Endoscopy 2011; 43(9): 771-781
DOI: 10.1055/s-0030-1256504
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Colonoscopy and fecal occult blood test use in Germany: results from a large insurance-based cohort

C.  Stock1 , P.  Ihle2 , I.  Schubert2 , H.  Brenner1
  • 1Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
  • 2PMV Research Group, Department of Child and Adolescents Psychiatry, University of Cologne, Cologne, Germany
Further Information

Publication History

submitted 13 October 2010

accepted after revision 21 March 2011

Publication Date:
09 August 2011 (online)

Background and study aims: Colonoscopy and guaiac-based fecal occult blood tests (FOBT) are recommended and offered for colorectal cancer (CRC) screening in Germany. We aimed to explore their utilization in a large insurance-based cohort.

Patients and methods: Claims data from between 2000 and 2008 were collected for 170 493 individuals who were insured by a large health insurance plan in the federal state of Hesse, Germany. The percentages of individuals who had recently utilized CRC screening-related procedures were calculated. Additionally, multiple test use and identification of CRC screening providers were ascertained.

Results: Following the inception of the current CRC screening program in 2002, colonoscopy utilization rates varied only slightly and FOBT use decreased in individuals aged ≥ 50 years. At the end of 2008, the age-standardized percentages of individuals who had undergone colonoscopy within ≤ 10 years were 23 % for men and 26 % for women. The proportions of individuals who had used FOBT within ≤ 1 year were 14 % for men and 22 % for women. Patient education had been utilized by 38 % of eligible persons and was increasingly followed by screening colonoscopy. For women, practices that specialized in gynecology were the main providers of FOBT (93 %) and patient education (61 %).

Conclusions: This study provides new insights into the inter-related utilization of colonoscopy, FOBT, and patient education in Germany, and may be particularly informative for the design of strategies to increase CRC screening uptake. It indicates that sex differences in CRC screening test use could result to a large extent from general visits to different types of specialist physicians involved in the CRC screening process.

