Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1013 — Increasing Use of Post-Polypectomy Surveillance Colonoscopy in the Veterans Health Administration

Lead/Presenter: Sameer Saini, COIN - Ann Arbor
All Authors: Saini SD (VA Ann Arbor Center for Clinical Management Research) Adams MA (VA Ann Arbor Center for Clinical Management Research) Holleman R (VA Ann Arbor Center for Clinical Management Research) Klamerus M (VA Ann Arbor Center for Clinical Management Research) Lohman S (VA Ann Arbor Center for Clinical Management Research) Lipson R (VA Ann Arbor Center for Clinical Management Research) Rubenstein JH (VA Ann Arbor Center for Clinical Management Research)

Objectives:
Efforts to enhance appropriate use of colonoscopy have largely focused on primary screening. We hypothesized that as more Veterans are screened for colorectal cancer, there would be a substantial increase in the proportion of procedures performed for post-polypectomy surveillance. Therefore, we quantified changes in colonoscopy indication over time in VHA.

Methods:
Retrospective study using data from VHA Corporate Data Warehouse. Colonoscopies performed in 2005-2014 were classified by indication into 4 groups using a validated electronic algorithm: (1) average-risk screening; (2) high-risk screening; (3) post-polypectomy surveillance; (4) diagnostic. Changes in colonoscopy indication were stratified by year of exam and selected patient characteristics (age, Charlson comorbidity index (CCI)).

Results:
2.5 million (2,562,091) colonoscopies were performed in 2005-2014. The total number of colonoscopies per year increased modestly, from 236,841 in 2005, to 276,430 in 2014 (17% increase). However, the number of colonoscopies performed for prevention (screening or surveillance) increased markedly, from 107,940 in 2005, to 184,585 in 2014 (71% increase). Concurrently, there was a 30% decrease in colonoscopies performed for diagnostic purposes. Screening use increased dramatically from 2005 to 2009 (82% increase), but remained relatively stable from 2009 to 2014 (5% increase). In contrast, surveillance use increased steadily over the entire study period, surpassing screening in 2011. Increased use was primarily driven by preventive colonoscopies performed in Veterans 60-69 years of age (181% increase). Of 276,430 procedures performed in 2014, 30% were for average-risk screening, 1% for high-risk screening, 37% for surveillance, and 32% for diagnostic purposes. In Veterans > = 70 years of age, 44% of colonoscopies (22,402/50,997) were performed for surveillance. In Veterans > = 70 years of age with CCI > = 4 (indicating poor health and limited life expectancy), 38% of colonoscopies (1,787/4,634) were performed for surveillance.

Implications:
Over the last decade, the number of colonoscopies performed for surveillance has increased significantly and continues to rise. Surveillance use is particularly pronounced in older Veterans, including those with limited life expectancy, raising concerns for possible overuse.

Impacts:
Efforts to reduce inappropriate use of colonoscopy in VHA need to consider the growing impact of surveillance colonoscopy, particularly in older adults in whom the harms may outweigh the benefits.