Underuse and Overuse of Colonoscopy for Repeat Screening and Surveillance in the Veterans Health Administration

Abstract

Background & Aims Regular screening with colonoscopy lowers colorectal cancer incidence and mortality. We aimed to determine patterns of repeat and surveillance colonoscopy and identify factors associated with over- and underuse of colonoscopy. Methods We analyzed data from participants in a previous Veterans Health Administration (VHA) study who underwent outpatient colonoscopy at 25 VHA facilities between October 2007 and September 2008 (n=1455). The proportion of patients who received a follow-up colonoscopy was calculated for 3 risk groups, defined based on the index colonoscopy: no adenoma, low-risk adenoma, or high-risk adenoma. Results Colonoscopy was overused (used more frequently than intervals recommended by guidelines) by 16% of patients with no adenomas, 26% with low-risk adenomas, and 29% with high-risk adenomas. Most patients with high-risk adenomas (54%) underwent colonoscopy after the recommended interval or did not undergo colonoscopy. Patients who received a follow-up recommendation that was discordant with guidelines were more likely to undergo colonoscopy too early (no adenoma odds ratio [OR], 3.80; 95% CI, 2.31–6.25 and low-risk adenoma OR, 5.28; 95% CI, 1.88–14.83). Receipt of colonoscopy at non-academic facilities was associated with overuse among patients without adenomas (OR, 5.26; 95% CI, 1.96–14.29) or with low-risk adenomas (OR, 3.45; 95% CI, 1.52–7.69). Performance of colonoscopies by general surgeons vs gastroenterologists (OR, 2.08; 95% CI, 1.02–4.23) and female sex of the patient (OR, 3.28; 95% CI, 1.06–10.16) were associated with overuse of colonoscopy for patients with low-risk adenomas. No factors examined were associated with underuse of colonoscopy among patients with high-risk adenomas. Conclusions In an analysis of patients in the VHA system, more than a quarter of patients with low-risk adenomas received a follow-up colonoscopies too early, whereas more than half of those with high-risk adenomas did not undergo surveillance colonoscopy as recommended. Our findings highlight the need for system-level improvements to facilitate the appropriate delivery of colonoscopy based on individual risk.

Utilization and determinants of follow‐up colonoscopies within 6 years after screening colonoscopy: Prospective cohort study

“…Our findings of overuse of follow‐up colonoscopies among patients with nonadenomatous findings at screening and of underuse among participants with adenomas are in line with findings of previous studies that were mainly conducted in the United States (Supporting Information Table 2). Even the proportions of over‐ and underuse have been similar to those reported by some recent studies, highlighting that improvement of surveillance utilization is not just a national issue.…”

“…Our findings of overuse of follow‐up colonoscopies among patients with nonadenomatous findings at screening and of underuse among participants with adenomas are in line with findings of previous studies that were mainly conducted in the United States (Supporting Information Table 2). Even the proportions of over‐ and underuse have been similar to those reported by some recent studies, highlighting that improvement of surveillance utilization is not just a national issue. Our findings are also in line with our two previous studies from Germany evaluating utilization of surveillance colonoscopies in the first 3–4 years after screening, that found 6% and 12% use of subsequent colonoscopies after negative screening colonoscopy, respectively (Supporting Information Table 2) …”

“…Our findings of overuse of follow-up colonoscopies among patients with nonadenomatous findings at screening and of underuse among participants with adenomas are in line with findings of previous studies that were mainly conducted in the United States 14,15,[21][22][23][24][25] (Supporting Information Table 2).…”

Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-Risk Colorectal Adenomas and Effects on Outcome

“…28 A recent study of 25 Veterans Affairs Medical Center facilities found that general surgeons were more likely to overuse colonoscopy than gastroenterologists. 36 …”

Comparison of Telephone and Televideo Modes for Delivery of Genetic Counseling: a Randomized Trial

“…The second is that polyposis may not be the optimal health condition for which to compare modes. The VHA has a strong colon cancer screening program (Murphy et al 2016), and patients receive regular reminders to schedule more frequent colonoscopies once polyps have been identified. Based on 3 years of internal (as yet unpublished) data, our service was not offering genetic testing to all individuals with > 10 polyps at the time the study was conducted, but included family history lifestyle behaviors in the risk assessment.…”