Appendix (online only)The following material is available online

References

  • 1 Ferlay J, Parkin D M, Steliarova-Foucher E. Estimates of cancer incidence and mortality in Europe in 2008.  Eur J Cancer. 2010;  46 765-781
  • 2 Haberland J, Bertz J, Wolf U et al. German cancer statistics 2004.  BMC Cancer. 2010;  10 52
  • 3 Arditi C, Peytremann-Bridevaux I, Burnand B et al. Appropriateness of colonoscopy in Europe (EPAGE II) – screening for colorectal cancer.  Endoscopy. 2009;  41 200-208
  • 4 Hewitson P, Glasziou P, Watson E et al. Cochrane systematic review of colorectal cancer screening using the fecal occult blood test (Hemoccult): an update.  Am J Gastroenterol. 2008;  103 1541-1549
  • 5 Walsh J ME, Terdiman J P. Colorectal cancer screening: scientific review.  JAMA. 2003;  289 1288-1296
  • 6 Lansdorp-Vogelaar I, Knudsen A B, Brenner H. Cost-effectiveness of colorectal cancer screening – an overview.  Best Pract Res Clin Gastroenterol. 2010;  24 439-449
  • 7 Schmiegel W, Pox C, Reinacher-Schick A et al. S3 guidelines for colorectal carcinoma.  Results of an evidence-based consensus conference on February 6/7, 2004 and June 8/9, 2007 (for the topics IV, VI and VII). Z Gastroenterol. 2010;  48 65-136
  • 8 Pox C, Schmiegel W, Classen M. Current status of screening colonoscopy in Europe and in the United States.  Endoscopy. 2007;  39 168-173
  • 9 von der Schulenburg J M, Prenzler A, Schurer W. Cancer management and reimbursement aspects in Germany: an overview demonstrated by the case of colorectal cancer.  Eur J Health Econ. 2010;  10 21-26
  • 10 Gemeinsamer Bundesausschuss [Federal Joint Committee]. Richtlinie über die Früherkennung von Krebserkrankungen. [Guideline on early detection of cancers] (in German only). 2010 Available from: http://www.g-ba.de/ Accessed: 6 October 2010
  • 11 Kassenärztliche Bundesvereinigung (KBV) [National Association of Statutory Health Insurance Physicians]. Voraussetzungen gemäß § 135 Abs. 2 SGB V zur Ausführung und Abrechnung von koloskopischen Leistungen. (Qualitätssicherungsvereinbarung zur Koloskopie) [quality assurance directive concerning colonoscopy], as of 24 July 2006. Document number: 1 003 739 016. Available from: http://daris.kbv.de Accessed: 6 October 2010
  • 12 Sieverding M, Matterne U, Ciccarello L. Gender differences in FOBT use: evidence from a large German survey.  Z Gastroenterol. 2008;  46 Suppl 1 47-51
  • 13 Wuppermann D, Wuppermann U, Riemann J F. [Actual state of knowledge of the German population about the early detection of colorectal cancer – a study by the ‘Stiftung LebensBlicke’ in cooperation with the institute for demoscopy in Allensbach].  Z Gastroenterol. 2009;  47 1132-1136
  • 14 Sieverding M, Matterne U, Ciccarello L, Haug U. Colonoscopy use in a country with a long-standing colorectal cancer screening programme: evidence from a large German survey.  Z Gastroenterol. 2010;  48 1351-1357
  • 15 Stock C, Brenner H. Utilization of lower gastrointestinal endoscopy and fecal occult blood test in 11 European countries: evidence from the Survey of Health, Aging and Retirement in Europe (SHARE).  Endoscopy. 2010;  42 546-556
  • 16 Altenhofen L, Heringer M, Blaschy S et al. 6. Jahresbericht ‘Projekt wissenschaftliche Begleitung von Früherkennungs-Koloskopien in Deutschland’. [6th annual report ‘Project scientific monitoring of screening colonoscopy in Germany’] (in German only). Available from: http://www.zi-berlin.de/ Accessed: 6 October 2010
  • 17 Stock C, Haug U, Brenner H. Population-based prevalence estimates of history of colonoscopy or sigmoidoscopy: review and analysis of recent trends.  Gastrointest Endosc. 2010;  71 366-381
  • 18 Centers for Disease Control and Prevention (CDC) . Vital signs: colorectal cancer screening among adults aged 50 – 75 years – United States, 2008.  MMWR Morb Mortal Wkly Rep. 2010;  59 808-812
  • 19 Ihle P, Köster I, Herholz H et al. Versichertenstichprobe AOK Hessen/KV Hessen – Konzeption und Umsetzung einer personenbezogenen Datenbasis aus der Gesetzlichen Krankenversicherung. [Statutory Health Insurance Sample AOK Hesse/KV Hesse – concept and implementation of a person related database].  Gesundheitswesen. 2005;  67 638-645
  • 20 Busse R, Riesberg A. Health care systems in transition: Germany. Copenhagen: WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies; 2004 Available from: http://www.euro.who.int/ Accessed: 6 October 2010
  • 21 Kassenärztliche Bundesvereinigung (KBV) [National Association of Statutory Health Insurance Physicians]. Einheitlicher Bewertungsmaßstab (EBM).  Available from: http://www.kbv.de/8156.html Accessed: 6 October 2010
