Malhotra Ashish, Vaughan-Sarrazin Mary, Charlton Mary Elizabeth, Rosenthal Gary E
Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA, USA.
J Prim Care Community Health. 2014 Jan 1;5(1):24-9. doi: 10.1177/2150131913494842. Epub 2013 Jul 5.
To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs).
The VA Outpatient Care Files were used to identify 2 837 770 patients ≥ 50 years with ≥ 2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms.
CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely (P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC (P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years.
Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.
比较在退伍军人事务部（VA）社区门诊诊所（CBOC）和VA医疗中心接受初级保健（PC）的退伍军人的结直肠癌筛查率。
利用VA门诊护理档案识别出2010年年龄≥50岁且有≥2次PC就诊的2837770名患者。通过ICD-9-CM/CPT编码识别接受筛查/监测结肠镜检查、乙状结肠镜检查、粪便潜血试验（FOBT）和双对比钡灌肠（DCBE）的退伍军人。根据大多数PC就诊发生的地点，将患者分为VA医疗中心组（n = 1403273；49.5%）或CBOC组（1434497；50.5%），并根据结直肠癌风险因素和基于ICD-9-CM验证的算法分为高风险组（n = 284090）或平均风险组（n = 2553680）。
CBOC患者比VA医疗中心的患者年龄更大（平均年龄69.3岁对67.4岁；P <.001），更有可能是男性（96.5%对95.1%；P <.001）和白人（67.8%对64.2%），但高风险患者比例较低（9.4%对10.5%；P <.001）。CBOC的结肠镜检查、乙状结肠镜检查和DCBE的比率均较低（P <.001）。在高风险退伍军人中，CBOC和VA医疗中心的结肠镜检查率分别为27.4%对36.8%，乙状结肠镜检查率分别为1.3%对0.8%，DCBE率分别为0.8%对0.5%。在平均风险退伍军人中，这些比率分别为1.3%对1.9%、0.2%对0.1%和0.2%对0.1%。在调整年龄/合并症后差异仍然存在。CBOC平均风险患者结肠镜检查的调整后比值比为0.73（95%置信区间 = 0.64 - 0.82），高风险患者为0.76（95%置信区间 = 0.67 - 0.87）。相比之下，高风险（11.1%对11.2%）和平均风险（14.3%对14.1%）的退伍军人中，CBOC和VA医疗中心FOBT的使用相对相似。65岁以下和65岁以上患者的筛查率相似。
根据VA记录，在CBOC接受PC的退伍军人比在VA医疗中心接受筛查结肠镜检查、乙状结肠镜检查和DCBE的可能性更小。CBOC较低的使用率并未被FOBT较高的使用率所抵消，包括CBOC患者可能更依赖使用非VA服务的程度。这些差异的临床合理性值得进一步研究。
