Current guidelines recommend colorectal cancer (CRC) screening for men and women age 50-75 using either fecal occult blood test (FOBT) annually, sigmoidoscopy every five years coupled with FOBT every three years, or colonoscopy every 10 years. Currently 80% of Veterans Health Administration (VHA) users are adherent to these guidelines. However, prior studies suggest the possibility of duplicative CRC screening in VHA (i.e., undergoing a colonoscopy, sigmoidoscopy, or FOBT earlier than recommended by guidelines). Duplicative CRC screening can expose patients to unnecessary medical risks and increase demand for an already limited supply of colonoscopy. Therefore, studies are needed to assess the prevalence and associated resource implications of duplicative CRC screening for VHA. The scope of these studies depends on how well CRC screening procedures received by veterans outside of VHA are documented in VHA medical records, and whether robust estimates of duplicative screening levels and variation can be derived from administrative data.
The primary study objectives were to: (1) describe the documentation of non-VHA CRC screening procedures in VHA medical records; (2) estimate duplicative CRC screening prevalence; and (3) determine whether these rates vary across facility and patient subgroups.
To address Objective 1, we manually reviewed VHA medical records for a cohort of CRC screening eligible patients seen at the Minneapolis VHA Medical Center in 2006 for whom we had complete non-VA medical records documentation of CRC screening procedures for the prior ten years. To address Objectives 2 and 3, we combined data from a national survey of CRC screening eligible veterans with VHA administrative data for 2003-2009 to estimate: the proportion of procedures that were duplicative; the proportion of patients receiving one or more duplicative procedures; and the extent of variation in duplication screening across facility and patient subgroups. Estimates were derived from models that adjusted for the clustering of procedures within patients and facilities.
Analyses for Objective 1 revealed that only 58% of non-VHA colonoscopies, 34% of non-VHA sigmoidoscopies, and 2% of non-VHA FOBTs had any documentation in VA medical records, and information on results for these procedures was generally insufficient to adequately inform future screening decisions. Analyses for Objective 2 revealed that 65% of colonoscopies, 20% of sigmoidoscopies, and 33% of FOBTs would be considered duplicative if one assumed all of these procedures were conducted for screening (as opposed to diagnostic purposes); and that 37% of CRC screening eligible patients may have received a duplicative CRC screening procedure. Analyses for Objective 3 revealed that duplicative CRC screening rates do not vary significantly by patient gender, race, education, income, or utilization of non-VHA medical services, but are significantly higher among patients age 65 and older, vary significantly across VHA facilities (range 25-75%), and have modestly increased over time (from 33% in 2003 to 45% in 2009).
These findings suggest that CRC screening procedures received by veterans outside of VHA are not well documented in VHA medical records, and that many CRC procedures conducted within VHA may be performed sooner than recommended by guidelines.
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