Patterns of endoscopy use in the United States

Overall and cause-specific mortality among patients diagnosed with gastric precancerous lesions in Sweden between 1979 and 2014: an observational cohort study

BACKGROUND

The Correa's cascade, encompassing chronic non-atrophic gastritis, atrophic gastritis, intestinal metaplasia, and dysplasia, represents the well-recognized pathway for the development of non-cardia gastric cancer. Population-based studies on all-cause and cause-specific mortalities among patients with gastric lesions in Correa's cascade are scarce.

METHODS

We compiled a cohort of 340 744 eligible patients who had undergone endoscopy with biopsy for non-malignant indications during the period 1979-2011, which was followed up until 2014. Standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) provided estimation of the relative risk, using the general Swedish population as reference. Cox regression model was used to estimate hazard ratios (HRs) of death for internal comparison.

RESULTS

A total of 306 117 patients were included in the final analysis, accumulating 3,049,009 person-years of follow-up. In total 106,625 deaths were observed during the study period. Compared to the general population, excess risks of overall mortality were noted in all subgroups, with SMRs ranging from 1.11 (95% CI 1.08-1.14) for the normal mucosa group to 1.54 (95% CI 1.46-1.62) for the dysplasia group. For cause-specific mortalities, mortality from gastric cancer gradually increased along Correa's cascade, with excess risk rising from 105% for patients with chronic gastritis to more than 600% for the dysplasia group. These results were confirmed in the comparison with the normal mucosa group. For non-cancer conditions, increased death risks were noted for various diseases compared to the general population, especially among patients with more severe gastric precancerous lesions. But the results were confirmed only for "infectious diseases and parasitic diseases", "respiratory system diseases", and "digestive system disease", when using the normal mucosa group as reference.

CONCLUSIONS

Increased mortality from gastric cancer suggests that early recognition and intervention of gastric precancerous lesions probably benefit the patients. Excess mortality due to non-cancer conditions should be interpreted with caution, and future studies are warranted.

Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve three-year adherence to colorectal cancer screening among patients cared for in rural community health centers

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality, yet significant disparities persist among those living in rural areas, from minority backgrounds, and those having low income. The purpose of this two-arm randomized controlled trial is to test the effectiveness and fidelity of a stepped care (increasing intensity as needed) approach to promoting 3-year adherence to CRC screening via fecal immunochemical testing (FIT) or colonoscopy in rural community clinics serving high rates of low-income and minority patients. We hypothesize that, compared to enhanced usual care (EUC), patients receiving the multifaceted CRC screening intervention will demonstrate higher rates of CRC screening completion over 3 years. Participants from six federally qualified health centers (FQHCs; N = 1200 patients) serving predominately low-income populations in rural Louisiana will be randomized to the intervention or EUC arm. All participants will receive health literacy-directed CRC counseling, simplified materials about both the FIT and colonoscopy procedures, and motivational interviewing to aid in the determination of test preference. Participants in the intervention arm will also receive motivational reminder messages from their primary care provider (via audio recording or tailored text) for either a scheduled colonoscopy or return of a completed FIT. Participants in the EUC arm will receive the standard follow-up provided by their clinic or colonoscopy facility. The primary outcome will be completion of either colonoscopy or annual FIT over 3 years. Results will provide evidence on the effectiveness of the intervention to decrease disparities in CRC screening completion related to health literacy, race, and gender. Trial registration:Clinicaltrials.gov Identifier NCT04313114.

≥3 Nonadvanced Adenomas are More Common in the Era of Contemporary Colonoscopy and Not Associated With Metachronous Advanced Neoplasia

INTRODUCTION

Data from standard definition colonoscopy era demonstrate patients with an advanced adenoma (≥10 mm, villous features or high-grade dysplasia) or ≥3 nonadvanced adenomas are considered high-risk for metachronous advanced neoplasia (MAN). Low-risk adenoma (LRA) patients are those with 1 to 2, <10 mm tubular adenomas. High definition colonoscopy, split-dose bowel preparation, and attention to adenoma detection enhance diminutive adenoma detection. We compared baseline adenoma characteristics between patients undergoing colonoscopy in a historic cohort (HC) and contemporary cohort (CC) to determine if number of patients with ≥3 nonadvanced adenomas are increased in CC, and if those features are associated with MAN in CC.

MATERIALS AND METHODS

Patients undergoing their first colonoscopy in HC (<2006) and CC (≥2006) at age 50 and above were identified through natural language processing. Multivariable regression analysis compared baseline adenoma characteristics between HC and CC, and determined the association between baseline characteristics and MAN in CC patients.

RESULTS

In total, 255,074 colonoscopies were performed between 1990 and 2015. A total of 9773 colonoscopies performed in the HC and 59,531 in the CC were included. At baseline, CC patients were more likely to have ≥3 nonadvanced adenomas [odds ratio (OR): 2.1, 95% confidence interval (CI): 1.7-2.6]. In 3,377 CC patients undergoing follow-up colonoscopy, the risk of MAN did not differ between patients with LRA versus those with ≥3 nonadvanced adenomas (6.3% vs. 4.6%, OR: 1.4, CI: 0.58-3.5) including 3-4 (6.1%, OR: 1.4, CI: 0.52-3.6) and ≥5 (7.7%, OR: 1.8, CI: 0.23-14.6), although few patients had ≥5 nonadvanced adenomas.

CONCLUSIONS

Colonoscopy in the contemporary era increases detection of patients with ≥3 nonadvanced adenomas, which do not increase the risk of MAN compared with LRA patients. A similar surveillance to LRA patients should be considered for those patients.

Impact of a Clinical Decision Support System on Guideline Adherence of Surveillance Recommendations for Colonoscopy After Polypectomy

Background: Surveillance colonoscopy is required in patients with polyps due to an elevated colorectal cancer (CRC) risk; however, studies suggest substantial overuse and underuse of surveillance colonoscopy. The goal of this study was to characterize guideline adherence of surveillance recommendations after implementation of an electronic medical record (EMR)-based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS). Methods: We performed a retrospective cohort study of patients who underwent colonoscopy with polypectomy at a safety-net healthcare system before (n=1,822) and after (n=1,320) implementation of CoRS in December 2013. Recommendations were classified as guideline-adherent or nonadherent according to the US Multi-Society Task Force on CRC. We defined surveillance recommendations shorter and longer than guideline recommendations as potential overuse and underuse, respectively. We used multivariable generalized linear mixed models to identify correlates of guideline-adherent recommendations. Results: The proportion of guideline-adherent surveillance recommendations was significantly higher post-CoRS than pre-CoRS (84.6% vs 77.4%; P<.001), with fewer recommendations for potential overuse and underuse. In the post-CoRS period, CoRS was used for 89.8% of cases and, compared with cases for which it was not used, was associated with a higher proportion of guideline-adherent recommendations (87.0% vs 63.4%; RR, 1.34; 95% CI, 1.23-1.42). In multivariable analysis, surveillance recommendations were also more likely to be guideline-adherent in patients with adenomas but less likely among those with fair bowel preparation and those with family history of CRC. Of 203 nonadherent recommendations, 70.4% were considered potential overuse, 20.2% potential underuse, and 9.4% were not provided surveillance recommendations. Conclusions: An EMR-based CoRS was widely used and significantly improved guideline adherence of surveillance recommendations.

Poor Knowledge of Colorectal Cancer Screening and Surveillance Guidelines in a National Cohort of Digestive Disease Specialists

BACKGROUND

Colorectal cancer (CRC) screening is cost-effective and prevents death from CRC if used appropriately. Physicians do not recommend CRC screening according to guidelines. Physician-related factors associated with CRC screening knowledge are unknown.

AIMS

We tested the accuracy of CRC screening knowledge in a nationwide cohort of practicing and trainee physicians and assessed respondent's interest in a mobile app to improve appropriate CRC screening use.

