a) Project Background/Rationale. Colorectal cancer (CRC) is a common disease whose impact on mortality can be reduced through routine screening. Current guidelines recommend CRC screening for men and women age 50 to 75 using either fecal occult blood test (FOBT) annually, sigmoidoscopy every five years coupled with FOBT every three years, or colonoscopy every 10 years. The most recent available data suggest that CRC screening rates among Veterans Health Administration (VA) users (at 80%) are well above the national average, and that many VA facilities have achieved their performance goals in this area. However, not all of the CRC screening procedures received by VA users are performed or paid for by the VA. Indeed, one recent CRC screening validation study with access to both VA and non-VA medical records found that, although only 11% of FOBT and sigmoidoscopy procedures received by eligible patients were performed off- site (i.e., conducted by a non-VA facility and not paid for by the VA), 46% of colonoscopies were. If off-site CRC screening procedures are not well documented in VA medical records, they may not be taken into account by providers making future screening decisions, which in turn could result in duplicative CRC screening among VA users (i.e., receiving a sigmoidoscopy, FOBT, or colonoscopy earlier than recommended by guidelines, given the results of a previous CRC screening procedure). Additionally, CRC screening procedures conducted within the VA may be followed by subsequent CRC screening procedures sooner than recommended by guidelines. Because this duplicative screening could expose VA users to unnecessary medical procedures and generate unwarranted demand for the already limited supply of colonoscopy within the VA, studies are needed to assess its prevalence and associated resource implications for the VA. The scope of these studies depends in part on whether and how well off-site CRC screening procedures are documented in VA medical records; the robustness of these and other relevant measures across VA facilities and patient subgroups; and the validity of available data on the cost of CRC screening procedures. b) Project Objectives. The proposed pilot study is designed to address these key issues in order to inform the data collection, measurement, and sample size requirements for a future IIR that will examine the prevalence and costs of duplicative screening in a national sample of VA users.
The specific aims of the pilot are to: (1) Assess how accurately and completely the performance and results of off-site CRC screening procedures are documented in VA medical records; (2) Derive preliminary estimates of the extent of duplicative CRC screening; (3) Determine the extent to which duplicative CRC screening estimates vary across facilities and patient subgroups; and (4) Validate methodologies for costing CRC screening procedures in the VA. c) Project Methods. During this one-year observational pilot study we will add manual VA chart reviews to existing VA administrative and non-VA medical records collected in a recently completed single site CRC screening validation study in order to: (1) examine how accurately and completely the performance and results of off-site CRC screening procedures are documented in VA medical records, and (2) derive preliminary duplicative screening estimates. We will then use existing VA medical records, administrative data and self- reported behavior from a national sample of CRC screening eligible veterans to project these estimates to a more representative veteran sample, and to explore potential variability in the estimates across VA facilities and patient subgroups. Finally, we will conduct comparisons of CRC screening procedures documented in DSS files with those documented in the medical records and VA administrative data sources in order to develop optimal methodologies for estimating the costs of CRC screening procedures conducted in the VA setting. All of this information will be instrumental in supporting the rationale and design of the future IIR that will quantify the national prevalence and cost of duplicative CRC screening in a national sample of VA users.
This pilot study will inform the data collection, measurement, and sample size requirements for a future IIR examining the prevalence and costs of duplicative colorectal cancer screening in a national sample of Veterans Health Affairs users. This will be accomplished by: (1) assessing how accurately and completely the performance and results of off-site CRC screening procedures are documented in VA medical records;(2) deriving preliminary estimates of the extent of duplicative CRC screening;(3) assessing whether these estimates vary across facilities and patient subgroups;and (4) validating methodologies for costing CRC screening procedures within VA settings.