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    Preventive Medicine
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    A cost-effectiveness analysis of a colorectal cancer screening program in safety net clinics 
    Richard T. Meenana, , Gloria D. Coronadoa, Amanda Petrika, Beverly B. Greenb
    a Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA
    b Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA
    Colon cancer
    Cancer screening
    Cost analysis Cost effectiveness analysis
    Prevention & control 
    STOP CRC is a cluster-randomized pragmatic study of a colorectal cancer (CRC) screening program within eight federally-qualified health centers (FQHCs) in Oregon and California promoting fecal immunochemical testing (FIT) with appropriate colonoscopy follow-up. Results are presented of a cost-effectiveness analysis of STOP CRC. Organization staff completed activity-based costing spreadsheets, assigning labor hours by intervention activity and job-specific wage rates. Non-labor costs were from study data. Data were collected over February 2014–February 2016; analyses were performed in 2016–2017. Incremental cost-effectiveness ratios (ICERs) using completed FITs adjusted for number of screening-eligible patients (SEPs), as the effectiveness measure were calculated overall and by organization. Intervention delivery costs totaled $305 K across eight organiza-tions (range: $10.2 K–$110 K). Overall delivery cost per SEP was $14.43 (range: $10.37–$19.10). The largest cost category across organizations was implementation, specifically mailing preparation. The overall ICER was $483 per SEP-adjusted completed FIT (range: $96–$1021 among organizations with positive effectiveness). Lagged data accounting for implementation delay produced comparable results. The costs of colonoscopies following abnormal FITs decreased the overall ICER to S409 because usual care clinics generated more such colonoscopies than intervention clinics. Using lagged data, follow-up colonoscopies increase the ICER by 4.3% to $460. Results indicate the complex implications for cost-effectiveness of implementing standard CRC screening within a pragmatic setting involving FQHCs with varied patient populations, clinical structures, and resources. Performance variation across organizations emphasizes the need for future evaluations that inform the in-troduction of efficient CRC screening to underserved populations.
    1. Introduction
    Over the past two decades, colorectal cancer (CRC) incidence has declined in the United States, yet CRC remains the third most common cancer and the second most common cause of death, with over 140,000 new cases and over 50,000 deaths expected in 2018 (Siegel et al., 2018). It has been known for at least consumers long that effective CRC screening can reduce incidence and mortality, as reflected in US Pre-ventive Services Task Force recommendations for CRC screening among adults aged 50–75. However, in 2015 only 63% of adults aged 50 and older were up-to-date on CRC screening (American Cancer Society, 2017), a rate below the targets of the National Colorectal Cancer Roundtable (80%) (National Colorectal Cancer Roundtable, 2018) and Healthy People 2020 (70.5%) (Office of Disease Prevention and Health Promotion, 2017). Despite recent improvement (30.2% in 2012 to 39.9% in 2016), CRC screening rates among adults served by federally