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2019 HSR&D/QUERI National Conference Abstract

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1106 — Trends in Wait Times for Outpatient Colonoscopy in the Veterans Health Administration, 2008-2015

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

Objectives:
The Veterans Health Administration (VA) has been scrutinized for prolonged wait times for routine medical care, including for elective outpatient procedures such as colonoscopy. In this study, we aimed to investigate time trends in wait time for outpatient colonoscopy in VA. We also sought to better understand factors associated with increased wait time.

Methods:
Retrospective cohort study using mixed-effects logistic regression of national VA administrative data regarding all Veterans who underwent outpatient colonoscopy for an indication of a positive fecal occult blood test (FOBT) in 2008-2015. We focused on colonoscopies performed for an indication of positive FOBT in order to define an objective time point when waiting commenced. Intervals of > 6 months between positive FOBT and colonoscopy have been shown to be associated with increased risk of colorectal cancer and advanced-stage disease. We calculated wait time (in days) between positive FOBT and colonoscopy completion, stratified by year and adjusted for patient- and facility-level factors, including sedation type (standard endoscopist-directed sedation versus resource-limited monitored anesthesia care).

Results:
There were 135,162 outpatient colonoscopy encounters for positive FOBT during the study period, across 129 VA facilities. The number of colonoscopies performed for an indication of positive FOBT remained roughly stable (18,849 in 2008 vs. 14,338 in 2015; range 14,338-21,107). In 2008, the median wait time across sites was 50 days (interquartile range [IQR] = 33, 76). There was no secular trend in wait times (2015 median = 52 days, IQR = 34, 78). Examining the adjusted effect of sedation type on wait time, no clinically meaningful difference was found.

Implications:
Wait times for colonoscopy for positive FOBT have been stable over time in VA, with few Veterans waiting > 80 days.

Impacts:
While these data suggest that VA is able to meet current colonoscopy demand within a clinically-reasonable timeframe, even a clinically-reasonable delay may be excessive from the perspective of Veterans with concerns about occult malignancy and providers unfamiliar with underlying outcome data. Future studies should explore how best to define appropriate specialty care access times in a manner that incorporates both evidence regarding clinical outcomes and also key stakeholder perspectives.