Limited life expectancy among a subgroup of medicare beneficiaries receiving screening colonoscopies

Effect of alverine citrate plus simethicone in colonoscopy: a randomized controlled trial

Colonoscopy is the standard procedure for screening, and surveillance of colorectal cancer, including the treatment for colonic lesions. Colonic spasm is an important problem from colonoscopy that affects both surgeons and patients. The spasm also might be the cause of longer cecal intubation time, difficulty of the procedure, and increased pain. Previous reports indicated that antispasmodic agents can decrease such symptoms. Therefore, we conducted this study to investigate the cecal intubation time of antispasmodic agents. A single blinded randomized controlled trial was conducted from 01/11/2020 to 31/08/2021. One hundred four patients were allocated to antispasmodic agent group and control group, in 1:1 ratio. The efficacy of median (range) cecal intubation time showed similar results of 5 (2, 14) and 5 (2, 15) minutes with no statistically significant difference. The mean scores of all domains i.e., pain, spasm, cleanliness, and difficulty were better in the antispasmodic agent group about 2.6 (1.4), 1.8 (0.8), 2.4 (0.9), and 2.0 (0.9), respectively, than control group but there were spasm and cleanliness showed statistically significant difference. Moreover, the satisfaction scores showed better efficacy in decreased spasm, decreased difficulty, and increased cleanliness than control group. Prescribing of antispasmodic drugs before colonoscopy might be the choice of treatment for the patients. The antispasmodic drugs will be beneficial to both of the patient and the doctor.

Colorectal Cancer Screening Receipt Does Not Differ by 10-Year Mortality Risk Among Older Adults

BACKGROUND

Health status and life expectancy are important considerations for assessing potential benefits and harms of colorectal cancer (CRC) screening programs, particularly among older adults.

METHODS

We examined receipt of past-year CRC screening according to predicted 10-year mortality risk among 25,888 community-dwelling adults aged 65-84 years who were not up-to-date with screening in the nationwide National Health Interview Survey. Ten-year mortality risk was estimated using a validated index; from the lowest to highest quintiles of the index, risk was 12%, 24%, 39%, 58%, and 79%, respectively. We also examined the proportion of screening performed among adults with life expectancy <10 years.

RESULTS

The prevalence of past-year CRC screening was 39.5%, 40.6%, 38.7%, 36.4%, and 35.4%, from the lowest to highest quintile of 10-year mortality risk. Odds of CRC screening did not differ between adults in the lowest vs highest quintile (adjusted odds ratio 1.05, 95% confidence interval: 0.93-1.20). One-quarter (27.9%) of past-year CRC screening occurred in adults with life expectancy <10 years, and more than half (50.7%) of adults aged 75-84 years had 10-year mortality risk ≥50% at the time of screening. In an exploratory analysis, invasive but not noninvasive screening increased as 10-year mortality risk increased ( P < 0.05) among adults aged 70-79 years.

DISCUSSION

Past-year CRC screening does not differ by predicted 10-year mortality risk. An age-based approach to CRC screening results in underscreening of older, healthier adults and overscreening of younger adults with chronic conditions. Personalized screening with incorporation of individual life expectancy may increase the value of CRC screening programs.

An Estimate of the US Rate of Overuse of Screening Colonoscopy: a Systematic Review

BACKGROUND

This study aims to assess the rate at which screening colonoscopy is performed on patients younger or older than the age range specified in national guidelines, or at shorter intervals than recommended. Such non-indicated use of the procedure is considered low-value care, or overuse. This study is the first systematic review of the rate of non-indicated completed screening colonoscopy in the USA.

METHODS

PubMed and Embase were queried for relevant studies on overuse of screening colonoscopy published from January 1, 2002, until January 23, 2019. English-language studies that were conducted for screening colonoscopy after 2001 for average-risk patients were included. Studies must have followed national guidelines for detecting rates of overuse. We followed methods outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the reporting recommendations of the Meta-analysis of Observational Studies in Epidemiology group (MOOSE).

RESULTS

A total of 772 papers were reviewed for inclusion; 42 were reviewed in full text. Of those reviewed, six studies met eligibility criteria, including a total of 459,503 colonoscopies of which 242,756 were screening colonoscopies. The rate of overuse ranged credibly from 17 to 25.7%.

DISCUSSION

This study demonstrates that screening colonoscopy is regularly performed in the USA more often, and in populations older or younger, than recommended by national guidelines. Such overuse wastes resources and places patients at unnecessary risk of harm. Efforts to reduce non-indicated screening colonoscopy are needed.

The role of VES-13 to identify limited life expectancy in older adults in primary healthcare settings

OBJECTIVE

To investigate the potential role of the Vulnerable Elders Survey to identify older adults with limited life expectancy in primary healthcare settings.

