Colonoscopy practice for veterans within and outside the Veterans Affairs setting: a matched cohort study

Background and Aims: To minimize delays for colonoscopy within Veterans Affairs (VA) facilities, veterans may receive care at non-VA facilities based on fee-for-service contracts, and more recently, through the Veterans Access, Choice, and Accountability Act. The impact of diverting care from VA to non-VA facilities on quality of colonoscopy practice is unknown. Methods: We identified all veterans aged 50 to 85 years who received a fee-basis colonoscopy for colorectal cancer screening or surveillance at non-VA facilities in 2007 to 2010. These patients were matched for sex, age, and year of procedure to veterans who underwent colonoscopies at VA medical centers. The outcomes of interest were the adenoma detection rates (ADR) and compliance with surveillance guidelines. Results: During the observation period, 409 veterans (mean age 64 years; 94% men) underwent a fee-basis colonoscopy at 30 nonacademic (54%) and 2 academic (46%) facilities. Compared with colonoscopies performed at VA facilities, fee-basis colonoscopy patients had lower ADRs (38% vs 52%; P <.001), lower mean number of adenomas per procedure (0.72 vs 1.41; P <.001), and lower number of advanced ADRs (13% vs 22%; P <.001). Colonoscopies done at non-VA facilities were associated with lower ADRs in multivariate regression analysis (odds ratio 0.64; 95% CI, 0.44-0.92), whereas colonoscopies done in nonacademic settings or by colonoscopists who were not gastroenterologists were not. Compliance with surveillance guidelines was lower for colonoscopies performed outside VA facilities (80% vs 87%; P = .03). Conclusions: In this regional study (Northern New England), compliance with colonoscopy surveillance guidelines was high in both VA and non-VA settings; however, lower ADRs raise concern that referring veterans outside the VA system may impact colonoscopy quality.