METHODS

An electronic survey was emailed to practicing gastroenterology professionals and medical and surgical trainees. We assessed accuracy of responses compared to CRC screening and surveillance guidelines. We assessed factors associated with higher accuracy of knowledge, frequency of workplace smartphone use, and interest in a smartphone app to aid CRC screening and surveillance recommendations.

RESULTS

In total, 1432 responses were received. Hundred percent accuracy was noted in 22% of respondents for screening and 37% for surveillance. Factors associated with higher accuracy of screening guidelines included more recent training completion; academic practice; performing 21-100 colonoscopies per month (vs. < 21 or > 100). Higher accuracy of surveillance guidelines was associated with more recent training completion; academic practice; being a third-year fellow. In total, 53% use smartphones at least "often" in patient care. In total, 87% would use a CRC screening and surveillance smartphone app.

CONCLUSIONS

Accuracy in applying CRC screening guidelines by gastroenterologists is poor. Smartphone use for patient care is prevalent. Our data show a high interest in a CRC screening/surveillance mobile app. Mobile tools appear an opportunity for rapid access and an increased adherence to CRC screening guidelines.

Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center

BACKGROUND/OBJECTIVES

Noncompliance with physician and procedure appointments is associated with poor disease control and worse disease outcomes. This also impacts the quality of care, decreases efficiency, and affects revenue. Studies have shown that no-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group.

METHODS

We performed a 17-month retrospective observational cohort study of patients scheduled for outpatient procedures in the Gastroenterology endoscopy suite at the University of Florida Health, Jacksonville. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 6157 patients were scheduled to undergo different GI procedures during the study period. A total of 4388 (71%) patients completed their procedure, whereas 2349 (29%) failed to attend their appointment and were considered "no-show". There was a significant relationship between the visit attendance and race, insurance, gender, and marital status. Males had a higher no-show rate compared with females (30% vs. 28%; P<0.05). African Americans had the highest no-show rate (32%; P<0.05) amongst different races. Patients scheduled for surveillance colonoscopy (ie, history of polyps, IBD, Colon cancer) were more likely to show (78%) than those obtaining initial colorectal cancer screening (74%) or other indications (71%) (P<0.05).In the logistic regression model, patients with commercial insurance are more likely to show for their appointments than those with noncommercial insurance (eg, Medicare, Medicaid, City contract etc) [odds ratio (OR), 2.6; 95% confidence interval (CI), 2.2-3.0]. The odds of showing up are 1.7 times higher for married men compared with single men (OR, 1.7; 95% CI, 1.3-2.0). Similarly, married females are more likely to show up for appointment than single females (OR, 1.1; 95% CI, 0.9-1.3). We did not find significant association between the type of GI procedure (eg, colonoscopy vs. esophagogastroduodenoscopy vs. advanced endoscopic procedures) (P>0.05).

CONCLUSIONS

Predictors of no-shows for endoscopic gastrointestinal procedures included unpartnered or single patients, African American race and noncommercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than initial screening. Further studies are required to better characterize these factors and improve adherence to the outpatient appointments based on the identified predictors.

Three-year colonoscopy surveillance after polypectomy in Korea: a Korean Association for the Study of Intestinal Diseases (KASID) multicenter prospective study

Background/Aims

Colonoscopic surveillance is currently recommended after polypectomy owing to the risk of newly developed colonic neoplasia. However, few studies have investigated colonoscopy surveillance in Asia. This multicenter and prospective study was undertaken to assess the incidence of advanced adenoma based on baseline adenoma findings at 3 years after colonoscopic polypectomy.

Methods

A total of 1,323 patients undergoing colonoscopic polypectomy were prospectively assigned to 3-year colonoscopy surveillance at 11 tertiary endoscopic centers. Relative risks for advanced adenoma after 3 years were calculated according to baseline adenoma characteristics.

Results

Among 1,323 patients enrolled, 387 patients (29.3%) were followed up, and the mean follow-up interval was 31.0±9.8 months. The percentage of patients with advanced adenoma on baseline colonoscopy was higher in the surveillance group compared to the non-surveillance group (34.4% vs. 25.7%). Advanced adenoma recurrence was observed in 17 patients (4.4%) at follow-up. The risk of advanced adenoma recurrence was 2 times greater in patients with baseline advanced adenoma than in those with baseline non-advanced adenoma, though the difference was not statistically significant (6.8% [9/133] vs. 3.1% [8/254], P=0.09). Advanced adenoma recurrence was observed only in males and in subjects aged ≥50 years. In contrast, adenoma recurrence was observed in 187 patients (48.3%) at follow-up. Male sex, older age (≥50 years), and multiple adenomas (≥3) at baseline were independent risk factors for adenoma recurrence.

Conclusions

A colonoscopy surveillance interval of 3 years in patients with baseline advanced adenoma can be considered appropriate.

Predictive overbooking and active recruitment increases uptake of endoscopy appointments among African American patients

BACKGROUND AND AIMS

Use of GI endoscopy is historically lower in nonwhite ethnic and racial groups compared with whites. These disparities are multifactorial but likely contribute to differences in GI clinical outcomes. We sought to improve endoscopy uptake overall and in minorities by predictive overbooking and active recruitment in a hospital-based GI clinic.

METHODS

From January to October 2014, we alternated between traditional booking for Veterans Affairs Healthcare Network patients with a physician recommendation for endoscopy and active recruitment of patients to fill projected open endoscopy appointment slots. On intervention weeks, patients attending a GI clinic were given the opportunity to "fast track" to an endoscopy appointment on short notice. During control weeks, patients were not actively recruited. We compared uptake of endoscopy appointments in both groups and performed logistic regression to determine predictors of participation in fast-track active recruitment.

RESULTS

During fast-track active recruitment for endoscopy, the clinic recruited an additional 111 patients for endoscopy over passive recruitment, including 46 African Americans (41.4%). In a logistic regression model controlling for demographic and clinical characteristics, African Americans were twice as likely (adjusted OR, 1.99; 95% CI, 1.26-3.17) than whites to participate in the fast-track option for recommended endoscopy.

CONCLUSIONS

Interventions to actively recruit patients for endoscopy increased the overall percentage of GI clinic patients undergoing endoscopy and disproportionately improved endoscopy appointment uptake in African Americans.

Designing for Spatial Orientation in Endoscopic Environments

Disorientation or “getting lost” in colonoscopy is common experience even for expert endoscopists. This paper describes a new navigational aid display concept for colonoscopy and presents results of an experiment conducted to evaluate the usefulness of various types of spatial information for supporting navigation and spatial orientation in colonoscopy. Six combinations of 1) direction, 2) location, and 3) shape information were tested. Results show that even though the new navigational aid display concept did not improve navigation performance, spatial orientation error and workload were reduced significantly. This new navigational aid display which provides shape combined with location and direction information in a perspective view and in real time is a useful tool for colonoscopy.

Most Premature Surveillance Colonoscopy Is Not Attributable to Bowel Preparation or New Clinical Indications

BACKGROUND AND AIMS

Surveillance colonoscopy frequently occurs prior to recommended intervals. Studies delineating the reasons why premature surveillance occurs are limited. We sought to define the frequency in which premature surveillance colonoscopy occurs in the setting of an inadequate bowel preparation or with a provided patient clinical indication versus when premature surveillance colonoscopy occurs without any provided discernible rationale in the setting of adequate bowel preparation.

METHODS

A retrospective cross-sectional cohort study of 700 patients undergoing colonoscopy for an indication of "surveillance of polyps" from 2008 to 2014 at two tertiary-care referral centers was carried out. Patients were deemed either "adherent" or "premature" based on US Multi-Society Task Force guideline intervals for surveillance colonoscopy. A documented decision-making rationale for premature surveillance was determined through review of the electronic medical record with assessment of clinical notes and endoscopy order and report.

RESULTS

Premature surveillance occurred in 43.0 % (n = 301) of all surveillance colonoscopies performed. Among the premature cases, rationale was attributed to inadequate bowel preparation in 17.3 % (n = 52) and due to a new clinical indication in 21.6 % (n = 65). Most commonly, in 61.1 % (n = 184) of premature cases, no rationale was documented for the early colonoscopy.

