Potentially Inappropriate Screening Colonoscopy in Medicare Patients Variation by Physician and Geographic Region
Potentially Inappropriate Screening Colonoscopy in Medicare Patients Variation by Physician and Geographic Region
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DOI：
10.1001/jamainternmed.2013.2912
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发表时间：
2013-04-08
影响因子：
39
通讯作者：
Goodwin, James S.
中科院分区：
文献类型：
--
作者：
Sheffield, Kristin M.;Han, Yimei;Goodwin, James S.
重要性：结肠镜检查的不当使用会给老年患者带来不必要的风险，并消耗本可以更有效地使用的资源。目的：确定德克萨斯州医疗保险受益人中潜在的不适当结肠镜检查的频率，并检查医生之间和地理区域之间的差异。设计、设置和参与者：这项回顾性队列研究使用了德克萨斯州100%的医疗保险索赔数据和2000年至2009年美国5%的样本。我们确定了2008年10月1日至2009年9月30日期间接受结肠镜检查的70岁或70岁以上的医疗保险受益人。主要结果测量：结肠镜检查在没有诊断提示该程序适应症的情况下被归类为筛查。根据患者年龄或结肠镜检查后出现阴性结果的时间太快，认为筛选性结肠镜检查可能不合适。估计每个结肠镜医师和医院服务区域进行可能不适当的筛查结肠镜检查的患者的百分比。结果：老年人进行结肠镜检查的比例很大，可能是不适当的：在整个德克萨斯州队列中为23.4%，在70 - 75岁、76 - 85岁或86岁或以上的患者中分别为9.9%、38.8%和24.9%。在797名结肠镜医师中，进行的可能不适当的结肠镜检查的百分比存在相当大的差异。在一个包括患者性别、种族或民族、合并症数量、教育水平和城市或农村居住地的多水平模型中，73名结肠镜医师的百分比显著高于平均值（23.9%），范围为28.7%至45.5%，119名结肠镜医师的百分比显著低于平均值（23.9%），范围为6.7%至18.6%。百分比显著高于平均值的结肠镜医生更有可能是外科医生，美国医学院毕业生，1990年以前的医学院毕业生，以及比百分比显著低于平均值的结肠镜医生更高的结肠镜医生。随着时间的推移，结肠镜排名相当稳定（2006-2007年vs 2008-2009年）。也有在得克萨斯州和美国的地理变化，在得克萨斯州和从19.5%至30.5%across the UnitedStates.Conclusions和相关性的百分比范围从13.3%至34.9%：许多结肠镜检查在老年人可能是不适当的。接受可能不适当的结肠镜检查的可能性部分取决于患者居住的地方和他们看的医生。
Importance: Inappropriate use of colonoscopy involves unnecessary risk for older patients and consumes resources that could be used more effectively.Objectives: To determine the frequency of potentially inappropriate colonoscopy in Medicare beneficiaries in Texas and to examine variation among physicians and across geographic regions.Design, Setting, and Participants: This retrospective cohort study used 100% Medicare claims data for Texas and a 5% sample from the United States from 2000 through 2009. We identified Medicare beneficiaries aged 70 years or older who underwent a colonoscopy from October 1, 2008, through September 30, 2009.Main Outcome Measures: Colonoscopies were classified as screening in the absence of a diagnosis suggesting an indication for the procedure. Screening colonoscopy was considered potentially inappropriate on the basis of patient age or occurrence too soon after colonoscopy with negative findings. The percentage of patients undergoing potentially inappropriate screening colonoscopy was estimated for each colonoscopist and hospital service area.Results: A large percentage of colonoscopies performed in older adults were potentially inappropriate: 23.4% for the overall Texas cohort and 9.9%, 38.8%, and 24.9%, respectively, in patients aged 70 to 75, 76 to 85, or 86 years or older. There was considerable variation across the 797 colonoscopists in the percentages of colonoscopies performed that were potentially inappropriate. In a multilevel model including patient sex, race or ethnicity, number of comorbid conditions, educational level, and urban or rural residence, 73 colonoscopists had percentages significantly above the mean (23.9%), ranging from 28.7% to 45.5%, and 119 had percentages significantly below the mean (23.9%), ranging from 6.7% to 18.6%. The colonoscopists with percentages significantly above the mean were more likely to be surgeons, graduates of US medical schools, medical school graduates before 1990, and higher-volume colonoscopists than those with percentages significantly below the mean. Colonoscopist rankings were fairly stable over time (2006-2007 vs 2008-2009). There was also geographic variation across Texas and the United States, with percentages ranging from 13.3% to 34.9% in Texas and from 19.5% to 30.5% across the United States.Conclusions and Relevance: Many colonoscopies performed in older adults may be inappropriate. The likelihood of undergoing potentially inappropriate colonoscopy depends in part on where patients live and what physician they see.