1182 — Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in the Veterans Health Administration

Lead/Presenter: Sameer Saini,  COIN - Ann Arbor
All Authors: Adams MA (VA Ann Arbor Center for Clinical Management Research), Kerr EA (VA Ann Arbor Center for Clinical Management Research) Gao Y (VA Ann Arbor Center for Clinical Management Research) Saini SD (VA Ann Arbor Center for Clinical Management Research)

Objectives:
Overuse of colonoscopy for screening and other preventive indications is a common and well-documented problem in the Veterans Health Administration (VHA) and other US healthcare systems. Early restrictions in ambulatory utilization during the COVID-19 pandemic induced an acute state of backlogged cases that served as motivation to minimize low-value care to conserve limited endoscopic resources for high-need patients. Indeed, VHA’s National GI Program Office distributed guidance in April 2020 asking facilities to prioritize procedures by indication and time-sensitivity. We aimed to evaluate whether this effect of COVID-19 decreased low-value screening colonoscopy use (“overuse”) in VHA.

Methods:
Retrospective cohort study of Veterans undergoing an index screening colonoscopy at one of 110 VHA endoscopy facilities in October-December 2019 (“pre-COVID”) and October-December 2020 (“COVID”). Facility-level screening colonoscopy overuse rates were calculated in the pre-COVID and COVID periods using a validated ICD-10-based electronic measure and adjusted for facility endoscopy volume. 95% confidence intervals (CI) were calculated. We also developed a multilevel multivariable logistic regression model with a random intercept for facility to examine the association between facility-level predictors and relative changes in screening colonoscopy overuse. Facility characteristics examined included: (1) VHA facility complexity score, (2) geographic region, (3) academic affiliation, and (4) capacity (comparing Q3 2020 procedural volume with Q3 2019 volume to calculate proportion of pre-COVID/Q4 2019 capacity recovered in Q4 2020). Procedure-level data was aggregated by facility and time-period. We then fit a generalized estimating equation negative binomial model with the number of screening colonoscopies as the outcome, total number of colonoscopies as the offset, and geographic region, time-period (Q4 2019/Q4 2020), facility complexity, academic affiliation, capacity, and interactions of time-period with facility complexity, academic affiliation, and capacity as predictors. The model assumed that observations from the same facility were correlated with an exchangeable covariance structure.

Results:
27,736 average risk screening colonoscopies were performed during the study period at 110 VHA facilities (18,376 pre-COVID; 9,360 COVID). The adjusted mean pre-COVID facility-level screening colonoscopy overuse rate was 22.6% (95% CI 21.3-23.8%), compared with 29.4% (95% CI 27.9%-30.8%) COVID. There was a 6.8% (95% CI 5.4%-8.3%) increase in screening colonoscopy overuse in Q4 2020/COVID compared to the pre-COVID/Q4 2019 baseline, with significant variability across facilities (interquartile range: 1.4%-12.1%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed < 9 years after previous colonoscopy (47.0% pre-COVID vs. 42.3% COVID). Medium-complexity and academically affiliated facilities experienced the largest relative increases in screening colonoscopy overuse. Facilities that failed to regain their pre-COVID capacity by Q4 2020/COVID were no more likely to decrease screening colonoscopy overuse than those that had regained their capacity (p = 0.187).

Implications:
Contrary to our hypothesis that COVID would induce decreased utilization of low-value care, median facility-level screening colonoscopy overuse rates remained relatively stable in Q4 2020 despite pandemic-induced backlogs and resource constraints.

Impacts:
Our findings illuminate the complexity of changing practice patterns to reduce low-value services and suggest that future interventions must address underlying facility-level structural and/or cultural factors to sustainably curb inappropriate or unnecessary services.