American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation.

INTRODUCTION: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS: The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS: The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION: This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.

American Gastroenterological Association-American College of Gastroenterology Clinical Practice Guideline: Pharmacological Management of Chronic Idiopathic Constipation.

INTRODUCTION: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS: The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol, magnesium oxide, lactulose), stimulant laxatives (bisacodyl, sodium picosulfate, senna), secretagogues (lubiprostone, linaclotide, plecanatide), and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used the Grading of Recommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS: The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION: This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation.

Survey Finds Gender Disparities Impact Both Women Mentors and Mentees in Gastroenterology.

INTRODUCTION: Gastroenterologists at all levels of practice benefit from formal mentoring. Much of the current literature on mentoring in gastroenterology is based on expert opinion rather than data. In this study, we aimed to identify gender-related barriers to successful mentoring relationships from the mentor and mentee perspectives. METHODS: A voluntary, web-based survey was distributed to physicians at 20 academic institutions across the United States. Overall, 796 gastroenterology fellows and faculty received the survey link, with 334 physicians responding to the survey (42% response rate), of whom 299 (90%; 129 women and 170 men) completed mentorship questions and were included in analysis. RESULTS: Responses of women and men were compared. Compared with men, more women preferred a mentor of the same gender (38.6% women vs 4.2% men, P < 0.0001) but less often had one (45.5% vs 70.2%, P < 0.0001). Women also reported having more difficulty finding a mentor (44.4% vs 16.0%, P < 0.0001) and more often cited inability to identify a mentor of the same gender as a contributing factor (12.8% vs 0.9%, P = 0.0004). More women mentors felt comfortable advising women mentees about work-life balance (88.3% vs 63.8%, P = 0.0005). Nonetheless, fewer women considered themselves effective mentors (33.3% vs 52.6%, P = 0.03). More women reported feeling pressured to mentor because of their gender (39.5% vs 0.9% of men, P < 0.0001). Despite no gender differences, one-third of respondents reported negative impact of the COVID-19 pandemic on their ability to mentor and be mentored. DISCUSSION: Inequities exist in the experiences of women mentees and mentors in gastroenterology, which may affect career advancement and job satisfaction.

Trends in Sociodemographic Disparities in Colorectal Cancer Staging and Survival: A SEER-Medicare Analysis.

INTRODUCTION: Race, ethnicity, and socioeconomic status are known to influence staging and survival in colorectal cancer (CRC). It is unclear how these relationships are affected by geographic factors and changes in insurance coverage for CRC screening. We examined the temporal trends in the association between sociodemographic and geographic factors and staging and survival among Medicare beneficiaries. METHODS: We identified patients 65 years or older with CRC using the 1991-2010 Surveillance, Epidemiology, and End Results-Medicare database and extracted area-level sociogeographic data. We constructed multinomial logistic regression models and the Cox proportional hazards models to assess factors associated with CRC stage and survival in 4 periods with evolving reimbursement and screening practices: (i) 1991-1997, (ii) 1998-June 2001, (iii) July 2001-2005, and (iv) 2006-2010. RESULTS: We observed 327,504 cases and 102,421 CRC deaths. Blacks were 24%-39% more likely to present with distant disease than whites. High-income areas had 7%-12% reduction in distant disease. Compared with whites, blacks had 16%-21% increased mortality, Asians had 32% lower mortality from 1991 to 1997 but only 13% lower mortality from 2006 to 2010, and Hispanics had 20% reduced mortality only from 1991 to 1997. High-education areas had 9%-12% lower mortality, and high-income areas had 5%-6% lower mortality after Medicare began coverage for screening colonoscopy. No consistent temporal trends were observed for the associations between geographic factors and CRC survival. DISCUSSION: Disparities in CRC staging and survival persisted over time for blacks and residents from areas of low socioeconomic status. Over time, staging and survival benefits have decreased for Asians and disappeared for Hispanics.

Racial Disparities in Colorectal Cancer Mortality: the Role of Endoscopy Wait-Time and Stage at Diagnosis.

