Overuse and underuse of colonoscopy in a European primary care setting

Background: Efforts to decrease overuse of health care may result in underu se. Overuse and underuse of colonoscopy have never been simultaneously eval uated in the same patient population. Methods: In this prospective observational study, the appropriateness and n ecessity of referral for colonoscopy were evaluated by using explicit crite ria developed by a standardized expert panel method. Inappropriate referral s constituted overuse. Patients with necessary colonoscopy indications who were not referred constituted underuse. Consecutive ambulatory patients wit h lower gastrointestinal (GI) symptoms from 22 general practices in Switzer land, a country with ready access to colonoscopy, were enrolled during a 4- week period. Follow-up data were obtained at 3 months for patients who did not undergo a necessary colonoscopy. Results: Eight thousand seven hundred sixty patient visits were screened fo r inclusion; 651 patients (7.4%) had lower GI symptoms (mean age 56.4 years , 68% women). Of these, 78 (12%) were referred for colonoscopy. Indications for colonoscopy in 11 patients (14% of colonoscopy referrals or 1.7% of al l patients with lower GI symptoms) were judged inappropriate. Among 573 pat ients not referred for the procedure, underuse ranged between 11% and 28% o f all patients with lower GI symptoms, depending on the criteria used. Conclusions: Applying criteria from an expert panel of nationally recognize d experts indicates that underuse of referral for colonoscopy exceeds overu se in primary care in Switzerland. To improve quality of care, both overuse and underuse of important procedures must be addressed.