Colorectal Cancer Screening May Be Overused for Many Veterans
As pressure to reduce health care expenditures mounts in this country, the value of preventive health care services such as cancer screening is being increasingly scrutinized. Currently, the U.S. Preventive Services Task Force recommends colorectal cancer (CRC) screening for men and women ages 50-75 using either an annual fecal occult blood test (FOBT), sigmoidoscopy every five years coupled with FOBT every three years, or colonoscopy every 10 years. In its initiative to transform health care delivery, VA has called for a number of specific efforts to reduce the inappropriate use of CRC screening, including reducing the number of FOBTs ordered for Veterans with evidence of a colonoscopy in the past 10 years. This study examined levels and correlates of FOBT overuse in a nationally representative sample of Veterans. Using VA data, investigators identified 1,844 screening-eligible Veterans who had one or more FOBTs between 2003 and 2009 and responded to a 2007 survey that was conducted at 24 VAMCs. Investigators then estimated the extent of FOBT overuse related to screening frequency by reason (e.g., too soon after a prior FOBT vs. too soon after other CRC screening procedures); determined whether overuse varied across facilities, regions, calendar year, or patient sub-groups; and documented the demand for colonoscopy associated with FOBT overuse.
- Of 4,236 FOBTs received by Veterans in this study, 885 (21%) met overuse criteria: 323 (8%) were done sooner than recommended after a previous FOBT, and 562 (13%) sooner than recommended after other procedures (colonoscopy, barium enema, or combination).
- FOBT overuse after prior FOBT declined between 2003 and 2009 (8%-5%), while overuse after other procedures increased (11%-19%).
- More than 11% of overused FOBTs were followed by colonoscopy within 12 months.
- FOBT overuse varied across facilities (9%-32%) and regions (12%-23%).
- Although the odds of FOBT overuse did not vary by patient demographics, they did increase by 16% with each additional outpatient visit. This pattern is consistent with prior studies documenting a positive association between healthcare utilization and CRC screening.
- Results may underestimate actual levels of FOBT overuse following colonoscopy because data did not include information on colonoscopies performed outside VA.
- Investigators were unable to examine CRC screening overuse that was related to repeat colonoscopy because data did not include information on colonoscopy.
- The inappopriate use of FOBT among Veterans with a family history of CRC, for whom colonoscopy is the recommended test, and the overuse of CRC screening due to screening Veterans unlikely to benefit were not examined in this study.
This study was supported by HSR&D (PPO 09-292). Drs. Partin, Powell, and Nelson, and Mss. Bangerter and Halek are part of HSR&D's Center for Chronic Disease Outcomes Research, Minneapolis, MN. Dr. Burgess is part of HSR&D's Center for Organization, Leadership and Management Research, Boston, MA.
Partin M, Powell A, Bangerter A, Halek K, Burgess J, Fisher D, and Nelson D. Levels and Variation in Overuse of Fecal Occult Blood Testing in the Veterans Health Administration. Journal of General Internal Medicine July 19, 2012;Epub ahead of print.