INTRODUCTION: In Western Washington (WA), colorectal cancer (CRC) mortality between 2012 and 2016 was highest in American Indian/Alaska Natives (AI/AN) and African-Americans (AA) at 20.7 and 18.7, respectively, compared with non-Hispanic Whites at 14.1/100,000 people. We hypothesized that time from billed encounters for CRC-associated symptoms to endoscopy completion or CRC stage at diagnosis contributed to observed differences. METHODS: Using administrative insurance claims linked to WA cancer registry data, we performed a retrospective cohort study of patients diagnosed with CRC between 2011 and 2017, with continuous insurance for 15 months prior to diagnosis and a billed encounter for CRC-associated symptoms. We determined the wait-time (days) and stage at diagnosis and conducted logistic regression analysis to identify the factors associated with endoscopy completion. RESULTS: Of the 3461 CRC patients identified, 57% had stage 2 or 3 disease with no differences in stage by race, and 84% completed an endoscopy after a billed encounter for CRC-associated symptoms. The median wait-time to endoscopy was 52 days (IQR 14-218) without differences by race. Compared with patients diagnosed with stage 1 CRC, patients with stage 4 CRC were more likely to complete an endoscopy within the first quartile of time (22.2% vs. 17.4%, p < 0.01). Living arrangement, insurance type, and comorbidity, but not race, were significant factors associated with endoscopy completion. CONCLUSIONS: We found no statistically significant differences in time from billed CRC-associated symptoms to endoscopy completion or in CRC stage among AA and AI/AN compared to Whites. This suggests that other factors are more likely to contribute to observed mortality disparities.

Screening flexible sigmoidoscopy versus colonoscopy for reduction of colorectal cancer mortality.

PURPOSE: Colonoscopy and flexible sigmoidoscopy are both recommended colorectal cancer (CRC) screening strategies, but their relative effectiveness is unclear. We sought to evaluate the ability of each of these two modalities to reduce CRC mortality. METHODS: We conducted a case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Cases were persons aged 70-85 years who died of CRC and were matched to up to three non-CRC controls. Receipt of endoscopy was ascertained from Medicare claims and endoscopy indication assigned using a validated algorithm. Conditional logistic regression models were developed to estimate the association between screening colonoscopy or sigmoidoscopy and CRC mortality. We conducted secondary analyses by race, sex, and endoscopist characteristics, and with varying duration of the look-back period. RESULTS: In the initial analysis using all available look-back years, screening flexible sigmoidoscopy was associated with a 35% reduction in CRC mortality (OR 0.65, 95% CI 0.48, 0.89), while screening colonoscopy was associated with a 74% reduction (OR 0.26, 95% CI 0.23, 0.30). Sigmoidoscopy was not associated with any reduction in proximal CRC mortality. The association between colonoscopy and reduced CRC mortality was stronger in the distal than the proximal colon. Results were similar in analyses using a 5-year look-back period. CONCLUSIONS: Screening colonoscopy was associated with greater reductions in CRC mortality than screening sigmoidoscopy, and with a greater reduction in the distal than the proximal colon. These results provide additional information on the relative benefits of screening for CRC with sigmoidoscopy and colonoscopy.

Case-Control Studies of the Efficacy of Screening Tests That Seek to Prevent Cancer Incidence: Results of an Approach That Utilizes Administrative Claims Data That Do Not Provide Information Regarding Test Indication.

