Key findings and recommendations
Most colonoscopies are performed to detect bowel cancer. Australia’s National Bowel Cancer Screening Program recommends colonoscopy for people who have a positive faecal occult blood test.
The Atlas found low rates of hospitalisation for colonoscopy in the following groups, raising concerns about their access to colonoscopy services:
- Aboriginal and Torres Strait Islander Australians
- People living in outer regional and remote areas
- People living in areas of low socioeconomic status.
Strategies to increase participation in the National Bowel Cancer Screening Program and follow-up colonoscopy for those with a positive screening test will drive more appropriate care. Addressing preventable risk factors, such as physical inactivity, obesity, smoking, heavy alcohol consumption and poor diet, which account for 51% of Australia’s bowel cancer burden22, would reduce the rate of bowel cancer and lead to better use of healthcare services.
Inappropriate rates of gastroscopy
Gastroscopy is used predominantly to investigate upper gastrointestinal symptoms such as heartburn and dyspepsia. It is also used to exclude a diagnosis of cancer.23-25 Rates of gastroscopy in Australia rose by 3% per year between 2008 and 2017 26, despite low and relatively stable rates of oesophageal and stomach cancers.27
The Atlas found that the rate of hospitalisation for gastroscopy varies up to seven-fold between local areas in Australia. The pattern of use suggests overuse of gastroscopy. Lower rates of gastroscopy in outer regional and remote areas may reflect either appropriate use or a lack of access to gastroscopy in these areas. The lower rates for Aboriginal and Torres Strait Islander Australians warrant further investigation.
The Atlas found that, in 2016–17, 274,559 gastroscopies and colonoscopies were performed during the same hospitalisation, representing 1,044 hospitalisations per 100,000 people of all ages. Both investigations are indicated in only a limited number of conditions, so the high rates reported suggest inappropriate use. This should be reviewed so that gastroscopies that are of little benefit are minimised, and theatre time can be allocated to people with greater need for a timely colonoscopy.
Proton pump inhibitor medicines in adults
PPI medicines are among the most commonly used medicines in Australia. Most use is for gastro‑oesophageal reflux disease. There is good evidence that PPI medicines are overused and that many people are inappropriately using them for long periods.28-30 Lifestyle changes can reduce symptoms of reflux in many patients, without the risk of long‑term complications that may be caused by PPI medicines.31-34
The Atlas found that the rate of dispensing of PPI medicines in adults varies five-fold between local areas in Australia.
2a. State and territory health departments to adopt triaging systems to prioritise colonoscopy for individuals who are most at risk of bowel cancer. Colonoscopy should not be used routinely for primary screening, and timing of repeat surveillance colonoscopies should follow National Health and Medical Research Council guidelines.
2b. Health service organisations to ensure that, in settings where colonoscopy and gastroscopy are provided in the same clinic, patient need and likelihood of benefit of each procedure determine the overall clinical priority.
2c. The National Bowel Cancer Screening Program to develop and test methods to improve uptake by Aboriginal and Torres Strait Islander Australians.
2d. Relevant colleges and clinical societies to review their training programs to incorporate the Colonoscopy Clinical Care Standard and meet the needs of at‑risk groups, including Aboriginal and Torres Strait Islander Australians, people at socioeconomic disadvantage and people living outside major cities.
2e. Health service organisations and facilities providing colonoscopies to monitor adherence to the Colonoscopy Clinical Care Standard to ensure that patients with the greatest need for colonoscopy are prioritised.
2f. The Medicare Benefits Schedule (MBS) Review Taskforce to review descriptors for gastroscopy with evidence-based criteria using a consensus process. The taskforce to consider reserving subsidies for a set of specific indications for gastroscopy, including:
- Upper abdominal symptoms that persist despite an appropriate trial of therapy
- Upper abdominal symptoms associated with other symptoms or signs suggesting structural change (for example, difficulty swallowing), or new-onset symptoms in patients over 50 years of age.
2g. State and territory health departments to prioritise gastroscopy for individuals, consistent with the epidemiology of upper gastrointestinal cancer.
Proton pump inhibitor medicines for adults
2h. Relevant colleges and clinical societies to:
- Develop educational programs targeting both general practitioners and specialists to improve the appropriateness of use of PPI medicines
- Review their training programs to ensure that guidance on the use of PPI medicines is consistent with the current evidence base.
2i. Relevant colleges and clinical societies to develop educational programs for consumers to educate them about the importance and benefits of lifestyle changes to reduce their risk of chronic diseases, particularly gastro-oesophageal reflux disease and bowel cancer.
2j. The Commission to develop a clinical care standard on investigation and management of dyspepsia and gastro-oesophageal reflux disease.
2k. NPS MedicineWise to ensure that information for consumers about appropriate use of PPI medicines and about modifiable lifestyle factors that increase the risk of gastro-oesophageal reflux disease is highlighted, where appropriate, in its public education campaigns.
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