CONCLUSIONS

Documented decision-making rationale for premature surveillance colonoscopy is usually absent in premature cases with inadequate bowel preparation and new clinical indications explaining only a minority of the occurrences.

Colonoscopy at a tertiary healthcare facility in Southwest Nigeria: Spectrum of indications and colonic abnormalities

BACKGROUND AND AIM

Colonoscopy is considered the gold standard for diagnosing structural colonic diseases. It is safe and effective both for diagnosis and therapeutic interventions. This study was carried out to evaluate the pattern of indications and spectrum of colonic disease at a tertiary healthcare facility in Southwest Nigeria.

PATIENTS AND METHODS

All consenting patients who were referred for colonoscopy were recruited into the study. A proforma was used to record information such as biodata of the patients, indications for the procedure, and the findings at colonoscopy.

RESULTS

There were 250 patients, comprising 130 (52.0%) males and 120 (48.0%) females, with a male to female ratio of 1.1:1. The mean age of the patients was 57.9 ± 14.2 years with a range of 15-90 years. The most common indication for colonoscopy was hematochezia 85 (34.0%), others were abdominal pain 46 (18.4%), suspected colonic cancer 27 (10.8%), constipation 27 (10.8%), and chronic diarrhea 22 (8.8%). Sixty-five (26%) patients had normal colonoscopy while various abnormalities were detected in 185 (74%) patients. The most common abnormalities were colonic polyps (23.2%), hemorrhoids (20.8%), diverticulosis (14.8%), colorectal tumor (12.1%), and colitis (4.0%).

CONCLUSION

Colonoscopy is an effective means of diagnosing colonic diseases and that the diagnostic yield could be high if the indication were appropriate. The most common indication in our practice was hematochezia, and the most frequent diagnosis was colonic polyps.

Colorectal cancer screening: Estimated future colonoscopy need and current volume and capacity

BACKGROUND

In 2014, a national campaign was launched to increase colorectal cancer (CRC) screening rates in the United States to 80% by 2018; it is unknown whether there is sufficient colonoscopy capacity to reach this goal. This study estimated the number of colonoscopies needed to screen 80% of the eligible population with fecal immunochemical testing (FIT) or colonoscopy and determined whether there was sufficient colonoscopy capacity to meet the need.

METHODS

The Microsimulation Screening Analysis-Colon model was used to simulate CRC screening test use in the United States (2014-2040); the implementation of a national screening program in 2014 with FIT or colonoscopy with 80% participation was assumed. The 2012 Survey of Endoscopic Capacity (SECAP) estimated the number of colonoscopies that were performed and the number that could be performed.

RESULTS

If a national screening program started in 2014, by 2024, approximately 47 million FIT procedures and 5.1 million colonoscopies would be needed annually to screen the eligible population with a program using FIT as the primary screening test; approximately 11 to 13 million colonoscopies would be needed annually to screen the eligible population with a colonoscopy-only screening program. According to the SECAP survey, an estimated 15 million colonoscopies were performed in 2012, and an additional 10.5 million colonoscopies could be performed.

CONCLUSIONS

The estimated colonoscopy capacity is sufficient to screen 80% of the eligible US population with FIT, colonoscopy, or a mix of tests. Future analyses should take into account the geographic distribution of colonoscopy capacity. Cancer 2016;122:2479-86. © 2016 American Cancer Society.

A systematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management

INTRODUCTION

Although uncommon, the incidence of splenic injury from colonoscopy has been increasing significantly since first being reported in 1974. Early recognition is critical because mortality may be as high as 5%.

METHODS

We systematically searched PubMed and EMBASE to identify English-language cases of splenic injury from colonoscopy from inception until January 26, 2015. We used descriptive statistics to characterize the identified cases.

RESULTS

A total of 172 cases from 122 reports were included. The mean age was 64 years and 70.8% were females. Prior abdominal or pelvic surgeries were identified in 63.8%. 57.3% of patients underwent polypectomies or biopsies. There was a statistically significant increase in use of computerized tomography for diagnosis in the past 5 years (81.8% versus 65.2%). 76.1% patients received transfusions. Mean inpatient length of stay was 7.83 ± 5.32 days. A non-significant trend toward conservative management was noted in the past 5 years (37.7% versus 23.1%), and a non-significant drop in mortality was noted (4.9% versus 5.4%).

DISCUSSION

Our data support prior literature suggesting a higher incidence of splenic injuries during colonoscopies in females, advanced age, prior history of abdominal/pelvic surgeries and biopsies/polypectomies during the procedure.

CONCLUSIONS

Significant mortality associated with splenic injuries during colonoscopies warrants prompt recognition of this potentially life threatening, albeit uncommon, complication.

Colorectal cancer screening by colonoscopy: putting it into perspective

Implementation of nationwide screening programs aims to decrease the disease burden of colorectal cancer (CRC) in the general population. Globally, most population screening programs for CRC are carried out by either fecal occult blood test, flexible sigmoidoscopy or colonoscopy. For screening programs with colonoscopy as the primary method, only circumstantial evidence from observational studies is available to prove its effectiveness, suggesting that colonoscopy effectively reduces CRC incidence and mortality. Currently, large randomized trials are being conducted to corroborate these findings. Besides the direct effect of a screening program for CRC, its protective effect is further enhanced by enrolment of patients that underwent polypectomy in surveillance programs. However, despite CRC screening and surveillance colonoscopies, interval CRC still occur. Those are predominantly located in the right-sided colon and potential explanations, besides unfavorable tumor characteristics, are preventable operator-dependent factors relating to the quality of the colonoscopy procedure. In an effort to reduce differences in endoscopists' performance and thereby the occurrence of interval CRC, quality indicators of colonoscopy have been introduced. In addition, emerging advanced colonoscopy techniques might contribute to improvement in polyp detection and removal. Meticulous inspection of the colonic mucosa not only results in the detection of advanced and relevant lesions, but also in the removal of many diminutive and small lesions leading to an increasing number of surveillance colonoscopies, known as the 'high-detection paradox'. More data on the cost-effectiveness of high-quality colonoscopy as a primary screening method and surveillance programs with intervals based on optimal risk stratification are eagerly awaited.

Outreach invitations for FIT and colonoscopy improve colorectal cancer screening rates: A randomized controlled trial in a safety-net health system

BACKGROUND

The effectiveness of colorectal cancer (CRC) screening is limited by underuse, particularly among underserved populations. Among a racially diverse and socioeconomically disadvantaged cohort of patients, the authors compared the effectiveness of fecal immunochemical test (FIT) outreach and colonoscopy outreach to increase screening participation rates, compared with usual visit-based care.

METHODS

Patients aged 50 to 64 years who were not up-to-date with CRC screening but used primary care services in a large safety-net health system were randomly assigned to mailed FIT outreach (2400 patients), mailed colonoscopy outreach (2400 patients), or usual care with opportunistic visit-based screening (1199 patients). Patients who did not respond to outreach invitations within 2 weeks received follow-up telephone reminders. The primary outcome was CRC screening completion within 12 months after randomization.

RESULTS

Baseline patient characteristics across the 3 groups were similar. Using intention-to-screen analysis, screening participation rates were higher for FIT outreach (58.8%) and colonoscopy outreach (42.4%) than usual care (29.6%) (P <.001 for both). Screening participation with FIT outreach was higher than that for colonoscopy outreach (P <.001). Among responders, FIT outreach had a higher percentage of patients who responded before reminders (59.0% vs 29.7%; P <.001). Nearly one-half of patients in the colonoscopy outreach group crossed over to complete FIT via usual care, whereas <5% of patients in the FIT outreach group underwent usual-care colonoscopy.

CONCLUSIONS

Mailed outreach invitations appear to significantly increase CRC screening rates among underserved populations. In the current study, FIT-based outreach was found to be more effective than colonoscopy-based outreach to increase 1-time screening participation. Studies with longer follow-up are needed to compare the effectiveness of outreach strategies for promoting completion of the entire screening process.

Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study

OBJECTIVE

To determine adherence to recommended surveillance intervals in clinical practice.

DESIGN

2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ± 3 months of a 1-year recommended interval and ± 6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2-3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1-2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing.

RESULTS

Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4-5%, p<0.01).

CONCLUSIONS

There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.

Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system

PURPOSE

Appropriate surveillance intervals for colorectal cancer (CRC) screening is one of the Centers for Medicare and Medicaid Services 2014 physician quality reporting system measures. Appropriateness of surveillance intervals will continue to be monitored closely, particularly as reimbursements become tied to quality measures.

AIMS

Quantify and identify predictors for guideline-concordant surveillance recommendations after adenoma polypectomy.

METHODS

We conducted a retrospective cohort study of patients who had colonoscopy with polypectomy at a safety-net health system between June 2011 and December 2013. Surveillance recommendations shorter and longer than guideline recommendations were defined as potential overuse and underuse. We used multivariate logistic regression to identify correlates of guideline-concordant surveillance recommendations, overuse, and underuse.

RESULTS

Among 1,822 patients with polypectomy, 1,329 had ≥1 adenoma. Surveillance interval recommendations were guideline-concordant in 1,410 (77.4%) patients, potential overuse in 263 (14.4%), potential underuse in 85 (4.7%), and missing in 64 (3.5%) patients. Predictors of guideline-concordant recommendations in multivariate analyses included age >65 years (OR 1.36, 95% CI 1.02-1.80), incomplete resection (OR 3.58, 95% CI 1.41-9.09), and good/excellent prep quality (OR 2.22, 95% CI 1.72-2.86). Underuse recommendations were more likely in patients with ≥3 adenomas; overuse recommendations were more likely in patients with high-grade dysplasia or fair prep quality and less likely in those with piecemeal resection, ≥3 adenomas, age >65, or Hispanic ethnicity.

CONCLUSIONS

Surveillance recommendations are not concordant with guidelines in one of four cases. Interventions to improve prep quality and guideline concordance of surveillance recommendations can improve cost-effectiveness of CRC screening.

Postcolonoscopy Followup Recommendations: Comparison with and without Use of Polyp Pathology

Background. Appropriate recommendations for a followup exam after an index colonoscopy are an important quality indicator. Lack of knowledge of polyp pathology at the time of colonoscopy may be one reason that followup recommendations are not made. Aim. To describe and compare the accuracy of followup recommendations made at colonoscopy based on the size and number of polyps with recommendations made at a later date based on actual polyp pathology. Methods. All patients who underwent screening and surveillance colonoscopy from March, 2012, to August, 2012, were included. Surveillance recommendations from the endoscopy reports were graded as “accurate” or “not accurate” based on the postpolypectomy surveillance guidelines established by US Multisociety Task Force on Colon Cancer. Polyp pathology was then used to regrade the surveillance recommendations. Results. Followup recommendations were accurate in 759/884 (86%) of the study colonoscopies, based upon size and number of polyps with the assumption that all polyps were adenomatous. After incorporating actual polyp pathology, 717/884 (81%) colonoscopies had accurate recommendations. Conclusion. In our practice, the knowledge of actual polyp pathology does not change the surveillance recommendations made at the time of colonoscopy in the majority of patients.

Adherence to physician recommendations for surveillance in opportunistic colorectal cancer screening: the necessity of organized surveillance

Background

Limited evidence exists on the utilization of surveillance colonoscopy in colorectal cancer (CRC) screening programs. We assessed adherence to physician recommendations for surveillance in opportunistic CRC screening in Germany.

Methods

A follow-up study of screening colonoscopy participants in 2007-2009 in Saarland, Germany, was conducted using health insurance claims data. Utilization of additional colonoscopies through to 2011 was ascertained. Adherence to surveillance intervals of 3, 6, 12 and 36 months, defined as having had colonoscopy at 2.5 to 4, 5 to 8, 10.5 to 16 and 33 to 48 months, respectively (i.e., tolerating a delay of 33% of each interval) was assessed. Potential predictors of non-adherence were investigated using logistic regression analysis.

Results

A total of 20,058 screening colonoscopy participants were included in the study. Of those with recommended surveillance intervals of 3, 6, 12 and 36 months, 46.5% (95%-confidence interval [CI]: 37.3-55.7%), 38.5% (95%-CI: 29.6-47.3%), 25.4% (95%-CI: 21.2-29.6%) and 28.0% (95%-CI: 25.5-30.5%), respectively, had a subsequent colonoscopy within the specified margins. Old age, longer recommended surveillance interval, not having had polypectomy at screening and negative colonoscopy were statistically significant predictors of non-adherence.

Conclusion

This study suggests frequent non-adherence to physician recommendations for surveillance colonoscopy in community practice. Increased efforts to improve adherence, including introduction of more elements of an organized screening program, seem necessary to assure a high-quality CRC screening process.

Shortened surveillance intervals following suboptimal bowel preparation for colonoscopy: results of a national survey

PURPOSE

Suboptimal bowel preparation can result in decreased neoplasia detection, shortened surveillance intervals, and increased costs. We assessed bowel preparation recommendations and the relationship to self-reported proportion of suboptimal bowel preparations in practice; and evaluated the impact of suboptimal bowel preparation on colonoscopy surveillance practices. A random sample of a national organization of gastroenterologists in the U.S. was surveyed.

METHODS

Demographic and practice characteristics, bowel preparation regimens, and proportion of suboptimal bowel preparations in practice were ascertained. Recommended follow-up colonoscopy intervals were evaluated for optimal and suboptimal bowel preparation and select clinical scenarios.

RESULTS

We identified 6,777 physicians, of which 1,354 were randomly selected; 999 were eligible, and 288 completed the survey. Higher proportion of suboptimal bowel preparations/week (≥10 %) was associated with hospital/university practice, teaching hospital affiliation, >25 % Medicaid insured patients, recommendation of PEG alone and sulfate-free. Those reporting >25 % Medicare and privately insured patients, split dose recommendation, and use of MoviPrep® were associated with a <10 % suboptimal bowel preparations/week. Shorter surveillance intervals for three clinical scenarios were reported for suboptimal preparations and were shortest among participants in the Northeast who more often recommended early follow-up for normal findings and small adenomas. Those who recommended 4-l PEG alone more often advised <1 year surveillance interval for a large adenoma.

CONCLUSIONS

Our study demonstrates significantly shortened surveillance interval recommendations for suboptimal bowel preparation and that these interval recommendations vary regionally in the United States. Findings suggest an interrelationship between dietary restriction, purgative type, and practice and patient characteristics that warrant additional research.

Overutilization of post-polypectomy surveillance colonoscopy in clinical practice: a prospective, multicentre study

BACKGROUND

Although the adherence to post-polipectomy recommendations is advocated as a quality indicator of colonoscopy programmes, prospective data on actual use of surveillance are lacking.

AIM

To evaluate the appropriateness of post-polypectomy surveillance colonoscopy on a community-wide basis and to identify factors associated with it.

METHODS

Data on consecutive post-polypectomy surveillance examinations performed over a 4-week period in 29 Italian endoscopy units were collected. The time interval between index and surveillance colonoscopy was calculated and compared to guidelines recommendations. Determinants of surveillance timing appropriateness were assessed by logistic step-wise regression.

RESULTS

Of 7081 consecutive outpatients, 1218 (17.2%) were referred for post-polypectomy surveillance and 902 were included into the analysis. Surveillance colonoscopy was prescribed correctly in 330 subjects (36.6%) and earlier than recommended by guidelines in 490 (54.3%). Low-risk subjects had an anticipated surveillance colonoscopy more frequently than global cohort (67.4% vs. 54.3%, p<0.001). At multivariate analysis, determinants of correct surveillance timing were high-volume workload centres (OR 1.92; 1.41-2.63 95%CI), centres providing written recommendation on surveillance interval (OR 1.70; 1.18-2.58 95%CI) and surveillance examinations performed within the national screening programme (OR 2.62; 1.92-3.59 95%CI).