Case-control studies evaluating a screening test's efficacy in reducing cancer mortality require accurate classification of test indication to obtain a valid result. However, for analogous studies of cancer incidence, determination of test indication is not as critical because, to define exposure, we need consider only tests that can identify precursor lesions whose treatment might prevent cancer, not tests leading to cancer diagnosis. This study utilizes US Surveillance, Epidemiology, and End Results (SEER)-Medicare data, which do not include information about colonoscopy indication, to evaluate the efficacy of colonoscopy in preventing colorectal cancer (CRC) incidence. Cases were Medicare enrollees diagnosed with CRC between 1996 and 2013; up to 3 controls were matched to each case. Colonoscopy receipt prior to presumed onset of occult cancer was associated with an approximately 60% reduction in CRC incidence (odds ratio = 0.41, 95% confidence interval: 0.40, 0.42). The association was robust to differing exposure windows and estimates of occult cancer duration and is similar to those from CRC incidence studies in which exam indication was available. Our results suggest that, when it is impractical/impossible to determine whether tests were conducted for screening, the efficacy of a test in preventing cancer incidence can still be estimated using a case-control study design.

Temporal Trends in Geographic and Sociodemographic Disparities in Colorectal Cancer Among Medicare Patients, 1973-2010.

PURPOSE: Colorectal cancer (CRC) incidence and mortality in the United States have steadily declined since the 1980s, but racial and socioeconomic disparities remain. The influence of geographic factors is poorly understood and may be affected by evolving insurance coverage and screening test uptake. We characterized temporal trends in the association between geographic and sociodemographic factors and CRC outcomes. METHODS: We used the 1973-2010 SEER-Medicare files to identify patients aged ≥65 years with and without CRC. Beneficiary residential ZIP codes were used to extract local-level data. We constructed multivariable logistic regression models for CRC incidence and mortality using geographic and sociodemographic variables in 4 time periods: (1) 1973-1997; (2) 1998-2001; (3) 2002-2006; and (4) 2007-2010. FINDINGS: We analyzed 1,093,758 records, including 336,321 CRC cases. Compared to urban residence, small rural residence was strongly associated with increased CRC incidence (OR 1.50, 95% CI: 1.43-1.57) and mortality (OR 1.35, 95% CI: 1.26-1.45) in 1973-1997, but the associations diminished by 2007-2010 (OR 1.09, 95% CI: 1.04-1.15 for incidence; OR 1.10, 95% CI: 1.01-1.20 for mortality). The disparity between blacks and whites increased over time for both incidence (OR 1.09, 95% CI: 1.05-1.13 in 1973-1997 vs OR 1.32, 95% CI: 1.27-1.37 in 2007-2010) and mortality (OR 1.22, 95% CI: 1.16-1.28 in 1973-1997 vs OR 1.34, 95% CI: 1.26-1.42 in 2007-2010). High socioeconomic status was associated with greater incidence and mortality in 1973-1997, but it became protective after 1998. CONCLUSIONS: Although disparities persist among Medicare beneficiaries, the relationship between geographic and sociodemographic factors and CRC incidence and mortality has evolved over time.

Determination of colonoscopy indication from administrative claims data.

BACKGROUND: Colonoscopy outcomes, such as polyp detection or complication rates, may differ by procedure indication. OBJECTIVES: To develop methods to classify colonoscopy indications from administrative data, facilitating study of colonoscopy quality and outcomes. RESEARCH DESIGN: We linked 14,844 colonoscopy reports from the Clinical Outcomes Research Initiative, a national repository of endoscopic reports, to the corresponding Medicare Carrier and Outpatient File claims. Colonoscopy indication was determined from the procedure reports. We developed algorithms using classification and regression trees and linear discriminant analysis (LDA) to classify colonoscopy indication. Predictor variables included ICD-9CM and CPT/HCPCS codes present on the colonoscopy claim or in the 12 months prior, patient demographics, and site of colonoscopy service. Algorithms were developed on a training set of 7515 procedures, then validated using a test set of 7329 procedures. RESULTS: Sensitivity was lowest for identifying average-risk screening colonoscopies, varying between 55% and 86% for the different algorithms, but specificity for this indication was consistently over 95%. Sensitivity for diagnostic colonoscopy varied between 77% and 89%, with specificity between 55% and 87%. Algorithms with classification and regression trees with 7 variables or LDA with 10 variables had similar overall accuracy, and generally lower accuracy than the algorithm using LDA with 30 variables. CONCLUSIONS: Algorithms using Medicare claims data have moderate sensitivity and specificity for colonoscopy indication, and will be useful for studying colonoscopy quality in this population. Further validation may be needed before use in alternative populations.

