Megan A. Adams,Eve A. Kerr,Yuqing Gao,Sameer D. Saini
Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in a Large Integrated Healthcare Delivery System
colonoscopy,colorectal cancer,access,COVID-19,appropriate use
Background Decreasing low-value colonoscopy is critical to optimizing access for high-need patients, particularly in resource-constrained environments such as those created by the COVID-19 pandemic. We hypothesized that rates of screening colonoscopy overuse would decline during COVID compared to pre-COVID due to enhanced procedural scrutiny and prioritization in the setting of constrained access. Objective To characterize impacts of COVID-19 on screening colonoscopy overuse Design Retrospective national cohort study using Veterans Health Administration administrative data Participants Veterans undergoing screening colonoscopy in Q4 2019 (pre-COVID) and Q4 2020 (COVID) at 109 endoscopy facilities Main Measures Rates of screening colonoscopy overuse Key Results 18,376 screening colonoscopies were performed pre-COVID, 19% (3,641) of which met overuse criteria. While only 9,360 screening colonoscopies were performed in Q4 2020, 25% met overuse criteria. Overall change in median facility-level overuse during COVID compared to pre-COVID was 6% (95%CI 5%-7%), with significant variability across facilities (IQR: 2%-11%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous screening procedure (55% pre-COVID, 49% during COVID). The largest shifts in overuse category were in screening procedures performed <9 years after prior screening colonoscopy (-6% decline COVID vs. pre-COVID) and screening procedures performed in patients below average-risk screening age (i.e., age <40 (5% increase COVID compared to pre-COVID), age 40-44 (4% increase COVID vs. pre-COVID)). Within facility performance was stable over time; 83/109 facilities changed their performance by <=1 quartile during COVID compared to pre-COVID. Conclusions Despite pandemic-related resource constraints and enhanced procedural scrutiny and prioritization in the setting of COVID-related backlogs, screening colonoscopy overuse rates remained roughly stable during COVID compared to pre-COVID, with continued variability across facilities. These data highlight the need for systematic and concerted efforts to address overuse, even in the face of strong external motivating factors. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-023-08233-0.
Impacts of COVID-19 on Appropriate Use of Screening Colonoscopy in a Large Integrated Healthcare Delivery System

Decreasing low-value colonoscopy is critical to optimizing access for high-need patients, particularly in resource-constrained environments such as those created by the COVID-19 pandemic. We hypothesized that rates of screening colonoscopy overuse would decline during COVID compared to pre-COVID due to enhanced procedural scrutiny and prioritization in the setting of constrained access.

To characterize impacts of COVID-19 on screening colonoscopy overuse

Retrospective national cohort study using Veterans Health Administration administrative data

Veterans undergoing screening colonoscopy in Q4 2019 (pre-COVID) and Q4 2020 (COVID) at 109 endoscopy facilities

Rates of screening colonoscopy overuse

18,376 screening colonoscopies were performed pre-COVID, 19% (3,641) of which met overuse criteria. While only 9,360 screening colonoscopies were performed in Q4 2020, 25% met overuse criteria. Overall change in median facility-level overuse during COVID compared to pre-COVID was 6% (95%CI 5%-7%), with significant variability across facilities (IQR: 2%-11%). Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous screening procedure (55% pre-COVID, 49% during COVID). The largest shifts in overuse category were in screening procedures performed <9 years after prior screening colonoscopy (-6% decline COVID vs. pre-COVID) and screening procedures performed in patients below average-risk screening age (i.e., age <40 (5% increase COVID compared to pre-COVID), age 40-44 (4% increase COVID vs. pre-COVID)). Within facility performance was stable over time; 83/109 facilities changed their performance by <=1 quartile during COVID compared to pre-COVID.

Despite pandemic-related resource constraints and enhanced procedural scrutiny and prioritization in the setting of COVID-related backlogs, screening colonoscopy overuse rates remained roughly stable during COVID compared to pre-COVID, with continued variability across facilities. These data highlight the need for systematic and concerted efforts to address overuse, even in the face of strong external motivating factors.

The online version contains supplementary material available at 10.1007/s11606-023-08233-0.

