Risk Stratification in Cost-Effectiveness Analyses of Cancer Screening: Intervention Eligibility, Strategy Choice, and Optimality

Introduction: There is increasing interest in risk-stratified approaches to cancer screening in cost-effectiveness analysis (CEA). Current CEA practice regarding risk stratification is heterogeneous and guidance on the best approach is lacking. This article suggests how stratification in CEA can be improved. Methods: I use a simple example of a hypothetical screening intervention with 3 potential recipient risk strata. The screening intervention has 6 alternative intensities, each with different costs and effects, all of which vary between strata. I consider a series of alternative stratification approaches, demonstrating the consequences for estimated costs, effects, and the choice of optimal strategy. I supplement this analysis with applied examples from the literature. Results: Adopting the same screening policy for all strata yields the least efficient strategies, where efficiency is understood as the volume of net health benefit generated across a range of cost-effectiveness threshold values. Basic stratification that withholds screening from lower-risk strata while adopting a common strategy for those screened increases efficiency. Greatest efficiency is achieved when different strata receive separate strategies. While complete optimization can be achieved within a single analysis by considering all possible policy combinations, the resulting number of strategy combinations may be inconveniently large. Optimization with separate strata-specific analyses is simpler and more transparent. Despite this, there can be good reasons to simulate all strata together in a single analysis. Conclusions: If the benefits of risk stratification are to be fully realized, policy makers need to consider the extent to which stratification is feasible, and modelers need to simulate those choices adequately. It is hoped this analysis will clarify those policy and modeling choices and therefore lead to improved population health outcomes.