Adherence to Physician Recommendations for Surveillance in Opportunistic Colorectal Cancer Screening: The Necessity of Organized Surveillance

Abstract

BackgroundLimited evidence exists on the utilization of surveillance colonoscopy in colorectal cancer (CRC) screening programs. We assessed adherence to physician recommendations for surveillance in opportunistic CRC screening in Germany.MethodsA follow-up study of screening colonoscopy participants in 2007-2009 in Saarland, Germany, was conducted using health insurance claims data. Utilization of additional colonoscopies through to 2011 was ascertained. Adherence to surveillance intervals of 3, 6, 12 and 36 months, defined as having had colonoscopy at 2.5 to 4, 5 to 8, 10.5 to 16 and 33 to 48 months, respectively (i.e., tolerating a delay of 33% of each interval) was assessed. Potential predictors of non-adherence were investigated using logistic regression analysis.ResultsA total of 20,058 screening colonoscopy participants were included in the study. Of those with recommended surveillance intervals of 3, 6, 12 and 36 months, 46.5% (95%-confidence interval [CI]: 37.3-55.7%), 38.5% (95%-CI: 29.6-47.3%), 25.4% (95%-CI: 21.2-29.6%) and 28.0% (95%-CI: 25.5-30.5%), respectively, had a subsequent colonoscopy within the specified margins. Old age, longer recommended surveillance interval, not having had polypectomy at screening and negative colonoscopy were statistically significant predictors of non-adherence.ConclusionThis study suggests frequent non-adherence to physician recommendations for surveillance colonoscopy in community practice. Increased efforts to improve adherence, including introduction of more elements of an organized screening program, seem necessary to assure a high-quality CRC screening process.

Utilization and determinants of follow‐up colonoscopies within 6 years after screening colonoscopy: Prospective cohort study

“…Even the proportions of over‐ and underuse have been similar to those reported by some recent studies, highlighting that improvement of surveillance utilization is not just a national issue. Our findings are also in line with our two previous studies from Germany evaluating utilization of surveillance colonoscopies in the first 3–4 years after screening, that found 6% and 12% use of subsequent colonoscopies after negative screening colonoscopy, respectively (Supporting Information Table 2) …”

“…In two previous studies we assessed utilization of surveillance in the German screening colonoscopy program . In these studies, information on surveillance was available for up to 3 years after colonoscopy only.…”

Expected long-term impact of screening endoscopy on colorectal cancer incidence: a modelling study

“…On the other hand, surveillance colonoscopies that are recommended after detection and removal of adenomas might partly or fully compensate for this excess risk. [25–26] Depending on the extent of such compensation, which also depends on organization of and adherence to surveillance, [27] net risk reduction might be somewhat weaker or stronger than suggested by our models.…”

Expected long-term impact of the German screening colonoscopy programme on colorectal cancer prevention: Analyses based on 4,407,971 screening colonoscopies

“…Although risk reduction has been shown to vary by subsite of the colon and rectum [7] and according to multiplicity of adenomas, we used this overall estimate to derive the expected total impact of screening colonoscopy. Although close to full protection might be achieved in case of optimal surveillance, less than full protection has to be assumed due to non-adherence or adenoma miss rates at surveillance colonoscopy [22,23].…”