Retrospective study finds overuse of colonoscopies for colorectal cancer screening, surveillance

Brigham and Women's HospitalSep 30 2014

A retrospective study led by researchers at Brigham and Women's Hospital (BWH), has found an overuse of colonoscopies for colorectal cancer screening and surveillance. The study demonstrated that endoscopists commonly recommended shorter follow-up intervals than established guidelines support, and these recommendations were strongly correlated with subsequent colonoscopy overuse.

"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," said Thomas D. Sequist MD, MPH, BWH Division of General Medicine and Primary Care, senior study author.

The study is published online September 30, 2014 in the Journal of General Internal Medicine.

In the retrospective cohort study, researchers combed electronic health record data of primary care patients at Harvard Vanguard Medical Associates, a multispecialty physician group practice in Massachusetts. The study included 1,429 patients 50 to 65 years old who underwent their first screening colonoscopy between 2001 and 2010; and underwent an additional 871 follow-up colonoscopies during a median follow-up of six years.

According to the researchers, 88 percent of follow-up screening colonoscopies and 49 percent of surveillance colonoscopies repeated during the study represented overuse-meaning they were performed more than one year early, and often times over three to four years earlier than is recommended by national guidelines. At the same time, one-quarter of study patients identified as higher risk based on initial colonoscopy findings failed to receive follow-up colonoscopy within the recommended three or five year time period.

Early colonoscopy was recommended by endoscopists following more than one-half of the initial colonoscopies. Colonoscopy overuse was strongly associated with these early follow-up recommendations by endoscopists; patients were up to 13 times more likely to undergo an early colonoscopy when their endoscopist recommended such follow up.

"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," said Sequist. "Examining practice variation and establishing locally endorsed standards among endoscopists may be a way to target interventions to reduce overuse."

Added Sequist: "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."

"The overused colonoscopies on the patients in this study alone represent a potential excess of over $1 million in health care spending-resources that might benefit those who are overdue for colon cancer screening," said Gina Kruse, MD, Massachusetts General Hospital, lead study author.

Overuse of screening exams has become a focus of national efforts, such as the Choosing Wisely campaign by the American Board of Internal Medicine Foundation and the American Gastroenterological Association, which are jointly encouraging physicians to cut back on colorectal cancer screening exams of uncertain value.