Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening

Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy

BACKGROUND & AIMS

Screening colonoscopy can prevent cancer by removal of adenomatous polyps. Recent evidence suggests that insufficient time for inspection during overly rapid colonoscope withdrawal may compromise adenoma detection. We conducted a study of the effect of a minimum prespecified time for instrument withdrawal and careful inspection on adenoma detection rates during screening colonoscopy.

METHODS

Baseline data consisted of neoplasia detection rates during 2053 screening colonoscopies performed without a specified withdrawal protocol. During a subsequent 13-month period we performed 2325 screening colonoscopies using dedicated inspection techniques and a minimum 8-minute withdrawal time. With colonoscopists comprising the study population, we compared overall and individual rates of neoplasia detection in postintervention procedures with those in baseline examinations.

RESULTS

As compared with baseline subjects, postintervention subjects had higher rates of any neoplasia (34.7% vs 23.5%, P < .0001) and of advanced neoplastic lesions per patient screened (0.080 +/- 0.358 vs 0.055 +/- 0.241, P < .01). Twenty-five percent of advanced neoplastic lesions detected in postintervention examinations were 9 mm or less in diameter, versus 10% in baseline examinations (P < .001). Endoscopists with mean withdrawal times of 8 minutes or longer had higher rates of detection of any neoplasia (37.8% vs 23.3%, P < .0001) and of advanced neoplasia (6.6% vs 4.5%, P = .13) compared with those with mean withdrawal times of less than 8 minutes.

CONCLUSIONS

After implementing a protocol of careful inspection during a minimum of 8 minutes to withdraw the colonoscope, we observed significantly greater rates of overall and advanced neoplasia detection during screening colonoscopy.

Colorectal cancer screening practices of primary care physicians in Washington State

BACKGROUND

Colorectal cancer screening reduces death from colorectal cancer, but screening rates are low. While research has identified barriers to screening from the patient perspective, less research has addressed screening from the physician perspective.

METHODS

The Washington Comprehensive Cancer Control Partnership conducted a survey of primary care physicians in Washington State to measure their knowledge, attitudes, and practices for colorectal cancer screening of average-risk patients. The survey was mailed to a simple random sample of 700 primary care physicians in Washington State. Sixty-nine percent of the eligible physicians in the sample participated.

RESULTS

Most respondents (76%) recommended one or more colorectal cancer screening tests in agreement with American Cancer Society guidelines, and 93% perceived patient anxiety about colorectal cancer screening tests to be a significant barrier to screening. Ninety percent of physicians reported using the fecal occult blood test (FOBT) as a screening test, but most did not report performing any tracking or using any mechanism to encourage their patients to complete and return FOBT kits.

CONCLUSIONS

These findings suggest three intervention approaches to increase colorectal cancer screening in primary care settings: improve physicians' knowledge about current screening guidelines (especially appropriate age and screening intervals), encourage physicians to strongly recommend screening to patients, and help physicians adopt tracking systems to follow screening to completion.

Screening practices in cancer survivors

INTRODUCTION

Ten percent of all new cancers are diagnosed in cancer survivors and second cancers are the sixth leading cause of cancer deaths. Little is known, however, about survivors' screening practices for other cancers. The purpose of this study was to examine the impact of a cancer diagnosis on survivors' screening beliefs and practices compared to those without a cancer history.

MATERIALS AND METHODS

This study examined cancer survivors' (n = 619) screening beliefs and practices compared to those without cancer (n = 2,141) using the National Cancer Institute's 2003 Health Information National Trends Survey (HINTS).

RESULTS

The typical participant was Caucasian, employed, married, and female with at least a high school education, having a regular health care provider and health insurance. Being a cancer survivor was significantly associated with screening for colorectal cancer but not for breast or prostate cancer screening. Screening adherence exceeded American Cancer Society recommendations, national prevalence data, and Healthy People 2010 goals for individual tests for both groups. Physician recommendations were associated with a higher level of screening but recommendations varied (highest for breast cancer and lowest for colorectal cancer screening).

CONCLUSIONS

Cancer survivors had different health beliefs and risk perceptions for screening compared to the NoCancer group. While there were no differences between survivors' screening for breast and prostate cancer, survivors were more likely to screen for colorectal cancer than the comparison group. Screening adherence met or exceeded recommendations for individual tests for both cancer survivors and the comparison group.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors should continue to work with their health care providers to receive age and gender appropriate screening for many types of cancers. Screening for other cancers should also be included in cancer survivorship care plans.

Utilization of upper endoscopy for surveillance of gastric ulcers in the United States

BACKGROUND

Current guidelines recommend that all gastric ulcers (GUs) be biopsied extensively to exclude underlying malignancy. However, many gastroenterologists opt to also perform surveillance endoscopy (EGD) to document ulcer healing. The purpose of this study was to examine frequency of utilization of surveillance EGD in patients found to have GUs using a national endoscopic database.

METHODS

The Clinical Outcomes Research Initiative (CORI) database was used to identify ambulatory patients diagnosed with a GU between 2001 and 2005. A surveillance EGD was defined as any EGD performed < or =3 months after index EGD. Results were stratified by patient demographic factors, index ulcer size and location, practice setting, and geographic region. Multivariate logistic regression was performed to identify independent predictors of surveillance EGD utilization.

RESULTS

In the database, 6,113 patients met our inclusion/exclusion criteria, of which 1,510 (24.7%) underwent surveillance EGD. Older patients were more likely to undergo surveillance than younger patients (P < 0.0001), though a substantial minority (15.2%) of patients <40 years of age underwent a surveillance examination. Index ulcer size > or =1 cm and care in a Veterans Affairs (VA) setting were also independent predictors of surveillance EGD utilization. Significant geographic variation was noted, with surveillance rates varying from 16.0% to 35.9% across the United States (P < 0.0001).

CONCLUSIONS

In contrast to guideline recommendations, approximately 25% of ambulatory patients diagnosed with GUs underwent surveillance EGD within 3 months. Notably, patients at low-risk for gastric cancer, including young patients, those with small index ulcers, and those with antral ulcers, underwent surveillance at higher than expected rates, which suggests overuse of surveillance EGD.

Evaluation of formal feedback on endoscopic competence among trainees: the EFFECT trial

INTRODUCTION

The medical literature describes disparity in colonoscopy performance. This randomised, controlled study aimed to characterise the impact of feedback on colonoscopy performance among gastroenterology (GI) trainees.

METHODS

Gastroenterology trainees of similar experience levels who independently performed 581 colonoscopies over the study period were randomised to receive feedback/no feedback on their colonoscopy performance.

RESULTS

Baseline colonoscopy performance was similar in both groups. Following feedback, caecal intubation improved by 10.5% (from 72.9 to 83.4%, p = 0.04) in the feedback group and declined by 6.1% (from 78 to 71.9%, p = 0.2) in the control group; polyp detection improved by 5.1% (from 12.9 to 18.0%, p = 0.2) in the feedback group and by 2.9% (from 16.7 to 19.6%, p = 0.5) in the control group.

CONCLUSIONS

Systematic feedback appears to enhance colonoscopy performance among GI trainees.

Assessment of colorectal cancer knowledge and patient attitudes towards screening: is Ireland ready to embrace colon cancer screening?

INTRODUCTION

The level of awareness among the Irish public regarding colorectal cancer (CRC) remains uncertain. This study aimed to characterise CRC knowledge levels among a cohort of Irish patients.

METHODS

A survey evaluating CRC knowledge levels was distributed among outpatients at a gastroenterology clinic in a Dublin teaching hospital.

RESULTS

In total, 472 surveys were distributed of which 465 (98.5%) were returned. Twenty-nine percent of respondents correctly judged CRC to be the commonest cause of cancer death among the options provided while 26% correctly judged the lifetime risk of CRC; 59% underestimated and 15% overestimated the risk. Most patients (91%) were willing to pay 300 euros for a prompt colonoscopy if recommended by their physician while 7% opted to wait 6 months for a free colonoscopy.

CONCLUSIONS

There is a willingness to embrace CRC screening and to shoulder some of the financial burden that this entails.

Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology

In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that primarily is effective at early cancer detection and a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening.

