Adherence to recommended intervals for surveillance colonoscopy in average-risk patients with 1 to 2 small (<1 cm) polyps on screening colonoscopy

Frequency of colorectal surveillance colonoscopies for adenomatous polyps: systematic review and meta-analysis

BACKGROUND AND AIM

The purpose of this study was to assess evidence on the frequency of polyp surveillance colonoscopies performed earlier than the recommended follow-up intervals in clinical practice guidelines.

METHODS

A systematic review was performed based on electronic searches in PubMed and Embase. Research articles, letters to the editors, and review articles, published before April 2022, were included. Studies that focused on the intervals of polyp surveillance in adult populations were selected. The Risk Of Bias In Non-randomized Studies of Exposure (ROBINS-E) was used to assess the risk of bias. A meta-analysis was performed with Forest plots to illustrate the results.

RESULTS

In total, 16 studies, comprising 11 172 patients from Australia, Europe, and North America, were included for analysis. The quality of the studies was moderate. Overall, 38% (95% CI: 30-47%) of colonoscopies were undertaken earlier than their respective national clinical guidelines. In risk-stratified surveillance, 10 studies contained data relating to low-risk polyp surveillance intervals and 30% (95% CI: 29-31%) of colonoscopies were performed earlier than recommended. Eight studies contained data relating to intermediate-risk polyp surveillance and 15% (95% CI: 14-17%) of colonoscopies were performed earlier than recommended. One study showed that 6% (95% CI: 4-10%) of colonoscopies performed for high-risk polyp surveillance were performed earlier than recommended.

CONCLUSIONS

A significant proportion of polyp surveillance was performed earlier than the guidelines suggested. This provides evidence of the potential overuse of healthcare resources and the opportunity to improve hospital efficiency.

Recurrence rates of advanced colorectal neoplasia (ACN) in subjects with baseline ACN followed up at different surveillance intervals

BACKGROUND

Current clinical guidelines recommend that a baseline finding of advanced colorectal neoplasia (ACN) should be followed-up within 1-3 years.

AIM

We compared the recurrence rate of ACN at 1 year vs. 3 years among individuals with ACN detected and polypectomised at baseline colonoscopy.

METHODS

We extracted data from eligible patients in a Chinese population database from 2008 to 2018. The outcome variables included recurrence of advanced adenoma and advanced neoplasia, respectively, at follow-up colonoscopy. Binary logistic regression modeling was constructed to examine the association between length of surveillance and the outcome variables, controlling for risk factors of colorectal cancer, including age, gender, smoking, alcohol drinking, body mass index and chronic diseases.

RESULTS

We included 147,270 subjects who have received a baseline colonoscopy from our dataset. They were aged 69.3 years and 59.7% of them were male subjects. The crude 1-year and 3-year recurrence rate of ACN was 7.57% and 7.74%. From a binary logistic regression model, individuals with surveillance colonoscopy performed at 3 years did not have significantly higher recurrence rate of ACN than those followed-up at 1 year.

CONCLUSIONS

No statistically significantly difference in recurrence of ACN between individuals who received workup at 1vs. 3 years. These findings support a 3-year surveillance period after baseline ACN was polypectomised.

Guideline Adherence to Colonoscopic Surveillance Intervals after Polypectomy in Korea: Results from a Nationwide Survey

Background/Aims

People around the world are increasingly choosing to undergo colorectal cancer screening via colonoscopy. As a result, guideline adherence to postpolypectomy colonoscopy surveillance has drawn increasing attention. The present study was performed to assess recognition and adherence to guidelines among primary care physicians and gastroenterologists and to identify characteristics associated with compliance.

Methods

A nationwide sample of primary care physicians employed at cancer screening facilities and registered members of the Korean Society of Gastrointestinal Endoscopy were recruited. Participants were asked to complete a survey of six hypothetical clinical scenarios designed to assess their potential course of action in response to screening or follow-up colonoscopy results. Frequencies and odds ratios and 95% confidence intervals for guideline adherence were estimated.

