Result card

  • ECO3: What are the unit costs of the resources used when delivering FIT and its comparators gFOBT and no screening?
English

What are the unit costs of the resources used when delivering FIT and its comparators gFOBT and no screening?

Authors: Principal Investigators: Anna-Theresa Renner, Ingrid Rosian-Schikuta, Investigators: Nika Berlic, Neill Booth, Valentina Prevolnik Rupel

Internal reviewers: Pseudo178 Pseudo178, Pseudo283 Pseudo283, Pseudo291 Pseudo291, Pseudo293 Pseudo293, Pseudo294 Pseudo294, Pseudo297 Pseudo297, Pseudo298 Pseudo298

Thirteen different articles from the systematic review of the literature outlined in the domain methodology section were used to identify the unit costs (according to the standard definition used in health economic evaluation, a unit cost is the cost of natural resource unit, e.g. cost of test kit; in some situations, it can also be the cost of the medical resources required to treat a certain stage of disease, e.g. cost of the resources required to treat metastatic colon cancer) of the resources used when delivering FIT and its comparator gFOBT.

The unit costs of resources used were not presented in every study. The studies that did mention the unit costs are presented below. 

Heitman et al. (2010) in their study concludes that gFOBT screening, when comparing overall costs, is slightly more expensive in comparison to FIT screening. Nevertheless, when comparing unit costs in the study from 2010 and also in the report of 2009, it can be seen that the unit costs for FIT are slightly higher than the unit costs for gFOBT. Unit costs for FIT are 19 CAN$ (i.e. base case: direct health care costs including costs of the kit and the processing), whereas unit costs for gFOBT amount to 12 CAN$ (the test of the kit costs 5 CAN$ and processing costs 7 CAN$). They also specified non-medical costs, which included patients and caregivers time and travel costs, but excluded productivity losses, and in both cases amount to 36 CAN$. Heitman et al. indicated also the unit costs for diagnostic follow-up and further treatment. They estimated that diagnostic colonoscopy (includes physician costs of diagnostic colonoscopy – 327 CAN$ and nonphysician costs of colonoscopy – 530 CAN$) amounts 857 CAN$, while therapeutic colonoscopy (includes physician costs of therapeutic colonoscopy – 401 CAN$ and nonphysician costs of colonoscopy – 598 CAN$) amounts to 999 CAN$. The authors also presented the total cost of managing CRC, which amount for stage I on average to 25,049 CAN$, for stage II on average to 36,143 CAN$, for stage III on average to 96,768 CAN$ and for stage IV on average to 134,014 CAN$ {15}.

 

Van Ballegooijen et al. (2003) revealed that FIT has a unit cost of approximately 13 $ (i.e. when specificity is 98% and sensitivity 70%), whereas a gFOBT Hemoccult II has a unit cost of approximately 4.50 $ (i.e. when specificity is 98% and sensitivity 40%). But rather than providing an estimate of the unit cost of FIT, van Ballegooijen et al. used a threshold analysis to estimate the unit cost at which FIT could be considered to be as equally cost effective as gFOBT. Van Ballegooijen et al. also made estimations on the average number of colonoscopy, which follows a positive screening result. The estimated costs for colonoscopy were based on information provided by CMS (i.e. Centers for Medicare and Medicaid Services) on Medicare payment rates for 2002 for colonoscopy procedures and polypectomy procedures performed in free standing clinic settings, on outpatient hospital settings and ambulatory surgical settings. The weighted average payment across these settings was 646$ for diagnostic colonoscopy and 683 $ for diagnostic colonoscopy together with biopsy {10}.

 

Berchi et al. (2004) indicated the following annual cost per individual {12}:

  • organization of screening campaign – 0.38 €;
  • FIT test – 8.84 € (i.e. purchasing, distribution, revelation of the test);
  • gFOBT test – 10.98 € (i.e. purchasing, distribution, revelation of the test);
  • colonoscopy – 457.35 €;
  • treatment(1) of stage A – 17,579 €;
  • treatment of stage B – 21,858 €;
  • treatment of stage C – 31,110 €;
  • treatment of metastasized cancer – 17,384 € .