Acceptance of colonoscopy requires more than test tolerance

BACKGROUND

Colon cancer screening, including colonoscopy, lags behind other forms of cancer screening for participation rates. The intrinsic nature of the endoscopic procedure may be an important barrier that limits patients from finding this test acceptable and affects willingness to undergo screening. With colon cancer screening programs emerging in Canada, test characteristics and their impact on acceptance warrant consideration.

OBJECTIVES

To measure the acceptability of colonoscopy and define factors that contribute to procedural acceptability, in relation to another invasive gastrointestinal scope procedure, gastroscopy.

PATIENTS AND METHODS

Consecutive patients undergoing a colonoscopy (n=55) or a gastroscopy (n=33) were recruited. Their procedural experience was evaluated and compared pre-endoscopy, immediately before testing and postendoscopy. Questionnaires were used to capture multiple domains of the endoscopy experience and patient characteristics.

RESULTS

Patient scope groups did not differ preprocedurally for general or procedure-specific anxiety. However, the colonoscopy group did anticipate more pain. Those who had a gastroscopy demonstrated higher preprocedural acceptance than those who had a colonoscopy. The colonoscopy group had a significant decrease in scope concerns and anxiety postprocedurally. As well, they reported less pain than they anticipated. Regardless, postprocedurally, the colonoscopy group's acceptance did not increase significantly, whereas the gastroscopy group was almost unanimous in their test acceptance. The best predictor of pretest acceptability of colonoscopy was anticipated pain.

CONCLUSIONS

The findings indicate that concerns that relate specifically to colonoscopy, including anticipated pain, influence acceptability of the procedure. However, the experience of a colonoscopy does not lead to improved test acceptance, despite decreases in procedural anxiety and pain. Patients' preprocedural views of the test are most important and should be addressed directly to potentially improve participation in colonoscopy.

An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium

BACKGROUND

The majority of studies on upper-GI hemorrhage (UGIH) to date have been based on clinical experience at academic centers. There is limited information about patients with UGIH who are evaluated by endoscopy at nonacademic settings, which comprise the majority of endoscopic practices in the United States.

OBJECTIVE

The aims of this retrospective study were to use a large national endoscopy database to describe the population of patients who received an EGD for nonvariceal upper-GI hemorrhage at diverse clinical practice sites and to characterize their endoscopic diagnoses.

METHODS

Between 2000 and 2004, the Clinical Outcomes Research Initiative (CORI) database received endoscopic reports from 72 diverse practice sites in the United States. All adult patients who underwent an EGD during this period at a CORI site for the indications of hematemesis, melena, or "suspected upper-GI bleed" were identified. Variceal bleeding was excluded. The nonvariceal UGIH cohort was described, and this group's endoscopic findings were characterized by the prevalence, indication, and location of an EGD (inpatient vs outpatient). A repeat EGD within a 2-week period was also evaluated.

RESULTS

A total of 243,427 EGDs were performed during the study period; 12,392 (4.9% of all EGDs) were performed for evaluation of hematemesis, melena, or "suspected" upper-GI bleed. Patients in this cohort were more likely to be older, men, and nonwhite compared with their nonbleeding counterparts. Melena was the most common indication for an EGD. The most common endoscopic finding was an ulcer (32.7%), followed by erosion (18.8%). A "normal" EGD was reported on 17.2% of EGDs. Among patients with ulcers, gastric ulcers were more common that duodenal ulcers (54.4% vs 37.1%), whereas clean-based ulcers comprised 52% of all ulcers. Ulcers and Mallory-Weiss tears were significantly more common on inpatient procedures. Ulcers identified on outpatient EGDs were more likely to be clean based. A repeat endoscopy was performed on 4% of the cohort within a 2-week follow-up period, hematemesis was the most common indication for a repeat EGD, and 24.3% of the cohort had a documented therapeutic intervention on their initial EGD. Among inpatients, 6.0% had a repeat EGD within two weeks for an UGIH indication compared with only 1.4% of outpatients (P < .0001).

CONCLUSIONS

These results allow association of EGD findings with patient presentation. Furthermore, it allows us to characterize endoscopic findings in a particular patient population (those patients with UGIH) in clinical practice, outside of traditional academic medical centers. The CORI database is a valuable resource for characterizing the epidemiology of endoscopic findings and, in particular, patient populations and across diverse practice settings, thus, enabling the development of hypotheses for future studies.

Patterns of endoscopy in the United States: analysis of data from the Centers for Medicare and Medicaid Services and the National Endoscopic Database

BACKGROUND

Patterns of GI endoscopy are influenced by the underlying epidemiology of GI disease, as well as by policy and practice guidelines.

OBJECTIVE

To compare practice patterns of GI endoscopy between two large national databases of the United States.

DESIGN

Descriptive database analysis.

SETTING

A 5% sample of the entire U.S. Medicare population (Centers for Medicare and Medicaid Services, CMS data files) and endoscopic data repository of U.S. gastroenterology practices (Clinical Outcomes Research Initiative, CORI database) from 1999 to 2003.

PATIENTS

The study population included 1,121,215 Medicare and 635,573 CORI patients undergoing various types of GI endoscopy.

INTERVENTIONS

EGD, colonoscopy, and flexible sigmoidoscopy.

MAIN OUTCOME MEASUREMENTS

Patient demographics, endoscopic diagnoses, time trends of diagnoses.

RESULTS

A colonoscopy was the most common endoscopic procedure performed (CMS 53%, CORI 58%), followed by an EGD (37%, 32%), and a flexible sigmoidoscopy (10%, 10%). In the CMS data, women accounted for 59% of the EGDs, 57% of the colonoscopies, and 56% of the flexible sigmoidoscopies, and in the CORI data, the corresponding numbers were 57%, 55%, and 54%, respectively. Compared with their distribution in the U.S. census population, nonwhite patients in both databases underwent relatively more EGDs and fewer colonoscopies. The most common upper-GI diagnosis was GERD, followed by GI bleeding, gastric ulcer, and duodenal ulcer. The most common lower-GI diagnosis was colorectal polyp. Over the period of 1999 to 2003, the rates of colorectal cancer diagnosed with colonoscopy declined.

LIMITATIONS

Only a limited amount of information about individual patients was retrievable from the electronic databases.

CONCLUSIONS

A colonoscopy is now the most common endoscopic procedure in the United States. Women undergo both upper and lower endoscopic procedures more often than men. Nonwhite patients are underrepresented in the use of colonoscopy relative to the prevalence of nonwhite persons in the U.S. population. Increased use of a colonoscopy for colon screening and surveillance has been associated with a decreased rate of cancer diagnosis.

Community-based preferences for stool cards versus colonoscopy in colorectal cancer screening

BACKGROUND

In the United States, compliance with colorectal cancer (CRC) screening recommendations remains suboptimal. Professional organizations advocate use of shared decision making in screening test discussions, but strategies to facilitate informed choice in CRC screening have not been well elucidated.

OBJECTIVE

The objectives of the study were to determine screening test preference among colonoscopy-naïve adults after considering a detailed, written presentation of fecal occult blood testing (FOBT) and colonoscopy and to assess whether their preferences are associated with demographic characteristics, attitudes, and knowledge.

DESIGN

The design of the study was a cross-sectional survey.

PARTICIPANTS

Colonoscopy-naïve supermarket shoppers age 40-79 in low- and middle-income, multiethnic neighborhoods in Denver, CO, reviewed a detailed, side-by-side description of FOBT and colonoscopy and answered questions about test preference, strength of preference, influence of physician recommendation, basic knowledge of CRC, and demographic characteristics.

MEASUREMENTS AND MAIN RESULTS

Descriptive statistics characterized the sample, and bivariate and multivariable logistic regression analyses identified correlates of screening test preference. In a diverse sample of 323 colonoscopy-naïve adults, 53% preferred FOBT, and 47% preferred colonoscopy for CRC screening. Individuals of Latino ethnicity and those with lower educational attainment were more likely to prefer FOBT than non-Latino whites and those with at least some college. Almost half of the respondents felt "very strongly" about their preferences, and one third said they would adhere to their choice regardless of physician recommendation.

