Levels and variation in overuse of fecal occult blood testing in the Veterans Health Administration.
BACKGROUND
Policy-makers have called for efforts to reduce overuse of cancer screening tests, including colorectal cancer screening (CRCS). Overuse of CRCS tests other than colonoscopy has not been well documented.


OBJECTIVE
To estimate levels and correlates of fecal occult blood test (FOBT) overuse in a national Veterans Health Administration (VHA) sample.


METHODS
Observational


METHODS
Participants included 1,844 CRCS-eligible patients who responded to a 2007 CRCS survey conducted in 24 VHA facilities and had one or more FOBTs between 2003 and 2009.


METHODS
We combined survey data on race, education, and income with administrative data on region, age, gender, CRCS procedures, and outpatient visits to estimate overuse levels and variation. We coded FOBTs as overused if they were conducted <10 months after prior FOBT, <9.5 years after prior colonoscopy, or <4.5 years after prior barium enema. We used multinomial logistic regression models to examine variation in overuse by reason (sooner than recommended after prior FOBT; sooner than recommended after colonoscopy, barium enema, or a combination of procedures), adjusting for clustering of procedures within patients, and patients within facilities.


RESULTS
Of 4,236 FOBTs received by participants, 885 (21 %) met overuse criteria, with 323 (8 %) sooner than recommended after FOBT, and 562 (13 %) sooner than recommended after other procedures. FOBT overuse varied across facilities (9-32 %, p<0.0001) and region (12-23 %, p< .0012). FOBT overuse after prior FOBT declined between 2003 and 2009 (8 %-5 %, p= .0492), but overuse after other procedures increased (11-19 %, p= .0002). FOBT overuse of both types increased with number of outpatient visits (OR 1.15, p<0.001), but did not vary by patient demographics. More than 11 % of overused FOBTs were followed by colonoscopy within 12 months.


CONCLUSIONS
Many FOBTs are performed sooner than recommended in the VHA. Variation in overuse by facility, region, and outpatient visits suggests addressing FOBT overuse will require system-level solutions.
Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417, USA. melissa.partin@va.gov
Melissa R
MR
Partin
Adam A
AA
Powell
Ann
A
Bangerter
Krysten
K
Halek
James F
JF
Burgess
Deborah A
DA
Fisher
David B
DB
Nelson
D000368:Aged; D003113:Colonoscopy / Q000706:statistics & numerical data; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000453:epidemiology; D055088:Early Detection of Cancer / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D019538:Health Care Surveys; D006300:Health Services Misuse / Q000706:statistics & numerical data*; D006787:Hospitals, Veterans; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009780:Occult Blood; D016017:Odds Ratio; D014481:United States; D014493:United States Department of Veterans Affairs