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Colonoscopy Utilization After Elimination of Copay for Screening: Implications for Implementation of National Health Reform
AGA Abstracts
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Sa1000 On-Therapy Versus Off-Therapy Testing in Patients With Symptoms of Refractory Gastroesophageal Reflux Disease: A Cost-Utility Analysis Ryan D. Madanick, Stephane Kass, Nicholas J. Shaheen Background: Symptoms of refractory gastroesophageal reflux disease (GERD) despite proton pump inhibitors (PPIs) are highly prevalent among patients presenting to gastroenterologists. pH-impedance (pH-MII) testing is commonly employed in this patient population, however the optimal diagnostic strategy is unclear. Objective: To evaluate the cost-effectiveness of pH-MII testing on vs. off PPIs in patients with refractory GERD symptoms. Methods: A cost-utility analysis using a hybrid decision tree-Markov model with a 10-year time horizon and third-party payer perspective was conducted to estimate costs, outcomes in qualityadjusted life-years (QALYs), and incremental cost-effectiveness in a base-case cohort of 10,000 patients aged 30-60 with refractory GERD symptoms. After pH-MII testing, patients could undergo surgery (laparoscopic Nissen fundoplication; LNF) or remain on medical therapy. In the base case analysis, patients were assumed to undergo surgery if either pathologic acid or nonacid reflux was noted, and remained on medical therapy if pH-MII was negative. Sources of probabilities and transitions were identified through a search of the medical literature via PubMED. Costs were identified through hospital data for hospital costs, the Physicians Fee Reference for tests, procedures, and physician visits, and through the Master Drug Data Base v2.5. Utility weights were based on previously published data to reflect those used in prior economic analyses of GERD. Costs and QALYs were discounted at 3% annually. One-way and probabilistic sensitivity analyses were conducted of key parameters, including the therapy selected after pH-MII, to account for model uncertainty. Results: In the base-case analysis, a strategy of pH-MII testing on PPIs cost $44,069 and yielded 6.28 QALYs per person, vs. $50,104 and 5.93 QALYs off therapy. Testing on PPIs dominated testing off PPIs, being both less costly and yielding a larger number of QALYs. In one-way sensitivity analysis, the base-case interpretation was highly sensitive to symptom response to LNF. If this response declined below 50% in patients who had persistent nonacid reflux when tested on PPIs, a strategy of testing off PPIs became dominant. Probabilistic sensitivity analysis revealed that pH-MII on PPIs was the dominant or cost-effective strategy 89% of the time at a willingness-to-pay threshold of $50,000/QALY. Conclusions: In patients with refractory GERD symptoms, testing on therapy is a cost-effective strategy. As more data regarding the implications of the management decisions based on test results become available, the optimal testing strategy can be further clarified.
Graph 2 Inset: Graph 2.1 1171 Colonoscopy Utilization After Elimination of Copay for Screening: Implications for Implementation of National Health Reform Shabnam S. Khatami, Rolando Roman, Lei Xuan, Song Zhang, Charles E. McConnel, Lance T. Rowell, Ethan Halm, Samir Gupta Background: Charging patients a copay for colonoscopy may be a financial barrier to cancer screening. To promote screening, the Patient Protection and Affordable Care Act mandates all new health plans eliminate copays for cancer screening tests endorsed by the US Preventive Services Task Force, including colonoscopy. While removing the copay on colonoscopy seems sensible, the impact of removing such a financial disincentive to screening is unknown. We took advantage of a natural experiment in which The University of Texas employee health plan (UT SELECT) instituted and promoted a “no copay” policy as a means of increasing uptake of screening colonoscopy in 2008. Aim: Assess the impact of copay waiver on colonoscopy uptake. Methods: We conducted a retrospective cohort study of rate of colonoscopy among UT SELECT beneficiaries aged 50-64 years from 2001-2008. The primary outcome was colonoscopy incidence based on insurance claims data. The age and sex standardized incidence ratio (SIR) was computed as the ratio of observed incidence in 2008 with the copay waiver vs. expected incidence in 2008 without waiver estimated by historical trends. To isolate the effect on colonoscopies most likely done for screening, analyses restricted to beneficiaries age 50 (who would be newly eligible for screening), and colonoscopies not associated with gastrointestinal symptoms, signs, or diagnoses were also done. We excluded those age ≥65 years, because most would be Medicare insured. Results: Among 68,468 unique beneficiaries aged 50-64, 57% were women, 71% were primary beneficiaries, 