CONCLUSION

After considering a detailed, side-by-side comparison of the FOBT and colonoscopy, a large proportion of community-dwelling, colonoscopy-naïve adults prefer FOBT over colonoscopy for CRC screening. In light of professional guidelines and time-limited primary care visits, it is important to develop improved ways of facilitating informed patient decision making for CRC screening.

Poorly differentiated colorectal carcinoma with invasion restricted to lamina propria (intramucosal carcinoma): a follow-up study of 15 cases

Invasive colorectal carcinomas (CRCs) with invasion confined to the lamina propria (LP) [intramucosal carcinoma (IMC)] lack access to lymphatics and therefore have no potential for metastases and local intervention (usually polypectomy) should be adequate treatment. For this reason, they are classified as "Tis" in the TNM system. It is believed that carcinomas invading the submucosa with unfavorable histology (tumors at/near the margin, and/or vascular invasion, and/or poor differentiation) require additional intervention after polypectomy, whereas those with favorable histology can be safely treated endoscopically. However, there are few data on poorly differentiated (PD) carcinomas showing invasion confined to the LP. Polypectomy is theoretically curative but in practice this has not been well demonstrated. Thus, the clinicopathologic features of 15 cases of PD CRCs with invasion limited to the LP on initial biopsies were studied to determine the best course of management for this rare subset of carcinomas. A computer search and histologic review of cases seen at Johns Hopkins Hospital was performed. Fifteen cases of PD CRC with invasion limited to the LP were identified. The clinicopathologic features of these tumors were reviewed. All 15 cases showed PD IMC with single cells infiltrating only the LP. Patients were 38 to 79 years (median, 62) of age with a male predominance (M:F=4:1). Three cases had signet ring cell differentiation, 1 had focal small cell features, and another had focal squamous differentiation. Fourteen of the cases were associated with background adenomas or adenomalike lesions including: 7 involving tubulovillous or villous adenomas, 6 involving tubular adenomas, 1 involving dysplasia associated with chronic inflammatory bowel disease. Nine of the lesions had surrounding high-grade dysplasia. One case showed no background dysplasia or adenoma. One patient was lost to follow-up and the remaining 14 were followed for 1 to 96 months (mean, 21.3 mo; median, 13 mo). Seven patients had no residual disease on follow-up colonoscopy, and no resection was performed. The remaining 7 patients were treated with partial colectomy (6) or low anterior resection (1), and of these, 5 had no infiltrating carcinoma and negative lymph nodes. One patient had a separate large colorectal (T3) carcinoma with 8/10 positive regional lymph nodes; the IMC seen on biopsy was presumably a metastasis as it was unassociated with an in situ component. Finally, the resected rectum from which an IMC had been previously detected had no residual invasive carcinoma, but the anal skin was involved by Paget disease. Thus, of the 15 cases of PD CRCs limited to the LP, 1 was a metastasis from a separate CRC and another had associated Paget disease of the anal skin. As such, even in the setting of PD carcinomas, no metastatic disease was seen arising from any of the cases that were confirmed as early primary lesions. These preliminary findings suggest that patients with isolated intramucosal PD CRCs may be managed endoscopically.

[The state of the colorectal screening in Hungary: lessons of the pilot programs]

In Hungary, colorectal cancer is the second most common malignant disease. Due to its natural history, colorectal cancer is particularly suitable for screening. At present, epidemiological evidences of the effectiveness of detection of the symptomless colorectal cancer and its precursors are only available for the demonstration of fecal occult blood, endoscopic methods are also in use. For mass screening, fecal occult blood tests are recommended. Guaiac-type chemical methods are widely criticized because of the lack of specificity. Out of the emerging technologies, immunochemical methods based on the antigenicity of blood proteins (hemoglobin) seem to be the most suitable. In the model programmes organized in the frame of the National Public Health Programme, an immunochemical method using two blood proteins (hemoglobin and albumin) have been used. The compliance was not more than 30-45%. About one-third of those with positive blood test refused colonoscopy. The programmes revealed a great number of adenomatous polyps and early cancers, and in the way, the effectiveness of the method has been proved. The model programmes are still continued. Before the continuous and gradual extension of colorectal screening, the validity of the specific method needs to be tested and proved in order to be recognized as a routine procedure for screening. There is a need to test the feasibility of total colonoscopy, however, to this effect the colonoscopic capacity in the country has to be further developed.

The nature of anesthesia and procedural sedation outside of the operating room

PURPOSE OF REVIEW

Procedural sedation and monitored anesthesia care have become increasingly common in locations outside of the operating room. The different types of procedures are presented along with pertinent safety issues with the use of different drug combinations.

RECENT FINDINGS

Based on the annual data from one hospital, of approximately 63,000 patients undergoing diagnostic or therapeutic procedures under sedation or anesthesia, 41% were sedated by non-anesthesiologists. Monitored anesthesia care was given to 0.4% of patients outside of the operating room. Events associated with monitored anesthesia care have been related to age, American Society of Anesthesiologists physical status, and obesity. Without the use of capnography, significant delays in the detection of apnea were demonstrable. Respiratory compromise with propofol for sedation appears less than that described for sedation using opiates and benzodiazepines.

SUMMARY

The number and types of procedures done outside of the operating room are steadily increasing. Sedation for these is often provided by nonanesthesiologists. A quality assurance system dedicated to track events associated with procedural sedation and anesthesia done outside of the operating room is instrumental for the maintenance of exemplary quality of sedation and safety of our patients.

Adherence to colorectal cancer screening guidelines in Canada

BACKGROUND

To identify correlates of adherence to colorectal cancer (CRC) screening guidelines in average-risk Canadians.

METHODS

2003 Canadian Community Health Survey Cycle 2.1 respondents who were at least 50 years old, without past or present CRC and living in Ontario, Newfoundland, Saskatchewan, and British Columbia were included. Outcomes, defined according to current CRC screening guidelines, included adherence to: i) fecal occult blood test (FOBT) (in prior 2 years), ii) endoscopy (colonoscopy/sigmoidoscopy) (prior 10 years), and iii) adherence to CRC screening guidelines, defined as either (i) or (ii). Generalized estimating equations regression was employed to identify correlates of the study outcomes.

RESULTS

Of the 17,498 respondents, 70% were non-adherent CRC screening to guidelines. Specifically, 85% and 79% were non-adherent to FOBT and endoscopy, respectively. Correlates for all outcomes were: having a regular physician (OR = (i) 2.68; (ii) 1.91; (iii) 2.39), getting a flu shot (OR = (i) 1.59; (ii) 1.51; (iii) 1.55), and having a chronic condition (OR = (i) 1.32; (ii) 1.48; (iii) 1.43). Greater physical activity, higher consumption of fruits and vegetables and smoking cessation were each associated with at least 1 outcome. Self-perceived stress was modestly associated with increased odds of adherence to endoscopy and to CRC screening guidelines (OR = (ii) 1.07; (iii) 1.06, respectively).

CONCLUSION

Healthy lifestyle behaviors and factors that motivate people to seek health care were associated with adherence, implying that invitations for CRC screening should come from sources that are independent of physicians, such as the government, in order to reduce disparities in CRC screening.

Value of a negative colonoscopy in patients with non-specific gastrointestinal symptoms

BACKGROUND

The yield of colonoscopy for neoplasia among patients aged <50 years with non-specific gastrointestinal symptoms is very low. However, a negative colonoscopy may benefit these patients by decreasing anxiety and thereby reducing subsequent health resource utilization. This study sought to characterize the effect of a negative colonoscopy in terms of: (i) reassurance value; and (ii) decreasing health resource utilization, in patients under 50 years of age with non-specific gastrointestinal symptoms (abdominal pain, diarrhea, constipation).

METHODS

Consecutive patients, aged 18-49 years, undergoing their first colonoscopy for evaluation of non-specific gastrointestinal symptoms (abdominal pain, diarrhea, constipation) were prospectively enrolled. Health-related anxiety was evaluated before and immediately after disclosure of the negative result of colonoscopy using a validated questionnaire and at 1-, 2- and 6-month intervals postcolonoscopy by telephone follow-up. Symptom scores and health resource utilization were assessed prior to colonoscopy and at 2 and 6 months postcolonoscopy.