Results

The proportions of doctors recommending shortened colonoscopy surveillance intervals for low- and high-risk adenomas were greater than 90% among primary physicians and were much lower among gastroenterologists. Guideline adherence was relatively good among groups of doctors who were young, had a specialty in gastroenterology, worked at tertiary hospitals, and cared for an appropriate number of patients.

Conclusions

The present study reveals a remaining discrepancy between practitioner recommendations and current guidelines for postpolypectomy surveillance. Several factors were shown to be related to guideline adherence, suggesting a need for appropriate control and continuing education or training programs among particular groups of practitioners.

Young patients with sporadic colorectal adenomas: current endoscopic surveillance practices and outcomes

BACKGROUND AND AIMS

For young individuals (age <40 years) without strong family histories that would put them at risk for genetic colorectal cancer syndromes, it is unclear if national Multi-Society Task Force surveillance recommendations apply or if endoscopists follow these guideline recommendations when such patients are incidentally found to have adenoma(s) on colonoscopy.

METHODS

We reviewed records on young (age <40 years) patients, with either no family history or only a moderate family history (1 first-degree family member with colorectal cancer at age ≥50), who were found to have neoplastic polyp(s) on their index colonoscopy. We assessed the pattern of endoscopist surveillance recommendations, whether endoscopist recommendations complied with national guidelines, and compliance with surveillance recommendations.

RESULTS

One hundred forty-one subjects were included, of whom 19 (13.5%) had a moderate family history of colorectal cancer. For patients with non-high-risk findings, 27.7% were asked to repeat their colonoscopy in ≤3 years and 99.0% within 5 years. Endoscopist surveillance recommendation compliance rates with national guidelines were >65.0% for low-risk neoplasia but lower for high-risk (40.0%), nonpolypoid (44.2%), and serrated neoplasia (54.2%, P < .001 for all). Subjects whose endoscopist recommendations were noncompliant with guidelines were usually recalled too early (96%). Only 24.7% of subjects were actually compliant with endoscopist surveillance recommendations.

CONCLUSIONS

For young patients with neoplastic polyp(s) but no strong family history, most endoscopists complied with national guidelines and recommended repeat colonoscopy in 3 to 5 years. However, relatively few patients were compliant with repeat colonoscopy recommendations. For most cases that were noncompliant with guidelines, patients were recalled too early as opposed to too late.

Impact of Colonoscopy Bowel Preparation Quality on Follow-up Interval Recommendations for Average-risk Patients With Normal Screening Colonoscopies: Data From the New Hampshire Colonoscopy Registry

BACKGROUND AND AIMS

National guidelines for colonoscopy screening and surveillance assume adequate bowel preparation. We used New Hampshire Colonoscopy Registry (NHCR) data to investigate the influence of bowel preparation quality on endoscopist recommendations for follow-up intervals in average-risk patients following normal screening colonoscopies.

METHODS

The analysis included 9170 normal screening colonoscopies performed on average risk individuals aged 50 and above between February 2005 and September 2013. The NHCR Procedure Form instructs endoscopists to score based on the worst prepped segment after clearing all colon segments, using the following categories: excellent (essentially 100% visualization), good (very unlikely to impair visualization), fair (possibly impairing visualization), and poor (definitely impairing visualization). We categorized examinations into 3 preparation groups: optimal (excellent/good) (n=8453), fair (n=598), and poor (n=119). Recommendations other than 10 years for examinations with optimal preparation, and >1 year for examinations with poor preparation, were considered nonadherent.

RESULTS

Of all examinations, 6.2% overall received nonadherent recommendations, including 5% of examinations with optimal preparation and 89.9% of examinations with poor preparation. Of normal examinations with fair preparation, 20.7% of recommendations were for an interval <10 years. Among those examinations with fair preparation, shorter-interval recommendations were associated with female sex, former/nonsmokers, and endoscopists with adenoma detection rate ≥20%.

