Early Repeated Screening Colonoscopy among Medicare Beneficiaries

Increased rates of screening for colorectal cancer (CRC) have led to reductions in rates of mortality from CRC; the screening procedure preferred by the American Cancer Society is colonoscopy, which can identify and remove precancerous lesions. Studies have shown that among ethnic minorities and the uninsured, rates of colonoscopy are lower than in other populations. However, according to researchers, there have been few studies to identify possible overuse of the procedure. Overuse is a concern because screening colonoscopy can have adverse effects, including hospitalization and death; it is also costly and is a limited resource in terms of facilities and practitioners. The recommended time interval for a repeated procedure for patients whose initial colonoscopy reveals no findings relevant to cancer is 10 years. Researchers recently conducted a study to determine the frequency of early repeated colonoscopy among fee-for-service Medicare patients in the United States. They also conducted analyses to assess the association of early screening with demographic variables, geographic location, and healthcare provider specialty. Study results were reported in Archives of Internal Medicine [2011;171(15):1335-1343]. The researchers identified patients at average risk who underwent colonoscopy between 2001 and 2003 through a 5% national survey of Medicare enrollees from 2000 through 2008. Results of the colonoscopy were defined as negative if the claims did not include an indication for anything other than the screening procedure, and if no biopsy, fulguration, or polypectomy was performed. Time to repeated colonoscopy was calculated. There were 24,071 Medicare patients who had a negative screening colonoscopy during the study period. Of those, 46.2% underwent a repeated procedure in <7 years. In 42.5% of those patients (23.5% of the total sample), the researchers did not find a clear indication for the early repeated screening. Among patients 75 to 79 years of age at the time of the initial negative screening result, 45.6% had a repeated procedure within 7 years. Among those ≥80 years of age with a negative result to the initial screening, the rate of early repeated screening was 32.9%. Factors associated with early repeated screening without a clear indication for the early repeated screening included male sex, increased number of comorbidities, and colonoscopy performed in an office setting or by a colonoscopist who performed a high volume of the procedure. The risk for early repeated screening was reduced in patients ≥80 years of age. By examining rates of early repeated screenings of patients with no clear indication for the repeated screening at the level of the 306 US health referral regions, the researchers also identified variations in geographic regions. The rates of early repeated screenings varied from 50% in Pueblo, Colorado, and Bryan, Texas, to <5% in other regions. Study limitations cited by the authors included the lack of information on the quality of the initial colonoscopy because early repeated screenings could result from initial screenings that were incomplete or poor quality, confining the study to Medicare fee-for-service beneficiaries ≥66 years of age, and limitations inherent in the evidence base for the determination of optimal spacing for screening colonoscopy. In summary, the researchers said, “A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.”