Regional variation in anesthesia assistance during outpatient colonoscopy is not associated with differences in polyp detection or complication rates.

BACKGROUND & AIMS: We investigated the rate and predictors of anesthesia assistance during outpatient colonoscopy and whether anesthesia assistance is associated with colonoscopy interventions and outcomes. METHODS: We performed a retrospective cohort study using a 20% sample of Medicare administrative claims submitted during the 2003 calendar year. We analyzed data from 328,177 adults, 66 years old or older, who underwent outpatient colonoscopy examinations. RESULTS: Overall, 8.7% of outpatient colonoscopies were performed with anesthesia assistance. In multivariate analysis, independent predictors of anesthesia assistance included black race, female sex, and a nonscreening indication; anesthesia assistance increased with median income and comorbidities. General and colorectal surgeons, fewer years in their practice, and nonhospital site of service were also significantly associated with anesthesia assistance. The strongest predictor of anesthesia assistance was the Medicare carrier, with odds ratios ranging from 0.22 (95% confidence interval: 0.12-0.43) for the Arkansas carrier (crude rate 0.9%) to 9.90 (95% confidence interval: 7.92-12.39) for the Empire carrier in New York area (crude rate 35.3%) compared with the Wisconsin carrier (crude rate 4.3%). There was also considerable variation among endoscopists; 75% of providers had no colonoscopies with anesthesia assistance recorded in their dataset, and 4.5% of providers had anesthesia assistance in at least three quarters of their examinations. Anesthesia assistance was not associated with the diagnosis of polyps, the performance of biopsy or polypectomy, or complications in multivariate analyses. CONCLUSIONS: There are significant variations among regions and sites of service in anesthesia assistance during outpatient colonoscopies of Medicare beneficiaries. Although this variation has considerable economic implications, it was not associated with measures of patient risk or outcomes, such as polyp detection or procedure-related complications.

Accuracy of Medicare claims for identifying findings and procedures performed during colonoscopy.

BACKGROUND: Administrative claims data are frequently used for quality measurement. OBJECTIVE: To examine the accuracy of administrative claims for potential colonoscopy quality measures, including findings (polyp or tumor detection), procedures (biopsy or polypectomy), and incomplete colonoscopy. DESIGN: Cross-sectional study. PATIENTS: Patients age 65 and older undergoing colonoscopy in the Clinical Outcomes Research Initiative National Endoscopic Database in 2006. We linked colonoscopy records for these patients to Medicare colonoscopy claims by using patient age, sex, date of procedure, and performing provider's Unique Physician Identification Number. MAIN OUTCOME MEASUREMENTS: Sensitivity, specificity, positive and negative predictive values of the Medicare claims for potential quality measures, including colonoscopy findings and procedures. RESULTS: We linked Medicare colonoscopy claims to 15,168 of the 30,011 Clinical Outcomes Research Initiative colonoscopy records. Sensitivity of the claims for colon polyps was 93.4%, with a specificity of 97.8%. Sensitivity of claims for other diagnoses, including colorectal tumors was suboptimal, although specificity was high. In contrast, sensitivity of claims for procedures-biopsy (with or without cautery) or polypectomy-was high (87.2%-97.6%), with specificity >97%. Claims had poor sensitivity for identification of incomplete colonoscopy. LIMITATIONS: Potential for inaccurate matching of colonoscopy records and Medicare claims. CONCLUSIONS: Medicare claims have high sensitivity and specificity for polyp detection, biopsy, and polypectomy at colonoscopy, but sensitivity is low for other diagnoses such as tumor detection and for incomplete colonoscopy. Caution is needed when using Medicare claims data for certain important quality measures, in particular tumor detection and incomplete colonoscopy.

Utilization and predictors of early repeat colonoscopy in Medicare beneficiaries.