CONCLUSIONS

In community practice, post-polipectomy surveillance colonoscopy is often performed earlier than recommended, especially in low-risk subjects. Interventions to improve adherence to guidelines and to reduce unnecessary examinations are needed.

Concerns and challenges in flexible sigmoidoscopy screening

In 1992, two well-conducted case-control studies used data from two different health maintenance organizations and demonstrated a 59-79% reduction in mortality from colorectal cancer (CRC) following exposure to sigmoidoscopy. These studies highlight the possibility of reducing mortality from CRC using population-based endoscopic screening. The development of fiber optics improved the technology, and the ease of performing flexible sigmoidoscopy (FS) with widespread adoption of this screening modality. To date, FS is the only endoscopic screening modality that has been shown to reduce mortality in randomized clinical trials. This article reviews the development of sigmoidoscopy, its use in CRC screening and the current reduced role of this proven screening modality, and explores new frontiers for population-based FS screening.

Splenic injury during colonoscopy--a complication that warrants urgent attention

INTRODUCTION

Colonoscopy is a safe procedure that is performed routinely worldwide. There is, however, a small but significant risk of splenic injury that is often under-recognized. Due to a lack of awareness about this injury, the diagnosis may be delayed, which can lead to an increased risk of morbidity as well as mortality. This paper presents a comprehensive review of the medical literature on colonoscopy-associated splenic injury and describes the clinical presentation and management of this rare but potentially life-threatening complication.

MATERIALS AND METHODS

A comprehensive literature search identified 102 patients worldwide, including patients from our experience, with splenic injury during colonoscopy. A meta-regression analysis was completed using a mixed generalized linear model for repeated measures to identify risk factors for this rare complication.

RESULTS

A total of 75 articles were identified and 102 patients were studied. The majority of the papers were in English (92 %). Only 23.4 % of patients (26/102) were reported prior to the year 2000. Among the patients reported after the year 2000, the majority (84.2 %, 64/76) were reported after 2005. There were more females (76.5 %), median age was 65 years (range, 29-90 years), and most of the colonoscopies were performed without difficulty (66.6 %). Nearly 67 % of patients presented within 24 h of colonoscopy with complaints ranging from abdominal pain to dizziness. The most common symptom was left upper quadrant pain (58 %), and CT scan was found to be the most sensitive tool for diagnosis. Seventy-three patients underwent operative intervention; 96 % of these were treated with splenectomy. Hemoglobin drop of more than 3 gm/dL was identified as the only significant predictor of operative intervention. The overall mortality rate was 5 %.

CONCLUSION

Splenic injury during colonoscopy is rare; however, it is associated with significant morbidity and mortality. Splenic injury warrants a high degree of clinical suspicion critical to prompt diagnosis, and early surgical consultation is warranted.

Diagnostic yield of colonoscopy to evaluate melena after a nondiagnostic EGD

BACKGROUND

Melena can be caused by bleeding from lower GI sources. Colonoscopy is frequently used to investigate melena after a nondiagnostic EGD.

OBJECTIVE

To determine the diagnostic yield and rate of therapeutic intervention during colonoscopy in patients with melena and a nondiagnostic EGD.

DESIGN

Retrospective case-control study.

SETTING

Community and academic centers over a diverse geographic area in the United States.

PATIENTS

This study involved patients in the Clinical Outcomes Research Initiative database with a colonoscopy performed to investigate melena within 30 days of a nondiagnostic EGD for the same indication. A control group had colonoscopies performed for average-risk screening.

MAIN OUTCOME MEASUREMENTS

The endoscopic finding of a suspected bleeding source defined as right-sided arteriovenous malformation, colitis, polyp ≥ 20 mm, tumor, or ulcer. Rate of therapeutic intervention during colonoscopy.

RESULTS

Colonoscopy found a suspected bleeding source in 4.8% of patients with melena, more frequently than in the control group (odds ratio [OR] 2.17; 95% confidence interval [CI], 1.65-2.86; P < .0001). The rate of therapeutic intervention during melena-related colonoscopy was 1.7%. Patients with melena were more likely to have a colon tumor (OR 2.87; 95% CI, 1.82-5.51; P < .0001) than were control patients.

LIMITATIONS

Retrospective design, conclusions being dependent on the accuracy of database input, and lack of pertinent clinical data (eg, hemoglobin).

CONCLUSION

The diagnostic yield of colonoscopy to investigate melena after nondiagnostic EGD is low. The need for therapeutic intervention during colonoscopy for this indication is very low. This population should undergo colonoscopy because they are at increased risk of colorectal cancer. Colonoscopy can potentially be performed electively in stable patients without continued bleeding.

Reflux and sex: what drives testing, what drives treatment?

Gastroesophageal reflux (GER) affects ∼10-20% of American adults. Although symptoms are equally common in men and women, we hypothesized that sex influences diagnostic and therapeutic approaches in patients with GER. PubMed database between 1997 and October 2011 was searched for English language studies describing symptoms, consultative visits, endoscopic findings, use and results of ambulatory pH study, and surgical therapy for GER. Using data from Nationwide Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we determined the sex distribution for admissions and reflux surgery between 1997 and 2008. Studies on symptoms or consultative visits did not show sex-specific differences. Even though women are less likely to have esophagitis or Barrett's esophagus, endoscopic studies enrolled as many women as men, and women were more likely to undergo ambulatory pH studies with a female predominance in studies from the US. Surgical GER treatment is more commonly performed in men. However, studies from the US showed an equal sex distribution, with Nationwide Inpatient Sample data demonstrating an increase in women who accounted for 63% of the annual fundoplications in 2008. Despite less common or severe mucosal disease, women are more likely to undergo invasive diagnostic testing. In the US, women are also more likely to undergo antireflux surgery. These results suggest that healthcare-seeking behavior and socioeconomic factors rather than the biology of disease influence the clinical approaches to reflux disease.

Portal hypertensive colopathy and haematochezia in cirrhotic patients: an endoscopic study

BACKGROUND AND STUDY AIMS

In patients with liver cirrhosis, portal hypertensive colopathy (PHC) and anorectal varices (ARVs) are thought to cause lower gastrointestinal (GI) bleeding. In the present work, we studied the diagnostic yield of colonoscopy in cirrhotic patients and haematochezia.

PATIENTS AND METHODS

The current study was conducted on 77 consecutive cirrhotic patients who underwent colonoscopy at Mansoura Emergency Hospital, Egypt, between May 2007 and May 2011. Following rapid evaluation and adequate resuscitation, a thorough history was obtained with complete physical examination including digital rectal examination and routine laboratory investigations. Colonoscopic evaluation was performed for the included patients by recording endoscopic abnormalities and obtaining biopsies from lesions.

RESULTS

There was no significant difference between the PHC-positive group when compared with the PHC-negative group regarding patients' age, sex, severity of haematochezia, positive family history and the history of intake of non-steroidal anti-inflammatory drugs (NSAIDs). Significant difference was noted regarding the Child-Pugh class (p<0.05), history of splenectomy (p<0.05), prior history of endoscopic sclerotherapy (EST) or endoscopic variceal ligation (EVL) (p<0.05), prior history of upper gut bleeding (p<0.05), the presence of gastric varices (GVs) (p<0.05), presence of portal hypertensive gastropathy (PHG) (p<0.05), presence of haemorrhoids (p<0.05) and rectal varices (<0.05) and therapy with β-blockers (p<0.05). Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation. Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p<0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.

CONCLUSION

Our data revealed that it is not only PHC which is involved in haematochezia in cirrhotic patients despite the significant association. Instead, a high prevalence of inflammatory lesions came on the top of the list. Complete colonoscopy is highly advocated to detect probable proximal neoplastic lesions.

