‘Where clinicians are not following best practice, they are subjecting people to procedures they don’t need, while others are not getting the care they do need,’ says Professor Anne Duggan, the Commission’s Clinical Director.
The Fourth Atlas shows that in 2018–19 there were almost 148,000 Medical Benefits Schedule (MBS)-subsidised repeat colonoscopies – defined as a colonoscopy repeated within two years and 10 months of a previous procedure – in Australia.
The rate in areas with the highest use was almost 20 times the rate in areas with the lowest uptake, with a range from 62 to 1,236 per 100,000 people. Repeat colonoscopy is used mainly to check for polyps and bowel cancer in people with a higher risk of bowel cancer. There are limited reasons why a colonoscopy would be repeated within three years if guidelines are followed.
Consumers living in metropolitan areas, particularly those from high socioeconomic status (SES) areas, have markedly higher rates of repeat colonoscopy than consumers living in rural and remote regions, and those from lower SES areas.
The Atlas also highlights differences in uptake between states and territories, with a rate of 596 per 100,000 people in Queensland compared with 191 in the Northern Territory.
Disease burden mismatch
These patterns of use do not reflect the geographic and socioeconomic burden of disease from bowel cancer, the Atlas notes. [REF: Australian Institute of Health and Welfare. National Bowel Cancer Screening Program: monitoring report 2020. (AIHW Cat. No. CAN 133.) Canberra: Australian Government Department of Health; 2020 [cited 2020 Aug].
And the findings are not new. Although different datasets were used, the First and Third Atlases also identified substantial variation in the rates of colonoscopy across the country.
High-quality colonoscopy can detect about 95% of bowel cancers and polyps, the Atlas notes, but it is an invasive and costly procedure with a risk of complications.
Professor Duggan, who is also a gastroenterologist, says the National Bowel Cancer Screening Program plays a critical role in detecting bowel cancer, the second most common cancer in Australia.
‘If we use that program successfully and have great uptake, then we can reduce bowel cancer in a safe, targeted way,’ she says. ‘Only those people at higher risk would undergo an initial colonoscopy and then, if polyps were found, go on to surveillance and repeat colonoscopy according to the frequency recommended in the guidelines.’
Equity concerns
Workforce distribution issues are partly responsible for the low rates of colonoscopy in rural and remote Australia and in areas of socioeconomic disadvantage, Professor Duggan says.
While health workforce distribution is on the Commonwealth’s radar, she says specialist colleges also have an important role to play in ensuring equity of access to care.
‘The training colleges have a responsibility with the numbers of specialist trainees they take on and training locations need to reflect the need for care,’ she says.
A stark divide in the accessibility of services in the public and private sectors adds to concerns about equity. Professor Duggan says most large public teaching hospitals have limited resources, and there are often waiting lists for colonoscopies.
‘It is particularly important that hospitals apply the evidence and triage patients according to need,’ Professor Duggan says, adding that triage needs to be done on a hospital level, not individually by each doctor, to ensure equitable access to care.
Promoting best practice
Consumers in higher socioeconomic areas may come to expect annual or second yearly colonoscopies, says Professor Duggan, but many of these procedures are unnecessary. There are well established national guidelines on the appropriate frequency of repeat colonoscopies if they are needed.
‘We need to talk about risks and benefits specific to the individual patient before us and, hand on heart, if there aren't benefits at this time, we should be saying that to the patient,’ she says.
Professor Duggan led the development of the Commission’s Colonoscopy Clinical Care Standard (2018), which calls on GPs to provide detailed referrals so specialists can assess the ‘appropriateness, risk, and urgency of the consultation’.
‘The Clinical Care Standard is a huge step forward,’ she says. ‘We need good referrals, and we need patients to be informed of the risks and benefits of undergoing a colonoscopy. Although the risks may be rare, the benefits of early repeat colonoscopy may be rare also.’
Professor Duggan says the Standard also ‘lifts the bar’ on the quality of colonoscopies performed – with proceduralists required to have up-to-date, certified training – and reinforces the importance of patients understanding the importance of good bowel preparation so the bowel is empty.
‘We want proceduralists to look at the whole bowel,’ she says. ‘We know from the literature that a proportion of colonoscopies used to be poor quality and polyps were missed or the procedure had to be repeated.’
Lifestyle focus
Around 50% of bowel cancers in Australia are due to lifestyle factors, Professor Duggan says, and yet counselling patients on these modifiable risks often falls by the wayside.
Colonoscopy reports should not only suggest when patients should return for a colonoscopy, but the measures patients should take to reduce their bowel cancer risk.
‘We often have such a focus on technology, that we forget to talk about the important lifestyle factors that affect our risk, like smoking, poor diet and a sedentary lifestyle,’ she says.