The study also found that in some pockets of the country — including across most of Minnesota — the rate of unnecessary colonoscopies among Medicare recipients may be even higher.
Not only are inappropriate colonoscopy screenings a waste of Medicare funds, they also put older people at increased risk of screening-related complications, including bowel perforation, bleeding and incontinence. The likelihood of having such a complication increases with age, particularly after age 75. In addition, the screenings may produce false-positive results that lead to unnecessary worry and medical treatments.
For the study, which was published online Monday in the journal JAMA Internal Medicine, researchers analyzed claim data on almost 75,000 colonoscopies performed on Medicare beneficiaries in Texas between October 2008 and September 2009. For comparison, they also examined claims from a 5 percent sample across the United States. In all, more than 168,000 records were reviewed.
The data revealed that 23.4 percent of the colonoscopies may have been done inappropriately during that year. The procedures were either performed too soon after a previous negative screening or on people over the recommended age.
The American College of Physicians and the U.S. Preventive Services Task Force (USPSTF), an independent panel of medical experts that advises the government, recommend that people aged 50 to 75 undergo routine colonoscopy screening only every 10 years. They also recommend against routine colonoscopy screening of people aged 76 and older. Because colon cancer is slow growing, the risks associated with the screening are believed to outweigh the benefits for people in that age group.
Two key influences
The study’s data also revealed that where older patients live and which doctor they see significantly influence whether they are likely to undergo an unnecessary colonoscopy screening.
For some doctors, more than 30 percent of the colonoscopies they performed on Medicare patients during the year of this study fell into the “inappropriate” category. The doctors with the highest percentage of unnecessary procedures were surgeons, those who graduated from a U.S. medical school before 1990, and those whose practices included a high volume of colonoscopies. (Only Texas physicians were included in this part of the analysis because the researchers had access to 100 percent of that state’s Medicare claims, which made the results more statistically significant.)
Colorectal surgeons perform one-third of all screening colonoscopies in the United States. Other research has shown that in the practices of colorectal surgeons, colonoscopies account for, on average, 25 percent of the surgeon’s time with patients and the fees he or she charges.
The study also found considerable geographic variation in the rates of potentially inappropriate colonoscopies among Medicare beneficiaries — both within Texas and across the United States. The variation across the U.S. ranged from 19.4 percent to 30.5 percent. Minnesota was among the quarter of the country with the highest percentage (25.1 percent to 30.5 percent) of inappropriate colonoscopies.
“Inappropriate use of colonoscopy results in higher Medicare expenditures, involves unnecessary risk for older patients, and represents a substantial proportion of endoscopists’ workloads, consumer resources that could be used more effectively,” the authors of the study conclude. “Public education campaigns on appropriate screening colonoscopy may reduce unnecessary testing and increase available screening capacity for the at-risk population.”
A skeptical public
Those public education campaigns will have to overcome a lot of skepticism, however — skepticism that’s the result of decades of campaigns that stressed only the benefits of health screening and not their risks. A second study published Monday in JAMA Internal Medicine — a survey of 33 older adults (aged 63 to 91) in a senior health center — found that older Americans tend to see colonoscopy screening as a moral obligation.
“Many asserted that they had never discussed screening cessation with their physicians or considered stopping on their own; some reported being upset when their physician recommended stopping,” the study’s authors report. “Although some would accept a physician’s strong recommendation to stop, others thought that such a physician’s recommendation would threaten trust or lead them to get another opinion.”
“These findings emphasize,” the authors add, “how public health campaigns are working well to communicate the health benefits of screening, so much so that patients do not even consider undergoing screening as something to decide. Patients expect clinicians, like the rest of the health care establishment, to encourage and endorse screening. Given the steady drumbeat of physicians and public health campaigns in favor of screening, patients may find a recommendation to stop, once they reach a certain age, to be jarring.”
You can read both studies in full at the JAMA Internal Medicine website.