Colonoscopy: Balancing Access and Equity
The accessibility of colonoscopy services should be uniform across Australia, but recent data reveals a concerning disparity in MBS-subsidized colonoscopy rates across the country. Over the past decade, these gaps have widened, raising questions about how to ensure that some patients don't undergo unnecessary colonoscopies while others with greater need are left waiting.
My recent patient interactions have highlighted this issue. Some individuals without symptoms or risk factors for bowel cancer are eager for colonoscopies due to media attention, while others over 45 require significant persuasion to participate in regular bowel cancer screening with faecal occult blood tests. This discrepancy between concern and clinical indication is not isolated to my practice; it's a systemic challenge.
The healthcare system often struggles to meet the demand for colonoscopy services, and it's crucial that colonoscopies are performed for the right reasons at the appropriate time. On a national scale, an interactive map in the Atlas of Healthcare Variation report reveals higher MBS-subsidized colonoscopy rates in major cities, despite higher bowel cancer mortality rates in rural areas. This mismatch persists across socioeconomic lines, with the most disadvantaged areas having the lowest rates of MBS-subsidized colonoscopy.
While we don't know the 'ideal' rate of colonoscopy for each region, analyzing repeat colonoscopies within a short timeframe provides valuable insights. The Guidelines for Surveillance Colonoscopy advise that only a small percentage of high-risk individuals need a repeat colonoscopy before three years. However, Atlas data on MBS-subsidized repeat colonoscopy before the three-year mark again shows discrepancies based on rurality and socioeconomic disadvantage.
A widening divide
Trend data in the Atlas report indicates that the variation in colonoscopy rates has increased over the last decade. Nationally, the rate of MBS-subsidized repeat colonoscopy before three years decreased by 8% between 2013-2014 and 2023-2024. However, the changes over time have been starkly different for city dwellers versus remote areas and for affluent versus socio-economically disadvantaged areas.
The data for repeat colonoscopy before three years revealed the following trends over the last decade:
- Major cities: 6% decrease
- Remote areas: 26% decrease
- Most disadvantaged areas: 17% decrease
- Least disadvantaged areas: 2% increase
These disparities suggest that not everyone has equal access to repeat colonoscopy when needed, and some individuals are having it done too early, particularly in affluent areas.
Why are these patterns occurring?
Several factors may contribute to the variation in MBS-subsidized colonoscopy and repeat colonoscopy rates:
- Availability of clinicians and health facilities
- Ability to pay, if there are out-of-pocket costs
- Awareness of bowel cancer symptoms and participation in screening
- Logistical barriers to access
- Funding through models other than the MBS
Enhancing equity of access
Ensuring colonoscopy for all who need it requires a sustained, multi-faceted approach. Several initiatives are underway to improve access to colonoscopy in regional areas.
The Gastroenterological Society of Australia's (GESA) Regional, Remote, and Indigenous (RRI) program has established Fellowship training positions in Darwin and Alice Springs, the Visiting Professor Program, and the Gut Centre Conference in Alice Springs. These initiatives foster sustainable workforce development while addressing health disparities in regional and remote communities.
Additional system-level changes, such as financial incentives and outreach programs, are necessary to boost rates in underserved areas. GPs play a crucial role in encouraging patients to participate in the National Bowel Cancer Screening Program, as only two in five eligible individuals currently do.
Balancing access and overuse
While working to increase access in some areas, we must also reduce inappropriate colonoscopy use in others. This is essential not only for optimizing our limited healthcare resources but also for minimizing patient exposure to the risks of unnecessary procedures, even though these risks are rare.
The revised Colonoscopy Clinical Care Standard, released in September 2025 alongside the Atlas Focus Report: Colonoscopy, provides an updated national standard for quality colonoscopy. It mandates processes for referral, credentialling, the procedure, communication, and follow-up for all health services delivering colonoscopy across Australia.
The Standard addresses two key contributors to early repeat colonoscopies: difficulty accessing patient colonoscopy reports and non-adherence to surveillance guidelines. Colonoscopists should locate previous reports and confirm alignment with clinical practice guidelines before arranging repeat colonoscopies.
To mitigate this issue, the updated Standard guides health services and clinicians on best practices for reporting and follow-up by uploading colonoscopy reports to both the patient's healthcare record and shared record management systems like My Health Record.
The Standard also emphasizes the importance of communicating colonoscopy reports, histopathology findings, and ongoing surveillance requirements to both the patient and their GP. Clear communication is vital for avoiding premature repeat colonoscopies.
What's happening in your area?
Healthcare services and clinicians can utilize the interactive data in the Atlas report to analyze colonoscopy and repeat colonoscopy rates in their local area, identifying any care gaps. Where variations exist, it's crucial to reflect on the reasons and take appropriate action.
Since 2018, the Colonoscopy Clinical Care Standard has supported high-quality colonoscopy for all Australians. The deepening divide in colonoscopy rates highlighted in the new Atlas Focus Report: Colonoscopy underscores health inequity. To build on Australia's success in bowel cancer detection and treatment, the healthcare system and clinicians must unite to ensure that all Australians, regardless of their location, can access high-quality colonoscopy.
