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Publication Briefs

Veterans Receiving Primary Care in CBOCs Less Likely to Receive Several Types of Colon Cancer Screening Tests

Colorectal cancer (CRC) is the second most common cause of cancer-related deaths in men and women. Multiple reports show wide variation in the choice of a CRC screening test, however, it remains unknown if factors related to the medical practice environment may influence the choice of a screening test. For instance, lack of provision of colonoscopy within the local referral network of a practice may lead to more utilization of fecal occult blood tests (FOBT). This study evaluated differences in the choice of CRC screening test in Veterans receiving primary care at community-based outpatient clinics (CBOCs) and at VAMCs. Using VA administrative data, investigators identified nearly 3 million Veterans aged 50 years and older with two or more primary care visits in FY10, and identified whether they received one of four CRC screening tests: colonoscopy, sigmoidoscopy, FOBT, or double-contrast barium enema (DCBE) in FY10. Veterans were categorized as CBOC patients or VAMC patients based on the site where they received the majority of their primary care, and were categorized as high or average risk based on CRC risk factors. Investigators also analyzed demographics, comorbidities, and distance between a Veteran's residence and the nearest VAMC.


  • Veterans receiving care at a CBOC were less likely to receive colonoscopy, sigmoidoscopy and DCBE than veterans receiving care at VAMCs, even after adjusting for rural location, distance from a parent VAMC, and other patient demographic and clinical characteristics.
  • Lower rates of screening procedures were not offset by higher utilization of FOBT, and were consistent in Veterans at average and high risk for CRC.
  • The difference in the use of colonoscopy in CBOCs and VAMCs was larger for Veterans 65 years or older than for patients less than 65 years, suggesting that older Veterans who receive primary care through CBOCs may use more CRC screening services outside VA relative to those under 65.


  • This study relied on administrative data, which may not completely capture the use of CRC screening procedures, particularly FOBT, and which may not adequately assess severity of illness or categorize patients according to their risk for colon cancer and do not capture important domains, such as functional status, that may impact the use of CRC screening procedures.
  • The study used a cross-sectional design and did not account for CRC screening tests Veterans may have received prior to 2010 and was also unable to account for care that Veterans may have received from non-VA providers.


  • These findings provide indirect evidence of the importance of examining data from non-VA providers when making judgments about adherence to VA performance measures.

All authors are part of HSR&D's Center for Comprehensive Access and Delivery Research, Iowa City.

Malhotra A, Vaughan-Sarrazin M, Charlton M, and Rosenthal G. Comparison of Colorectal Cancer Screening in Veterans Based on the Location of Primary Care Clinic. Journal of Primary Care & Community Health July 5, 2013;e-pub ahead of print.

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What are HSR Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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