Clinical and programmatic costs of implementing colorectal cancer screening: Evaluation of five programs

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Abstract

Background

The Centers for Disease Control and Prevention (CDC) initiated the Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 to explore the feasibility of establishing a colorectal cancer screening program for underserved US populations. We provide a detailed overview of the evaluation and an assessment of the costs incurred during the service delivery (screening) phase of the program.

Methods

Tailored cost questionnaires were completed by staff at the five CRCSDP sites for the first 2 years of the program. We collected cost data for clinical and programmatic activities (program management, data collection and tracking, etc.). We also measured in-kind contributions and assigned values to them.

Results

During the first 2 years of the demonstration excluding the start-up cost, the average cost per person was $2569. Per person cost of clinical services alone ranged from $264 to $1385, while per person programmatic costs ranged from $545 to $3017.

Conclusion

Colorectal cancer screening programs can incur substantial costs for some non-clinical activities, such as data collection/tracking, and these support activities should be managed carefully to control costs and ensure successful program implementation. Our findings highlight the importance of performing economic evaluation to guide the design of future colorectal cancer screening programs.

Introduction

Colorectal cancer (CRC) is the third most common cancer in the United States and is the second leading cause of cancer-related death. (USCS, 2009) In addition, there are significant racial disparities in CRC mortality and survival (Alexander et al., 2007, Rim et al., 2009). Although there is strong scientific evidence that regular screening decreases the incidence and mortality of colorectal cancer, only about half of the eligible population in the United States has been screened as recommended by national guidelines (ACS-CCAG, 2008, Shapiro et al., 2008, Subramanian et al., 2005, Whitlock et al., 2008). Screening programs that specifically target the underserved population might help reduce disparities in CRC screening, incidence, and mortality (Seeff et al., 2004).

There are few organized colorectal cancer screening programs designed for underserved populations, and only limited evaluations have been performed of these existing programs (MDCCSP, 2009, NYCCSP, 2009). The Centers for Disease Control and Prevention (CDC) established the 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 to explore the feasibility of establishing a national colorectal cancer screening program for underserved US populations (Seeff et al., 2008).

The five organizations selected by CDC to receive funding included the Maryland Department of Health and Mental Hygiene, the Missouri Department of Health and Senior Services, the Nebraska Department of Health and Human Services, Stony Brook University Medical Center (New York), and Public Health—Seattle & King County (Washington).

CDC is undertaking a detailed evaluation of CRCSDP to describe the implementation processes, assess patient outcomes, estimate the cost of implementation, and determine the relative cost-effectiveness of screening modalities. We have previously reported on the process and cost of initiating the five colorectal cancer screening programs (DeGroff et al., 2008, Tangka et al., 2008). The start-up costs of establishing colorectal cancer screening programs included all the expenditures incurred before starting service. During the start-up period, the programmatic categories requiring the most resources were program management, database development, and quality assurance.

No studies have been reported that include an evaluation of the costs during the service delivery phase (when screening services are provided) of organized colorectal cancer screening programs in the United States. This information is critical to understand the costs involved in offering colorectal cancer screening in the real world setting. We provide a detailed assessment of the costs incurred during the initial service delivery phase of the program. Overall, these costs include clinical costs (costs of screening and diagnostic testing) and programmatic costs such as program management, data collection and tracking, service delivery contract management, administrative costs, patient support, public education and outreach, professional education, partnership development and maintenance, quality assurance and professional development, and program evaluation. Our findings provide practical guidance for estimating the cost of future screening programs at both the state and the national levels.

Section snippets

Materials and methods

We developed a questionnaire to collect activity-based costs from the programs to facilitate analysis using a programmatic perspective. These cost estimates were derived by allocating parts of the total expenditure to specific activities performed by the programs (Drummond, Sculpher, Torrance, O’Brien, & Stoddart, 2005). The derivation of activity-based costs is important, because they allow for a more in-depth comparison of the programs and their distribution of costs across key activities,

Results

Table 3 presents the total expenditure and funding source for the service delivery phase in the first (1–3 months) and second (12 months) years of the demonstration. The total adjusted expenditure incurred varied among the programs from $396,310 (Program 2) to $905,541 (Program 4). CRCSDP funds (with a range of 61–91%) were the largest source of funding for the programs, followed by in-kind contributions (9–36%). Only Program 1 reported receiving other monetary funds (from Comprehensive Cancer

Discussion

We have presented details of the costs incurred during the service delivery (screening) phase of five colorectal cancer screening programs. Cost per person served ranged from $810 to $4216 (average $2569). Although the majority of the funding for the programs was provided by CDC CRCSDP funds, in-kind contributions were an important source of resources that were required for the successful execution of these programs. Potential sources of in-kind contributions and their anticipated values should

Lessons learned

Our findings highlight the importance of performing economic evaluation to guide the design of future colorectal cancer screening programs. Substantial costs can be incurred in performing activities, such as database management, which are not direct patient services. These support activities might be a large component of the total cost of screening programs, and should be taken into consideration. Future studies should assess how these program activities can be performed in a cost-effective

Dr. Sujha Subramanian is a Senior Health Economist at RTI International. Her primary research interests are in the fields of cancer economics and health services research. She is currently directing the economic evaluation of the National Breast and Cervical Cancer Screening Program (NBCCEDP) and the National Program of Cancer Registries (NPCR).

References (20)

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Dr. Sujha Subramanian is a Senior Health Economist at RTI International. Her primary research interests are in the fields of cancer economics and health services research. She is currently directing the economic evaluation of the National Breast and Cervical Cancer Screening Program (NBCCEDP) and the National Program of Cancer Registries (NPCR).

Dr. Florence K. Tangka is an Economist at the Division of Cancer Prevention and Control, Centers for Disease Control and Prevention (CDC). She is the lead CDC economist directing the economic evaluation of CDC funded colorectal cancer screening programs. She is also currently leading other projects focused on cancer economics including an assessment of the cost of screening and treating cancers.

Ms. Sonja Hoover is a research analyst at RTI International. She is currently working on several program evaluations and has developed Excel and Web based data collection tools to collect cost and resource use data from programs.

Dr. Amy DeGroff lead the qualitative assessment of CDC's Colorectal Cancer Screening Demonstration Program (CRCSDP). She lead the case study team and performed site visits to all five colorectal cancer screening programs that were funded by CDC.

Ms. Janet Royalty is currently serving as the lead evaluator of the CDC funded Colorectal Cancer Control Program (CRCCP). She has several years of experience designing data collection instruments to monitor program operations and effectiveness.

Dr. Laura C. Seeff is the acting Branch Chief of the Comprehensive Cancer Control Branch in the Division of Cancer Prevention and Control (DCPC) at the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. She has authored several studies related to colorectal cancer screening programs including the low rates of use for colorectal cancer screening tests in the United States.

This research was funded by Contract No. 200-2002-00575 TO 09 from the Centers for Disease Control and Prevention (CDC). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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