title: Physician Non-adherence to Colonoscopy Interval Guidelines in the Veterans Affairs Healthcare System.
abstract: OBJECTIVE
  Colonoscopy can decrease colorectal cancer (CRC) mortality, although performing this procedure more frequently than recommended could increase costs and risks to patients. We aimed to determine rates and correlates of physician non-adherence to guidelines for repeat colonoscopy screening and polyp surveillance intervals.
  
  
  METHODS
  We performed a multi-center, retrospective, observational study using administrative claims, physician databases, and electronic medical records (EMR) from 1455 patients (50-64 y old) who underwent colonoscopy in the Veterans Affairs healthcare system in fiscal year 2008. Patients had no prior diagnosis of CRC or inflammatory bowel disease, and had not undergone colonoscopy examinations in the previous 10 years. We compared EMR-documented, endoscopist-recommended intervals for colonoscopies with intervals recommended by the 2008 Multi-Society Task Force guidelines.
  
  
  RESULTS
  The overall rate of non-adherence to guideline recommendations was 36% and ranged from 3% to 80% among facilities. Non-adherence was 28% for patients who underwent normal colonoscopies, but 45%-52% after colonoscopies that identified hyperplastic or adenomatous polyps. Most of all recommendations that were not followed recommended a shorter surveillance interval. In adjusted analyses, non-adherence was significantly higher for patients whose colonoscopies identified hyperplastic (odds ratio [OR] = 3.1; 95% CI, 1.7-5.5) or high-risk adenomatous polyps (OR = 3.0; 95% CI, 1.2-8.0), compared to patients with normal colonoscopy examinations, but not for patients with low-risk adenomatous polyps (OR = 1.8; 95% CI, 0.9-3.7). Nonadherence was also associated with bowel preparation quality, geographic region, Charlson comorbidity score, and colonoscopy indication.
  
  
  CONCLUSIONS
  In a managed care setting with salaried physicians, endoscopists recommend repeat colonoscopy sooner than guidelines for more than one third of patients. Factors associated with non-adherence to guideline recommendations were colonoscopy findings, quality of bowel preparation, and geographic region. Targeting endoscopist about non-adherence to colonoscopy guidelines could reduce overuse of colonoscopy and associated healthcare costs.
authors.affiliation: Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Marcus R
authors.initials: MR
authors.lastname: Johnson
authors.affiliation: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Janet
authors.initials: J
authors.lastname: Grubber
authors.affiliation: Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina.
authors.forename: Steven C
authors.initials: SC
authors.lastname: Grambow
authors.affiliation: Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Maciejewski
authors.affiliation: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina.
authors.forename: Tyra
authors.initials: T
authors.lastname: Dunn-Thomas
authors.affiliation: Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Medical Center, Durham, North Carolina; Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
authors.forename: Dawn
authors.initials: D
authors.lastname: Provenzale
authors.affiliation: Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, North Carolina; Division of Gastroenterology, Department of Medicine, Duke University Medical Center, Durham, North Carolina. Electronic address: Deborah.Fisher@Duke.edu.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Fisher
mesh_terms: D018256:Adenomatous Polyps / Q000473:pathology*; D003110:Colonic Neoplasms / Q000473:pathology*; D003111:Colonic Polyps / Q000473:pathology*; D003113:Colonoscopy / Q000592:standards*; D016208:Databases, Factual; D057286:Electronic Health Records; D005260:Female; D019983:Guideline Adherence / Q000592:standards*; D006801:Humans; D006965:Hyperplasia; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians' / Q000592:standards*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D014481:United States; D014493:United States Department of Veterans Affairs / Q000592:standards*; D019564:Unnecessary Procedures / Q000592:standards*
keywords: Colon Cancer; Early Detection; VA