OBJECTIVES: Early repeat colonoscopy after an index examination may be justifiable, but may also reflect quality issues during the first examination. The aims of this study were to examine the use of second colonoscopy within 1 year of an index colonoscopy, and to examine patient and provider factors associated with use of early repeat colonoscopy. METHODS: We performed a retrospective cohort study using a 20% nationally representative sample of 2003 Medicare claims. Patients aged ≥ 66 years undergoing colonoscopy were included in this study. We identified the use of second colonoscopy and barium enema within 1 year of the index procedure. We used logistic regression analyses to examine the independent predictors of these procedures. RESULTS: We included 328,167 outpatient colonoscopies. In all, 5% had second colonoscopy and 2.2% had barium enema within 1 year of the index examination. Early repeat colonoscopy was more common if the index examination was performed by a family physician (odds ratio 1.39, 95% confidence interval 1.23-1.56), general surgeon (odds ratio 1.18, 95% confidence interval 1.10-1.27) or internist (odds ratio 1.12, 95% confidence interval 1.02-1.23) compared with a gastroenterologist, or after colonoscopies by an endoscopist in the lower quartiles of colonoscopy volume compared with endoscopists in the highest quartile. Increasing patient age and comorbidity, polyp detection, biopsy, polyp removal, incomplete index examination, and site of service were also significantly associated with early repeat colonoscopy. CONCLUSIONS: Early repeat colonoscopy is not unusual. The association of specialty and colonoscopy volume with early repeat colonoscopy suggests that there are modifiable processes of care or training that may prevent some of these repeat procedures.

Risk factors for gallstone-related hospitalization during pregnancy and the postpartum.

OBJECTIVES: Gallbladder disease is a leading nonobstetrical cause for hospitalization in the first year postpartum. The aim of this study was to define the incidence and risk factors for postpartum hospitalization as a result of gallstone-related disease. METHODS: We identified 6,670 women with discharge diagnoses related to biliary disease from linked birth certificate and hospital discharge databases for Washington State from 1987 through 2001. Cases were women with gallstone-related diagnoses at delivery or as primary diagnosis in the postpartum. Four controls who were within 1 yr postpartum were randomly selected for each case and matched for year of delivery. From the birth certificates, we obtained data about patient demographics, reproductive history, and pregnancy-related risk factors. In a retrospective case-control study, we developed multiple logistic regression models to identify independent risk factors for hospitalization. RESULTS: We identified 6,211 women as cases (0.5% of all births) during the study period. The median time to hospitalization was 95 days (interquartile range 46-191 days), with a median length of stay of 3 days. Seventy-six percent were diagnosed with uncomplicated cholelithiasis, 16% with pancreatitis, 9% with acute cholecystitis, and 8% with cholangitis. Seventy-three percent of hospitalized women underwent cholecystectomy, and 5% underwent endoscopic retrograde cholangiopancreatography (ERCP). On multivariate analysis, independent risk factors for hospitalization included maternal race, age, being overweight or obese prepregnancy, pregnancy weight gain, and estimated gestational age. CONCLUSIONS: Hospitalization for gallstone-related disease is common in the first year postpartum, most commonly for uncomplicated cholelithiasis. Risk factors for hospitalization include prepregnancy body mass index, race, Hispanic ethnicity, and maternal age.

Comparing risks and benefits of colorectal cancer screening in elderly patients.

BACKGROUND & AIMS: In patients with limited life expectancy, the risks of colorectal cancer screening may outweigh the benefits. The aim of this study was to quantify risks and benefits of different screening strategies in elderly patients with varying life expectancies. METHODS: We examined risks and benefits of screening in patients aged 70-94 years with differing health status using 3 strategies: annual fecal occult blood tests, flexible sigmoidoscopy every 5 years, or colonoscopy every 10 years. We compared the number needed to screen to prevent one cancer-related death and the number needed to encounter one screening-related complication for different strategies. RESULTS: The potential benefit from screening varied widely with age, life expectancy, and screening modality. One cancer-related death would be prevented by screening 42 healthy men aged 70-74 years with colonoscopy, 178 healthy women aged 70-74 years with fecal occult blood tests, 431 women aged 75-79 years in poor health with colonoscopy, or 945 men aged 80-84 years in average health with fecal occult blood tests. Colonoscopy screening had the greatest benefit but the highest risk of complications. The potential for screening-related complications was greater than estimated benefit in some population subgroups aged 70 years and older. At all ages and life expectancies, the potential reduction in mortality from screening outweighed the risk of colonoscopy-related death. CONCLUSIONS: The potential benefits and risks of screening vary in elderly patients of different life expectancies. For any individual patient, the potential for harm from screening must be weighed against the likelihood of benefit, especially with shorter life expectancy.

