Atlas Focus Report: Colonoscopy

Common reasons for needing another colonoscopy after a previous one include:

• Poor bowel preparation or an incomplete procedure
• Pre-operative planning or assessment
• Surveillance of the bowel after removal of pre-cancerous polyp(s) that can lead to bowel cancer
• Surveillance of the bowel after an initial diagnosis and management of bowel cancer
• Surveillance of chronic conditions of the bowel such as inflammatory bowel disease, that may increase the risk of bowel cancer
• Surveillance of people with a strong family history of bowel cancer, or a hereditary cancer syndrome that can lead to bowel cancer
• Investigation of new signs or symptoms related to the bowel, such as rectal bleeding, change in bowel habit and weight loss.

If current national guidelines are followed⁴, only a small proportion of people would be expected to need a repeat colonoscopy before 3 years. These are usually people with specific risk factors identified at their initial colonoscopy that require a repeat procedure within a shorter interval, and it is important that the repeat procedure is performed without undue delay. 

Substantial variation in repeat colonoscopy data for 2018–19 was reported in the Fourth Australian Atlas of Healthcare Variation: rates were substantially higher in major cities than in other areas and decreased with socioeconomic disadvantage.⁵ This is the reverse of the pattern of mortality rates, which are lower in major cities and higher in socioeconomically disadvantaged populations.⁶ Waiting time between a positive screening test and colonoscopy is also longer outside major cities and in the most disadvantaged areas.⁶

Overuse of colonoscopy in low-risk patients in some areas may be diverting resources away from where they are needed most, and contribute to reduced access to colonoscopy for people in rural, remote and socioeconomically disadvantaged areas.⁷ Overuse in low-risk patients also exposes them to unnecessary risks associated with complications of colonoscopy, such as perforation or complications from bowel preparation or anaesthesia.⁸

Changes to MBS items

In 2019, MBS items for colonoscopy services were changed in response to the Gastroenterological Clinical Committee of the MBS Review Taskforce’s concerns about inequity of access and high volumes of unnecessary colonoscopies for low-risk patients. The MBS items for surveillance colonoscopy were aligned with the surveillance intervals recommended in national guidelines.^{9, 10}

This report examines the number of MBS-subsidised colonoscopies performed within 2 years and 10 months of a previous colonoscopy, per 100,000 people between 2013–14 and 2023–24 (repeat colonoscopy). The interval was chosen to exclude services to people who presented slightly early for a 3-year surveillance colonoscopy.

The report presents trend data and visualisations for:

• Australia and its states and territories
• Remoteness and socioeconomic status levels
• Primary Health Networks (PHNs)
• Local areas (SA3s).

Possible reasons for variation in rates of MBS-subsidised repeat colonoscopy include:

Consumer factors

• Ability to pay out of pocket costs and to take time off work
• Ability to afford private health insurance and variation in level of cover for colonoscopy items
• Language and cultural barriers^{11, 12}
• Comorbidities and other competing demands¹²
• Expectation of colonoscopy and desire for peace of mind, which may drive up rates in some areas¹³
• Awareness of bowel cancer symptoms and the NBCSP, and participation in screening.

Clinician factors

• Performing surveillance colonoscopy earlier than recommended ^14-16, which may be influenced by fear of missing pathology, the fee for service model, malpractice concerns and patient and referrer expectations^{13, 15, 16}
• Lack of awareness, and complexity, of current guidelines^{15, 17}
• Difficulty sharing reports or accessing previous reports.⁷

System factors

• Differences in the proportion of services subsidised by the MBS in each state and territory, which also varied over time
• Fee for service model^{13, 15}
• Limited endoscopist workforce and infrastructure in some regional and remote areas¹⁸
• Limited access to General Practitioners in some areas, reducing referrals¹⁹
• Waiting time for outpatient appointments
• Lack of information management and communication systems for both recall and follow-up
• Lack of access to previous patient reports and multiple platforms for reporting in use
• Logistical barriers to screening in some areas, such as environmental heat effect on samples, and postal access²⁰
• Limited governance over private colonoscopy
• State/territory programs to address access to colonoscopy.

