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

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          Abstract

          Background

          Limited evidence exists on the utilization of surveillance colonoscopy in colorectal cancer (CRC) screening programs. We assessed adherence to physician recommendations for surveillance in opportunistic CRC screening in Germany.

          Methods

          A follow-up study of screening colonoscopy participants in 2007-2009 in Saarland, Germany, was conducted using health insurance claims data. Utilization of additional colonoscopies through to 2011 was ascertained. Adherence to surveillance intervals of 3, 6, 12 and 36 months, defined as having had colonoscopy at 2.5 to 4, 5 to 8, 10.5 to 16 and 33 to 48 months, respectively (i.e., tolerating a delay of 33% of each interval) was assessed. Potential predictors of non-adherence were investigated using logistic regression analysis.

          Results

          A total of 20,058 screening colonoscopy participants were included in the study. Of those with recommended surveillance intervals of 3, 6, 12 and 36 months, 46.5% (95%-confidence interval [CI]: 37.3-55.7%), 38.5% (95%-CI: 29.6-47.3%), 25.4% (95%-CI: 21.2-29.6%) and 28.0% (95%-CI: 25.5-30.5%), respectively, had a subsequent colonoscopy within the specified margins. Old age, longer recommended surveillance interval, not having had polypectomy at screening and negative colonoscopy were statistically significant predictors of non-adherence.

          Conclusion

          This study suggests frequent non-adherence to physician recommendations for surveillance colonoscopy in community practice. Increased efforts to improve adherence, including introduction of more elements of an organized screening program, seem necessary to assure a high-quality CRC screening process.

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          Most cited references23

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          A perspective from countries using organized screening programs.

          Cancer screening may be offered to a population opportunistically, as part of an organized program, or as some combination of the preceding two options. Organized screening is distinguished from opportunistic screening primarily on the basis of how invitations to screening are extended. In organized screening, invitations are issued from centralized population registers. In opportunistic screening, however, due to the lack of central registers, invitations to screening depend on the individual's decision or on encounters with health care providers. The current article outlines key differences between organized and opportunistic screening. In the current study, literature searches were performed using PubMed and MEDLINE. Additional data were assembled from interviews with health officials in the five countries investigated and from the authors' personal files. Opportunistic screening was found to be distinguishable from organized screening on the basis of whether screening invitations were issued from centralized population registers. Organized screening programs also assumed centralized responsibility for other key elements of screening, such as eligibility requirements, quality assurance, follow-up, and evaluation. Organized programs focused on reducing mortality and morbidity at the level of the population rather than at the level of the individual. Thus, programs did not necessarily offer the most sensitive screening test for a particular cancer, and tests sometimes were offered at suboptimal intervals with respect to individual-level protection. Nonetheless, organized systems paid greater attention to the quality of screening, as measured by factors such as cancer detection rates, tumor characteristics, and false-positive biopsy rates. As a result, participants in organized screening programs received greater protection from the harmful effects associated with screening. In addition, organized programs worked more systematically toward providing value for money in an inevitably resource-limited environment. Although organized and opportunistic models of screening can yield similar uptake rates, organized programs exhibited greater potential ability to reduce cancer incidence and mortality, because of the higher levels of population coverage and centralized commitment to quality and monitoring; were more likely to be cost-effective; and offered greater protection against the harmful effects associated with poor quality or overly frequent screening.
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            Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy.

            Increasing use of colonoscopy for colorectal cancer screening and surveillance of colorectal adenomas after polypectomy has given rise to concerns about the availability of endoscopic resources in the United States. Guidelines recommend surveillance after polypectomy at 3 to 5 years for a small adenoma, and follow-up is not advised for hyperplastic polyps. The intensity of physicians' surveillance is largely unstudied. To survey practicing gastroenterologists and general surgeons about their perceived need for the frequency of surveillance after polypectomy, to compare survey responses to practice guidelines, and to identify factors influencing their recommendations for surveillance. Survey study conducted by the National Cancer Institute. A nationally representative study of physicians in the United States. 349 gastroenterologists and 316 general surgeons. Questionnaires mailed in 1999 and 2000 assessed physicians' recommendations for surveillance after polypectomy in asymptomatic, average-risk patients. Response rates were 83%. Among gastroenterologists (317 of 349) and surgeons (125 of 316) who perform screening colonoscopy, 24% (95% CI, 19.3% to 28.7%) of gastroenterologists and 54% (CI, 44.9% to 62.5%) of surgeons recommend surveillance for a hyperplastic polyp. For a small adenoma, most physicians recommended surveillance colonoscopy and more than 50% recommended examinations every 3 years or more often. Physicians indicated that published evidence was very influential in their practice (83% [CI, 78.8% to 87.2%] of gastroenterologists and 78% [CI, 72.5% to 86.8%] of surgeons). By contrast, only half of respondents reported that guidelines were very influential. The study was based on physicians' self-reported practice patterns. Results may overestimate or underestimate the performance of surveillance colonoscopy. Some surveillance colonoscopy seems to be inappropriately performed and in excess of guidelines, particularly for hyperplastic polyps and low-risk lesions such as a small adenoma. These results suggest unnecessary demand for endoscopic resources.
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              [Update S3-guideline "colorectal cancer" 2008].

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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2013
                6 December 2013
                : 8
                : 12
                : e82676
                Affiliations
                [1 ]Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
                [2 ]Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
                [3 ]Saarland Cancer Registry, Saarbrücken, Germany
                [4 ]Gastroenterologische Schwerpunktpraxis Völklingen, Kreppstraße 3-5, Völklingen, Germany
                Sookmyung Women's University, Korea, Republic Of
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: C. Stock HB. Analyzed the data: C. Stock. Wrote the manuscript: C. Stock HB MH BH C. Stegmaier TS. Acquisition of data: BH C. Stegmaier C. Stock. Drafting of the manuscript: C. Stock. Critical revision of the manuscript for important intellectual content: C. Stock BH MH C. Stegmaier TS HB. Obtained funding: C. Stock HB. Study supervision: HB.

                Article
                PONE-D-13-23141
                10.1371/journal.pone.0082676
                3855836
                24324821
                440417fd-8447-48b3-a558-02935b8b5609
                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 4 June 2013
                : 26 October 2013
                Funding
                The study was funded by the young scientists programme of the German network 'Health Services Research Baden-Württemberg' of the Ministry of Science, Research and Arts in collaboration with the Ministry of Employment and Social Order, Family, Women and Senior Citizens, Baden-Württemberg. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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                Research Article

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