Overuse of Colonoscopy for Colorectal Cancer Screening and Surveillance
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Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources.
Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse.
DESIGN, SETTING, AND PARTICIPANTS
Our approach was a retrospective cohort study using electronic health record data for patients 50–65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice.
MAIN OUTCOME MEASURES
We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies.
We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88 %) and many surveillance colonoscopies (49 %) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1–10.0; hyperplastic polyp: 5.7 years, IQR: 4.9–9.7; low-risk adenoma: 5.1 years, IQR: 3.3–6.3; high-risk adenoma: 2.9 years, IQR: 2.0–3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95 % CI: 3.15–12.50) and surveillance colonoscopy (OR 13.47, 95 % CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam.
Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.
KEY WORDScolorectal cancer screening colonoscopy overuse efficiency
We would like to thank Craig Salman (Harvard Vanguard Medical Associates and Atrius Health) for his assistance with data management and analysis, Amy Marston (Harvard Vanguard Medical Associates and Atrius Health) for her project management, and Debby Collins (Department of Health Care Policy, Harvard Medical School) for project coordination.
Dr. Kruse had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
The study was supported by the National Cancer Institute R01 CA112367. Dr. Kruse was supported by Health Resources and Services Administration training grant T32HP12706, the Ryoichi Sasakawa Fellowship Fund, and the National Cancer Institute 5R25 CA057711-20.
An earlier version of the manuscript was accepted for presentation at the Annual Meeting of the Society for General Internal Medicine in Denver, Colorado on 26 May 2013 and was named the Top Abstract presented in the category of Quality Improvement/Patient Safety.
Conflicts of Interest
The authors declare no conflicts of interest pertaining to this work.
- 2.Levin B, Lieberman DA, McFarland B, et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008;134(5):1570–1595.CrossRefPubMedGoogle Scholar
- 8.Centers for Disease Control and Prevention. Vital signs: Colorectal cancer screening, incidence, and mortality--United States, 2002-2010. Morb Mortal Wkly Rep. 2011; 60(26):884-889.Google Scholar
- 9.Massachusetts Healthcare Quality Partners. Quality Insights: Clinical Quality in Primary Care 2012. http://www.mhqp.org/quality/clinical/cqMeasSumm.asp?nav=032460&MGList=100766, 100770, 100771, 100785, 100791, 100794, 100822, 100899, 100834, 101010, 100857, 100863, 100866, 100875, 100891, 100892, 100893&MeasureID = 26. Accessed August 19, 2014.
- 21.American Board of Internal Medicine Foundation. Choosing Wisely. 2013; http://www.choosingwisely.org/doctor-patient-lists/american-gastroenterological-association/. Accessed August 19, 2014.
- 27.Snijders TAB, Bosker RJ. Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling. London: Sage; 1999.Google Scholar
- 34.Murray MF, Giovanni MA, Klinger E, et al. Comparing Electronic Health Record Portals to Obtain Patient-Entered Family Health History in Primary Care. J Gen Intern Med. 2013.Google Scholar
- 39.Consumer Reports. Consumer Reports Health "What's Fair?" Fair healthcare pricing from Healthcare Blue Book: Colonoscopy. 2012; http://consumerhealthchoices.org/wp-content/uploads/2012/10/Colonoscopy-HCBB.pdf. Accessed August 19, 2014.
- 41.U.S. Census Bureau. Current Population Survey, Annual Social and Economic Supplement. 2011; http://www.census.gov/population/age/data/2011comp.html. Accessed August 19, 2014.