Endoscopic findings in patients presenting with dysphagia: analysis of a national endoscopy database

Dysphagia is a common problem and an indication for upper endoscopy. There is no data on the frequency of the different endoscopic findings and whether they change according to demographics or by single versus repeat endoscopy. To determine the prevalence of endoscopic findings in patients with dysphagia and whether findings differ in regard to age, gender, ethnicity, and repeat procedure. This was a retrospective study using a national endoscopic database (CORI). A total of 30,377 patients underwent esophagogastroduodenoscopy (EGD) for dysphagia of which 4,202 patients were repeat endoscopies. Overall frequency of endoscopic findings was determined by gender, age, ethnicity, and single vs. repeat procedures. Esophageal stricture was the most common finding followed by normal, esophagitis/ulcer (EU), Schatzki ring (SR), esophageal food impaction (EFI), and suspected malignancy. Males were more likely to undergo repeat endoscopies and more likely to have stricture, EU, EFI, and suspected malignancy (P = 0.001). Patients 60 years or older had a higher prevalence of stricture, EU, SR, and suspected malignancy (P < 0.0001). Esophageal stricture was most common in white non-Hispanic patients compared to other ethnic groups. In patients undergoing repeat EGD, stricture, SR, EFI, and suspected malignancy were more common (P < 0.0001). The prevalence of endoscopic findings differs significantly by gender, age, and repeat procedure. The most common findings in descending order were stricture, normal, EU, SR, EFI, and suspected malignancy. For patients undergoing a repeat procedure, normal and EU were less common and all other abnormal findings were significantly more common.

A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre

BACKGROUND

The appropriateness and safety of open-access endoscopy are very important issues as its use continues to increase.

OBJECTIVE

To present a review of a nine-year experience with open-access upper gastrointestinal endoscopy with respect to indications, diagnostic efficacy, safety and diseases diagnosed.

METHODS

A retrospective, observational case series of all patients who underwent open-access endoscopy between January 2000 and December 2008 was conducted. Indications were classified as appropriate or not appropriate according to American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic diagnoses were based on widely accepted criteria. Major complication rates were assessed.

RESULTS

A total of 20,620 patients with a mean age of 58 years were assessed, of whom 11,589 (56.2%) were women and 9031 (43.8%) were men. Adherence to ASGE indications led to statistically significant, clinically relevant findings. The most common indications in patients older than age 45 years of age were dyspepsia (28.5%) and anemia (19.7%) in the ASGE-appropriate group, and dyspepsia in patients younger than 45 years of age without therapy trial (6.6%) in the nonappropriate group. Of the examinations, 38.57% were normal. Hiatal hernia and nonerosive gastritis were the most common findings. Important diagnoses such as malignancies and duodenal ulcers would have been missed if endoscopies were performed only according to appropriateness. There were only two major complications and no mortalities.

CONCLUSIONS

Open-access upper gastrointestinal endoscopy is a safe and effective system. More relevant findings were found when adhering to the ASGE guidelines. However, using these guidelines as the sole determining factor in whether to perform an endoscopy is not advisable because many clinically relevant diagnoses may be overlooked.

Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program--Endoscopy

BACKGROUND

Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.

OBJECTIVE

To evaluate a colonoscopists' practice audit tool that provides point-of-care data collection and peer-comparator feedback.

METHODS

A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smartphones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.

RESULTS

Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference -11.3% [95% CI -2.8% to -19.9%]; P=0.01).

DISCUSSION

Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.

CONCLUSION

Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.

Surveillance colonoscopy is cost-effective for patients with adenomas who are at high risk of colorectal cancer

BACKGROUND & AIMS

Guidelines recommend that patients with colon adenomas undergo periodic surveillance colonoscopy. The purpose of this study was to estimate the cost-effectiveness of these recommendations.

METHODS

We developed a Markov model to study various surveillance strategies from the perspective of a long-term payer. We modeled a cohort of 50-year-old patients with newly diagnosed adenomas, following them until death. Thirty percent of the population was assumed to be at high risk for colorectal cancer. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) were measured.

RESULTS

Performing colonoscopies every 3 years in high-risk patients and every 10 years in low-risk patients (3/10 strategy) was more costly but also more effective than no surveillance, with an ICER of $5,743 per QALY gained. Compared with this 3/10 strategy, a 3/5 strategy was considerably more costly but only marginally more effective, with an ICER of $296,266 per QALY. A 3/3 strategy was more costly and less effective than a 3/5 strategy (dominated). Results were most sensitive to the annual probability of advanced adenoma formation and the relative risk (RR) of advanced adenoma formation in high-risk versus low-risk patients. Assuming that the probability of advanced adenoma formation was 1.3% per year (base: 0.5%), the ICER of the 3/5 strategy was <$50,000 per QALY gained if the RR of advanced adenoma formation was <2.4 (base: 3.9).

CONCLUSIONS

Surveillance colonoscopy is cost-effective for patients who are at high risk for developing colorectal cancer. Aggressive surveillance can be expensive or even harmful; efforts should be made to improve risk models for colonic neoplasia.

Utilization of surveillance colonoscopy in community practice

BACKGROUND & AIMS

The recommended timing of surveillance colonoscopy for individuals with adenomatous polyps is based on adenoma histology, size, and number. The burden and cost of surveillance colonoscopy are significant. The aim of this study was to examine the use of surveillance colonoscopy on a community-wide basis.

METHODS

We retrospectively queried participants in the Prostate, Lung, Colorectal, and Ovarian Cancer screening trial in 9 US communities about use of surveillance colonoscopy. Subjects whose initial colonoscopy showed advanced adenoma (AA), nonadvanced adenoma (NAA), or no adenoma (NA) findings were included. Colonoscopy examinations were confirmed by reviewing colonoscopy reports.

RESULTS

Of 3876 subjects selected for inquiry, 3627 (93.6%) responded. The cumulative probability of a surveillance colonoscopy within 5 years was 58.4% (n = 1342) in the AA group, 57.5% in those with >or=3 NAAs (n = 117), 46.7% in those with 1-2 NAAs (n = 905), and 26.5% (n = 1263) in subjects with NAs. Within 7 years, 33.2% of subjects with AAs received >or=2 surveillance examinations versus 26.9% for those with >or=3 NAAs, 18.2% for those with 1 or 2 NAAs, and 10.4% for those with NAs. Incomplete colonoscopy, family history of colorectal cancer, or interval adenomatous findings could explain only a minority of surveillance colonoscopy in low-risk subjects.

CONCLUSIONS

In community practice, there is substantial overuse of surveillance colonoscopy among low-risk subjects and underuse among subjects with AAs. Interventions to better align use of surveillance colonoscopy with risk for advanced lesions are needed.

Endoscopic hemostasis in nonvariceal upper gastrointestinal bleeding: comparison of physician practice in the East and the West

BACKGROUND

Endoscopic hemostasis is commonly practiced during GI endoscopy practice. We hypothesized that, because the choice of endoscopic intervention is influenced by many factors, for example personal experience, prior training, guidelines, etc., there would be differences in practice patterns among different groups of endoscopists.

OBJECTIVE

To explore the potentially different practices for endoscopic hemostasis between the "East" (eight Asian countries) and the "West" (USA and Canada).

DESIGN

Cross-sectional descriptive study (internet-based survey).

STUDY SUBJECTS

We administered a questionnaire survey to American Society of Gastrointestinal Endoscopy (ASGE) and Korean Society of Gastroenterology (KSGE) members (see: http://www4.utsouthwestern.edu/inetdemo/endoscopy/hemostasis.html , or supplementary paper for review online).

RESULTS

Eastern ASGE members (n = 112) were more likely to complete this survey than ASGE members in the West (n = 180): 15.1 vs. 5.0%, P < 0.001. Choice of hemostatic method, regardless of primary or recurrent bleeding, varied significantly among Eastern and Western endoscopists. For example, for treatment of a gastric ulcer with a visible vessel, a vast majority (70%) of Western endoscopists preferred pre-injection followed by thermocoagulation whereas responses from the East were more diverse, with endoclip application +/- pre-injection being the top choice (29%) (P < 0.001). Personal EGD volume and hospital bed numbers did not seem to be associated with hemostatic choices in either the East or the West.