 

Heresbach et al. (2010) reported that the screening test proposal in both screening alternatives (FIT and gFOBT) costs 2.1 €. In addition to that, FIT costs 8.84 €, whereas the gFOBT is a little more expensive and it costs10.98 €. They have estimated that CTC (computed tomographic colonography) procedure costs 128.7 €, Colonoscopy without polypectomy costs 779 €, Colonoscopy with polypectomy of nonadenomatous polyps 1561 € and Colonoscopy with polypectomy of adenomatous polyps 3,610 € on average. They have calclated that the colorectal cancer treatment costs 17,000 € on average in stage I, 22.000 on average in stage II, 30,700 on average in stage III and 36,600 on average in stage IV {16}.

 

The results of the study by van Rossum et al. (2011) indicated that the participation-independent costs(2) of the FOBTs were: €5.20 for gFOBT and €4.39 for FIT. Compared with the manually operated and evaluated gFOBT, the automated analyzer (OC-Sensor micro) reduced operation and evaluation time for the FIT with more than 90%. When assuming 100% participation of individuals in performing the test, one gFOBT overall cost €9.63 and one FIT cost €8.50. The actual participation was 47% for gFOBT and 60% for FIT. Therefore, the overall cost according to intention to screen for one gFOBT was €7.06 and for one FIT €6.22. Van Rossum et al. also presented the screening costs, which are independent of the type of test and the participation rate, as equal for FIT and gFOBT, i.e. 2.40 €. They presented equal screening costs also for screening that is independent on the type of test and depending on participation. Those costs amount to 3.04 € for both tests. The differences that they identified were only among the test specific invitation costs that are independent of participation (FIT costs 1.35 €; gFOBT costs 2.80 €) and among test specific costs that depend on participation (1.71 € for FIT and 1.39 € for gFOBT). Van Rossum et al. also presented colonoscopy and treatment costs. They have estimated that the average costs for colonoscopy (Including polypectomy and pathology) amounts 921 €. They divided the treatment base costs to a costs for surgery (12,366 €), chemotherapy (12,731 €), Surgery and chemotherapy metastasis (23,097 €) and Radiotherapy (5,710 €) {19}.

 

Lejeune et al. (2010) concluded that FIT is more expensive as gFOBT. Distribution costs per FIT test performed amount to 18 €, whereas for gFOBT these costs amount to 11.8 €. They also identified costs of revelation per test performed, which amounts 5 € for FIT and 4.5 € for gFOBT. They have also presented costs relative to positive tests and concluded that diagnostic colonoscopy on average costs 526 €, while colonoscopy together with polypectomy  costs 641 €. They have also indicated the treatment cost: 17,596 € for stage I, 20,472 € for stage II, 29,013 € for stage III and 35,059 € for stage IV {17}.

 

Some other studies came to similar conclusions (i.e. that FIT unit costs are higher than gFOBT’s). Parekh et al. (2008) assumed that the base case costs of FIT amount to 22 $ (for each cycle of FIT – i.e. per year), whereas for gFOBT they amount to15 $ (for each cycle – i.e. per year). Parekh et al. also indicated that the costs of colonoscopy costs on average 920 €. They concluded that the base case value for localized cancer stage amounts 51,000 €, base case value for regional cancer stage amounts 98,000 € and base case value for distant cancer stage amounts 200,000 € {18}.

 

Sharp et al. (2012) indicated that the costs for one FIT kit (i.e. cost per kit dispatched/per individual invited to participate in screening) amounts to 3.75 €, whereas a gFOBT kit costs less – 1.70 €. They claim that the costs of FIT processing/ analysis (i.e. costs per kit completed and returned/ cost per screening participant) amount to 11.60 €, in comparison to gFOBT, where the costs amount to 7.81 €. They indicated that cost of colonoscopy amounts 650 €, while cost of CTC amounts 550 €. They have calculated that the lifetime cost of stage I CRC-screen-detected amounts 22,885 €, of stage II 36,377 €, of stage III 48,032 € and of stage IV 35,799 € {20}.