METHOD

This cross-sectional study was performed in all (nine) healthcare units in Jatai, Goiás (Brazil) from July to December 2018. A sample size of 407 older adults was obtained considering an older population (≥ 60 years old). Participants answered a questionnaire about sociodemographic and clinical characteristics, including the Vulnerable Elders Survey and the Suemoto index. We tested the association between limited life expectancy and the Vulnerable Elders Survey using multiple logistic regression analysis.

RESULTS

The mean age was 68.9 ± 6.6 yo, and 58.0% were women. The mean score of the Vulnerable Elders Survey was 2.0 ± 2.2, the mean score of Suemoto index was 31.5 ± 21.1%, and 17.2% had limited life expectancy. The Vulnerable Elders Survey was associated with limited life expectancy (OR = 1.57; p = < 0.0001).

CONCLUSION

The Vulnerable Elders Survey was able to identify older adults with limited life expectancy in primary healthcare settings and can play a role in detecting older adults who would not benefit from screening and strict control of chronic diseases.

Patients over Age 75 Are at Increased Risk of Emergency Department Visit and Hospitalization Following Colonoscopy

BACKGROUND

The age to stop screening or surveillance colonoscopy is not well established, and unplanned hospital use after colonoscopy in the elderly is not well understood.

AIMS

To evaluate unplanned emergency department (ED) visits and hospitalization in patients over 75 within 7 days of outpatient colonoscopy.

METHODS

In this retrospective, single-center, cohort study, we reviewed outpatient screening or surveillance colonoscopies in patients ≥ 50 in a tertiary care academic medical center or affiliated facility between January 2008 and September 2013. Colonoscopies were divided by age based on USPSTF recommendations. The rate of ED visits and hospitalizations per colonoscopy for each age-group was determined. Predictors of ED visit and hospitalization were assessed through univariate and multivariate logistic regressions, and mortality following colonoscopy was evaluated using Kaplan-Meier analysis.

RESULTS

A total of 30,409 colonoscopies were performed in 27,173 patients (51% male) by 40 endoscopists. ED visits occurred after 188 colonoscopies (0.62%). Age over 75 years was independently associated with ED visit (OR 1.58, 95% CI 1.05-2.37, p = 0.027) and hospitalization (OR 3.7, 95% CI 2.03-6.73, p < 0.001) within 7 days of colonoscopy. Higher number of medication classes, recent ED visit, polypectomy, and endoscopic mucosal resection were also independent variables associated with ED utilization after procedure. The mortality rate at the end of the follow-up (median 4.4; IQR 2.7-6 years) was 1.9, 8.6, and 15.8% for the age-groups 50-75, 76-85, and > 85 years, respectively.

CONCLUSION

Patients over age 75 are 1.6 times as likely to use the ED and 3.7 times as likely to be hospitalized after colonoscopy. Further prospective studies are needed to assess the risk/benefit of nondiagnostic colonoscopy in geriatric patients.

Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults

PURPOSE OF REVIEW

The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group.

RECENT FINDINGS

Age is a risk factor for CRC; however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear. There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.

Influence of Age, Health, and Function on Cancer Screening in Older Adults with Limited Life Expectancy

BACKGROUND/OBJECTIVES

We examined the relationship between cancer screening and life expectancy predictors, focusing on the influence of age versus health and function, in older adults with limited life expectancy.

DESIGN

Longitudinal cohort study SETTING: National Health and Aging Trends Study (NHATS) with linked Medicare claims.

PARTICIPANTS

Three cohorts of adults 65+ enrolled in fee-for-service Medicare were constructed: women eligible for breast cancer screening (n = 2043); men eligible for prostate cancer screening (n = 1287); men and women eligible for colorectal cancer screening (n = 3759).

MEASUREMENTS

We assessed 10-year mortality risk using 2011 NHATS data, then used claims data to assess 2-year prostate and breast cancer screening rates and 3-year colorectal cancer screening rates. Among those with limited life expectancy (10-year mortality risk > 50%), we stratified participants at each level of predicted mortality risk and split participants in each risk stratum by the median age. We assembled two sub-groups from these strata that were matched on predicted life expectancy: a "younger sub-group" with relatively poorer health/functional status and an "older sub-group" with relatively better health/functional status. We compared screening rates between sub-groups.

RESULTS

For all three cancer screenings, the younger sub-groups (average ages 73.4-76.1) had higher screening rates than the older sub-groups (average ages 83.6-86.9); screening rates were 42.9% versus 34.2% for prostate cancer screening (p = 0.02), 33.6% versus 20.6% for breast cancer screening (p < 0.001), 13.1% versus 6.7% for colorectal cancer screening in women (p = 0.006), and 20.5% versus 12.1% for colorectal cancer screening in men (p = 0.002).