RESULTS

Fifty-nine patients were prospectively enrolled. Mean health anxiety score declined immediately after colonoscopy from 20.6 to 17.8. Sustained improvement was seen in anxiety scores at 1, 2 and 6 months. Symptom scores also decreased at 6 months for abdominal pain (2.3 to 1.5), diarrhea (2.3 to 1.6) and constipation (1.9 to 1.6). There was a significant decrease in all four measures of health resource utilization at 6 months postcolonoscopy.

CONCLUSIONS

Despite minimal diagnostic yield, colonoscopy for non-specific gastrointestinal symptoms in patients <50 years of age is associated with a decline in health-related anxiety and symptom scores. These effects appear to translate into reductions in health resource utilization.

Primer: applying the new postpolypectomy surveillance guidelines in clinical practice

Colonoscopy is being increasingly used for colorectal cancer screening, which has resulted in a growing cohort of patients who have polyps that require postpolypectomy surveillance. Risk stratification enables postpolypectomy surveillance to be tailored to individual patient needs, and this is one of the fundamental points emphasized by the unified US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society (USMSTF-ACS) guidelines. Most patients do not require intensive surveillance; those patients who have one or two small (<1 cm) adenomas can safely undergo repeat colonoscopy after 5-10 years. Consensus guidelines that merge the recommendations of all societies are more user-friendly than individual guidelines, decrease confusion, and eliminate conflicting recommendations that are a barrier to guideline uptake. Nonetheless, studies have shown that specialists and nonspecialists overutilize colonoscopy for postpolypectomy surveillance, which places a large burden on already strained resources. Barriers to guideline implementation include factors involving the patient, physician, and health-care system. Physician education and widespread implementation of continuous quality improvement programs are required to bridge the gap between the guidelines and their clinical application.

Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable

BACKGROUND

Standardized reporting systems for diagnostic and screening tests facilitate quality improvement programs and clear communication among health care providers. Although colonoscopy is commonly used for screening, diagnosis, and therapy, no standardized reporting system for this procedure currently exists. The Quality Assurance Task Group of the National Colorectal Cancer Roundtable developed a reporting and data system for colonoscopy based on continuous quality improvement indicators.

DESIGN

The Task Group systematically reviewed quality indicators recommended by the Multi-Society Task Force on Colorectal Cancer and developed consensus-based terminology for reporting and data systems to capture these data elements. The Task Group included experts in several disciplines: gastroenterology, primary care, diagnostic imaging, and health care delivery.

RESULTS AND CONCLUSIONS

The standardized colonoscopy reporting and data system provides a tool that can be used for efforts in continuous quality improvement within and across practices that use colonoscopy.

Incidence of minor complications and time lost from normal activities after screening or surveillance colonoscopy

BACKGROUND

Few studies address the development of minor complications after screening or surveillance colonoscopy.

OBJECTIVES

Our purpose was to examine in previously asymptomatic people the incidence of new symptoms after colonoscopy, risk factors for symptoms, and patients' perceptions of this examination.

DESIGN

Prospective cohort study. Patients completed a standardized interview at 7 and 30 days after colonoscopy.

PATIENTS

A total of 502 patients aged 40 years and older undergoing colonoscopy for colorectal cancer screening, surveillance, or follow-up of another abnormal screening test result. Patients were excluded if they had a history of inflammatory bowel disease, visible GI bleeding, or anemia.

MAIN OUTCOME MEASURES

Incidence of minor complications and patient perceptions about colonoscopy.

RESULTS

Minor complications occurred in 162 subjects (34%) before day 7 and in 29 subjects (6%) between day 7 and day 30, most commonly bloating (25%) and abdominal pain (11%). Six subjects had unexpected emergency department visits or hospitalizations within 30 days, including 2 with postpolypectomy bleeding. On multivariate analysis, minor complications were more common in women (odds ratio 1.78, 95% CI 1.21-2.62) and when the procedure lasted 20 minutes or longer. Bowel preparation was rated the most difficult part of the examination for 77%. Most subjects (94%) lost 2 or fewer days from normal activities for the colonoscopy itself, preparation, or recovery.

CONCLUSIONS

Minor complications were common after screening and surveillance colonoscopy. The bowel preparation was the most difficult part of the examination for most patients. Most subjects lost 2 or fewer days from normal activities because of colonoscopy.

Trends in colonoscopy for colorectal cancer screening

BACKGROUND

A major health priority is to increase colorectal cancer screening, and colonoscopy has become an increasingly important method of screening. The Medicare program began coverage for colonoscopy for average risk individuals in 2001.

OBJECTIVES

We sought to examine whether overall colorectal cancer screening increased over time and whether these increases were a result of increased utilization of all methods or a result of greater use of colonoscopy but reduced use of other methods, whether the enactment of Medicare coverage was associated with an increase in colonoscopy among Medicare enrollees, and whether these trends equally affected subpopulations.

METHODS

We used nationally representative data from the 2000 and 2003 National Health Interview Surveys and analyzed data using used chi, difference-in-differences tests, and logistic regression analyses to examine whether screening rates differed between 2000 and 2003.

RESULTS

The percentage of individuals being screened for colorectal cancer using any method increased modestly from 2000 to 2003 (3%), with increases a result of increased use of colonoscopy and a reduction in the use of other methods. Increases in colonoscopy use were significant among all populations except the insured, non-Medicare population with low incomes. Among Medicare enrollees with high/middle incomes, colonoscopy use increased 14% from 2000 to 2003 compared with an increase of only 7% among low-income groups, which was a significant difference (P < 0.01). Similarly, among insured, non-Medicare enrollees with high/middle incomes, colonoscopy use increased 11% from 2000 to 2003 compared with an increase of only 4% among low-income groups, which also was a significant difference (P < 0.01).

CONCLUSIONS

Colorectal cancer screening utilization increased modestly from 2000 to 2003, with the increases that primarily were the result of increased colonoscopy use. Increases in colonoscopy use, however, were primarily among high/middle income groups. Although Medicare coverage may have indirectly facilitated the increase in colonoscopy, we could not determine that coverage directly increased screening rates. Screening rates remain modest and lower income individuals continue to be screened less. Topics for future research include approaches to facilitating screening among low-income individuals and evaluating the impact of policy coverage decisions.

Racial disparities in colon cancer. Primary care endoscopy as a tool to increase screening rates among minority patients

Colon cancer is a condition whose far-reaching effects have been well documented nationally and within the state of South Carolina. Fortunately, the disease is amenable to both primary and secondary prevention through screening colonoscopy. Despite the conceptual simplicity of recommending colonoscopy, barriers exist to universal (or even widespread) screening. Currently the infrastructure necessary to achieve screening goals set by the American Cancer Society (ACS), the American College of Gastroenterology (ACG), and the South Carolina Department of Health and Environmental Control (DHEC) has not been established. At current rates of training gastroenterologists, the medical community will not be able to come close to achieving widespread screening. Given the discrepancy between the public health benefit of achieving the goals and the deaths that have occurred because of the resource shortfall, we propose alternative measures to screen the at-risk population for consideration. This need is most acute in the black community, in which where screening rates tend to be lower and polyps have been found to progress more quickly than among white populations. In South Carolina, one model has used primary care physicians as the labor force to provide routine screening colonoscopy for their own patients. This model makes screening much more accessible to minority patients, as the wait is shorter and the cost typically lower. In combination with a faith-based partnership with minority religious organizations, this model has begun to make needed inroads toward addressing the disparities associated with colon cancer. Cancer 2007. (c) 2006 American Cancer Society.

Colonoscopy demand and capacity in New Hampshire

BACKGROUND

Screening for colorectal cancer has been clearly shown to decrease the incidence and mortality from this disease. Accurate information about the demand and capacity for screening, particularly with colonoscopy, is critical in planning screening strategies. National assessments have recently begun; estimates of smaller geographic regions should improve the accuracy of national estimates, as well as inform strategies for individual states. This study evaluates the demand and capacity for colonoscopy in the state of New Hampshire.