 

Sobhani et al. (2011) compared FIT and gFOBT alternatives and concluded that the costs for the screening program, the invitation of the population and the distribution of the tests are the same for both tests. A screening program costs 1.26 € for both tests, inviting the population amounts to 0.65 € and the distribution amounts to 9.32 €. Sobhani et al. (2011) estimated that the gFOBT purchase costs 4 € and gFOBT analysis 3.2 €. He made the same assumption for FIT tests. They have calculated that the colonoscopy, performed in case of positive results, would cost 526 € on average, colonoscopy with polypectomy – 641 €. They have also made a calculation for the phase of treatment, where the stage I amounts 17,596 €, stage II 20,472 €, stage III 29,013 € and stage IV 35,059 € {21}.

 

Telford et al. (2010) concluded that the FIT test is more expensive than gFOBT test. The costs of the FIT kit ranges between 10 and 40 CAN$, whereas the gFOBT kit ranges between 5 and 20 CAN$ {22}.

 

Zauber (2010) identified the base case costs for FIT to be 22.22 US$ (payer is CMS - Center for Medicare and Medicaid Services) and modified societal costs to be 39.22 US$ (these costs include beneficiary costs (copayments) and time costs in addition to the payer costs). They identified the base case costs for gFOBT to be 4.54 US$ (payer is CMS) and modified societal costs to be 21.54 US$. Telford et a.l also made an estimation for colonoscopy and further treatment. They indicated that colonoscopy costs between 200 and 2000 €, cost of cancer care in year 1 for stage I ranges between 5,000 and 30,000 €, for stage II between 20,000 and 50,000 €, for stage III 30,000 – 100,000 € and for stage IV 50,000 – 500,000 € {22}.

 

Wilschut et al. (2011) also came to the conclusion that the unit costs of FIT are more expensive than of gFOBT. Costs for FIT invitation (organization and test kit), according to their data, amount to 14.85 €, whereas for gFOBT they amount to 14.05 €. They have also identified costs per attendee (personnel and material costs for analysis) to 4.37 € for FIT and 1.90 € for gFOBT. They have estimated that the colonoscopy costs are 303 € without polypectomy and 393 € with polypectomy. Initial treatment in stage I was estimated to be 12,500 € initial treatment in stage II was estimated to be 17,000 €, initial treatment in stage III was estimated to be 21,000 € and in stage IV to 25,000. All 4 treatment scenarios had also additional costs both for continuing treatment after the first year and in the event of terminal care due to either CRC or other causes. {24}.

 

From the studies that present the unit costs it could be summarized that the ratio of the price between FIT’s and gFOBT’s unit costs usually corresponds to the ratio of the overall amount of resources (i.e total strategy costs) between those two screening strategies. This means, if FIT unit costs are higher compared to the gFOBT unit costs, the total amount of resources for a FIT screening strategy are higher in comparison to a gFOBT screening strategy. Nevertheless, there are some exceptions (e.g. {15}) that are presented above. In addition, if FIT is used at a low cut-off value, a higher number of colonoscopies will be required which consequently results in higher total costs of screening (and vice versa). Van Rossum et al. {19}, for example, indicated that colonoscopy costs have a relatively high impact on the total costs of a screening strategy. The unit costs of colonoscopy and further treatment are comparable between studies. The colonoscopy costs on average amounts to 600 €, while further treatment costs increase with the cancer stages.

 

Author (year), Country

Study design

Included costs

FIT

FOBT

Colonoscopy

Treatment/management

van Ballegoijen et al.

(2003), USA

Use of MISCAN-COLON micro-simulation model

Direct costs including a co-payment from the patient

 

$13

 

$4.50

$646

 

$683

 

Hemocult II

 

*Diagnostic colonoscopy (weighted average payment)

**Diagnostic colonoscopy together with biopsy (weighted average payment)

 

 

Berchi et al.

