Follow-up colonoscopies too frequent and overused by endoscopists

A retrospective study has found an overuse of colonoscopies for colorectal cancer screening and surveillance. The study demonstrated that endoscopists commonly recommended shorter follow-up intervals than established guidelines support, and these recommendations were strongly correlated with subsequent colonoscopy overuse.

"Our study shows that a high percentage of follow-up colonoscopies are being performed too early, resulting in use of scarce health care resources with potentially limited clinical benefit," said senior study author Thomas D. Sequist, MD, MPH, Brigham and Women's Hospital (BWH) Division of General Medicine and Primary Care.

This retrospective cohort study was published in the Journal of General Internal Medicine (2014; doi:10.1007/s11606-014-3015-6). The researchers combed electronic health record data of primary care patients at Harvard Vanguard Medical Associates, a multispecialty physician group practice in Massachusetts. The study included 1,429 patients age 50 to 65 years who underwent their first screening colonoscopy between 2001 and 2010, with an additional 871 colonoscopies as follow-ups were undertaken during a median follow up of 6 years.

According to the researchers, 88% of follow-up screening colonoscopies and 49% of surveillance colonoscopies repeated during the study represented overuse, meaning they were performed more than 1 year early, and often times more than 3 to 4 years earlier than is recommended by national guidelines. At the same time, one-quarter of study patients identified as higher risk based on initial colonoscopy findings failed to receive follow-up colonoscopy within the recommended 3 or 5 year time period.

Endoscopists recommended early follow-up colonoscopy after more than one-half of the initial colonoscopies. Colonoscopy overuse was strongly associated with these early follow-up recommendations; patients were up to 13 times more likely to undergo an early colonoscopy when their endoscopist recommended such follow up.

"Previous research has shown that most endoscopists do not consistently agree with the follow-up intervals recommended in national guidelines and report preferences for shorter screening and surveillance intervals," said Sequist. "Examining practice variation and establishing locally endorsed standards among endoscopists may be a way to target interventions to reduce overuse."

Sequist added, "There are likely multiple drivers of recommendations for early colonoscopy, including disagreement with current guidelines, fear of poor patient outcomes or malpractice, or misaligned financial incentives."

"The overused colonoscopies on the patients in this study alone represent a potential excess of over $1 million in health care spending—resources that might benefit those who are overdue for colon cancer screening," said lead study author Gina Kruse, MD, of Massachusetts General Hospital in Boston.

Overuse of screening examinations has become a focus of national efforts, such as the Choosing Wisely campaign by the American Board of Internal Medicine Foundation and the American Gastroenterological Association, which are jointly encouraging physicians to cut back on colorectal cancer screening examinations of uncertain value.

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