CONCLUSIONS

In 8453 colonoscopies with optimal preparations, most recommendations (95%) were guideline-adherent. No guideline recommendation currently exists for fair preparation, but in this investigation into community practice, the majority of the fair preparation group received 10-year follow-up recommendations. A strikingly high proportion of examinations with poor preparation received a follow-up recommendation greater than the 1-year guideline recommendation. Provider education is needed to ensure that patients with poor bowel preparation are followed appropriately to reduce the risk of missing important lesions.

Adherence to CRC Screening and Surveillance Guidelines when Using Split-Dose Bowel Preparation

Goal

To prospectively assess physician recommendations for repeat colonoscopy in an average-risk screening cohort.

Background

Endoscopists' adherence to colorectal cancer screening and surveillance guidelines for repeat colonoscopy have not been well characterized. Furthermore, little is known about patient and colonoscopy factors that are associated with endoscopists' nonadherence to guideline recommendation.

Study

This is a prospective cohort of average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. The primary outcome was assessment of physician recommendations for repeat colonoscopy.

Results

462 participants were prospectively enrolled. 13.6% (62) had guideline-inconsistent recommendations. 89% of the guideline-inconsistent recommendations were for an earlier interval. Endoscopists' reports cited suboptimal bowel preparation as the most common reason for earlier repeat colonoscopy. On multivariable analysis, patient split-dose preparation noncompliance was significantly associated with guideline-inconsistent recommendation (OR = 2.7) even after adjusting for other patient or bowel preparation-related characteristics. Additionally, increased odds of guideline-inconsistent recommendation were associated with older age (>70 years old), higher BMI, having 3 or more polyps, having had at least two previous colonoscopies, suboptimal bowel preparation, and having taken at least 12 hours till clear bowel movement.

Conclusions

Gastroenterologists are adherent to CRC screening and surveillance guidelines. Suboptimal bowel preparation is the most frequently cited factor in endoscopy reports leading to deviation from guidelines. Continued emphasis on optimization of bowel preparation, particularly patient compliance to split-dose regimen, is needed.

Less Is More: A Minimalist Approach to Endoscopy

A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.

Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-Risk Colorectal Adenomas and Effects on Outcome

BACKGROUND & AIMS

Endoscopists do not routinely follow guidelines to survey individuals with low-risk adenomas (LRAs; 1-2 small tubular adenomas, < 1 cm) every 5-10 years for colorectal cancer; many recommend shorter surveillance intervals for these individuals. We aimed to identify the reasons that endoscopists recommend shorter surveillance intervals for some individuals with LRAs and determine whether timing affects outcomes at follow-up examinations.

METHODS

We collected data from 1560 individuals (45-75 years old) who participated in a prospective chemoprevention trial (of vitamin D and calcium) from 2004 through 2008. Participants in the trial had at least 1 adenoma, detected at their index colonoscopy, and were recommended to receive follow-up colonoscopy examinations at 3 or 5 years after adenoma identification, as recommended by the endoscopist. For this analysis we collected data from only participants with LRAs. These data included characteristics of participants and endoscopists and findings from index and follow-up colonoscopies. Primary endpoints were frequency of recommending shorter (3-year) vs longer (5-year) surveillance intervals, factors associated with these recommendations, and effect on outcome, determined at the follow-up colonoscopy.

RESULTS

A 3-year surveillance interval was recommended for 594 of the subjects (38.1%). Factors most significantly associated with recommendation of 3-year vs a 5-year surveillance interval included African American race (relative risk [RR] to white, 1.41; 95% confidence interval [CI], 1.14-1.75), Asian/Pacific Islander ethnicity (RR to white, 1.7; 95% CI, 1.22-2.43), detection of 2 adenomas at the index examination (RR vs 1 adenoma, 1.47; 95% CI, 1.27-1.71), more than 3 serrated polyps at the index examination (RR=2.16, 95% CI, 1.59-2.93), or index examination with fair or poor quality bowel preparation (RR vs excellent quality, 2.16; 95% CI, 1.66-2.83). Other factors that had a significant association with recommendation for a 3-year surveillance interval included family history of colorectal cancer and detection of 1-2 serrated polyps at the index examination. In comparisons of outcomes, we found no significant differences between the 3-year vs 5-year recommendation groups in proportions of subjects found to have 1 or more adenomas (38.8% vs 41.7% respectively; P = .27), advanced adenomas (7.7% vs 8.2%; P = .73) or clinically significant serrated polyps (10.0% vs 10.3%; P = .82) at the follow-up colonoscopy.