CONCLUSION

Among older adults with limited life expectancy, those who are relatively younger with poorer health and functional status are over-screened for cancer at higher rates than those who are older with the same predicted life expectancy.

Colon Cancer Screening among Patients Receiving Dialysis in the United States: Are We Choosing Wisely?

The American Society of Nephrology recommends against routine cancer screening among asymptomatic patients receiving maintenance dialysis on the basis of limited survival benefit. To determine the frequency of colorectal cancer screening among patients on dialysis and the extent to which screening tests were targeted toward patients at lower risk of death and higher likelihood of receiving a kidney transplant, we performed a cohort study of 469,574 Medicare beneficiaries ages ≥50 years old who received dialysis between January 1, 2007 and September 30, 2012. We examined colorectal cancer screening tests according to quartiles of risk of mortality and kidney transplant on the basis of multivariable Cox modeling. Over a median follow-up of 1.5 years, 11.6% of patients received a colon cancer screening test (57.9 tests per 1000 person-years). Incidence rates of colonoscopy, flexible sigmoidoscopy, and fecal occult blood test were 27.9, 0.6, and 29.5 per 1000 person-years, respectively. Patients in the lowest quartile of mortality risk were more likely to be screened than those in the highest quartile (hazard ratio, 1.53; 95% confidence interval, 1.49 to 1.57; 65.1 versus 46.4 tests per 1000 person-years, respectively), amounting to a 33% higher rate of testing. Additionally, compared with patients least likely to receive a transplant, patients most likely to receive a transplant were more likely to be screened (hazard ratio, 1.68; 95% confidence interval, 1.64 to 1.73). Colon cancer screening is being targeted toward patients on dialysis at lowest risk of mortality and highest likelihood of transplantation, but absolute rates are high, suggesting overscreening.

Screening for colorectal cancer

This review will comprise a general overview of colorectal cancer (CRC) screening. We will cover the impact of CRC, CRC risk factors, screening modalities, and guideline recommendations for screening in average-risk and high-risk individuals. Based on this data, we will summarize our approach to CRC screening.

Receipt of Cancer Screening Is a Predictor of Life Expectancy

BACKGROUND

Obtaining cancer screening on patients with limited life expectancy has been proposed as a measure for low quality care for primary care physicians (PCPs). However, administrative data may underestimate life expectancy in patients who undergo screening.

OBJECTIVE

To determine the association between receipt of screening mammography or PSA and overall survival.

DESIGN

Retrospective cohort study from 1/1/1999 to 12/31/2012. Receipt of screening was assessed for 2001-2002 and survival from 1/1/2003 to 12/31/2012. Life expectancy was estimated as of 1/1/03 using a validated algorithm, and was compared to actual survival for men and women, stratified by receipt of cancer screening.

PARTICIPANTS

A 5 % sample of Medicare beneficiaries aged 69-90 years as of 1/1/2003 (n = 906,723).

INTERVENTIONS

Receipt of screening mammography in 2001-2002 for women, or a screening PSA test in 2002 for men.

MAIN MEASURES

Survival from 1/1/2003 through 12/31/2012.

KEY RESULTS

Subjects were stratified by life expectancy based on age and comorbidity. Within each stratum, the subjects with prior cancer screening had actual median survivals higher than those who were not screened, with differences ranging from 1.7 to 2.1 years for women and 0.9 to 1.1 years for men. In a Cox model, non-receipt of screening in women had an impact on survival (HR = 1.52; 95 % CI = 1.51, 1.54) similar in magnitude to a diagnosis of complicated diabetes or heart failure, and was comparable to uncomplicated diabetes or liver disease in men (HR = 1.23; 1.22, 1.25).

CONCLUSIONS

Receipt of cancer screening is a powerful marker of health status that is not captured by comorbidity measures in administrative data. Because life expectancy algorithms using administrative data underestimate the life expectancy of patients who undergo screening, they can overestimate the problem of cancer screening in patients with limited life expectancy.

