Colonoscopy 'Potentially Inappropriate' for 30% of Seniors

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these "potentially or probably inappropriate" procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

"We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines," says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, "procedures were repeated too soon after a negative exam," increasing the odds of avoidable harm, such as "perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events," she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force's prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

"For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines," she says. "So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults," Sheffield said.

Her report, published in this week's JAMA Internal Medicine, looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a "potentially or probably inappropriate" colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

"Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

"For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule."

And if that were the case, there wouldn't be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and "a moral obligation."

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, "would be the same as me taking my life. And that's a sin."

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn't be screened was made only to save money.

"Public health education and physician endorsements (of cancer screening) may have created a high degree of 'momentum' for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens."

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

"Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult's lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment."

She blames "unbalanced public health messages" for contributing to "perceptions that cancer screening should be continued indefinitely," she also points to the physician's recommendation as a strong driver of whether a senior citizen undergoes one.