As pressure to reduce health care expenditures mounts in this country, the value of preventive health care services such as cancer screening is being increasingly scrutinized. Some have claimed that the benefits of mammography have been overstated,1
others have documented excessive levels of cancer screening in populations unlikely to benefit from these services,2–8
and concern about overuse is beginning to receive attention in health policy circles. Indeed, in its initiative to transform health care delivery, the Veterans Health Administration (the nation’s largest integrated health care system) has called for a number of specific efforts to reduce inappropriate utilization of cancer screening, including reducing the number of fecal occult blood tests (FOBT) ordered for patients with evidence of a colonoscopy in the past 10 years.
The U.S. Preventive Services Task Force (USPSTF) currently recommends colorectal cancer screening (CRCS) for men and women age 50–75 using either FOBT annually, sigmoidoscopy every 5 years coupled with FOBT every 3 years, or colonoscopy every 10 years.9
Although recently removed from the list of CRCS modalities recommended by the USPSTF,9
double contrast barium enema every 5 years is still endorsed by some guideline-issuing bodies.10
Rates of adherence to CRSC guidelines have increased substantially in this country over the past decade,11
and in some settings12
have surpassed the Healthy People 2020 target of 70.5 %.13
In settings, such as the Veterans Health Administration (VHA), where CRCS rates exceed 80 %, attention is increasingly shifting away from addressing underutilization, toward documenting and ameliorating potential overuse of CRCS (e.g., screening individuals unlikely to benefit or screening more frequently than recommended by guidelines).14
Overuse of CRCS is important to address, because it can unnecessarily increase: (1) patient harm from overdiagnosis,15
including colonoscopy complications such as bowel perforation, gastrointestinal bleeding, serious cardiovascular events, and death;16,17
(2) demand for diagnostic colonoscopy (which remains in limited supply in many settings); and (3) health care costs.
Several studies have documented levels and variation in CRCS overuse attributable to screening individuals unlikely to benefit (such as those with limited life expectancy),2,7,18
and two studies have documented overuse of colonoscopy associated with shorter than recommended repeat screening19,20
intervals (i.e., the timing of repeat colonoscopy following the removal of adenomatous or hyperplastic polyps.) To our knowledge, however, only two studies have examined CRCS overuse stemming from too frequent utilization of screening modalities other than colonoscopy.2,21
One of these studies was limited by the fact that it relied on physician self-reported rather than medical records-documented patterns of screening behavior,21
and the other was conducted in a single medical facility that may not generalize to other settings.2
Therefore, additional research is needed to describe the prevalence and determinants of overuse of CRCS for modes other than colonoscopy.
While colonoscopy has become the dominant screening modality in many U.S. health care settings, at least two integrated health care systems in the U.S. have achieved high CRCS rates based on programs emphasizing FOBT,12,14
and many countries outside of the U.S. still rely primarily on FOBT for CRCS.22–25
Furthermore, while admittedly of less concern from a patient safety or cost perspective than colonoscopy overuse, FOBT overuse is nevertheless important to document in settings that offer more than one CRSC modality, because it may affect demand for diagnostic colonoscopy, and reveal inefficiencies in the screening system that stem from lack of coordination across services that share responsibility for delivering and monitoring CRCS procedures.
The current study adds to the nascent literature on CRCS overuse, by examining levels and correlates of FOBT overuse in a nationally representative sample of patients receiving care from 24 VHA medical facilities that historically have relied primarily on FOBT for CRCS, but have increased use of screening colonoscopy over the past 5 years. Specifically, we: (1) estimate the extent of FOBT overuse related to screening frequency by reason (too soon after a prior FOBT versus too soon after other CRCS procedures), (2) determine whether overuse varies across facilities, regions, calendar year, or patient subgroups, and (3) document demand for colonoscopy associated with FOBT overuse.