Multidimensional Geriatric Prognostic Index, Based on a Geriatric Assessment, for Long-Term Survival in Older Adults in Korea

The patient´s survival estimate is important for clinical decision-making, especially in frail patients with multimorbidities. We aimed to develop a multidimensional geriatric prognosis index (GPI) for 3- and 5-year mortality in community-dwelling elderly and to validate the GPI in a separate hospital-based population. The GPI was constructed using data for 988 participants in the Korean Longitudinal Study on Health and Aging (KLoSHA) and cross-validated with 1109 patients who underwent a geriatric assessment at the Seoul National University Bundang Hospital (SNUBH). The GPI, with a total possible score of 8, included age, gender, activities of daily living, instrumental activities of daily living, comorbidities, mood, cognitive function, and nutritional status. During the 5-year observation period, 179 KLoSHA participants (18.1%) and 340 SNUBH patients (30.7%) died. The c-indices for 3- and 5-year mortality were 0.78 and 0.80, respectively, in the KLoSHA group and 0.73 and 0.80, respectively, in the SNUBH group. Positive linear trends were observed for GPI scores and both 3- and 5-year mortality in both groups. In conclusions, using common components of a geriatric assessment, the GPI can stratify the risk of 3- and 5-year mortality in Korean elderly people both in the community and hospital.

Colorectal cancer screening and surveillance in the elderly: updates and controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.

Colon cancer screening in U.S. adults aged 65 and older according to life expectancy and age

OBJECTIVES

To examine receipt of colorectal cancer (CRC) screening according to age and life expectancy (LE) in adults aged 65 and older.

DESIGN

Population-based survey.

SETTING

United States.

PARTICIPANTS

Community dwelling adults aged 65 and older who participated in the 2008 or 2010 National Health Interview Survey (N = 7,747).

MEASUREMENTS

Receipt of CRC screening (e.g., colonoscopy within 10 years) was examined according to age and LE (≥10 and <10 years), adjusting for sociodemographic characteristics and survey year. Frequency of CRC screening was also examined according to age and LE at time of screening (e.g., age at colonoscopy rather than at interview). Participants screened when they were aged 75 and older or had less than a 10-year LE were considered to have received screening inconsistent with guidelines.

RESULTS

Overall, 38.5% of participants had less than a 10-year LE; 40.2% were aged 75 and older, and 56.3% had received recent CRC screening (90.1% by colonoscopy). CRC screening was higher in 2010 (58.9%) than 2008 (53.7%, P <.001) and was associated with longer LE and younger age, although 51.1% of adults aged 75 and older reported receiving CRC screening, as did 50.9% of adults with less than a 10-year LE. Based on age and LE at time of screening (rather than at interview), 28.4% of CRC screening of adults aged 65 and older was targeted to those aged 75 and older and those with less than a 10-year LE. Of adults aged 65 to 75 with a 10-year LE or more (adults recommended for screening by guidelines), 39.2% had not recently been screened.

CONCLUSION

Older adults with little chance of benefit because of limited LE commonly undergo CRC screening, whereas many adults aged 65 to 75 with a 10-year LE or greater are not screened.

Colorectal cancer of the elderly

OPINION STATEMENT

Colorectal cancer (CRC) disproportionately affects the elderly. Older age is a strong risk factor for both the development of precancerous adenomas and CRC, thus raising the issue of screening and surveillance in older patients. However, screening and surveillance decisions in the elderly can be complex and challenging. Elderly patients are a diverse and heterogeneous group and special considerations such as co-morbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance. Such considerations also play a role in factors related to screening modalities, such as colonoscopy, as well as CRC treatment options and regimens. This review addresses many of the unique factors associated with CRC of the elderly and critically examines many of the controversies and challenges surrounding CRC in older patients.

Potential overuse of screening mammography and its association with access to primary care

BACKGROUND

Cancer screening in individuals with limited life expectancy increases the risk of diagnosis and treatment of cancer that otherwise would not have become clinically apparent.

OBJECTIVE

To estimate screening mammography use in women with limited life expectancy, its geographic variation, and association with access to primary care and mammographic resources.

METHODS

We assessed screening mammography use in 2008-2009 in 106,737 women aged 66 years or older with an estimated life expectancy of <7 years using a 5% national sample of Medicare beneficiaries. Descriptive statistics were used to estimate the screening mammography utilization, by access to primary care.

RESULTS

Among women with a life expectancy of <7 years, 28.5% received screening mammography during 2008-2009. The screening rates were 34.6% versus 20.5% for women with and without an identifiable primary care physician, respectively. The screening rates were higher among women who saw >1 generalist physician and who had more visits to generalist physicians. There was substantial geographic variation across the United States, with an average rate of 39.5% in the hospital referral regions (HRRs) in the top decile of screening versus 19.5% in the HRRs in the bottom decile. The screening rates were higher among HRRs with more primary care physicians (r=0.14, P=0.02), mammography facilities (r=0.12, P=0.04), and radiologists (r=0.22, P<0.001).

CONCLUSIONS

Substantial proportions of women with limited life expectancy receive screening mammography. Results presented sound a cautionary note that greater access to primary care and mammographic resources is also associated with higher overuse.