Persistent demographic differences in colorectal cancer screening utilization despite Medicare reimbursement.

BACKGROUND: Colorectal cancer screening is widely recommended, but often under-utilized. In addition, significant demographic differences in screening utilization exist. Insurance coverage may be one factor influencing utilization of colorectal cancer screening tests. METHODS: We conducted a retrospective analysis of claims for outpatient services for Washington state Medicare beneficiaries in calendar year 2000. We determined the proportion of beneficiaries utilizing screening fecal occult blood tests, flexible sigmoidoscopy, colonoscopy, or double contrast barium enema in the overall population and various demographic subgroups. Multiple logistic regression analysis was used to determine the relative odds of screening in different demographic groups. RESULTS: Approximately 9.2% of beneficiaries had fecal occult blood tests, 7.2% had any colonoscopy, flexible sigmoidoscopy, or barium enema (invasive) colon tests, and 3.5% had invasive tests for screening indications. Colonoscopy accounted for 41% of all invasive tests for screening indications. Women were more likely to receive fecal occult blood test screening (OR 1.18; 95%CI 1.15, 1.21) and less likely to receive invasive tests for screening indications than men (OR 0.80, 95%CI 0.77, 0.83). Whites were more likely than other racial groups to receive any type of screening. Rural residents were more likely than urban residents to have fecal occult blood tests (OR 1.20, 95%CI 1.17, 1.23) but less likely to receive invasive tests for screening indications (OR 0.89; 95%CI 0.85, 0.93). CONCLUSION: Reported use of fecal occult blood testing remains modest. Overall use of the more invasive tests for screening indications remains essentially unchanged, but there has been a shift toward increased use of screening colonoscopy. Significant demographic differences in screening utilization persist despite consistent insurance coverage.

Effect of Medicare coverage on use of invasive colorectal cancer screening tests.

BACKGROUND: Colorectal cancer is the second leading cause of cancer death in the United States. Screening for colorectal cancer is now widely recommended but underused. Lack of insurance coverage for screening tests may be one reason patients do not undergo these procedures. OBJECTIVE: To determine the effect of Medicare reimbursement on utilization rates of invasive screening tests. Use of fecal occult blood testing was not studied before 1998. METHODS: We performed a retrospective analysis of ambulatory claims data for Washington State Medicare beneficiaries in 1994, 1995, and 1998. We determined the proportion of patients undergoing diagnostic and screening flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema in 1994, 1995, and 1998 and the proportion receiving fecal occult blood testing in 1998. RESULTS: Use of diagnostic and screening colon tests was low in all years. Fewer than 6% of beneficiaries received any colon test, and fewer than 4% received a screening test. Although more patients underwent diagnostic testing after Medicare coverage began, use of screening tests did not significantly change (odds ratio, 0.99; 95% confidence interval, 0.97-1.01 comparing 1994 and 1998 [P =.33]). Women, individuals older than 80 years, and nonwhite patients were statistically significantly less likely to be screened in all 3 years (P<.001). In 1998, fewer than 7% of patients underwent fecal occult blood testing, with men and nonwhites statistically significantly less likely to have this test (P<.001). CONCLUSIONS: Colorectal cancer screening tests are underused in the Washington State Medicare population, and insurance coverage for these tests did not substantially affect utilization rates in the period studied.