(2004), France

State-transition model (Markov process)

Direct costs based on French health care insurance contracts

 

€8.84

€10.98

€457.35

 

€17,579*

€21,858**

€31,110***

€17,384****

 

 

 

*Treatment of stage A

**Treatment of stage B

***Treatment of stage C

****Treatment of metastasized cancer

 

Heitmann et al.

(2010), Canada

Markov model, with calibration against the efficacy and effectiveness outcomes from the literature

Direct costs derived from the Canadian health care system, costs of patient time and transport costs

CAN$ 19

CAN$ 12

CAN$ 857*

 

CAN$ 999**

 

 

CAN$ 25,049*

CAN$ 36,143**

CAN$ 96,768***

CAN$ 134,014****

including costs of the kit and processing

including costs of the kit and processing

*diagnostic colonoscopy

**therapeutic colonoscopy

 

*Managing CRC at stage I

**Managing CRC at stage II

***Managing CRC at stage III

****Managing CRC at stage IV

Heresbach et al.

(2010), France

State-transition model (Markov process)

Direct costs obtained from French health care system

€ 8.84

 

€ 10.98

€ 128.7*

 

€ 779**

 

€ 1561***

 

€ 3610****

 

€ 17,000*

€ 22,000**

€ 30,700***

€ 36,600****

 

 

*CTC (computed tomographic colonography) procedure (on average)

 

**Colonoscopy without polypectomy (on average)

 

***Colonoscopy with polypectomy of nonadenomatous polyps (on average)

 

****Colonoscopy with polypectomy adenomatous polyps (on average)

on average:

*Treatment of CRC at stage I

**Treatment of CRC at stage II

***Treatment of CRC at stage III

****Treatment of CRC at stage IV

Lejeune et al.

(2010), France

State-transition model (Markov process)

Direct costs based on French health care insurance contracts

€ 23

 

€ 16,3

 

€ 526*

€ 641**

 

€ 17,596*

€ 20,472**

€ 29,013***

€ 35,059****

 

 

*diagnostic colonoscopy (on average)

**colonoscopy together with polypectomy (on average)

 

*Treatment of CRC at stage I

**Treatment of CRC at stage II

***Treatment of CRC at stage III

****Treatment of CRC at stage IV

Parekh et al.

(2008), USA

State-transition model (Markov process)

Direct costs derived from Medicare fee schedule

€ 22

 

€ 15

 

€ 920

 

€ 51,000*

€ 98,000**

€ 200,000***

per year

per year

 

*base case value for localized cancer stage

**base case value for regional cancer stage

***base case value for distant cancer stage

van Rossum et al.

(2011), Netherlands

State-transition model (Markov process)

Direct costs based on Dutch health care charges and retail prices)

€ 12,89

 

€ 14,63

 

€ 921

 

€ 12,366*

 

€ 12,731**

 

€23,097***

 

€ 5,710****

dependent costs of the test, assuming 100 % participation (costs of the FOBT itself and costs for laboratory analyses

 

dependent costs of the test, assuming 100 % participation (costs of the FOBT itself and costs for laboratory analyses

 

including polypectomy and pathology) (on average

*costs for surgery

 

**costs for chemotheraphy

 

***cost of surgery and chemotheraphy metastasis

 

****radiotheraphy

Sharp et al.

(2012), Ireland

State-transition model (Markov process), with calibration against the efficacy and effectiveness outcomes from the literature

Direct costs based on Health Service Executive

€ 3.75*

€ 11.60**

€ 7.81*

€ 1.70**

 

€ 650*

 

€ 550**

 

€ 22,885*

€ 36,377**

€ 48,032***

€ 35,799****

*FIT kit  (costs per kit dispatched/ per individual invited to participate in screening)

**FIT processing/analysis (costs per kit completed and returned/ costs per screening participant)

 

*gFOBT kit  (costs per kit dispatched/ per individual invited to participate in screening)

**gFOBT processing/analysis (costs per kit completed and returned/ costs per screening participant)

*colonoscopy

 

**CTC

 

*Lifetime costs of stage I CRC-screen-detected

*’Lifetime costs of stage II CRC-screen-detected

***Lifetime costs of stage III CRC-screen-detected

****Lifetime costs of stage IV CRC-screen-detected

Sobhani et al.