CONCLUSIONS

Possibly influenced by patients' family history, race, quality of bowel preparation, or number or size of polyps, endoscopists frequently recommend 3-year surveillance intervals instead of guideline-recommended intervals of 5 years or longer for individuals with LRAs. However, at the follow-up colonoscopy, similar proportions of participants have 1 or more adenomas, advanced adenomas, or serrated polyps. These findings support the current guideline recommendations of performing follow-up examinations of individuals with LRAs at least 5 years after the index colonoscopy.

Impact of physician compliance with colonoscopy surveillance guidelines on interval colorectal cancer

BACKGROUND AND AIMS

Interval colorectal cancer (iCRC) incidence is the criterion standard benchmark for measuring the effectiveness of colonoscopy. Colonoscopy surveillance guidelines are designed to minimize iCRC cases. Our aims were to describe characteristics of iCRC patients and to assess whether development of iCRC is related to colonoscopy surveillance guideline intervals.

METHODS

We performed a retrospective cohort study of postcolonoscopy iCRC cases in a large healthcare system. Guideline-based colonoscopy intervals were calculated based on the 2012 U.S. Multi-Society Task Force for Colorectal Cancer colonoscopy surveillance guidelines. Backward stepwise linear regression was used to determine predictors of iCRC before guideline-recommended follow-up intervals.

RESULTS

We identified 245 iCRC cases (mean age, 69.4 years; 56.3% male) out of 5345 colon cancers evaluated for a prevalence of 4.60%. On index colonoscopy, 75.1% had an adequate preparation, 93.0% reached the cecum, and 52.5% had polyps. iCRC developed before the guideline-recommended interval in 59.1% of patients (94/159). Independent predictive factors of this finding were inadequate preparation (OR, .012; 95% CI, .003-.06; P < .0001) and ≥3 polyps on index colonoscopy (OR, .2; 95% CI, .078-.52; P = .0009). An endoscopist-recommended follow-up interval past the guideline-recommended interval was seen in 23.9% of cases (38/159). Most (34/38, 89.5%) of these iCRCs had inadequate preparation and were diagnosed after the guideline-based follow-up interval.

CONCLUSIONS

Current colonoscopy surveillance guidelines may be inadequate to prevent many iCRC cases. Physician noncompliance with guideline-based surveillance intervals may increase in iCRC cases, especially in patients with an initially inadequate bowel preparation.

Organization of surveillance in GI practice

BACKGROUND

Several reports documented an inefficient utilisation of available resources, as well as a suboptimal compliance with surveillance recommendations. Although, evidence suggests that organisational issues can influence the quality of care delivered, surveillance protocols are usually based on non-organized approaches.

METHODS

We conducted a literature search (publication date: 01/2000-06/2016) on PubMed and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Cochrane Central Register of Controlled Trials for guidelines, or consensus statements, for surveys of practice, reporting information about patients, or providers attitudes and behaviours, for intervention studies to enhance compliance with guidelines. Related articles were also scrutinised. Based on the clinical relevance and burden on endoscopy services this review was focused on surveillance for Barrett's oesophagus, IBD and post-polypectomy surveillance of colonic adenomas.

RESULTS

Existing guidelines are generally recognising structure and process requirements influencing delivery of surveillance interventions, while less attention had been devoted to transitions and interfaces in the care process. Available evidence from practice surveys is suggesting the need to design organizational strategies aimed to enable patients to attend and providers to deliver timely and appropriate care. Well designed studies assessing the effectiveness of specific interventions in this setting are however lacking. Indirect evidence from screening settings would suggest that the implementation of automated standardized recall systems, utilisation of clinical registries, removing financial barriers, could improve appropriateness of use and compliance with recommendations.