  • 22 German Institute of Medical Documentation and Information (DIMDI) .Operations- und Prozedurenschlüssel (OPS).  Available from: http://www.dimdi.de/static/en/ Accessed: 6 October 2010
  • 23 van Rossum L G, van Rijn A F, Laheij R J et al. Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population.  Gastroenterology. 2008;  135 82-90
  • 24 Steele R JC, McClements P L, Libby G et al. Results from the first three rounds of the Scottish demonstration pilot of FOBT screening for colorectal cancer.  Gut. 2009;  58 530-535
  • 25 Maar C. Increasing public acceptance for CRC screening through public relation campaigns and networking.  Z Gastroenterol. 2008;  46 35-37
  • 26 Wolf M, Baker D, Makoul G. Physician–patient communication about colorectal cancer screening.  J Gen Intern Med. 2007;  22 1493-1499
  • 27 Canada R E, Turner B. Talking to patients about screening colonoscopy – where conversations fall short.  J Fam Pract. 2007;  56 E1-9
  • 28 McQueen A, Bartholomew L, Greisinger A et al. Behind closed doors: physician-patient discussions about colorectal cancer screening.  J Gen Intern Med. 2009;  24 1228-1235
  • 29 Lafata J E, Divine G, Moon C, Williams L K. Patient-physician colorectal cancer screening discussions and screening use.  Am J Prev Med. 2006;  31 202-209
  • 30 Ling B S, Trauth J M, Fine M J et al. Informed decision-making and colorectal cancer screening: is it occurring in primary care?.  Med Care. 2008;  46 S23-29
  • 31 Guessous I, Dash C, Lapin P et al. Colorectal cancer screening barriers and facilitators in older persons.  Prev Med. 2010;  50 3-10
  • 32 Zajac I T, Whibley A H, Cole S R et al. Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: a longitudinal analysis.  J Med Screen. 2010;  17 19-24
  • 33 Ziegler M, Schubring-Giese B, Bühner M, Kolligs F T. Attitude to secondary prevention and concerns about colonoscopy are independent predictors of acceptance of screening colonoscopy.  Digestion. 2010;  81 120-126
  • 34 Beydoun H, Beydoun M. Predictors of colorectal cancer screening behaviors among average-risk older adults in the United States.  Cancer Causes Control. 2008;  19 339-359
  • 35 Heitman S J, Ronksley P E, Hilsden R J et al. Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis.  Clin Gastroenterol Hepatol. 2009;  7 1272-1278
  • 36 Brenner H, Altenhofen L, Hoffmeister M. Sex, age, and birth cohort effects in colorectal neoplasms.  Ann Intern Med. 2010;  152 697-703
  • 37 Schmiegel W, Pox C, Adler G et al. [S3-guidelines conference ‘colorectal carcinoma’ 2004].  Z Gastroenterol. 2004;  42 1129-1177
  • 38 Robb K, Power E, Kralj-Hans I et al. Flexible sigmoidoscopy screening for colorectal cancer: uptake in a population-based pilot programme.  J Med Screen. 2010;  17 75-78
  • 39 Miles A, Cockburn J, Smith R A, Wardle J. A perspective from countries using organized screening programs.  Cancer. 2004;  101 1201-1213
  • 40 Anhang Price R, Zapka J, Edwards H, Taplin S H. Organizational factors and the cancer screening process.  J Natl Cancer Inst Monogr. 2010;  2010 38-57
  • 41 Farraye F A, Wong M, Hurwitz S et al. Barriers to endoscopic colorectal cancer screening: are women different from men?.  Am J Gastroenterol. 2004;  99 341-349
  • 42 McQueen A, Vernon S W, Meissner H I et al. Are there gender differences in colorectal cancer test use prevalence and correlates?.  Cancer Epidemiol Biomarkers Prev. 2006;  15 782-791
  • 43 Friedemann-Sanchez G, Griffin J, Partin M. Gender differences in colorectal cancer screening barriers and information needs.  Health Expectations. 2007;  10 148-160
  • 44 Holden D J, Jonas D E, Porterfield D S et al. Systematic review: enhancing the use and quality of colorectal cancer screening.  Ann Intern Med. 2010;  152 668-676
  • 45 von Euler-Chelpin M, Brasso K, Lynge E. Determinants of participation in colorectal cancer screening with faecal occult blood testing.  J Public Health (Oxf). 2010;  32 395-405
  • 46 Becker N. Epidemiological aspects of cancer screening in Germany.  J Cancer Res Clin Oncol. 2003;  129 691-702
  • 47 Hullegie P, Klein T J. The effect of private health insurance on medical care utilization and self-assessed health in Germany.  Health Econ. 2010;  19 1048-1062
  • 48 Razum O, Altenhöner T, Breckenkamp J, Voigtländer S. Social epidemiology after the German reunification: east vs. west or poor vs. rich?.  Int J Public Health. 2008;  53 13-22

H. BrennerMD, MPH 

German Cancer Research Center (DKFZ)
Division of Clinical Epidemiology and Aging Research

POB 10 19 49
69009 Heidelberg
Germany

Fax: +49-6221-548142

Email: h.brenner@dkfz.de

>