In the Journals

Endoscopists regularly overuse colonoscopy screenings for colorectal cancer

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November 21, 2014

Endoscopists commonly recommended more frequent colonoscopy screenings and surveillance for colorectal cancer than current recommended guidelines, according to study findings.

“Our study shows that a high percentage of follow-up colonoscopies are being performed too early, resulting in use of scarce health care resources with potentially limited clinical benefit,” researcher Thomas D. Sequist, MD, from the division of general medicine and primary care at Brigham and Women’s Hospital, said in a press release.

In the retrospective cohort study, Sequist and colleagues evaluated data of 1,429 patients aged 50 to 65 years who underwent an initial colonoscopy for colorectal cancer between 2001 and 2010. The researchers followed the patients for up to 10 years after their initial colonoscopy.

Sequist and colleagues conducted an exam-level analysis by calculating the percentage of follow-up screening and surveillance colonoscopies performed after the initial exam that constituted overuse. They analyzed overuse using models for two different scenarios: overuse among follow-up screenings in patients with no history of adenoma; and overuse among follow-up screenings after adenoma detection.

The primary outcome measures were time to next screening or surveillance colonoscopy and predictors of overuse. Overuse was defined as colonoscopies not performed within the national guidelines or more than 1 year earlier than the recommended timeline.

According to study results, during a median follow-up of 6 years, the patients in the study cohort underwent an additional 871 screening or surveillance colonoscopy exams. Overuse was identified in most of the follow-up screening colonoscopies (88%) and many of the surveillance colonoscopies (49%) repeated during this period.

“There are likely multiple drivers of recommendations for early colonoscopy, including disagreement with current guidelines, fear of poor patient outcomes or malpractice, or misaligned financial incentives,” Sequist said in the release.

Sequist and colleagues noted that exam findings influenced the time to next colonoscopy after the initial screening.

  • No polyp: median 6.9 years (interquartile range [IQR], 5.1-10);
  • Hyperplastic polyp finding: 5.7 years (IQR, 4.9-9.7);
  • Low-risk adenoma finding: 5.1 years (IQR, 3.3-6.3);
  • High-risk adenoma finding: 2.9 years (IQR, 2-3.4; P<.001).

Logistic regression models of overuse revealed a strong association between endoscopist recommendation for early follow-up and overuse of screening colonoscopy (OR=6.27; 95% CI, 3.14-12.5), as well as surveillance colonoscopy (OR=13.47; 95% CI, 6.61-27.46). Colonoscopy overuse was found to be strongly correlated with early follow-up recommendations by endoscopists, with patients up to 13 times more likely to adhere to early colonoscopy follow-up when advised by an endoscopist.

“Previous research has shown that most endoscopists do not consistently agree with the follow-up intervals recommended in national guidelines and report preferences for shorter screening and surveillance intervals,” Sequist said. “Examining practice variation and establishing locally endorsed standards among endoscopists may be a way to target interventions to reduce overuse.”

Disclosure: The researchers report no relevant financial disclosures.

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