CONCLUSIONS

Lack of sound evidence regarding utility and methodology of surveillance can contribute to explain the observed variability in providers and patients attitudes and in compliance with the recommended surveillance.

Surveillance after colorectal polyp removal

Surveillance colonoscopy is aimed to reduce CRC incidence and mortality by removing adenomas and detecting CRC in early stage. However, colonoscopy is an invasive and expensive procedure and surveillance colonoscopy should be targeted at those who are most likely to benefit at the minimum frequency required to protect for cancer. Surveillance recommendations are based on guidelines, but the recommendations in those guidelines are based on moderate to low quality evidence and adherence to these guidelines is poor. As surveillance colonoscopy is one of the main indications for colonoscopy and surveillance colonoscopies are filling colonoscopy lists, the current surveillance practice results in spending lots of money and capacity in a suboptimal way. Randomized controlled trials to compare surveillance intervals are not available. However, current evidence based on several case-control and cohort studies suggests there is no need for surveillance in patients with low-risk adenomas, i.e. 1-2 adenomas smaller than 10 mm. Patients with 3 or more adenomas or any adenoma larger than 10 mm seem to be the ones at real risk for metachronous adenomas or cancer. In those patients, surveillance colonoscopy is indicated at 3 years after baseline until ongoing studies will confirm the safety of enlarging this interval. Randomized controlled trials and experimental research are important in order to provide the necessary scientific evidence for the optimization of follow-up strategies for patients with adenomas and serrated polyps.

Colonoscopy practice for veterans within and outside the Veterans Affairs setting: a matched cohort study

BACKGROUND AND AIMS

To minimize delays for colonoscopy within Veterans Affairs (VA) facilities, veterans may receive care at non-VA facilities based on fee-for-service contracts, and more recently, through the Veterans Access, Choice, and Accountability Act. The impact of diverting care from VA to non-VA facilities on quality of colonoscopy practice is unknown.

METHODS

We identified all veterans aged 50 to 85 years who received a fee-basis colonoscopy for colorectal cancer screening or surveillance at non-VA facilities in 2007 to 2010. These patients were matched for sex, age, and year of procedure to veterans who underwent colonoscopies at VA medical centers. The outcomes of interest were the adenoma detection rates (ADR) and compliance with surveillance guidelines.

RESULTS

During the observation period, 409 veterans (mean age 64 years; 94% men) underwent a fee-basis colonoscopy at 30 nonacademic (54%) and 2 academic (46%) facilities. Compared with colonoscopies performed at VA facilities, fee-basis colonoscopy patients had lower ADRs (38% vs 52%; P < .001), lower mean number of adenomas per procedure (0.72 vs 1.41; P < .001), and lower number of advanced ADRs (13% vs 22%; P < .001). Colonoscopies done at non-VA facilities were associated with lower ADRs in multivariate regression analysis (odds ratio 0.64; 95% CI, 0.44-0.92), whereas colonoscopies done in nonacademic settings or by colonoscopists who were not gastroenterologists were not. Compliance with surveillance guidelines was lower for colonoscopies performed outside VA facilities (80% vs 87%; P = .03).

CONCLUSIONS

In this regional study (Northern New England), compliance with colonoscopy surveillance guidelines was high in both VA and non-VA settings; however, lower ADRs raise concern that referring veterans outside the VA system may impact colonoscopy quality.

Post-polypectomy Guideline Adherence: Importance of Belief in Guidelines, Not Guideline Knowledge or Fear of Missed Cancer

BACKGROUND

Adherence to post-polypectomy surveillance guideline recommendations is suboptimal. Surveillance is frequently over- and under-recommend, resulting in strained colonoscopy capacity, potential risks without expected benefits, and missed opportunities for colorectal cancer risk reduction.

AIMS

To identify factors associated with adherence to post-polypectomy surveillance guidelines.