The COVID-19 pandemic has deeply disrupted routine outpatient care delivery in unprecedented ways. In the pandemic’s early days, health care facilities were forced to divert resources from elective outpatient care to meet the demands of the initial COVID-19 surge, leading to cancellation and deferral of common elective outpatient procedures such as colonoscopy. As services have gradually resumed, there has been intense focus on understanding how deferral of high-value care has impacted morbidity and mortality across conditions. For example, sharp declines in colorectal cancer screening rates during the pandemic contributed to a screening deficit of 3.8 million men and women with a disproportionate impact on vulnerable populations. Much of this deficit is attributed to deferral of screening colonoscopy, though there is some evidence to suggest that use of stool-based colorectal cancer screening modalities (i.e., fecal immunochemical testing) counterbalanced decreases in colonoscopy in the early phases of the pandemic. In addition to this important focus on assessing and mitigating the impacts of pandemic-era deferral of high-value care, the pandemic also presents an unprecedented opportunity to expand our understanding of use of low-value care and how to reduce it to enhance overall access. Some have suggested that pandemic-related care disruptions could reduce use of low-value care and replace it with higher-value services in the recovery-phase of the pandemic and beyond. Overuse of colonoscopy for screening and other preventive indications is a common and well-documented problem across US healthcare systems. Overuse is not only wasteful and potentially harmful to patients—it also can impede access for patients who need care by unnecessarily increasing demand in the setting of limited resources. Overuse is particularly problematic when reduced access leads to longer-than-acceptable wait times for patients requiring diagnostic endoscopy. This occurred within the Veterans Health Administration (VA), the largest integrated healthcare system in the United States, during the COVID-19 pandemic. Specifically, early restrictions in ambulatory utilization induced an acute state of backlogged cases that served as motivation to minimize low-value care to conserve limited endoscopic resources for high-need patients. Indeed, VA’s National GI Program Office distributed guidance in April 2020 asking facilities to prioritize procedures by indication and time-sensitivity. Recent studies have found that colonoscopy workup of colorectal cancer ‘red flag’ symptoms (e.g., rectal bleeding) was not delayed within VA during COVID-19, possibly due to implementation of these policies. In this context, we sought to evaluate whether the global pandemic was associated with decreased overuse of screening colonoscopies across facilities in VA. We hypothesized that there would be decreased procedural overuse during the pandemic due to enhanced procedural prioritization and scrutiny of procedural appropriateness induced by pandemic-related procedural backlogs.

The Ann Arbor VA IRB deemed this study exempt from review. This was a retrospective observational study using VHA administrative, clinical, and laboratory data available in the Corporate Data Warehouse (CDW). The study population included Veterans undergoing a screening colonoscopy at one of 109 VA endoscopy facilities in October-December 2019 (“pre-COVID”) and October-December 2020 (“COVID”). Rates of screening colonoscopy overuse were estimated using an ICD-10-based electronic measure recently validated for use in VHA (specificity 99%, sensitivity 46%) and further detailed below.

Measure specifications were initially defined by an expert workgroup comprising VA experts in colorectal cancer screening and in performance measurement. Prior to the initial workgroup meeting, members were provided with relevant literature to review, including U.S. Preventive Services Task Force (USPSTF) guidelines for colorectal cancer screening and Veterans Health Administration (VHA) Colorectal Cancer Screening Directives in effect at the time of measure development. Workgroup members were charged with developing a measure that: (1) was based on high-quality evidence (i.e., the evidence summarized in pre-2021 USPSTF guidelines); (2) maximized specificity at the expense of sensitivity; and (3) could be implemented electronically. The final measure defined by the workgroup identified average-risk screening colonoscopies (comprising the eligible population in the denominator – Table 1) that met one or more criteria for probable or possible overuse (comprising the numerator – Table 1). For purposes of this study, we adapted the measure slightly by eliminating the 45-49-year age overuse category included in the original measure numerator given 2021 updates to USPSTF guidelines that recommended changing the age of screening initiation from 50 to 45 years old.