METHODS

All endoscopy sites in the state of New Hampshire were contacted to determine their number of endoscopists, monthly colonoscopies, and estimates of the percentage of colonoscopy done for screening. Barriers to increasing current capacity were also assessed. The capacity estimates were compared to demand estimates based on population census figures. Data were collected in 2003 to 2004 and analyzed in 2005 to 2006.

RESULTS

One hundred fourteen endoscopists at 36 centers performed 49,352 colonoscopies in 2002, an average of 39 to 43 total monthly colonoscopies per endoscopist. Approximately 60% were estimated to have been done for screening. Estimated demand was approximately twice the available capacity for screening and surveillance. The impact of factors such as compliance, percent screening, and population growth were assessed to inform future screening strategies.

CONCLUSIONS

In 2002, demand for screening colonoscopy in New Hampshire for patients aged more than 50 years was approximately twice the available capacity. However, if the assessed screening capacity of 2002 were to increase by 20%, combined with a target of 60% population compliance with screening as an initial goal, the demand for colonoscopy in New Hampshire would be met.

Colonoscopic withdrawal times and adenoma detection during screening colonoscopy

BACKGROUND

Colonoscopy is commonly used to screen for neoplasia. To assess the performance of screening colonoscopy in everyday practice, we conducted a study of the rates of detection of adenomas and the amount of time taken to withdraw the colonoscope among endoscopists in a large community-based practice.

METHODS

During a 15-month period, 12 experienced gastroenterologists performed 7882 colonoscopies, of which 2053 were screening examinations in subjects who had not previously undergone colonoscopy. We recorded the numbers, sizes, and histologic features of the neoplastic lesions detected during screening, as well as the duration of insertion and of withdrawal of the colonoscope during the procedure. We compared rates of detection of neoplastic lesions among gastroenterologists who had mean colonoscopic withdrawal times of less than 6 minutes with the rates of those who had mean withdrawal times of 6 minutes or more. According to experts, 6 minutes is the minimum length of time to allow adequate inspection during instrument withdrawal.

RESULTS

Neoplastic lesions (mostly adenomatous polyps) were detected in 23.5% of screened subjects. There were large differences among gastroenterologists in the rates of detection of adenomas (range of the mean number of lesions per subject screened, 0.10 to 1.05; range of the percentage of subjects with adenomas, 9.4 to 32.7%) and in their times of withdrawal of the colonoscope from the cecum to the anus (range, 3.1 to 16.8 minutes for procedures during which no polyps were removed). As compared with colonoscopists with mean withdrawal times of less than 6 minutes, those with mean withdrawal times of 6 minutes or more had higher rates of detection of any neoplasia (28.3% vs. 11.8%, P<0.001) and of advanced neoplasia (6.4% vs. 2.6%, P=0.005).

CONCLUSIONS

In this large community-based gastroenterology practice, we observed greater rates of detection of adenomas among endoscopists who had longer mean times for withdrawal of the colonoscope. The effect of variation in withdrawal times on lesion detection and the prevention of colorectal cancer in the context of widespread colonoscopic screening is not known. Ours was a preliminary study, so the generalizability and implications for clinical practice need to be determined by future studies.

Temporal trends in colorectal procedure use after colorectal cancer resection

BACKGROUND

After curative cancer resection, routine colon surveillance is recommended. It is not known whether trends over time in cancer survivors parallel that of the general population.

OBJECTIVE

Our purpose was to describe temporal changes in the use of posttreatment procedures.

DESIGN

Retrospective cohort study.

SETTING

Linked tumor registry and Medicare claims data.

PATIENTS

Medicare beneficiaries >65 years old who were diagnosed with local or regional stage colorectal cancer from 1992-2002 and who underwent surgical resection.

MAIN OUTCOME MEASUREMENTS

Use of colonoscopy, sigmoidoscopy, or barium enema within 1 year, 18 months, or 3 years of diagnosis.

RESULTS

A total of 62,882 patients were followed up for 1 year and 35,784 for 3 years. Colonoscopy within 1 year was performed in 25.9%, within 18 months in 53.8%, and within 3 years in 70.3%. Corresponding rates for sigmoidoscopy were 7.4%, 10.2%, and 14.9%, respectively, and were 3.4%, 5.1%, and 7.9%, respectively, for barium enema. There was a decrease over time in the receipt of colonoscopy within 1 year of diagnosis (31.3% in 1992 to 20.6% in 2002), no change in 18-month rates, and a smaller increase in colonoscopy use within 3 years (66.5% to 72.3%). The use of sigmoidoscopy and barium enema declined over time. Overall procedure use within 1 year and 18 months also decreased and 3-year rates were essentially unchanged. These differences were maintained in multivariate analyses.

LIMITATIONS

Accuracy of procedure coding and indications for tests could not be measured.

CONCLUSIONS

Temporal trends in procedure use in cancer survivors were consistent with the general population. Importantly, despite guideline recommendations and Medicare reimbursement, 25% of patients who undergo curative treatment do not receive surveillance examinations and this was unchanged over time.

Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia

BACKGROUND

Recommendations for colorectal-cancer screening are based solely on age and family history of cancer, not sex.

METHODS

We performed a cross-sectional analysis of the data from a large colonoscopy-based screening program that included 50,148 participants who were 40 to 66 years of age. People 40 to 49 years of age were eligible only if they had a family history of cancer of any type. Of the 43,042 participants 50 to 66 years of age, 13.3% reported a family history of colorectal cancer, as did 66.3% of the 7106 participants who were 40 to 49 years of age. We defined advanced neoplasia as cancer or adenoma that was at least 10 mm in diameter, had high-grade dysplasia, or had villous or tubulovillous histologic characteristics, or any combination thereof. We used multivariate logistic regression to identify associations between participants' characteristics and advanced neoplasia in a primary (or derivation) data set, and we confirmed the associations in a secondary (or validation) data set.

RESULTS

Advanced neoplasia was detected in 2553 (5.9%) participants 50 to 66 years of age and in 243 (3.4%) participants 40 to 49 years of age. The rate of complications during colonoscopy was 0.1%, and no participants died. In the validation set, a logistic-regression model showed that male sex was independently associated with advanced neoplasia (adjusted odds ratio, 1.73; 95% confidence interval, 1.52 to 1.98; P<0.001). In each age group (40 to 49 years, 50 to 54 years, 55 to 59 years, and 60 to 66 years), the number of persons who would have to undergo colorectal-cancer screening in order to detect one advanced neoplasia was significantly lower in men than in women (23 vs. 36, 17 vs. 28, 12 vs. 22, and 10 vs. 18, respectively).

CONCLUSIONS

We detected advanced neoplasia at a significantly higher rate in men than in women, which may warrant refinement of the screening recommendations for colorectal cancer.

Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly?

Racial and ethnic disparities in colorectal cancer screening have been documented extensively in the literature. In July 2001 Medicare began covering colonoscopy for average-risk beneficiaries. We examined the effect of Medicare reimbursement on the rate and disparity of colorectal cancer screening among the elderly in the United States. This policy alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy.

Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time

BACKGROUND

In 2002, a U.S. Multi-Society Task Force on Colorectal Cancer recommended that the withdrawal phase for colonoscopy should average at least 6-10 min. This was based on 10 consecutive colonoscopies by two endoscopists with different adenoma miss rates.

AIMS

To characterize the relationship between endoscopist withdrawal time and polyp detection at colonoscopy, and to determine the withdrawal time that corresponds to the median polyp detection rate.

DESIGN

Procedural data from out-patient colonoscopies performed at the Mayo Clinic, Rochester during 2003 were reviewed. Endoscopists were characterized by their mean withdrawal time for a negative procedure and individual polyp detection rate.

RESULTS

A total of 10 955 colonoscopies performed by 43 endoscopists were analysed. Median withdrawal time was 6.3 min (range: 4.2-11.9); polyp detection rate was 44.0% (all polyps), 29.8% (< or = 5 mm), 5.9% (6-9 mm), 6.7% (10-19 mm), 2.1% (> or = 20 mm). Longer withdrawal time was associated with higher polyp detection rate (r = 0.76; P < 0.0001); this relationship weakened for larger polyps (r = 0.19 for polyps 6-9 mm, r = 0.28 for polyps 10-19 mm, r = 0.02 for polyps > or = 20 mm). Overall median polyp detection rate corresponded to a withdrawal time of 6.7 min.