60% were employed by a health campus, and 58% had >5yrs of continuous plan insurance. Overall, 22% of beneficiaries had at least one colonoscopy 2001-2008 (n=14,774). Colonoscopy incidence increased linearly over time for beneficiaries aged 50-64, with the highest rate occurring in 2008 (Figure). Across those aged 50-64, colonoscopy increased significantly, but modestly after removal of the copay (SIR=1.18 (95%CI: 1.14-1.23). There was nonsignificant trend toward a smaller increase for those age 50 alone (SIR=1.07 (95%CI: 0.951.20). The absolute rate of colonoscopy increased by 1.47% after waiver of the copay compared to the expected trend. Results did not differ when analyses were restricted to colonoscopies more likely done for screening. Conclusions: In a large, employer sponsored health plan, elimination of copay for screening colonoscopy resulted in a significant, but modest increase in colonoscopy uptake. Factors limiting the impact of this policy may have included suboptimal awareness of the copay waiver and lack of knowledge of screening benefits. Major advances in colonoscopy screening will likely require optimizing implementation of the Affordable Care Act mandate to eliminate colonoscopy copays, as well as more potent interventions than removal of copay disincentives alone.
AGA Abstracts
Sa1001 The First Prospective Study of the Impact of Endoscopic and Surgical Treatment of Early Barrett's Neoplasia in Barrett's Esophagus on Quality of Life and Fear of Cancer Wilda Rosmolen, Pythia Nieuwkerk, Mark I. van Berge Henegouwen, Mirjam Sprangers, Jacques J. Bergman Introduction: Endoscopic treatment (ETx) of early neoplasia in Barrett's esophagus (BE) is an accepted alternative to surgical treatment (STx). The effect of ETx on quality of life (QOL) and fear of cancer recurrence (FOCR) has not been investigated prospectively. Aim: To prospective evaluate QOL and FOCR in ETx pts and to prospectively compare outcomes to 3 reference groups. Patients/ methods Between 2006 and 2009, 112 pts were included in 4 groups based on tumour size and stage: 1. Etx for early BE neoplasia (n=35, HGIN T1sm1N0M0). 2. Endoscopic surveillance for non-dysplastic BE (Surv pts, n= 37) 3. Stx for early BE neoplasia (STxE pts, n= 21 HGIN - T2N0M0). 4. Stx for advanded BE cancer (STxA pts, n=21 T1N1M0 - T3N1M0,). QOL was measured at baseline, 2 and 6 mo after Tx using the SF-36, the EORTC-QLQ-C30, and EORTC-QLQ-OES18. FOCR was measured with the Worry of Cancer Scale (WOCS) and the Fear of Recurrence Scale (FORS). Results The 4 groups were comparable in terms of age, gender and co-morbidity. Two and 6 months after Tx, ETx pts reported significantly better mean SF-36 scores compared to both surgical groups in physical functioning (ETx 78.5; STxE 58.1 p<0.000; STxA 65.3 p 0.001), and role functioning physical (Etx 72.9; STxE 25.5 p<0.000; STxA 22.8 p<0.000). Compared to Surv pts, ETx pts scored significantly lower on mental health (ETx 72.5; Sur 87.7; p 0.038) and role functioning emotional (ETx 71.6; Sur 83.2; p 0.011) 2 months after Tx. ETx pts also had significantly better EORTC-QLQ-C30 scores than STxE and STxA pts for physical functioning (ETx 84.8; STxE 71.2; STxA 71.8), role functioning (ETx 83.5; STxE 51.5; STxA 60.1), social functioning (ETx 88.3; STxE 69.1; STxA 75.8), and global QOL scores (ETx 74.4; STxE 61; STxA 55.4) at 2 mo after Tx (p< 0.017for all). In addition, surgical patients reported significantly more EORTC-QLQ-OES18 symptoms than ETx patients such as: fatigue (ETx 74%; STxE 90%; STxA 90%; p 0.029), dysphagia (ETx 17%; STxE 57%; STxA 75%; p< 0.000), eating problems (ETx 37%; STxE 95%; STxA 100%; p< 0.000) and choking (ETx 14%; STxE 47%; STxA 47%; p<0.000) compared to the ETx pts. These differences were absent 6 mo after Tx. STxE and STxA reported higher fear of cancer
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Graph 1
Sa1000 On-Therapy Versus Off-Therapy Testing in Patients With Symptoms of Refractory Gastroesophageal Reflux Disease: A Cost-Utility Analysis Ryan D. Madanick, Stephane Kass, Nicholas J. Shaheen Background: Symptoms of refractory gastroesophageal reflux disease (GERD) despite proton pump inhibitors (PPIs) are highly prevalent among patients presenting to gastroenterologists. pH-impedance (pH-MII) testing is commonly employed in this patient population, however the optimal diagnostic strategy is unclear. Objective: To evaluate the cost-effectiveness of pH-MII testing on vs. off PPIs in patients with refractory GERD symptoms. Methods: A cost-utility analysis using a hybrid decision tree-Markov model with a 10-year time horizon and third-party payer perspective was conducted to estimate costs, outcomes in qualityadjusted life-years (QALYs), and incremental cost-effectiveness in a base-case cohort of 10,000 patients aged 30-60 with refractory GERD symptoms. After pH-MII testing, patients could undergo surgery (laparoscopic Nissen fundoplication; LNF) or