The measure denominator (prior to application of exclusions to eliminate procedures with indications other than average-risk screening) consisted of all index colonoscopies performed during the study period in patients who had not had a colonoscopy within the preceding 12 months. To approximate the measure denominator (Table 1), we first identified all colonoscopies performed for any indication using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes (for a detailed list of codes, see Adams et al.). For patients who had more than one colonoscopy performed in the study period, only the first (index) procedure was included in the denominator. Likewise, only patients who had no prior colonoscopy performed in the 12 months preceding the index colonoscopy were included in the denominator. This is because when a colonoscopy is repeated within a year, there is a high probability that the repeat procedure was done for a reasonable indication such as inadequate bowel preparation on the prior procedure, sedation intolerance leading to an incomplete procedure, or failure to complete the prior procedure due to technical difficulty.

We then excluded procedures that may have been performed for diagnostic or high-risk screening or surveillance indications, using an approach previously developed and validated by Fisher and colleagues. First, we excluded patients who had an ICD-10 code for specific gastrointestinal symptoms or for colorectal neoplasia within 12 months of the Q4 2019/Q4 2020 colonoscopy. To further increase the specificity of the electronic measure, we also excluded individuals with ICD-9 and ICD-10 codes indicating high risk for colorectal cancer or prior total abdominal colectomy at any time in the prior 10 years. Specifically, patients were excluded if CPT or ICD-9/-10 codes revealed any of the following diagnoses within 10 years of the qualifying Q4 2019/Q4 2020 colonoscopy: (1) prior colectomy, (2) history of colorectal cancer; (3) history of colon polyps; (4) history of inflammatory bowel disease; or (5) family history of colorectal cancer. Both ICD-9 and ICD-10 codes were used because VHA (like most US healthcare systems) transitioned between these two coding systems on October 1, 2015. These additional exclusion criteria were selected to ensure that the cohort comprised individuals who were at average (rather than increased) risk of CRC. Finally, we excluded individuals who underwent their colonoscopy during a hospitalization (since such colonoscopies are unlikely to be performed for screening). Thus, the final denominator (after all exclusions) consisted of all average-risk screening colonoscopies performed in the study period.

Specification of electronic elements comprising the measure numerator (probable and possible overuse – Table 1) was more straightforward than for the denominator since these elements were primarily based on factors such as patient age and the time interval between colonoscopies (which are reliably-coded in administrative data). To identify fecal occult blood tests (FOBTs), we used Logical Observation Identifiers Names and Codes (LOINC). To identify patients with life expectancy <6 months, we used structured data from CDW that is used to indicate limited life expectancy for clinical purposes (i.e., the CDW Health FactorType domain, which contains information about health factors, severity level, and other indicators of health and includes a forecast of the probable outcome of a disease to flag patients with a life expectancy of <6 months).

Facility-level rates of screening colonoscopy overuse were calculated pre-COVID and COVID using the electronic measure and adjusted for facility endoscopy volume. 95% confidence intervals (CI) were calculated. Facilities that performed <10 screening colonoscopy procedures in either the pre-COVID or COVID periods were excluded. A sensitivity analysis assessing Q4 2021 overuse rates also was performed to capture potential longer-term changes in overuse during the pandemic. We also examined the association between certain facility-level predictors and changes in screening colonoscopy overuse. Facility characteristics examined included: (1) VHA facility complexity score (ranging from 1a (highest) to 3 (lowest)), (2) geographic region (Supplemental Table), (3) academic affiliation, and (4) capacity (comparing Q3 2020 procedural volume with Q3 2019 volume to calculate proportion of pre-COVID/Q4 2019 capacity recovered in Q4 2020). Procedure-level data was aggregated by facility and time-period. We then fit a generalized estimating equation negative binomial model with the number of overuse screening colonoscopies as the outcome, the total number of screening colonoscopies as the offset, and time-period (Q4 2019/Q4 2020), geographic region, facility complexity, academic affiliation, capacity, and interactions of time-period with facility complexity, academic affiliation, geographic region, and capacity as predictors. The model assumed that observations from the same facility were correlated with an exchangeable covariance structure. To examine the association between patient characteristics and changes in screening colonoscopy overuse, we estimated relative risk (RR) by Poisson regression with robust error variance using procedure-level data that included only patient-level factors -- specifically, race (black, non-black), sex (male, female), engagement in VA care (as measured by the number of primary care visits in the previous 12 months; 0-1, 2-4, >4), time-period (Q4 2019/Q4 2020), and the interactions of time-period with race, sex, and engagement in VA care. Data analysis was performed using SAS, Version 9.4 (SAS Institute Inc., Cary, NC) and STATA 16 (StataCorp, College Station, TX).

