot Chlorierte Pestizide Zitrusfrüchte 9. Sitzgurte Insassen Schulbusse 10. Verbot Asbest in Verpackungsmat erial 16

17 Einfluss des Screening Intervalls sowie der Altersgruppen Symbol Alter Intervall , gewonnene Lebensjahre Beemsterboer et al (1994) Kosten-Unterschied (mrd Euro) 17

18 Die Balance zwischen Grenzkosten und Grenznutzen Grenzkosten Grenznutzen Kostenzuwachsfunktion (Grenzkosten) Funktionale Gesundheitsversorgung Ökonomisches Behandlungsoptimum Nutzenzuwachsfunktion (Grenznutzen) Behandlungsintensität Medizinisches Behandlungsoptimum maximale Versorgung Conclusion Colonoscopic screening is most likely very costeffective in CH! 18

19 Gesundheitsreform Deutschland Künftig drohen Patienten finanzielle Einbussen, wenn sie Vorsorge- Untersuchungen auslassen und später Krebs oder andere schwere Krankheiten bekommen. Some final thoughts Medicine is about diagnosis and treatment Outcomes in preventive medicine require early detection and treatment of disease Disease is binary Some people are healthy Medicine is about making decisions Early detection may not necessarily enhance outcomes and can cause harm Disease is a process We are all sick 19

20 There is no disease that you either have or don't have except perhaps sudden death and rabies. All other diseases you either have a little or a lot of. - Geoffrey Rose, epidemiologist Trotzdem, eine zu starke Kostenorientierung macht kurzsichtig! 20

21 Danke für Ihre Aufmerksamkeit! 21

22 Contact Thomas D. Szucs, MD, MBA, MPH, LLM Institute for Social- and Preventive Medicine University of Zurich Hirschengraben 84 CH-8001 Zurich Tel Fax Web 1: Web 2: 22