Jump to: Page Content, Site Navigation, Site Search,

Screening

Costs

Screening is an expensive undertaking, but if not done well, the harms outlined in section 1.6 may be greater than the possible benefits. See Box 1 for the main costs associated with screening programmes and Table 1 for examples of cost estimates of some screening programmes.

Full economic appraisal of the cost effectiveness of screening is rarely performed before the programme is announced. Bowel screening is an exception to this and has been demonstrated to be cost effective. 1 2 3 4 . See Box 2.

In the absence of published economic data, it is essential to estimate the full costs of screening, which are considerably more than the cost of the test. The costs quickly mount up because the numbers involved are large and the pathway complex. 5

Costs of screening test:

  • Includes identification of eligible population, administration, and letters. For example, it is about £5 per person eligible;
  • Includes cost of sampling for test: such as taking blood samples and taking images. The costs are variable depending on technology, for example, £2 for faecal occult blood test (FOBT) for bowel and £30 for mammogram;

Cost of test reading/interpretation

  • This depends on staff grade from cytoscreener to consultant;

Cost of further investigations

  • Includes outpatient appointments, pathology and further imaging. This ranges from £80 for single appointment to £500 for complex investigation per patient recalled;

Costs of IT system to manage programme

Quality assurance processes

  • Local and regional/national to compare performance.

The initial faecal occult blood test (FOBT) is cheap, with the test kit itself available for less than £1. However, the new English programme is being centrally funded at about £14 per eligible person. This is because of the costs of identification and invitation of those eligible for screening (men and women aged 60-69 years), provision of information with invitations, and health promotion activities to encourage participation. About two-thirds of the costs of screening are associated with further investigation of the 2% likely to screen positive, because the cost of colonoscopy is so high. As this is the first national screening programme where the further investigation involves a risk of considerable harm or even death, the costs also include nurse-led clinics for preassessment and counselling of those with positive FOBT results 2 6 .

Table 1. Examples of cost estimates of some screening programmes

Screening programme Cost per participant Source
Bowel cancer About £14 per person aged 60-69, (assuming 60% uptake) Financial allocation for English BCSP 6
Breast screening £45 to £50 per woman screened Informal national office estimate
Cystic fibrosis £4 per baby, when added to existing newborn bloodspot programme infrastructure National allocation for programme roll-out
Diabetic retinopathy £25 for screening or £45 including investigations and laser per diabetic patient 2004 costing exercise 5

These costs are estimates because screening programmes are not commissioned as entities, and components may be included in other NHS budgets.

Comparing costs of screening with caring for those with the disease

The costs of screening must be compared with non-screening options.

Cost of treating more advanced disease

This may or may not be more expensive, for example, bowel cancer screening is expected to save lives, but it may not save on treatment costs of the early cancers detected. 2 The aim will be to treat to cure, including surgery and chemotherapy, possibly with new expensive drugs, whereas later symptomatic presentation may have been too late for anything except palliative treatment.

Costs to society of caring for those with long-term conditions

Screening for diabetic retinopathy is cost-effective in comparison with the care of people with diabetes, who lose their sight while still of working age. 7

Opportunity costs

If health care budgets are finite, there is often an alternative use for the money and any new development comes at the cost of not doing something else. This is called opportunity cost. Raffle states that expensive healthcare treatments are affordable for the few ‘from public funds, because the healthy majority make little call on resources’. 8 The balance can easily be tipped if we demand even inexpensive tests for large numbers of the worried well.

Opportunity costs relate to these physical resources and to availability of qualified staff as well as money. The recent age extension in the NHS Breast Screening Programme has resulted in slippage of the screening interval beyond three years in many areas due to inability to recruit radiographers without starving diagnostic hospital departments. 9

There is also a limit where screening ceases to be cost-effective screening, for example, it has been estimated that the incremental cost of expanding breast screening to include women aged 40-49 is US$105,000 per life-year saved, 10 this is because the disease is so much rarer in premenopausal women, and more difficult to detect in their dense breasts.

References

  1. Robert G, Brown J, Garvican L. Cost of quality management and information provision for screening: colorectal cancer screening. J Med Screen 2000; 7:31-34. External Link
  2. Garvican L. Planning for a possible national colorectal cancer screening programme. J Med Screen 1998; 5:187-194. External Link
  3. Whynes DK, Nottingham FOB Screening Trial. Cost-effectiveness of screening for colorectal cancer: evidence from the Nottingham faecal occult blood trial. J Med Screen 2004;11:11-15. External Link
  4. School of Health and Related Research, University of Sheffield. Colorectal cancer screening options appraisal: Cost-effectiveness, cost-utility and resource impact of alternative screening options for colorectal cancer. Report to the English Bowel Cancer Screening Working Group. 2004. Available at External Link
  5. Garvican L. Resources required for a local service in the national diabetic retinopathy screening programme. UK National Screening Committee, 2004. Available at External Link .
  6. Bowel Cancer Screening Programme. External Link
  7. Garvican L, Clowes J, Gillow T. Preservation of sight in diabetes: developing a national risk reduction programme. Diabet Med. 2000;17:627-634. External Link
  8. Raffle AE. Trust me, I'm a scientist: Will urologists set a lead for geneticists to follow? Lancet 1996; 347, 883-884. External Link
  9. National Statistics and NHS Health and Social Care Information Centre. Breast Screening Programme, England: 2004-05. NHS Health and Social Care Information Centre, Community Health Statistics, 2006. Available at: External Link
  10. Salzmann P, Kerlikowske K, Phillips K. Cost-effectiveness of extending screening mammography guidelines to include women 40 to 49 years of age. Ann Intern Med. 1997;127:955-965 External Link