FIT vs Colonoscopy for CRC Screening Not Sustainable at VHA Facilities During COVID-19 Pandemic

Researchers assessed the effects of the COVID-19 pandemic on the Veterans Health Administration’s use of colonoscopy screening.

During the COVID-19 pandemic, Veterans Health Administration (VHA) facilities have not maximized the opportunity to reduce screening colonoscopy demand by shifting to fecal immunochemical testing (FIT) for colorectal cancer (CRC) screening, according to a study published in Gastroenterology.

The retrospective cohort study sought to assess the effects of COVID-19 on VHA’s screening colonoscopy use and included veterans who had received a colonoscopy from October to December 2019 (pre-COVID-19) and from October to December 2020 (COVID-19).

The investigators calculated the overall and facility-level proportion of all colonoscopies performed for screening during each period and the change in facility-level proportion from the pre-COVID-19 to COVID-19 period.

A total of 99,595 total colonoscopies were conducted at 117 VHA facilities. Among them, 28,082 (28.2%) were screening colonoscopies (pre-COVID-19: 18,681; COVID-19: 9401). A 9.3% decrease (95% CI, -10.5% to -8.1%) was observed in the mean (adjusted) facility-level proportion of screening procedures from the pre-COVID-19 period to the COVID-19 period.

Most facilities had a modest reduction in screening colonoscopy use in the COVID-19 period, with wide variation among the facilities (IQR, -14.8% to -4.6%). The average monthly FIT rate increased by 7.9% (31,604 FIT/month pre-COVID-19; 34,109 FIT/month COVID-19).

Higher-complexity facilities had larger relative reductions in screening colonoscopy use compared with the lowest-complexity facilities. Academically affiliated facilities had larger relative decreases in screening colonoscopy use (-28%; 95% CI, -33% to -22%) vs nonacademically affiliated facilities (-15%; 95% CI, -23% to -6%).

Sustainability of FIT, the stool-based screening strategy, at the facility level will require a more systematic approach involving culture change and greater stakeholder engagement, noted the investigators.

“Despite acute COVID-19-related endoscopy access challenges and a related national policy directive, VHA facilities achieved only a modest reduction in the proportion of screening colonoscopies with substantial facility-level variation, suggesting poor system-wide uptake of this colonoscopy-to-FIT strategy,” the study authors commented. “Future work should focus on developing multi-level implementation strategies to provide facilities with effective tools to enhance uptake and sustainability of stool-based CRC screening to reduce colonoscopy demand and improve overall endoscopy access for high-need patients, particularly in integrated health care systems and other settings with limited endoscopy access.”


Adams MA, Kurlander JE, Gao Y, Yankey N, Saini SD. Impact of COVID-19 on screening colonoscopy utilization in a large integrated health system. Gastroenterology. Published online February 23, 2022. doi:10.1053/j.gastro.2022.02.034