remain on medical therapy. In the base case analysis, patients were assumed to undergo surgery if either pathologic acid or nonacid reflux was noted, and remained on medical therapy if pH-MII was negative. Sources of probabilities and transitions were identified through a search of the medical literature via PubMED. Costs were identified through hospital data for hospital costs, the Physicians Fee Reference for tests, procedures, and physician visits, and through the Master Drug Data Base v2.5. Utility weights were based on previously published data to reflect those used in prior economic analyses of GERD. Costs and QALYs were discounted at 3% annually. One-way and probabilistic sensitivity analyses were conducted of key parameters, including the therapy selected after pH-MII, to account for model uncertainty. Results: In the base-case analysis, a strategy of pH-MII testing on PPIs cost $44,069 and yielded 6.28 QALYs per person, vs. $50,104 and 5.93 QALYs off therapy. Testing on PPIs dominated testing off PPIs, being both less costly and yielding a larger number of QALYs. In one-way sensitivity analysis, the base-case interpretation was highly sensitive to symptom response to LNF. If this response declined below 50% in patients who had persistent nonacid reflux when tested on PPIs, a strategy of testing off PPIs became dominant. Probabilistic sensitivity analysis revealed that pH-MII on PPIs was the dominant or cost-effective strategy 89% of the time at a willingness-to-pay threshold of $50,000/QALY. Conclusions: In patients with refractory GERD symptoms, testing on therapy is a cost-effective strategy. As more data regarding the implications of the management decisions based on test results become available, the optimal testing strategy can be further clarified.
Graph 2 Inset: Graph 2.1 1171 Colonoscopy Utilization After Elimination of Copay for Screening: Implications for Implementation of National Health Reform Shabnam S. Khatami, Rolando Roman, Lei Xuan, Song Zhang, Charles E. McConnel, Lance T. Rowell, Ethan Halm, Samir Gupta Background: Charging patients a copay for colonoscopy may be a financial barrier to cancer screening. To promote screening, the Patient Protection and Affordable Care Act mandates all new health plans eliminate copays for cancer screening tests endorsed by the US Preventive Services Task Force, including colonoscopy. While removing the copay on colonoscopy seems sensible, the impact of removing such a financial disincentive to screening is unknown. We took advantage of a natural experiment in which The University of Texas employee health plan (UT SELECT) instituted and promoted a “no copay” policy as a means of increasing uptake of screening colonoscopy in 2008. Aim: Assess the impact of copay waiver on colonoscopy uptake. Methods: We conducted a retrospective cohort study of rate of colonoscopy among UT SELECT beneficiaries aged 50-64 years from 2001-2008. The primary outcome was colonoscopy incidence based on insurance claims data. The age and sex standardized incidence ratio (SIR) was computed as the ratio of observed incidence in 2008 with the copay waiver vs. expected incidence in 2008 without waiver estimated by historical trends. To isolate the effect on colonoscopies most likely done for screening, analyses restricted to beneficiaries age 50 (who would be newly eligible for screening), and colonoscopies not associated with gastrointestinal symptoms, signs, or diagnoses were also done. We excluded those age ≥65 years, because most would be Medicare insured. Results: Among 68,468 unique beneficiaries aged 50-64, 57% were women, 71% were primary beneficiaries, 60% were employed by a health campus, and 58% had >5yrs of continuous plan insurance. Overall, 22% of beneficiaries had at least one colonoscopy 2001-2008 (n=14,774). Colonoscopy incidence increased linearly over time for beneficiaries aged 50-64, with the highest rate occurring in 2008 (Figure). Across those aged 50-64, colonoscopy increased significantly, but modestly after removal of the copay (SIR=1.18 (95%CI: 1.14-1.23). There was nonsignificant trend toward a smaller increase for those age 50 alone (SIR=1.07 (95%CI: 0.951.20). The absolute rate of colonoscopy increased by 1.47% after waiver of the copay compared to the expected trend. Results did not differ when analyses were restricted to colonoscopies more likely done for screening. Conclusions: In a large, employer sponsored health plan, elimination of copay for screening colonoscopy resulted in a significant, but modest increase in colonoscopy uptake. Factors limiting the impact of this policy may have included suboptimal awareness of the copay waiver and lack of knowledge of screening benefits. Major advances in colonoscopy screening will likely require optimizing implementation of the Affordable Care Act mandate to eliminate colonoscopy copays, as well as more potent interventions than removal of copay disincentives alone.