METHODS

We conducted a three-phase study with a retrospective review of usual care post-polypectomy surveillance recommendations through medical chart abstraction (Phase I), prospective online physician survey (Phase II), and analysis of survey-based and other physician-based predictors of usual care surveillance recommendations (Phase III). Subjects included patients who underwent usual care colonoscopy 2011-2012 (Phases I and III) and gastroenterology (GI) attendings and fellows (Phases II and III). We identified rates of recommendations consistent with guideline adherence, surveillance overuse, and surveillance underuse based on usual care medical chart documentation and physician survey, as well as predictors of physician adherence to guidelines.

RESULTS

We reviewed 640 patient charts for 28 survey respondents. Rates of usual practice recommendations consistent with guideline adherence, surveillance overutilization, and underutilization were 84, 13, and 3%, respectively. At survey, 82% of physicians were concerned about missed cancer. Eleven percentage believed that guidelines were not aggressive enough. GI trainees were 2.5 times more likely to issue guideline-adherent recommendations [OR 2.5, 95% CI (1.5-4.2)]. Disagreement with guideline aggressiveness was independently associated with 40% lower likelihood of adherence [OR 0.6, 95% CI (0.4-0.8)].

CONCLUSIONS

Belief in the appropriate aggressiveness of guidelines and trainee position, but not fear of missed cancer or guideline knowledge, was associated with adherence to post-polypectomy surveillance guidelines.

Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system

PURPOSE

Appropriate surveillance intervals for colorectal cancer (CRC) screening is one of the Centers for Medicare and Medicaid Services 2014 physician quality reporting system measures. Appropriateness of surveillance intervals will continue to be monitored closely, particularly as reimbursements become tied to quality measures.

AIMS

Quantify and identify predictors for guideline-concordant surveillance recommendations after adenoma polypectomy.

METHODS

We conducted a retrospective cohort study of patients who had colonoscopy with polypectomy at a safety-net health system between June 2011 and December 2013. Surveillance recommendations shorter and longer than guideline recommendations were defined as potential overuse and underuse. We used multivariate logistic regression to identify correlates of guideline-concordant surveillance recommendations, overuse, and underuse.

RESULTS

Among 1,822 patients with polypectomy, 1,329 had ≥1 adenoma. Surveillance interval recommendations were guideline-concordant in 1,410 (77.4%) patients, potential overuse in 263 (14.4%), potential underuse in 85 (4.7%), and missing in 64 (3.5%) patients. Predictors of guideline-concordant recommendations in multivariate analyses included age >65 years (OR 1.36, 95% CI 1.02-1.80), incomplete resection (OR 3.58, 95% CI 1.41-9.09), and good/excellent prep quality (OR 2.22, 95% CI 1.72-2.86). Underuse recommendations were more likely in patients with ≥3 adenomas; overuse recommendations were more likely in patients with high-grade dysplasia or fair prep quality and less likely in those with piecemeal resection, ≥3 adenomas, age >65, or Hispanic ethnicity.

CONCLUSIONS

Surveillance recommendations are not concordant with guidelines in one of four cases. Interventions to improve prep quality and guideline concordance of surveillance recommendations can improve cost-effectiveness of CRC screening.

Overuse of colonoscopy for colorectal cancer screening and surveillance

BACKGROUND

Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources.

OBJECTIVE

Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse.

DESIGN, SETTING, AND PARTICIPANTS

Our approach was a retrospective cohort study using electronic health record data for patients 50-65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice.

MAIN OUTCOME MEASURES

We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies.

KEY RESULTS

We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88%) and many surveillance colonoscopies (49%) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1-10.0; hyperplastic polyp: 5.7 years, IQR: 4.9-9.7; low-risk adenoma: 5.1 years, IQR: 3.3-6.3; high-risk adenoma: 2.9 years, IQR: 2.0-3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95% CI: 3.15-12.50) and surveillance colonoscopy (OR 13.47, 95% CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam.

CONCLUSIONS

Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.