Atlas Focus Report: Colonoscopy

Australia has one of the highest rates of bowel cancer in the world, and bowel cancer was the fourth most common cancer diagnosed in both men and women in Australia in 2024.^2,3 Mortality rates for bowel cancer in Australia are higher outside of major cities and in socioeconomically disadvantaged areas.⁴ 

In Australia, most screening for bowel cancer involves an immunochemical faecal occult blood test (iFOBT) through the National Bowel Cancer Screening Program (NBCSP), which began in 2006. A relatively small proportion (10–14%) of colonoscopies subsidised by the MBS are thought to be performed on people with a positive screening test (this does not include the proportion investigated through state-funded services).⁵

The risk of bowel cancer increases with age, but the incidence in people under 50 years of age has increased in recent years.³ About 13% of bowel cancer cases were diagnosed in people under 50 years of age in 2024, compared to 8% in 2000.³ Roll out of the NBCSP to the target age group of 50–74 was achieved in 2019.⁶ The eligible starting age for screening was lowered from 50 to 45 years in July 2024.⁷

Bowel cancer and Aboriginal and Torres Strait Islander people

The data source in this report did not allow analysis by Indigenous status. Based on other research, when compared to non-Indigenous people, Aboriginal and Torres Strait Islander people: 

• Are more likely to be diagnosed with and die from bowel cancer.⁶
• Face increased barriers to participating in the NBCSP, such as lack of access to culturally safe health services, medical discrimination, and long-standing distrust in Western medicine and health staff⁸
• Have a higher rate of positive iFOBT through the NBCSP and a lower rate of follow-up with colonoscopy⁶
• Are estimated to have about half the rate of colonoscopy.⁹

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 followed¹, only a small proportion of people would be expected to need a repeat colonoscopy before three 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. 

Colonoscopy Clinical Care Standard

The Colonoscopy Clinical Care Standard, revised in 2025, supports high-quality colonoscopy, commencing with referral, timely and appropriate use of colonoscopy in line with guidelines, high-quality bowel preparation and procedure, and guidelines based surveillance intervals.¹⁰ To ensure timely follow-up, the Clinical Care Standard requires reporting and follow-up in a way that reduces the potential for repeat colonoscopy due to a lack of communication. 

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.¹¹ 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.¹² 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.¹³

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.^{14, 15} 

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 three-year surveillance colonoscopy.

The report presents trend data and visualisations for:

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

The data were sourced from the MBS database and were age and sex-standardised to allow comparisons between geographic areas with different age and sex structures. Data are reported according to where patients live, not where the services were conducted.

While this report focuses on repeat colonoscopies, age and sex-standardised data for all MBS-subsidised colonoscopies are available in the online dashboard and data files.

The number and proportion of colonoscopies performed in state or territory public health services and billed to the MBS varies across Australia and from year to year. Hence, the report does not provide information on the total number of repeat colonoscopies performed across Australia, which may include repeat colonoscopies that are performed in public facilities and are not MBS-subsidised. 

For more information about the data, see data resources.

National trends

• Rates of MBS-subsidised repeat colonoscopy before 2 years and 10 months decreased nationally by 8% between 2013–14 and 2023–24
• Greater decreases were seen in remote areas compared to major cities, and in areas of most socioeconomic disadvantage compared to least socioeconomic disadvantage
• In 2013–14, there were 126,992 MBS-subsidised repeat colonoscopy services (500 per 100,000 people) compared to 141,558 services in 2023–24 (460 per 100,000 people)
• In 2013–14, there was an 11-fold difference between the local area with the highest rate of MBS-subsidised repeat colonoscopy and the local area with the lowest rate, compared to 2023–24, when there was an 18-fold difference.

State and territory trends

• South Australia, Western Australia and the Northern Territory were the only states to record an increase in the rate of MBS-subsidised repeat colonoscopies between 2013–14 and 2023–24
• The largest decrease was 14% in New South Wales and the largest increase was 13% in South Australia.

Remoteness

• Remote areas decreased by 26% (157 to 116 per 100,000 people), compared to major cities which decreased by 6% (543 to 510 per 100,000 people), between 2013–14 and 2023–24
• The difference in MBS-subsidised repeat colonoscopy rates between major cities and remote areas increased from 3.5-fold in 2013–14 to 4.4-fold in 2023–24.

Socioeconomic status

• The most socioeconomically disadvantaged areas consistently had the lowest rate (334 per 100,000 people) of MBS-subsidised repeat colonoscopy, and the least socioeconomically disadvantaged areas consistently had the highest rate (609 per 100,000 people)
• The most socioeconomically disadvantaged areas decreased by 17%, compared to the least socioeconomically disadvantaged areas which increased by 2%
• The difference in MBS-subsidised repeat colonoscopy rates between the most disadvantaged areas and the least disadvantaged areas increased from 1.5-fold in 2013–14 to 1.8-fold in 2023–24.

Primary Health Networks (PHNs)

• The largest decrease in repeat colonoscopy rates between 2013–14 and 2023–24 was 43% in Northern Queensland PHN, and the largest increase was 37% in Brisbane North PHN.

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^{8, 16}
• Comorbidities and other competing demands¹⁶
• Expectation of colonoscopy and desire for peace of mind, which may drive up rates in some areas¹⁷
• Awareness of bowel cancer symptoms and the NBCSP, and participation in screening

Clinician factors

• Performing surveillance colonoscopy earlier than recommended^18-20, which may be influenced by fear of missing pathology, the fee for service model, malpractice concerns and patient and referrer expectations^{17, 19, 20}
• Lack of awareness, and complexity, of current guidelines^{19, 21}
• Difficulty sharing reports or accessing previous reports¹²

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^{17, 19}
• Limited endoscopist workforce and infrastructure in some regional and remote areas²²
• Limited access to General Practitioners in some areas, reducing referrals²³
• 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 access²⁴
• 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 you¹⁰
• 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 Template¹⁰
• 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 colonoscopy¹
• 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 intervals²⁵
• 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 patient¹⁰
• Provide reports to be recorded in the facility records, and upload to My Health Record, to enable accurate follow-up by other clinicians¹⁰
• 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 nurses¹²
• Provide training for clinicians about correct surveillance intervals¹²
• 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 intervals¹²
• Develop decision support tools to explain the absolute risk of bowel cancer at different ages to patients.¹²

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^{8, 12}
• Increase access to Aboriginal Community Controlled Health Organisations⁸
• Mandate and support uploading of colonoscopy reports and histology results to My Health Record through the share by default program¹²
• 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.¹²

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 intervals¹²
• 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.

The data files contain information for each indicator over an 11-year period, and are reported at national, state and territory, Primary Health Network and local area levels.

The technical note describes the analysis performed on the data to produce the reported rates.

Atlas Focus Report: Colonoscopy - technical note

The data specifications describe the databases and data codes used to extract the raw data.

Repeat colonoscopy and colonoscopy data specification

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: 

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