CONCLUSIONS

Endoscopic hemostasis practice patterns for upper GI tract bleeding differed among Eastern and Western endoscopists, suggesting fundamental differences in practice habit determinants.

Why don't gastroenterologists follow colon polyp surveillance guidelines?: results of a national survey

GOALS

To measure knowledge and acceptance of colon polyp surveillance guidelines among gastroenterologists.

BACKGROUND

Gastroenterologists often perform surveillance colonoscopy sooner than recommended by guidelines. Lack of knowledge may be an important factor, but gastroenterologists could also simply disagree with guideline recommendations.

STUDY

A 24-item multiple-choice survey was developed from the 2003 multisociety colorectal cancer screening and surveillance guideline. The survey was distributed to practicing gastroenterologists preparing for the gastroenterology board recertification examination at 2 major national gastroenterology board review courses. For each question, subjects were given a clinical scenario and asked: (1) the guideline recommendation for the scenario; (2) their usual practice in the scenario; and, (3) if they definitely knew the recommendation or were simply guessing at the correct answer. If a respondent knew the recommendation but differed in their usual practice, this was considered disagreement with the recommendation.

RESULTS

The survey was completed by 57.1% (116/203) of gastroenterologists preparing for 2004 recertification. Seventy-eight percent reported that they were familiar with the 2003 guideline, though only 57% reported that guidelines were "very influential" in their practice. Many did not correctly answer questions on the recommended interval for hyperplastic polyps (12%), 2 small adenomas (36%), 3 small adenomas (49%), and adenoma with high-grade dysplasia (41%). Of gastroenterologists who knew the guideline recommendations, up to 76% disagreed with the recommendations and chose to perform surveillance sooner than recommended.

CONCLUSIONS

Though many gastroenterologists lack knowledge about guideline recommendations for colon polyp surveillance, even those who know the recommendations often ignore them and perform surveillance colonoscopy sooner than recommended.

Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms

BACKGROUND & AIMS

Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy.

METHODS

We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment.

RESULTS

Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer.

CONCLUSIONS

Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.

Development and validation of a colon cancer risk assessment tool for patients undergoing colonoscopy

OBJECTIVES

Diagnostic criteria for hereditary colorectal cancer (CRC) are complex. "Open-access" colonoscopy makes it challenging to identify who needs genetic evaluation, intensive surveillance, and screening for extracolonic tumors. Our aim was to develop a simple, preprocedural risk assessment tool to identify who may be at highest risk for CRC.

METHODS

A total of 631 outpatients undergoing colonoscopy at two academic practices completed a questionnaire assessing personal and family histories of CRC, polyps, and Lynch syndrome (LS)-associated malignancies. Subjects were considered to be high-risk if one of the nine prespecified characteristics of hereditary CRC syndromes was met. Through recursive partitioning analysis, an algorithm of fewest questions needed to capture the most high-risk individuals was developed. The results were validated in 5,335 individuals undergoing colonoscopy at five private endoscopy centers and tested in 285 carriers of mismatch repair mutations associated with LS.

RESULTS

About 17.7% and 20.0% of individuals were classified as high-risk in the development and validation cohorts, respectively. Recursive partitioning revealed three questions that were most informative for identifying high-risk patients: (i) "Do you have a first-degree relative with CRC or LS-related cancer diagnosed before age 50?" (ii) "Have you had CRC or polyps diagnosed before age 50?" (iii) "Do you have > or =3 relatives with CRC?" When asked successively, these questions identified 77% of high-risk individuals in both cohorts and 271 of 285 (95%) of mutation carriers.

CONCLUSIONS

Approximately one in five individuals undergoing colonoscopy would benefit from further risk assessment. We developed a simple, three-question CRC Risk Assessment Tool to identify the majority of patients who require additional assessment and possible genetic evaluation.

Utilization and yield of surveillance colonoscopy in the continued follow-up study of the polyp prevention trial

BACKGROUND AND AIMS

Prospective information on the use and yield of surveillance colonoscopy is limited. We examined the use and yield of surveillance colonoscopy among participants in the Polyp Prevention Trial (PPT) after the 4-year dietary intervention trial ended.

METHODS

We followed a cohort of 1297 participants. We calculated the cumulative probability of posttrial colonoscopy and investigated the yield and predictive factors for adenoma and advanced adenoma recurrence over a mean time of 5.9 years.

RESULTS

Seven-hundred seventy-four subjects (59.7%) had a repeat colonoscopy. Among 431 subjects with low-risk adenomas (1-2 nonadvanced adenomas) at baseline and no adenoma recurrence at the end of the PPT (lowest-risk category), 30.3% underwent a repeat colonoscopy within 4 years. Among 55 subjects who had high-risk adenomas (advanced adenoma and/or > or =3 nonadvanced adenomas) at baseline and again at the final PPT colonoscopy (highest-risk category), 41.3% had a colonoscopy within 3 years and 63.5% had an examination within 5 years. The cumulative yield of advanced adenoma through 6 years was 3.6% for the lowest-risk category, 38.9% for the highest-risk category, and ranged from 6.6% to 13.8% for intermediate-risk categories. An advanced adenoma at the final PPT colonoscopy was associated significantly with an advanced adenoma recurrence during surveillance (hazard ratio, 6.2; 95% confidence interval, 2.5-15.4).

CONCLUSIONS

Surveillance colonoscopy was overused for low-risk subjects and underused for high-risk subjects. Advanced adenoma yield corresponded with the adenoma risk category. Resource consumption can be better managed by aligning use with the risk of adenoma recurrence.

Capacity for colorectal cancer screening by colonoscopy, Montana, 2008

BACKGROUND

Colorectal cancer is largely preventable by screening, but screening participation is low in Montana. Colonoscopy is often considered the most accurate screening test and has the potential to prevent colon cancer by pre-emptive removal of polyps. However, colonoscopy may not be equally available to all residents of rural states. The Montana Department of Public Health and Human Services (DPHHS) has assigned high priority to colorectal cancer prevention, but before beginning a campaign to increase screening, DPHHS conducted a survey to determine existing colonoscopy screening capacity.

METHODS

An eight-question survey was sent by DPHHS to all hospitals and ambulatory surgical centers that perform colonoscopy in Montana, assessing their current and projected capacity to perform screening colonoscopies. Data were collected from March to May 2008, and analysis was performed in June 2008.

RESULTS

Responses were received from 43 of 44 hospitals and ambulatory surgical centers performing colonoscopies in Montana. The number of screening colonoscopies performed was estimated to be 19,444 per year. Unused colonoscopy screening capacity was estimated to be 23,096 procedures per year. Although similar total capacity existed in urban and rural areas, more unused capacity existed in rural areas.

CONCLUSIONS

Montana has statewide capacity to meet moderately increased demand for screening colonoscopy but would be able to meet only 17% of demand in 2009 if all eligible adults chose colonoscopy as their primary form of screening. It is feasible to develop campaigns to increase screening colonoscopy participation now, but a systematic combination of colonoscopy and other screening modalities may be better able to meet Montana's long-term needs.

Design of a Compliant Endoscopic Suturing Instrument

This paper describes the initial design and optimization of a compliant endoscopic suturing instrument. The emerging field of Natural Orifice Transluminal Endoscopic Surgery (NOTES) requires innovative instruments to meet the size limitations inherent in this type of minimally invasive surgery; using compliant mechanisms is proposed as one method of meeting this requirement. The compliant design was modeled and optimized to maximize the distal opening and provide a puncture force of at least 4.6N, while being small enough to fit within a 3.3mm working channel. The design utilizes contact for stress relief and intertwining parts for added deflection. ANSYS® was used for finite element analysis including contact and nonlinear deformations. A prototype was fabricated from the optimized geometry and experimentally tested. The best geometry is predicted to have a distal opening of 14.6mm at the tips and supply a puncturing force of 4.83N. The force supplied at the tip was measured and was found to exceed the required 4.6N. The prototype successfully passed two complete sutures and qualitative results are provided. The results of the study will lead to further refinements and improvements in future designs.

