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.
This research was supported by the National Cancer Institute (R01 CA112367, 5R25 CA057711-20), Health Resources and Services Administration, and Ryoichi Sasakawa Fellowship Fund.
Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 3.5 million annual patient visits, is the largest birthing center in Massachusetts and employs nearly 15,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $650 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative.
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