A total of 119 VA endoscopy facilities performed screening colonoscopies in the study period. Of these, 10 were excluded because they performed <10 procedures in either the pre-COVID or COVID periods. There were 98,248 total colonoscopies (all indications) performed during the study period (57,078 pre-COVID; 41,170 COVID) at the remaining 109 facilities. Of these, 27,736 were average-risk screening colonoscopies (18,376 pre-COVID; 9,360 COVID). Of average-risk screening colonoscopies, 6,066 met criteria for overuse (3,641 pre-COVID; 2,425 COVID). The adjusted mean pre-COVID facility-level overuse rate was 19% (95%CI 18-20%), compared with 25% (95%CI 24%-27%) during COVID, translating to an overall 6% (95%CI 5%-7%) increase in screening colonoscopy overuse in Q4 2020/during COVID compared to the Q4 2019/pre-COVID baseline, with significant variability across facilities (interquartile range: 2%-11%). (Figure 1) Of colonoscopies meeting overuse criteria, the top reason for overuse in both periods was screening colonoscopy performed <9 years after previous colonoscopy (55% pre-COVID vs. 49% COVID). (Table 2) Of top-performing facilities (lowest quartile overuse) pre-COVID, 11/28 (39%) remained top-performers in Q4 2020/during COVID. Of bottom-performing facilities (highest quartile overuse) pre-COVID, 11/27 (41%) remained bottom-performers in Q4 2020/during COVID. Overall, 83/109 facilities changed (improved or worsened) their performance by no more than a quartile in Q4 2020/during COVID compared to the Q4 2019/pre-COVID baseline. In the sensitivity analysis, the overuse rate in Q4 2021 was 21% (95%CI 20-23%). Most VA facilities were high-complexity (75/109; 69%) and academically affiliated (105/109; 96%). Medium-complexity and academically affiliated facilities, and facilities in the Midwest and Southeast regions, experienced the largest relative increases in screening colonoscopy overuse (Table 3). Facilities that failed to regain their pre-COVID capacity by Q4 2020/COVID (i.e., remained “supply constrained”) were no more likely to decrease screening colonoscopy overuse than those that had regained their capacity (p=0.12). Examining patient characteristics, race and sex did not meaningfully impact pre-COVID overuse rates or the relative change in overuse rates during COVID as compared to pre-COVID (Table 3). Patients with higher levels of engagement in VA care (as measured by number of PCP visits in the previous year) were slightly more likely to have an overuse screening colonoscopy pre-COVID, but this difference became less prominent during COVID due to larger relative increases in overuse rates among Veterans less engaged in care.

