Capsule Commentary on Zafar et al., Predictor of CT Colonography Utilization Among Asymptomatic Medicare Beneficiaries

Abstract

Despite widespread availability, its universal recommendation and insurance coverage, colorectal cancer screening rates remain below targets. Current US Multisociety Task Force and American Cancer Society guidelines1 provide a menu of alternative tests for patients and providers, including stool-based, endoscopic and radiographic options. Of these options, CT colonography (CTC) is not used to a great extent because of lack of insurance reimbursement, including Centers for Medicare and Medicaid Services (CMS).2 The guidelines’ inclusion of newer procedures such as CTC and stool DNA testing, in addition to more established procedures, is intended to increase screening in the target population. In this issue, Dr. Zafar and colleagues3 present a population-based analysis of CTC use among Medicare beneficiaries prior to the CMS denial of reimbursement in 2009. The most frequent indication for CTC was follow-up to an incomplete colonoscopy, which is currently the only reimbursable indication. Other indications include patients who appear to be at increased sedation risk due to comorbidity or need for anticoagulation. However, even in an era where reimbursement was not a factor, the use of CTC as a primary screening test in average risk individuals appeared to be low. In addition, CTC was more frequently used in white patients and individuals who resided in more affluent geographic areas, two groups that have screening rates that are closer to or above targets.4,5 In addition to insurance reimbursement, in order to increase the overall use of colorectal screening, CTC should target otherwise unscreened patients. Efforts to minimize or eliminate any pre-procedure bowel preparation, and standardize same-day colonoscopy availability for those patients with positive findings on CTC, may help increase its use in the otherwise recalcitrant patient. In addition, agreement on the most effective follow-up strategy for small polyps seen on CTC, and avoidance of the overuse of follow-up testing to evaluate clinically insignificant extracolonic findings, should serve to increase provider endorsement.