VA Specialists Often Exceed Guidelines in Colonoscopy Screening Follow-Up

by U.S. Medicine

May 6, 2013

DURHAM, NC – Gastroenterologists often urge repeat colonoscopy for colonic polyp surveillance more frequently than recommended by the U.S. Multi-Society Task Force Colorectal Cancer and the American Cancer Society guidelines, according to a recent VA study warning that “overuse of colonoscopy for polyp surveillance poses a significant economic burden, may contribute to decreased colonoscopy capacity for initial screening, and increases the risk of complications.”1

While numerous studies describe the overuse of colonoscopy in the fee-for-service and Medicare populations, researchers from the Durham VAMC and Duke University in Durham sought to determine whether that also would be the case in a salaried, managed-care setting, administering a 57-item survey to all gastroenterologists in the United States employed by the VA system as of April 2010.

“Almost 20% of VA gastroenterologists participating in our survey recommended more frequent surveillance for hyperplastic polyps; this is similar to the findings of studies in other U.S. populations,” the authors report in a recent issue of the American Journal of Gastroenterology. “On the other hand, we noted underuse of surveillance colonoscopy for adenomatous polyps, even among physicians who knew the guideline recommendations.”

The study points out “substantial gaps in knowledge of guideline recommendations for polyp surveillance,” with survey responses indicating that up to 10% of gastroenterologists in the VA system would not know the guideline recommendations for hyperplastic and adenomatous polyps, and 15% would not know the recommendation for follow-up after piecemeal removal of a sessile adenoma, according to the report.

Incomplete knowledge was not the only issue, however. Study authors emphasize that 7% of physicians who correctly identified 10 years as the recommended surveillance interval for hyperplastic polyps still opted to repeat colonoscopy more frequently.

“Given that our study was conducted among gastroenterologists employed in a salaried setting, our findings highlight that overuse is not solely related to financial incentive,” the authors write. “Gastroenterologists who knew the guideline recommendation for hyperplastic polyps but recommended more frequent surveillance were less likely to agree that current clinical research justifies post-polypectomy intervals.”

Researchers recommend that interventions “to improve the appropriateness of colonoscopy utilization include strategies to improve education of gastroenterologists about colon polyp surveillance guidelines, improve distinction of serrated from typical hyperplastic polyps and clarify the management of hyperplastic polyps in the proximal colon.”

1. Shah TU, Voils CI, McNeil R, Wu R, Fisher DA. Understanding gastroenterologist adherence to polyp surveillance guidelines. Am J Gastroenterol. 2012 Sep;107(9):1283-7. doi: 10.1038/ajg.2012.59. PubMed PMID: 22951869.

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