Impact of comorbidity on colorectal cancer screening in the veterans healthcare system.
ABSTRACT The quality assessment measure of colorectal cancer screening in the veteran's health system reports the proportion of patients aged 52-80 years who were tested. This approach does little to assess for comorbid illnesses, which might limit the utility of screening. Our aim was to determine the relationship between patient comorbidity and screening by fecal occult blood test in a national sample of veterans.
We examined the Veterans Health Administration's national databases (October 2003-February 2005) for a random sample of primary care patients, aged > or = 50 years. The Charlson score, a validated measure of comorbidity burden, was calculated from diagnosis codes by the Deyo method. The association between Charlson score and colorectal cancer screening was assessed with logistic regression.
The sample of 77,268 was 97% men; mean age was 67 years. Charlson score distribution was 0, 45%; 1, 24%; 2, 14%; 3, 7%; 4, 4%; 5, 2%; 6, 1%; 7, 0.8%; 8, 0.6%; 9, 0.4%; > or = 10, 1%. Overall there was no consistent significant association between Charlson score and use of fecal occult blood testing except in the sickest 1%. There was a strong and incremental relationship between Charlson score and 1-year mortality.
Although there was a strong relationship in the veteran population between the Charlson score and survival, colorectal cancer screening utilization was not impacted by Charlson score. Instead, resources were expended evenly throughout the population, rather than directed toward screening the patients with the most life-years at stake. The quality measure for colorectal cancer screening should be modified to account for patient comorbidity.
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ABSTRACT: In older individuals, there are unclear effects of lower endoscopy on incidence of colorectal cancer (CRC) and of colonoscopy on site of CRC. We investigated whether sigmoidoscopy or colonoscopy is associated with decreased incidence of CRC in older individuals, and whether the effect of colonoscopy differs by anatomic location. We performed a case-control study, using linked US Veterans Affairs (VA) and Medicare data. Cases were Veterans 75 y or older diagnosed with CRC in fiscal year 2007. Cases were matched for age and sex to 3 individuals without a CRC diagnosis (controls). We determined the number of cases and controls that received colonoscopies or sigmoidoscopies from fiscal year 1997 to a date 6 months before the diagnosis of CRC (for cases) or to a corresponding index date (for controls). The probability of exposure was modeled using generalized linear mixed equations, adjusted for potential confounders. For the analysis of risk of CRC in different anatomic locations, the proximal colon was defined as proximal to the splenic flexure. We identified 623 cases and 1869 controls (mean age 81 y, 98.7% male, 86.2% Caucasian). Among cases, 243 (39.0%) underwent any lower endoscopy (177 colonoscopies). Among controls, 978 (52.3%) underwent any lower endoscopy (758 colonoscopies). Cases were significantly less likely than controls to have undergone lower endoscopy within the preceding 10 y (adjusted odds ratio [aOR], 0.58; 95% confidence interval [CI], 0.48-0.69). This effect was significant for colonoscopy (aOR, 0.57; 95% CI, 0.47-0.70) but not sigmoidoscopy. Similar results were observed when a 5 y exposure window was applied. Colonoscopy was associated with reduced risk of distal CRC (aOR, 0.45; 95% CI, 0.32-0.62; P<.001) and proximal CRC (aOR, 0.65; 95% CI, 0.46-0.92). In a study of the US VA and Medicare databases, lower endoscopy in the preceding 10 y was associated with significant reduction in CRC incidence among older Veterans. Colonoscopy was associated with significant reductions in distal and proximal CRC.Gastroenterology 12/2013; DOI:10.1053/j.gastro.2013.11.050 · 12.82 Impact Factor
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ABSTRACT: To determine whether regional variation in the rate of lower-extremity amputation (LEA) is associated with health behaviors.RESEARCH DESIGN AND METHODS: This was a cross-sectional prevalence study of merged data from the U.S. Census, Medicare parts A and B, and the Behavioral Risk Factor Surveillance System. We used regression models to determine whether previously described regional variation in LEA incidence was associated with responses to the Behavioral Risk Factor Surveillance System. Regions were created using Dartmouth Atlas Health Referral Regions.RESULTS: The mean and median incidence of LEA was 4.5 per 1,000 persons with diabetes; the rate varied from 2.4 to 7.9 LEA per 1,000 persons by health referral region. Statistically significant inverse associations were found between LEA and the rate of patients reporting colorectal screening (P < 0.0001) or the participation in diabetes management classes (P = 0.018). Most other factors, including daily foot evaluations, were not associated with a decreased risk of LEA. These findings were also found to be associated with geographically clustered regions known for increased risk of LEA.CONCLUSIONS: LEA is known to vary by region in the U.S., and regions with higher rates of LEA tend to be clustered together. Some of this variation may be explained by health behaviors in those regions, such as attending diabetes education classes or better health prevention habits (e.g., colon cancer screening). It should be possible to prevent unwanted LEAs by educating individuals with diabetes and foot ulcers about the need for participation in foot ulcer treatment.Diabetes Care 05/2014; 37(8). DOI:10.2337/dc14-0788 · 8.57 Impact Factor