BACKGROUND Among average-risk patients, repeat colonoscopy in 5 years is recommended after 1 to 2 small (<1 cm) adenomas are found on screening colonoscopy or in 10 years if hyperplastic polyps are found. However, sparse quantitative data are available about adherence to these recommendations or factors that may improve adherence. OBJECTIVE To quantify adherence to recommended intervals and to identify factors associated with lack of adherence. DESIGN Retrospective endoscopic database analysis. SETTING Tertiary-care institution and Veterans Affairs Health System. PATIENTS Average-risk individuals undergoing screening colonoscopy found to have 1 to 2 small polyps on screening colonoscopy. MAIN OUTCOME MEASUREMENTS Frequency of recommending repeat colonoscopy in 5 years if 1 to 2 small adenomas are found and in 10 years if hyperplastic polyps are found. RESULTS Of 922 outpatient screening colonoscopies with 1 to 2 small polyps found, 90.2% received appropriate recommendations for timing of repeat colonoscopy. Eighty-four percent of patients with 1 to 2 small adenomas and 94% of patients with 1 to 2 hyperplastic polyps received recommendations that were consistent with guidelines. Based on logistic regression analysis, patients aged >70 years (odds ratio [OR] 2.4, 95% confidence interval [CI], 1.0-5.7), fair bowel preparation (OR 12.7; 95% CI, 7.3-22.4), poor bowel preparation (OR 10.0; 95% CI, 4.3-23.6), and the presence of 2 small adenomas versus 1 small adenoma (OR 3.6; 95% CI, 2.2-6.0) were factors associated with "overuse" or recommendations inconsistent with guidelines. LIMITATIONS Retrospective study design. CONCLUSION More than 90% of endoscopists' recommendations for timing of surveillance colonoscopy in average-risk patients with 1 to 2 small polyps are consistent with guideline recommendations. Quality of preparation is strongly associated with deviation from guideline recommendations.