title: Overuse and underuse of colonoscopy in a European primary care setting.
abstract: BACKGROUND
  Efforts to decrease overuse of health care may result in underuse. Overuse and underuse of colonoscopy have never been simultaneously evaluated in the same patient population.
  
  
  METHODS
  In this prospective observational study, the appropriateness and necessity of referral for colonoscopy were evaluated by using explicit criteria developed by a standardized expert panel method. Inappropriate referrals constituted overuse. Patients with necessary colonoscopy indications who were not referred constituted underuse. Consecutive ambulatory patients with lower gastrointestinal (GI) symptoms from 22 general practices in Switzerland, a country with ready access to colonoscopy, were enrolled during a 4-week period. Follow-up data were obtained at 3 months for patients who did not undergo a necessary colonoscopy.
  
  
  RESULTS
  Eight thousand seven hundred sixty patient visits were screened for inclusion; 651 patients (7.4%) had lower GI symptoms (mean age 56.4 years, 68% women). Of these, 78 (12%) were referred for colonoscopy. Indications for colonoscopy in 11 patients (14% of colonoscopy referrals or 1.7% of all patients with lower GI symptoms) were judged inappropriate. Among 573 patients not referred for the procedure, underuse ranged between 11% and 28% of all patients with lower GI symptoms, depending on the criteria used.
  
  
  CONCLUSIONS
  Applying criteria from an expert panel of nationally recognized experts indicates that underuse of referral for colonoscopy exceeds overuse in primary care in Switzerland. To improve quality of care, both overuse and underuse of important procedures must be addressed.
authors.affiliation: Institute of Social and Preventive Medicine, Department of Gastroenterology, Medical Outpatient Department PMU/CHUV, University of Lausanne, Lausanne, Switzerland.
authors.forename: J P
authors.initials: JP
authors.lastname: Vader
authors.forename: I
authors.initials: I
authors.lastname: Pache
authors.forename: F
authors.initials: F
authors.lastname: Froehlich
authors.forename: B
authors.initials: B
authors.lastname: Burnand
authors.forename: C
authors.initials: C
authors.lastname: Schneider
authors.forename: R W
authors.initials: RW
authors.lastname: Dubois
authors.forename: R H
authors.initials: RH
authors.lastname: Brook
authors.forename: J J
authors.initials: JJ
authors.lastname: Gonvers
mesh_terms: D003113:Colonoscopy / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D011446:Prospective Studies; D013557:Switzerland