CONCLUSION

Our findings support a colonoscopy withdrawal time of at least 7 min, which correlates with higher colon polyp detection rates.

Prospective assessment of the impact of feedback on colonoscopy performance

BACKGROUND

Colonoscopy is an operator-dependent procedure. The medical literature describes disparity in colonoscopy performance with respect to polyp detection, caecal intubation rates and procedural times.

AIM

To assess prospectively the impact of feedback among a large cohort of colonoscopists on three performance parameters: caecal intubation rate, insertion time and withdrawal time.

METHOD

In a prospective clinical study, procedural data from all out-patient colonoscopies performed by attending gastroenterologists at our institution were recorded routinely in a computerized database. Enhanced serial feedback was provided on a quarterly basis for three procedure parameters: intubation to caecum, insertion time and withdrawal time. Feedback (absolute value, % rank and group distribution) was sent by email every 3 months beginning with January 2005 feedback for all of 2004, and subsequently quarterly in April 2005 (for January-March 2005), July 2005 (for April-June 2005) and October 2005 (for July-September 2005).

RESULTS

Feedback was provided to 58 endoscopists with a median experience level of 8 years. There was a relative decline of 19% in incomplete procedures, with median caecal non-intubation rates decreasing from 4.7% to 3.8% following the introduction of feedback while median insertion times declined from 10.6 to 9.5 mins, P = 0.02. Median withdrawal times did not change significantly, 9.1-8.9 mins, P = 0.6.

CONCLUSIONS

Feedback by email appears to improve colonoscopy performance, enhancing completion rates and shortening insertion times without compromising withdrawal times.

Incident rates of colonic neoplasia in older patients: when should we stop screening?

INTRODUCTION

Current guidelines endorse colon cancer screening every 5-10 years in patients over 50 years of age. However, there is no consensus regarding what age is appropriate to stop screening. The aim of this study was to characterize neoplasia occurrence/recurrence in a large cohort of patients > or =70 years of age undergoing colonoscopy.

METHODS

The Mayo Rochester endoscopic database was reviewed to determine the incidence of colonic neoplasia in patients > or =70 years undergoing two colonoscopies at least 12 months apart between January 1996 and December 2000. Patients were classified based on (i) age: 70-74, 75-79, > or =80 years; and (ii) polyp detection on initial examination, that is, subsequent examination for screening or surveillance.

RESULTS

Overall, 1353 patients underwent two colonoscopies at least 12 months apart (median interval 140 weeks) with removal of polyp on initial examination in 726 (53.7%) patients (surveillance cohort). On subsequent endoscopy, polyps > or =10 mm were detected in 54 (4.0%) and cancer in 13 (1.0%) patients. All age groups were well matched with respect to detection of neoplasia on index examination (P = 0.9) and polyp size on initial colonoscopy among the surveillance group (P = 0.9). Using a Cox proportional hazards model, adjusted hazard ratios (95% confidence interval [CI]) for neoplasia (polyps > or =10 mm) were: 2.0 (1.50-2.73, P < 0.0001) (surveillance vs screening), 1.33 (0.96-1.79, P = 0.08) (> or =80 vs 70-74), and 1.05 (0.78-1.38, P = 0.75) (75-79 vs 70-74). Adjusted hazard ratios for development of cancer were: 1.87 (1.03-3.97, P = 0.04) (surveillance vs screening), 1.73 (0.84-3.56, P = 0.13) (> or =80 vs 70-74), and 1.38 (0.71-2.77, P = 0.34) (75-79 vs 70-74).

CONCLUSIONS

Prior history of neoplasia remains a strong risk factor for colorectal neoplasia development in elderly patients and should be considered when deciding the need for continuing screening/surveillance. Incident neoplasia rates in a previously screened elderly population rise slowly with advancing age although cancer rates rise more sharply. Therefore, screening still retains a role in elderly patients; however, clinical judgment is still required to individualize screening practice. As the risk of competing comorbid illnesses continues to increase over time, the threshold to perform colon screening should increase accordingly.

Predictors of nonadherence to screening colonoscopy

BACKGROUND

Colonoscopy has become a preferred colorectal cancer (CRC) screening modality. Little is known about why patients who are referred for colonoscopy do not complete the recommended procedures. Prior adherence studies have evaluated colonoscopy only in combination with flexible sigmoidoscopy, failed to differentiate between screening and diagnostic procedures, and have examined cancellations/no-shows, but not nonscheduling, as mechanisms of nonadherence.

METHODS

Sociodemographic predictors of screening completion were assessed in a retrospective cohort of 647 patients referred for colonoscopy at a major university hospital. Then, using a qualitative study design, a convenience sample of patients who never completed screening after referral (n=52) was interviewed by telephone, and comparisons in reported reasons for nonadherence were made by gender.

RESULTS

Half of all patients referred for colonoscopy failed to complete the procedure, overwhelmingly because of nonscheduling. In multivariable analysis, female sex, younger age, and insurance type predicted poorer adherence. Patient-reported barriers to screening completion included cognitive-emotional factors (e.g., lack of perceived risk for CRC, fear of pain, and concerns about modesty and the bowel preparation), logistic obstacles (e.g., cost, other health problems, and competing demands), and health system barriers (e.g., scheduling challenges, long waiting times). Women reported more concerns about modesty and other aspects of the procedure than men. Only 40% of patients were aware of alternative screening options.

CONCLUSIONS

Adherence to screening colonoscopy referrals is sub-optimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in colonoscopy referral and scheduling mechanisms.

Endoscopic sedation in the United States: results from a nationwide survey

OBJECTIVES

The introduction of new sedative agents as well as a desire for improved patient satisfaction and greater efficiency has changed the practice of endoscopic sedation. This survey was designed to provide national and regional data on endoscopic sedation and monitoring practices within the United States.

METHODS

A 22-item survey regarding current practices of endoscopy and sedation was mailed to 5,000 American College of Gastroenterology physician members nationwide.

RESULTS

A total of 1,353 questionnaires (27.1%) were returned. Respondents performed an average of 12.3 esophagogastroduodenoscopies (EGDs) and 22.3 colonoscopies per wk. Endoscopic procedures were performed within a hospital setting (55.2) more often than at an ambulatory center (35.8%) or private office (8.8%). The vast majority of EGDs and colonoscopies (>98%) were performed with endoscopic sedation. Almost three quarters (74.3%) of the respondents used a narcotic and benzodiazepine for sedation, while propofol was preferred by 25.7%. Sedation practices varied considerably within different geographic regions of the United States. Respondents routinely monitored vital signs and pulse oximetry (99.2% and 98.6%, respectively), and supplemental oxygen was administered to all patients during EGD by 72.7% of endoscopists. Endoscopist satisfaction with sedation was greater among those using propofol than conventional sedation (10 vs 8, p < 0.0001).

CONCLUSIONS

During the past 15 yr, the volume of procedures performed by endoscopists in the United States has increased two- to fourfold. Propofol is currently being used for sedation in approximately one quarter of all endoscopies in the United States. The findings from this survey may help in the formulation of updated policies and practice guidelines pertaining to endoscopic sedation.

Total-body MR-imaging in oncology

Although MRI is an effective modality in oncology, state-of-the-art total-body MRI (TB-MRI) in the past was infeasible in the diagnostic work-up, due to the need for repeated examinations with repositioning and separate surface coils to cover all body parts. To overcome this limitation, either a moving table platform in combination with the body-coil or a special designed rolling table platform with one body phased-array coil have been implemented with promising results for both tumor staging and metastases screening. Since 2004, state-of-the-art TB-MR imaging with high spatial resolution has become feasible using a newly developed 1.5 Tesla TB-MRI system with multiple receiver channels. This review gives an overview based on the recent literature as well as our own experience concerning the possibilities, challenges, and limitations of TB-MRI in oncology, emphasizing both oncological staging and early tumor detection in asymptomatic subjects.

