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2023 HSR&D/QUERI National Conference Abstract

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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)

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.

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.

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).

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.

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.