In 1996, Salkeld et al. [1
] found that screening the average-risk Australian population for colorectal cancer using a faecal occult blood test (FOBT), compared to existing practice, would cost $24,660 per life-year gained (LYG). Due to uncertainty regarding the effectiveness of FOBT screening, they report a range of values, between $12,695 and $67,848 per LYG. Randomised controlled trials of population screening with FOBT conducted in the UK [2
] and Denmark [3
], but published after Salkeld et al.'s study, have reduced this uncertainty. The cost-effectiveness analyses based on the UK trial data [4
] suggest a cost per life-year gained between £1,371–£5,685 (approximately $AU3,370–13,974) and the analysis of the Danish trial data [5
] suggest a cost per life-year gained between 17,000–42,000DKK (approximately $AU3,916–9,672).
Three years before publication of Salkeld's study Bolin [6
] discussed the advantages of using colonoscopy for population screening, and in 1996, he suggested colonoscopy was cost-effective [7
]. In 1997, he asked whether the time had come to use colonoscopy for population screening in Australia [8
]. Kermond [9
] responded suggesting double contrast barium enema (DCBE) should not be overlooked arguing colonoscopy is 10 times more expensive, false negatives still occur and complication rates are higher. Bolin argued, in the same issue of the MJA, that the sensitivity of colonoscopy exceeds DCBE, the complication rate is only 0.1% and cost differentials are actually less than those suggested by Kermond [9
Bolin also claimed that FOBT at one and three years and colonoscopy at 10 years, assuming a 10-year period during which time the cancer is detectable and curable (known as the dwell time), are cost-effective modes of CRC screening, probably referring to data subsequently published in 1999 [10
]. For this research, the authors substituted Australian values for cost parameters into a US model of the cost-effectiveness of CRC screening [11
] and generalised the results to the Australian population. They reported change in cost and change in life-years gained, as compared to existing practice, for competing screening strategies that encompass FOBT, colonoscopy, flexible sigmoidoscopy and DCBE [10
]. By assuming that society is willing to pay up to $US40,000 (approximately $AU65,449 in 2002 prices) per LYG, Bolin proposed that annual FOBT, triennial FOBT, triennial DCBE, five-yearly DCBE, five-yearly colonoscopy and ten-yearly colonoscopy are all cost-effective and concluded that physicians have the option of offering individuals a range of screening alternatives, including colonoscopy [10
]. Since publishing the research Bolin has argued, on four separate occasions that population screening with colonoscopy is cost-effective [12
]. The last of these, in 2002 [14
], provoked Macrae and Hebbard [16
] to criticise Bolin's interpretation of epidemiological data.
In 2004, O'Leary et al. [17
] also addressed the economic questions around population screening in Australia. They estimated the cost-effectiveness, compared to existing practice, of FOBT, flexible sigmoidoscopy and colonoscopy, and found flexible sigmoidoscopy and colonoscopy were cost-effective but FOBT was not.
There are important differences in the way that Salkeld et al. [1
], Bolin et al. [10
] and O'Leary et al. [17
] report the Australian cost and effectiveness data. Salkeld et al. reports an incremental cost-effectiveness ratio, O'Leary et al. reports both average and incremental cost-effectiveness ratios, however they draw their conclusions from an average analysis. Bolin only calculates average cost-effectiveness ratios. The correct ratio for decision-making is an incremental cost-effectiveness ratio: McMahon [18
] argues the use of average ratios is not meaningful; Drummond [19
] and Gold [20
] both discuss why incremental rather than average cost-effectiveness ratios are relevant for decision making; and, both Torgerson [21
] and Neuhauser & Lewicki [22
] provide examples of how average analyses muddy the waters. In their much-cited 1975 paper, Neuhauser & Lewicki [22
] reviewed data on screening for CRC. They illustrated that repeatedly testing a stool sample up to six times, when a previous test result was negative, would capture all cases of CRC, at an average cost per case of $2451. They also did an incremental analysis, with the same data, and showed the incremental cost per case detected, from the fifth to sixth round of testing was $47 million. This illustrates that average analyses can be grossly misleading.
We have four objectives in this paper: first, to demonstrate why incremental, not average, cost-effectiveness ratios should be used for decision-making; second, to update the cost data reported by Salkeld et al. [1
], Bolin et al. [10
] and O'Leary et al. [17
] to 2002 Australian dollar prices; third, to calculate incremental cost-effectiveness ratios from the Bolin data; and fourth, to discuss the results of our re-analysis, comparing the outcomes from the three previous studies. This will provide readers with an up-to-date and appropriate assessment of the existing cost-effectiveness data for population-based CRC screening programmes in Australia.