Endoscopic procedures and diagnoses are not influenced by seasonal variations

BACKGROUND

The occurrences of various GI diseases are thought to be influenced by seasonal variations. The present study was done to test the hypothesis that seasonal variations in endoscopic diagnoses reflect underlying patterns in the performance of endoscopic procedures.

METHODS

The Clinical Outcomes Research Initiative (CORI) uses a computerized endoscopic report generator to collect endoscopic data from 73 diverse practice sites throughout the United States. We used the CORI database to analyze the date-specific occurrence of EGD and colonoscopy, as well as the endoscopic diagnoses of gastric ulcer, duodenal ulcer, and colorectal cancer. Time trends are analyzed by autocorrelation and by linear and nonlinear regression.

RESULTS

Between January 2000 and December 2003, the number of EGDs and colonoscopies increased 2.5- and 4.1-fold, respectively. The rate of duodenal ulcer fell from 21.2 (15.6-27.5) to 19.0 (15.8-22.8) per 1000 EGDs. The rate of gastric ulcer fell from 42.6 (33.3-50.1) to 33.4 (29.5-38.7) per 1000 EGDs. The rate of colorectal cancer fell from 109.9 (98.3-122.8) to 72.2 (67.4-77.2) per 1000 colonoscopies. The time trends of neither endoscopic procedures nor endoscopic diagnoses revealed any seasonal variation or other cyclic pattern.

CONCLUSIONS

The performance of endoscopic procedures is unaffected by any seasonal variation.

Results of a randomized controlled trial to increase colorectal cancer screening in a managed care health plan

BACKGROUND

Colorectal cancer (CRC) is the third most common cause of cancer deaths; however, rates of regular screening for this cancer are low. A quality improvement (QI) program to increase CRC screening was developed for use in a managed care health plan.

METHODS

Thirty-six provider organizations (POs) contracting with the health plan were recruited for a randomized controlled effectiveness trial testing the QI program. The intervention was delivered over a 2-year period, and its effectiveness was assessed by chart review of a random sample of patients from each PO.

RESULTS

Thirty-two of the 36 POs were evaluable for outcome assessment. During the 2-year intervention period, only 26% of the eligible patients received any CRC screening test. Twenty-nine percent of patients had any CRC screening test within guidelines, with no differences between the intervention or control POs. Significant predictors of having received CRC screening within guidelines were older age (P = 0.0004), receiving care in an integrated medical group (P < 0.0001) and having had a physical examination within the past 2 years (P < 0.0001).

CONCLUSIONS

A facilitated QI intervention program for CRC screening that focused on the PO did not increase rates of CRC screening. Overall CRC screening rates are low and are in need of improvement.

Surveillance colonoscopy in individuals at risk for hereditary nonpolyposis colorectal cancer: an evidence-based review

PURPOSE

Surveillance colonoscopy plays an important role in the management of asymptomatic patients known to carry and suspected of carrying hereditary nonpolyposis colorectal cancer gene mutations. Although the shortest interval between surveillance examinations may seem to offer the most benefit to patients, excessive use of this procedure may have unwanted consequences. This study was designed to evaluate the evidence and make recommendations regarding the optimal frequency of surveillance colonoscopy and the age at which to initiate surveillance based on the best available evidence.

METHODS

MEDLINE was searched for all articles assessing surveillance colonoscopy from 1966 to 2004 by using the MESH terms "hereditary nonpolyposis colorectal cancer" and "screening." The evidence was systematically reviewed and a critical appraisal of the evidence was performed.

RESULTS

There are no randomized, controlled, clinical trials examining the frequency of surveillance colonoscopy in hereditary nonpolyposis colorectal cancer. Three cohort studies were identified for review. There is one cohort study of good quality that provides evidence that surveillance colonoscopy every three years in patients with hereditary nonpolyposis colorectal cancer reduces the risk of developing colorectal cancer and the risk of death. The two remaining cohort studies provide poor evidence on which to make a recommendation.

CONCLUSIONS

The best available evidence supports surveillance with complete colonoscopy to the cecum every three years in patients with hereditary nonpolyposis colorectal cancer (B recommendation). There is no evidence to support or refute more frequent screening. Further research is required to examine the potential harms and benefits of more frequent screening. However, given the potential for rapid progression from adenoma to carcinoma and missing lesions at colonoscopy, there is consensus that screening more frequently than every three years is required.

Utilization of colonoscopy in the United States: results from a national consortium

BACKGROUND

To assess capacity for colonoscopy, we need to understand current utilization of colonoscopy in diverse clinical practice settings. The objective of this study was to determine the utilization of colonoscopy in diverse clinical practice settings.

METHODS

The Clinical Outcomes Research Initiative (CORI) data repository, which receives endoscopy reports from 73 diverse adult practice sites in the United States was used. Colonoscopy reports from January 2000 to August 2002 were analyzed to determine the demographic characteristics of adult patients who received a colonoscopy and the procedure indication. The relationship of age, race, gender, and procedure indication was analyzed.

RESULTS

Results of colonoscopies in 146,457 unique patients were analyzed. Of the reports, 68% came from nonacademic settings. Patients less than 50 years of age accounted for 20% of colonoscopies. The most common indications were rectal bleeding (33.6%), irritable bowel symptoms (23.8%), or screening because of a positive family history of colorectal cancer (22.4%) and screening with a primary colonoscopy or a fecal occult blood test (FOBT) (12.8%). In patients 50 years and older, asymptomatic screening (average-risk screening colonoscopy, positive family history, or FOBT positivity) accounted for 38.1% of all colonoscopies. Surveillance colonoscopy in patients with previous cancer or polyps accounted for 21.9% of colonoscopies performed in this age group. Differences in utilization were noted, based on gender and race.

CONCLUSIONS

Colonoscopy utilization varies based on age, gender, and race. Colonoscopy often is performed in patients less than 50 years old for irritable bowel symptoms; rectal bleeding; or average-risk screening, for which benefits are uncertain. In patients older than 50 years, surveillance after polyp removal is a common indication and may be overused. Understanding utilization can lead to further study to determine outcomes, to optimize utilization, and to provide a basis for shifting limited resources.

Screening colonoscopy in Chinese and Western patients: a comparative study

OBJECTIVES

The aim of this study was to compare findings on screening colonoscopy in a Chinese cohort versus a concurrent Western cohort.

METHODS

Asymptomatic adults aged 40 years or older concurrently underwent screening colonoscopy in two hospitals, one in Taiwan and the other in Seattle. The prevalence and distribution of colonic neoplasia and advanced neoplasia (defined as an adenoma >or=10 mm or with villous, high-grade dysplastic, or malignant features) were compared between the two groups.

RESULTS

The Taiwan cohort was composed of 1,456 subjects. Colonic neoplasms were found in 214 (14.7%), advanced neoplasms in 58 (4%), and colon cancers in 4 subjects (0.3%). The Seattle cohort was composed of 3,403 subjects. Neoplasms were found in 705 (20.7%), advanced neoplasms in 166 (4.9%), and cancers in 11 subjects (0.3%). Age and male sex were risk factors for neoplasia in both groups. The adjusted risk ratio was 1.30 (95% confidence interval: 1.08-1.57) in Western versus Chinese patients. However, the prevalence of advanced neoplasms was not statistically different between the two cohorts. The Chinese cohort had a higher proportion of distal neoplasia (66.4%vs 52.6%; p= 0.0004). The sensitivity of a sigmoidoscopic screening strategy for detecting advanced neoplasia was higher in Chinese (79.3%) than in Western patients (67.5%).

CONCLUSIONS

Compared to Westerners, Chinese patients have a slightly lower prevalence of colon neoplasia (but not advanced neoplasia), more distal distribution of neoplasia, and higher likelihood of concomitant proximal advanced neoplasia and distal neoplasia. Colonoscopy is safe, well-tolerated, and a viable screening option in Chinese patients, but its advantage over sigmoidoscopy as a screening tool may be smaller.

