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Endoscopists recommend shorter intervals than guidelines suggest for over one-third of colonoscopies
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A recent study found a 36% rate of physician nonadherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals in the Veterans Affairs health care system.
“The primary rationale for the study was twofold,” Deborah A. Fisher, MD, MHS, from Durham VA Medical Center and the division of gastroenterology at Duke University Medical Center, told Healio Gastroenterology. “VA funded the study because it is important to understand how colonoscopy resources are being used in their system, and we wanted to potentially debunk the cynical assumption that ‘overuse’ of colonoscopy shown in prior studies was all about the money.”
Deborah A. Fisher
To determine the rate of physician nonadherence to U.S. Multi-Society Task Force (MSTF) guideline recommendations for screening colonoscopy and polyp surveillance, and to identify factors associated with nonadherence, Fisher and colleagues performed a retrospective, observational study.
They evaluated information from administrative claims and physician databases and the electronic medical records (EMRs) of 1,455 patients aged 50 to 64 years (mean age at index colonoscopy, 57.5 ± 0.2 years; 93.2% male; 74.1% white) who underwent colonoscopy performed by 149 physicians at 25 VA medical centers during the 2008 fiscal year (from October 2007 through September 2008).
Patients with a history of colorectal cancer or inflammatory bowel disease were excluded, as were patients who had a colonoscopy in the previous 10 years. Endoscopist-recommended colonoscopy intervals were identified in EMRs and compared to those recommended by 2008 MSTF guidelines.
“We found that in a system with salaried physicians, recommendations to repeat colonoscopy more frequently than what guidelines support were common, which indicates that financial incentive is not the only issue,” Fisher said.
Overall, there was a 35.8% rate of nonadherence (mostly shorter intervals than guidelines), which ranged from 3% to 80% across all medical centers included in the study.
Nonadherence rates were 27.7% for patients who had normal colonoscopy results, 51.9% for patients in whom hyperplastic polyps were detected, 45.2% for patients in whom low-risk adenomas were detected and 49.2% for patients in whom higher risk adenomas were detected.
Compared to those with normal colonoscopy results, nonadherence was significantly more likely for patients in whom only hyperplastic polyps (OR = 3.1; 95% CI, 1.7-5.5) or high-risk adenomas were detected (OR = 3; 95% CI, 1.2-8), and nonadherence was found to be associated with “surveillance” rather than “screening” being listed as the indication on the colonoscopy report (OR = 2.4; 95% CI, 1.1-5.3).
“We also found that bowel preparation quality was a strong predictor of physicians recommending an earlier colonoscopy,” Fisher said.
Compared with “excellent/optimal” bowel prep, nonadherence was significantly associated with “adequate/moderate/fairly clean/fair/other” bowel prep (OR = 4.3; 95% CI, 1.9-9.5).
“Bowel prep is not a glamorous topic, but it may be the single most important modifiable factor in avoiding the costs and potential risks of ‘excess’ colonoscopy,” Fisher said.
Nonadherence was also found to be associated with sicker patients as measured by Charlson comorbidity score (adjusted OR = 1.2; 95% CI, 1.1-1.3), and geographic region.
“The strongest predictor of overuse was undergoing a colonoscopy at a facility in the Northeast,” Fisher said (compared to Midwest; OR = 4.8; 95% CI, 2.1-11.2). “This suggests that regional practice patterns may be very influential even in the face of evidence-based guidelines and without fee-for-service incentives.”
Fisher and colleagues concluded that, “given the United States’ current focus on lowering the operating costs of its health care delivery system while improving health care outcomes, the findings from this study represent an opportunity to reduce unnecessary use of a common medical procedure.” – by Adam Leitenberger
Disclosures: Fisher reports she previously consulted for Epigenomics. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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