(2011), France

 

State-transition model (Markov process)

Direct costs based on literature

€ 18.43

€ 18.43

€526*

€641**

 

€ 17,596*

€ 20,472**

€ 29,013***

€ 35,059***

costs for the screening programme, the invitation of the population and the distribution of the tests are the same for FIT and gFOBT:

Screening programme

Inviting the population

Distribution

Purchase costs

Analysis

*Colonoscopy in case of positive results (on average)

**Colonoscopy with polypectomy (on average)

 

*Treatment of CRC at stage I

**Treatment of CRC at stage II

***Treatment of CRC at stage III

****Treatment of CRC at stage IV

Telford et al.

(2010), Canada

State-transition model (Markov process)

Direct costs based on data from the Provincial Ministry of Health

Between 10 and 40 CAN$

 

Between 5 and 20 CAN$

 

 

 

 

 

 

Wilschut et al.

(2011) Netherlands

Use of MISCAN-COLON micro-simulation model

Direct costs derived from the Dutch health care system

€ 19.22

 

€ 15.95

€ 303*

 

€ 393**

 

€ 12,500*

€ 17,000**

€ 21,000***

€ 25,000****

Costs per invitation (organizational costs and test kit)

Costs per attendee (personnel and material costs for analysis)

 

*Colonoscopy

 

**Colonoscopy with polypectomy

 

*Treatment of CRC at stage I

**Treatment of CRC at stage II

***Treatment of CRC at stage III

****Treatment of CRC at stage IV

Zauber

(2010), USA

Use of MISCAN-COLON micro-simulation model

Direct costs derived from Medicare fee schedule excluding  co-payments borne by the patient

$ 22.22

 

$ 4.54

 

$ between 200 and 2,000

 

$ between 5,000 and 30,000*

$ between 20,000 and 50,000**

$ between 30,000 and 100,000***

$ between 50,000 and 500,000****

base-case costs

base-case costs

 

*Treatment of CRC at stage I

**Treatment of CRC at stage II

***Treatment of CRC at stage III

****Treatment of CRC at stage IV

 

  [1] Costs of treating cancers with regard to diagnostic stage (i.e. A, B, C and metastasized stage) were estimated using data from the Digestive Tumour Registry of Calvados and Social Security data on reimbursements for treating all CRCs incident in the Department of Calvados during the period 1st September 1997 to 31st August 1998. They were constituted of: hospital care (both public and private) and care given in the medical departments of retirement homes; outpatient care (specialised or non-specialised medical consultations, medical and paramedical acts); transportation for medical reasons; medical purchases such as pharmaceutical products and prosthesis (colostomy bags); and assistance provided to patients such as daily payments and other allowances (disability with or without recourse to a third person). [2] The costs of the FOBTs consist of costs that were independent and dependent on the type of test. Ignoring the differences in participation between the types of test, costs independent of the type of test were costs related to the invitation for screening as letters and information brochures, basic administration of tests, feedback of test results to the patient and postal charges. Costs dependent on the type of test were costs of the FOBT itself and costs for laboratory analyses.

Optional
Not
Renner P et al. Result Card ECO3 In: Renner P et al. Costs and economic evaluation In: Jefferson T, Cerbo M, Vicari N [eds.]. Fecal Immunochemical Test (FIT ) versus guaiac-based fecal occult blood test (FOBT) for colorectal cancer screening [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali; 2014. [cited 16 June 2021]. Available from: http://corehta.info/ViewCover.aspx?id=206

References