AGA Abstracts
Sa1001 The First Prospective Study of the Impact of Endoscopic and Surgical Treatment of Early Barrett's Neoplasia in Barrett's Esophagus on Quality of Life and Fear of Cancer Wilda Rosmolen, Pythia Nieuwkerk, Mark I. van Berge Henegouwen, Mirjam Sprangers, Jacques J. Bergman Introduction: Endoscopic treatment (ETx) of early neoplasia in Barrett's esophagus (BE) is an accepted alternative to surgical treatment (STx). The effect of ETx on quality of life (QOL) and fear of cancer recurrence (FOCR) has not been investigated prospectively. Aim: To prospective evaluate QOL and FOCR in ETx pts and to prospectively compare outcomes to 3 reference groups. Patients/ methods Between 2006 and 2009, 112 pts were included in 4 groups based on tumour size and stage: 1. Etx for early BE neoplasia (n=35, HGIN T1sm1N0M0). 2. Endoscopic surveillance for non-dysplastic BE (Surv pts, n= 37) 3. Stx for early BE neoplasia (STxE pts, n= 21 HGIN - T2N0M0). 4. Stx for advanded BE cancer (STxA pts, n=21 T1N1M0 - T3N1M0,). QOL was measured at baseline, 2 and 6 mo after Tx using the SF-36, the EORTC-QLQ-C30, and EORTC-QLQ-OES18. FOCR was measured with the Worry of Cancer Scale (WOCS) and the Fear of Recurrence Scale (FORS). Results The 4 groups were comparable in terms of age, gender and co-morbidity. Two and 6 months after Tx, ETx pts reported significantly better mean SF-36 scores compared to both surgical groups in physical functioning (ETx 78.5; STxE 58.1 p<0.000; STxA 65.3 p 0.001), and role functioning physical (Etx 72.9; STxE 25.5 p<0.000; STxA 22.8 p<0.000). Compared to Surv pts, ETx pts scored significantly lower on mental health (ETx 72.5; Sur 87.7; p 0.038) and role functioning emotional (ETx 71.6; Sur 83.2; p 0.011) 2 months after Tx. ETx pts also had significantly better EORTC-QLQ-C30 scores than STxE and STxA pts for physical functioning (ETx 84.8; STxE 71.2; STxA 71.8), role functioning (ETx 83.5; STxE 51.5; STxA 60.1), social functioning (ETx 88.3; STxE 69.1; STxA 75.8), and global QOL scores (ETx 74.4; STxE 61; STxA 55.4) at 2 mo after Tx (p< 0.017for all). In addition, surgical patients reported significantly more EORTC-QLQ-OES18 symptoms than ETx patients such as: fatigue (ETx 74%; STxE 90%; STxA 90%; p 0.029), dysphagia (ETx 17%; STxE 57%; STxA 75%; p< 0.000), eating problems (ETx 37%; STxE 95%; STxA 100%; p< 0.000) and choking (ETx 14%; STxE 47%; STxA 47%; p<0.000) compared to the ETx pts. These differences were absent 6 mo after Tx. STxE and STxA reported higher fear of cancer
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