Colonoscopy and flexible sigmoidoscopy practice patterns in Ontario: a population-based study

OBJECTIVE

To conduct a population-based study on the provision of large bowel endoscopic services in Ontario.

METHODS

Data from the following databases were analyzed: the Ontario Health Insurance Plan, the Institute for Clinical Evaluative Sciences Physicians Database and Statistics Canada. The flexible sigmoidoscopy and colonoscopy rates per 10,000 persons (50 to 74 years of age) by region between April 1, 2001, and March 31, 2002, were calculated, as well as the numbers and types of physicians who performed each procedure.

RESULTS

In 2001/2002, a total of 172,108 colonoscopies and 43,400 flexible sigmoidoscopies were performed in Ontario for all age groups. The colonoscopy rate was approximately five times that of flexible sigmoidoscopy; rates varied from 463.1 colonoscopies per 10,000 people in the north to 286.8 colonoscopies per 10,000 people in the east. Gastroenterologists in all regions tended to perform more procedures per physician, but because of the large number of general surgeons, the total number of procedures performed by each group was almost the same.

CONCLUSION

Population-based rates of colonoscopies and flexible sigmoidoscopies are low in Ontario, as are the procedure volumes of approximately one-quarter of physicians.

Factors associated with the technical performance of colonoscopy: An EPAGE Study

BACKGROUND

Variations in colonoscopy practice exist, which may be related to healthcare quality.

AIMS

To determine factors associated with three performance indicators of colonoscopy: complete colonoscopy, adenomatous polyp diagnosis, and duration.

PATIENTS

Consecutive patients referred for colonoscopy from 21 centres in 11 countries.

METHODS

This prospective observational study used multiple variable regression analyses to identify determinants of the quality indicators.

RESULTS

Six thousand and four patients were included in the study. Patients from private, open-access centres (odds ratio: 3.17, 95% confidence interval: 1.87-5.38) were more likely to have a complete colonoscopy than patients from public, gatekeeper centres. Patients from centres where over 50% of the endoscopists were of senior rank were roughly twice as likely to have an adenoma diagnosed, and longer average withdrawal duration (odds ratio: 1.08, 95% confidence interval: 1.07-1.09) was associated with more frequent adenoma diagnoses. Patients who had difficulty during colonoscopy had longer durations to caecum (time ratio: 2.87, 95% confidence interval: 2.72-3.01) and withdrawal durations (time ratio: 1.26, 95% confidence interval: 1.18-1.33) than patients who had no difficulties.

CONCLUSIONS

Multiple factors have been identified as being associated with key quality indicators. The non-modifiable factors permit the identification of patients who may be at greater risk of not having quality colonoscopy, while changes to the modifiable factors may help improve the quality of colonoscopy.

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.

Variations in colonoscopy practice in Europe: a multicentre descriptive study (EPAGE)

OBJECTIVE

The volume of colonoscopies performed is increasing and differences in colonoscopy practice over time and between centres have been reported. Examination of current practice is important for bench-marking quality. The objective of this study was to examine variations in colonoscopy practice in endoscopy centres internationally.

MATERIAL AND METHODS

This observational study prospectively included consecutive patients referred for colonoscopy from 21 centres in 11 countries. Patient, procedure and centre characteristics were collected through questionnaires. Descriptive statistics were performed and the variation between centres while controlling for case-mix was examined.

RESULTS

A total of 6004 patients were included in the study. Most colonoscopies (93%; range between centres 70-100%) were performed for diagnostic purposes. The proportion of main indications for colonoscopy showed wide variations between centres, the two most common indications, surveillance and haematochezia, ranging between 7-24% and 5-38%, respectively. High-quality cleansing occurred in 74% (range 51-94%) of patients, and 30% (range 0-100%) of patients received deep sedation. Three-quarters (range 0-100%) of the patients were monitored during colonoscopy, and one-quarter (range 14-35%) underwent polypectomy. Colonoscopy was complete in 89% (range 69-98%) of patients and the median total duration was 20 min (range of centre medians 15-30 min). The variation between centres was not reduced when case-mix was controlled for.

CONCLUSIONS

This study documented wide variations in colonoscopy practice between centres. Controlling for case-mix did not remove these variations, indicating that centre and procedure characteristics play a role. Centres generally were within the existing guidelines, although there is still some work to be done to ensure that all centres attain the goal of providing high-quality colonoscopy.

Colonoscopic evaluation of hematochezia in low and average risk patients for colorectal cancer: A prospective study

AIM: To relate the endoscopic findings in patients with hematochezia with regard to age in “low and average risk” for colorectal cancer (CRC) and to localize significant lesions in order to identify patients who need sigmoidoscopy or total colonoscopy.

METHODS: This prospective study was performed in an open access GI endoscopy unit. Out of 4322 consecutive patients undergoing colonoscopy, 918 reported hematochezia. The final study group comprized 180 patients aged below 45 and 237 over 45. Main exclusion criteria were a 1^st-degree family history of colorectal carcinoma, patients reporting blood mixed with stools and/or progressive colonic symptoms, or patients who had undergone colon surgery for neoplastic lesions.

RESULTS: Total colonoscopy could be performed in 96% of patients. Abnormal findings were observed in 34.3% of the younger and in 65.7% of the older ones. Findings were the presence of polyps in the distal colon (n = 2) and IBD in the proximal colon (n = 29) in the group of the younger patients, and polyps (n = 15), IBD (n = 13), and carcinoma (n = 6, 4 of the lesions were located proximal to the splenic flexure) in the elderly. Our findings suggest that the diagnostic potential of total colonoscopy in patients younger than 45 referring scant hematochezia, is not mandatory. By exploring only the distal tract of the colon we have misdiagnosed two cases of IBD located in the ascending colon. In this group of patients additional risk factors must be identified before performing a total colonoscopy. Regarding the patients older than 45 yr, the exploration of the distal colon would have led to our overlooking a carcinoma, two neoplastic polyps and one IBD located in the proximal colon.

CONCLUSION: Young patients with scant hematochezia but without risk factors for neoplasia do not need a total colonoscopy, whereas is mandatory performing a total colonoscopy in older patients even in the presence of anal pathology.

The prevalence of suspected Barrett's esophagus in children and adolescents: a multicenter endoscopic study

BACKGROUND

The prevalence of Barrett's esophagus (BE) in young individuals is unclear.

OBJECTIVE

To estimate the prevalence of suspected BE in children and adolescent patients undergoing endoscopy.

DESIGN

A retrospective cross-sectional study.

SETTING

Prospectively collected data in the Pediatric Clinical Outcomes Research Initiative (PEDS-CORI).

PATIENTS

We identified patients younger than 20 years of age with suspected BE in the PEDS-CORI between 1999 and 2002; the corresponding histopathologic records were examined.

MAIN OUTCOME MEASUREMENTS

We analyzed the distribution of demographic and endoscopic risk factors for BE between cases and non-cases with and without suspected BE in bivariate and multivariable analyses.

RESULTS

We identified a total of 6731 patients who underwent upper endoscopy in 12 pediatric facilities. Only 17 patients had suspected BE (prevalence, 2.5 per 1000). Intestinal metaplasia was reported in only 9 of these patients (53%). Patients with suspected BE were older than patients without BE (median 14.7 vs 10.1 years; P = .011). Hiatus hernia was more commonly recorded in patients with suspected BE (11.8% vs 2.2%; P = .008). In a logistic regression model, both older age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02-1.35) and hiatus hernia (OR 4.62, 95% CI 1.03-20.66) were independently associated with suspected BE.

CONCLUSIONS

Endoscopically suspected BE is rare (<0.25%) in children and adolescents. Older age and the presence of hiatus hernia are possible risk factors for BE in this group.

LIMITATIONS

Lack of standardization for identifying and recording endoscopic landmarks.