Potential strategies to support appropriate use of repeat colonoscopy and increase equity of access include:

Consumers

• Participate in the National Bowel Cancer Screening Program at recommended intervals
• If your doctor recommends a colonoscopy, ask questions so you understand the reason, the risks and the benefits for you²¹
• Ask your colonoscopist to upload your colonoscopy report to My Health Record
• Reduce your risk factors for bowel cancer with lifestyle changes.

General Practitioners

• Give patients advice on how to reduce their risk of bowel cancer and encourage participation in the NBCSP
• Base referrals for colonoscopy on evidence-based resources, such as Clinical practice guidelines for the prevention, early detection and management of colorectal cancer , the Red Book and the National guide to preventive healthcare for Aboriginal and Torres Strait Islander people
• Provide sufficient information for the receiving clinician to assess the appropriateness, risk and urgency of consultation when referring patients for colonoscopy, for example with the Colonoscopy Referral Information Template²¹
• Check specialist recommendations for colonoscopy that do not align with guidelines
• Support patients to understand any added risks of colonoscopy due to their advanced age or co-morbidities, and to understand their surveillance requirements and risk associated with inappropriate surveillance intervals.

Colonoscopists

• Provide high-quality colonoscopy aligned with the Colonoscopy Clinical Care Standard
• Align intervals for surveillance colonoscopy with the Cancer Council Australia’s Clinical practice guidelines for surveillance colonoscopy
• Critically evaluate and audit your own practice on a regular basis to ensure consistency with evidence-based guidelines for surveillance colonoscopy
• Ensure patient consent includes an understanding of the benefits and potential complications of colonoscopy and of evidence-based guidelines on colonoscopy surveillance intervals²²
• Communicate the reason for the colonoscopy, its findings, all histology results and recommendations for follow-up in writing to the GP, all other relevant clinicians and the patient²¹
• Provide reports to be recorded in the facility records, and upload to My Health Record, to enable accurate follow-up by other clinicians²¹
• Locate previous colonoscopy reports, from facility records or other shared record management system, before assessing for a repeat colonoscopy.

Clinical societies and colleges

• Support trainee gastroenterologist positions in underserved areas, with flexible training models if necessary
• Support training in colonoscopy for rural generalists, general practitioners and nurses⁷
• Provide training for clinicians about correct surveillance intervals⁷
• Promote exchange programs for regional/remote endoscopists with metropolitan colleagues to support the rural workforce
• Develop decision support tools to support selection of appropriate surveillance intervals⁷
• Develop decision support tools to explain the absolute risk of bowel cancer at different ages to patients.⁷

Policy makers

• Explore funding models that recognise the complexity and cost of providing colonoscopy services in regional and remote areas
• Provide culturally safe services
• Provide targeted education about screening for Aboriginal and Torres Strait Islander people, and consumers in underserved areas, in appropriate languages^{7, 11}
• Increase access to Aboriginal Community Controlled Health Organisations
• Mandate and support uploading of colonoscopy reports and histology results to My Health Record through the share by default program⁷
• Require justification of repeat colonoscopy intervals that do not align with guidelines to qualify for payments
• Require private health insurers to provide data about procedures to inform research on quality use of colonoscopy
• Map the need for colonoscopy against capacity, redistribute triaged waiting lists and support outreach programs for underserved areas.⁷

Hospitals, endoscopy clinics and private practices

• Review implementation of the Colonoscopy Clinical Care Standard, and associated policies and procedures, and monitor progress in indicators – see the Self-Assessment Tool
• Provide regular and repeated education to clinicians about appropriate surveillance intervals⁷
• Conduct audits of repeat colonoscopy to ensure follow-up intervals align with evidence-based guidelines
• Ensure systems are in place to allow access to previous colonoscopy and pathology results
• Consider employing a colonoscopy liaison nurse if volumes of colonoscopy are high.

Colonoscopy Topic Expert Group

The Atlas Focus Report: Colonoscopy was developed in consultation with a topic expert group that provided clinical advice for the report. Members of the group included: 

• Repeat colonoscopy data file
• Colonoscopy data file

• Repeat colonoscopy and colonoscopy data specification 

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