Mucosal benign epithelioid nerve sheath tumors

Mucosal nerve sheath tumors have been well described in the gastrointestinal tract and other mucosal sites. In a series of mucosal biopsies, we have encountered a distinct subset of mucosal peripheral nerve sheath tumors characterized by small epithelioid cells and a benign clinical course. Such epithelioid nerve sheath tumors have been observed as a component of a larger study of colorectal "schwannomas," but herein we describe them in detail. A series of 7 of these lesions detected on mucosal biopsies (6 colonic, 1 bladder) was received by a single large institution in consultation material. The histologic and clinicopathologic features of the cases were reviewed. The mean age at presentation was 58.6 years with a slight female predominance (4 females, 3 males). Five of the colonic lesions were from the left colon and one from the right colon. The bladder biopsy was from the bladder neck. All of the colonic lesions were discovered as small (0.2-1.0 cm) polyps during the time of colonoscopy (3 at the time of routine screening, 2 for the workup of occult blood in the stool). The bladder neck mass was seen on bladder ultrasound after the patient presented with vaginal bleeding. None of the patients had a known history of neurofibromatosis. Histologically, the lesions showed an infiltrative growth pattern and were composed of spindled to predominantly epithelioid cells arranged in nests and whorls. The epicenters of the lesions were located in the lamina propria and extended to the superficial submucosa. The proliferating cells had uniform round to oval nuclei with frequent intranuclear pseudoinclusions and eosinophilic fibrillary cytoplasm. No mitoses were seen. All lesions expressed diffuse S-100 protein, and 3 of 5 lesions stained showed CD34 labeling in supporting cells. All were negative for CD117. All 5 lesions tested were negative for calretenin, while SM31 showed no intralesional neuraxons. One lesion was stained for epithelial membrane antigen and was negative. One lesion was associated with superficial mucosal erosion, and 1 had an inflammatory infiltrate predominantly composed of eosinophils. On follow-up of 5 patients, none has had any symptoms or recurrence of disease. Mucosal epithelioid nerve sheath tumors are a rare entity characterized by prominent epithelioid round to oval cells with an infiltrative growth pattern. These lesions are often discovered incidentally and have a benign clinical course.

Incident rates of colonic neoplasia according to age and gender: implications for surveillance colonoscopy intervals

INTRODUCTION

Current guidelines endorse surveillance colonoscopy at 3 to 5 years following initial detection of neoplasia. However, individual patients' risks may vary according to age and gender. This study aimed to characterize neoplasia recurrence in a large patient cohort undergoing surveillance colonoscopy.

METHODS

All patients undergoing two colonoscopies at least 12 months apart between 1996 and 2000, with detection and removal of a polyp on the index colonoscopy, were identified using our endoscopic database to determine the incidence of colonic neoplasia. Patients were classified according to age (<50, 50-64, 65-74, > or =75 years) and gender.

RESULTS

Overall, 1803 patients underwent two colonoscopies at least 12 months apart (median interval, 140 weeks) with removal of a polyp on initial examination. Polyps > or =5 mm were detected in 334 (19%) patients and polyps > or =10 mm in 105 (6%) on subsequent endoscopy. All age and gender groups were well matched with respect to size of polyp detected on initial colonoscopy (P = 0.2). Kaplan-Meier curves and a Cox proportional hazards model demonstrated similar rates of neoplasia recurrence for all patients irrespective of age and gender.

CONCLUSIONS

Similar rates of neoplasia recurrence were observed among patients of different gender and age groups on surveillance colonoscopy. From a health resource utilization perspective, these findings support current recommendations for similar surveillance intervals for patients regardless of age and gender.

Predictors of nonadherence to screening colonoscopy

BACKGROUND

Colonoscopy has become a preferred colorectal cancer (CRC) screening modality. Little is known about why patients who are referred for colonoscopy do not complete the recommended procedures. Prior adherence studies have evaluated colonoscopy only in combination with flexible sigmoidoscopy, failed to differentiate between screening and diagnostic procedures, and have examined cancellations/no-shows, but not nonscheduling, as mechanisms of nonadherence.

METHODS

Sociodemographic predictors of screening completion were assessed in a retrospective cohort of 647 patients referred for colonoscopy at a major university hospital. Then, using a qualitative study design, a convenience sample of patients who never completed screening after referral (n=52) was interviewed by telephone, and comparisons in reported reasons for nonadherence were made by gender.

RESULTS

Half of all patients referred for colonoscopy failed to complete the procedure, overwhelmingly because of nonscheduling. In multivariable analysis, female sex, younger age, and insurance type predicted poorer adherence. Patient-reported barriers to screening completion included cognitive-emotional factors (e.g., lack of perceived risk for CRC, fear of pain, and concerns about modesty and the bowel preparation), logistic obstacles (e.g., cost, other health problems, and competing demands), and health system barriers (e.g., scheduling challenges, long waiting times). Women reported more concerns about modesty and other aspects of the procedure than men. Only 40% of patients were aware of alternative screening options.

CONCLUSIONS

Adherence to screening colonoscopy referrals is sub-optimal and may be improved by better communication with patients, counseling to help resolve logistic barriers, and improvements in colonoscopy referral and scheduling mechanisms.

Lack of seasonal variation in the endoscopic diagnoses of Crohn's disease and ulcerative colitis

BACKGROUND

Conflicting data have been reported about the seasonal variation of inflammatory bowel diseases (IBD). The purpose of the present analysis was to assess the occurrence of seasonal variations in the endoscopic diagnosis of Crohn's disease (CD) and ulcerative colitis (UC).

METHODS

The Clinical Outcomes Research Initiative (CORI) uses a computerized endoscopic report generator to collect endoscopic data from 73 diverse practice sites throughout the United States. We utilized the CORI database to analyze the date-specific occurrence of colonoscopy, as well as the colonoscopic diagnoses of CD and UC. Time trends were analyzed by autocorrelation, linear, and nonlinear regression.

RESULTS

Between January 2000 and December 2003, the number of colonoscopies increased 4.1-fold. The proportion of colonoscopies with a CD diagnosis fell by 28%, and the proportion of colonoscopies with a UC diagnosis fell by 50%. The occurrence of neither CD nor UC was shaped by any clear-cut seasonal periodicity. However, the trends of the two diseases revealed strikingly similar patterns with four resembling peaks superimposed on their monthly fluctuations.

CONCLUSIONS

Endoscopic diagnosis of IBD is unaffected by any seasonal variation. The decline in the diagnostic rate of colonic IBD may reflect a relative increase in the utilization of colonoscopy for colon cancer screening. The similarity in the monthly fluctuations of both IBD suggests that their incidence or flare-ups may be influenced by identical exogenous risk factors.

Projected national impact of colorectal cancer screening on clinical and economic outcomes and health services demand

BACKGROUND & AIMS

Colorectal cancer (CRC) screening is effective and cost-effective, but the potential national impact of widespread screening is uncertain. It is controversial whether screening colonoscopy can be offered widely and how emerging tests may impact health services demand. Our aim was to produce integrated, comprehensive estimates of the impact of widespread screening on national clinical and economic outcomes and health services demand.

METHODS

We used a Markov model and census data to estimate the national consequences of screening 75% of the US population with conventional and emerging strategies.

RESULTS

Screening decreased CRC incidence by 17%-54% to as few as 66,000 cases per year and CRC mortality by 28%-60% to as few as 23,000 deaths per year. With no screening, total annual national CRC-related expenditures were 8.4 US billion dollars. With screening, expenditures for CRC care decreased by 1.5-4.4 US billion dollars but total expenditures increased to 9.2-15.4 US billion dollars. Screening colonoscopy every 10 years required 8.1 million colonoscopies per year including surveillance, with other strategies requiring 17%-58% as many colonoscopies. With improved screening uptake, total colonoscopy demand increased in general, even assuming substantial use of virtual colonoscopy.

CONCLUSIONS

Despite savings in CRC care, widespread screening is unlikely to be cost saving and may increase national expenditures by 0.8-2.8 US billion dollars per year with conventional tests. The current national endoscopic capacity, as recently estimated, may be adequate to support widespread use of screening colonoscopy in the steady state. The impact of emerging tests on colonoscopy demand will depend on the extent to which they replace screening colonoscopy or increase screening uptake in the population.