Recently, there has been increased recognition of low-value care (i.e., services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary costs, or waste limited healthcare resources) as a major contributor to skyrocketing healthcare spending. Despite this increased recognition, use of low-value services has not substantially declined over the past decade. This illustrates the complexities of addressing low-value care, described as “swimming against the current,” given the need to de-implement entrenched practices. However, rapid and unprecedented disruptions to our healthcare system due to the COVID-19 pandemic, and pandemic-related resource constraints, introduced fresh motivation to reduce low-value care to conserve precious healthcare resources for the highest-need patients. Some have hypothesized that pandemic-related care disruptions could reduce use of low-value care and replace it with higher-value services in the recovery-phase of the pandemic and beyond. In this study, we examined the impacts of COVID-19 on screening colonoscopy overuse in a large integrated healthcare system by comparing facility-level overuse rates in Q4 2020 (during COVID) with baseline overuse rates in Q4 2019 (pre-COVID). Contrary to our hypothesis that there would be decreased utilization of low-value care during COVID, median facility-level screening colonoscopy overuse rates remained relatively stable in Q4 2020/during COVID despite pandemic-induced backlogs and resource constraints. Rates of overuse seen in our study were slightly lower than those seen in other contexts, though it is important to note that we adapted overuse criteria for our measure to exclude the 45-49-year age group considering recent changes to USPSTF guidelines so there is heterogeneity in measurement. There are several potential explanations for these findings. First, initial efforts at procedural prioritization and enhanced scrutiny of procedural indications may have been unsustainable such that by Q4 2020 there had been a rapid rebound in pre-pandemic practice patterns. Second, the fact that a majority of top/bottom performing facilities pre-pandemic remained so in Q4 2020/during COVID suggests enduring facility-level factors that may enhance or impede efforts to reduce low-value care. Finally, overuse is a complex problem that may require more attention and human capital than a pandemic can afford. COVID has disrupted care in unexpected ways and re-allocated precious human resources, potentially impeding the careful assessments, organizational changes, and stakeholder-engagement that often are needed to change complex care delivery processes. Accomplishing sustainable change will require multi-modal strategies including collaboration with willing leaders and frontline providers and patients, and rigorous performance measurement and feedback. More closely examining those facilities that substantially changed their performance (i.e., reduced or increased their use of potentially low-value colonoscopies) during COVID (positive and negative outliers) using qualitative methods could be instructive in highlighting elements critical to effecting sustainable change in this regard. It is also worth noting that, in addition to organizational/facility-level factors, other factors at the patient- and provider-levels have been shown to be associated with overuse. For example, prior work has demonstrated that patients may be uncomfortable stopping screening colonoscopies even when the benefit is low (e.g., older age), and screening colonoscopy overuse rates have been noted to be higher in males and non-Black patients in some studies (though our results showed the opposite). Further, provider factors such as specialty (surgeon endoscopists) and procedural volume (higher volume endoscopists) have been shown to be associated with screening colonoscopy overuse. Our study is among the first to explore impacts of the COVID-19 pandemic on use of low-value care related to high-volume specialty procedures. Other recent studies have explored the role of COVID-19 in changing or failing to change utilization of low-value care in a non-procedural context. For example, Shahzad et al. evaluated changes in use of 6 common low-value services and 6 comparable high-value services in a large commercially insured population from January 2019 to April 2021. They found that, overall, low-value and high-value services were disrupted similarly in the initial month of the pandemic (April 2020) relative to their 2019 baseline. However, recovery of low-value care use lagged recovery of high-value care use thereafter (i.e., low-value services and high-value services rebounded to 83% and 95% of baseline, respectively, by January 2021), suggesting that resumption of low-value care may have been perceived as a lesser priority. Notably, there was substantial heterogeneity observed across clinical contexts, suggesting that the pandemic may have had heterogenous effects on patient and provider decision-making regarding clinical value. Whether these results are generalizable to integrated healthcare delivery settings such as VA and to procedural contexts is unclear. In our study, we observed no reduction in overuse rates in Q4 2020 or Q4 2021 as compared with pre-pandemic baselines, suggesting that use of low-value screening colonoscopy had rebounded fully following early COVID-19-related shutdowns. Our study has several limitations. First, accurate coding of colonoscopy indication in administrative data is required to properly estimate screening colonoscopy overuse rates using our electronic measure. However, our measure showed high levels of accuracy as compared to manual record review in our previously published validation study. Furthermore, because we focused on changes in screening colonoscopy overuse relatively early in the COVID-19 pandemic (Q4 2020), we may have missed longer-term changes in overuse rates that may have manifested in later phases of the pandemic recovery. However, Q4 2021 screening colonoscopy overuse rates were found to approximate pre-COVID baselines in our sensitivity analysis, rebutting this critique. We also focused our analysis on the fourth quarter (Q4) of each year, rather than comparing a longer time-period, e.g., Q3 and Q4 of each year. This was intentional, however, because in Q3 of 2020, endoscopy volume across VHA had not recovered nearly to the extent that it had by Q4 2020 following initial pandemic-related ramp-down of elective outpatient procedures. Therefore, Q4 was felt to be a more appropriate comparison for purposes of calculating overuse rates. Finally, because we examined changes in use of low-value care related to a specific procedure/procedural indication, our results may not be generalizable to other clinical contexts. Still, the fact that we have failed to move the needle in reducing low-value services more globally over the past decade despite increased recognition suggests that this is not an isolated finding.

Even the presence of a pandemic, with associated backlogs and resource constraints and clear recommendations to prioritize appropriate and needed endoscopic services, failed to curb use of low-value screening colonoscopy in a large integrated healthcare system. Our findings illuminate the complexity of changing practice patterns to reduce low-value services and suggest that future interventions will need to address underlying facility-level structural and/or cultural factors to sustainably curb low-value care.

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