1
|
Su MY, Chiu CT. Ligation-assisted endoscopic mucosal resection has high complete resection rate in rectal carcinoid tumor. BMC Gastroenterol 2021; 21:464. [PMID: 34903169 PMCID: PMC8667363 DOI: 10.1186/s12876-021-02061-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
AIM We aimed to compare the outcomes of different therapeutic modalities in rectal carcinoid tumors. METHOD We retrospectively collected 145 patients with rectal carcinoid tumors which were pathologically diagnosed from 2005/01/01 to 2016/12/31. We compared tumor size, complete resection rate and recurrent rate between different therapeutic modalities. Then, prospectively compared the treatment outcomes of 28 patients treated with ligation assisted endoscopic mucosal resection (LEMR) and 25 patients treated with endoscopic mucosal resection with cap (EMRC). RESULT The mean size of tumors was 6.5 mm (1-25 mm), and the mean follow-up duration was 26 months (6-118 months). The therapeutic modalities included ligation-assisted endoscopic mucosal resection (LEMR) (25 tumors, 17%), endoscopic mucosal resection (EMR) (31 tumors, 21%), snare polypectomy (30 tumors, 21%), biopsy forceps removal (46 tumors, 32%) and surgical resection (13 tumors, 11%), including 6 tumors treated with transanal endoscopic microsurgery (TEM) method. In view of pathologically complete resection rate, LEMR was highest (100%), followed by surgical resection (85%). However, EMR only had 42% pathologically complete resection rate. Besides, LEMR and surgical resection had no local recurrence and significantly higher clinically complete resection rate, compared to other treatments. For the further prospective study, complete resection was noted in 28 (100%) patients in LEMR group and 13 (52%) patients in EMRC group. CONCLUSION In the treatment of rectal carcinoid tumors, LEMR is safe and effective compared with traditional endoscopic treatments.
Collapse
Affiliation(s)
- Ming-Yao Su
- Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, 6, Sec 2, Jincheng Rd, Tucheng Dist, New Taipei City, Taiwan, Republic of China. .,Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan. .,Chang Gung University College of Medicine, Taoyuan, Taiwan. .,Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan.
| | - Cheng-Tang Chiu
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan.,Chang Gung University College of Medicine, Taoyuan, Taiwan.,Taiwan Association for the Study of Small Intestinal Diseases, Taoyuan, Taiwan
| |
Collapse
|
2
|
Zullo A, Manta R, De Francesco V, Fiorini G, Hassan C, Vaira D. Diagnostic yield of upper endoscopy according to appropriateness: A systematic review. Dig Liver Dis 2019; 51:335-339. [PMID: 30583999 DOI: 10.1016/j.dld.2018.11.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/29/2018] [Accepted: 11/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Despite some official guidelines are available, a substantial rate of inappropriateness for upper gastrointestinal (UGI) endoscopies has been reported. This study aimed to estimate the inappropriate rate of UGI in different countries, also including the diagnostic yield. METHODS A systematic review of studies on UGI endoscopy appropriateness was performed by adopting official guidelines as reference standard. Diagnostic yield of relevant endoscopic findings and cancers was compared between appropriate and inappropriate procedures. The Odd Ratio (OR) values and the Number-Needed-to-Scope (NNS) were calculated. RESULTS Data of 23 studies with a total of 53,392 patients were included. UGI indications were overall inappropriate in 21.7% (95% CI = 21.4-22.1) of the patients. The inappropriateness rate significantly (P < 0.0001) decreased from 35.1% in the earlier studies to 22.1%-23% in the more recent ones. A relevant finding was found in 43.3% of appropriate and in 35.1% of inappropriate endoscopies (P < 0.0001; OR: 1.42, 95% CI = 1.36-1.49; NNS = 12). Prevalence of cancers was also higher in appropriate than in inappropriate UGIs (2.98% vs. 0.09%, P < 0.0001; OR = 3.33; NNS = 48). The prevalence of detected cancers significantly (P < 0.004) increased from 1.38% in the earlier studies to 2.11% in the more recent ones, whilst prevalence of other relevant findings remained similar. CONCLUSIONS Rate of inappropriate UGI endoscopies is still high. Diagnostic yield of appropriate endoscopies is higher than that of inappropriate procedures, including upper GI cancers. Therefore, implementation of guidelines in clinical practice is urged.
Collapse
Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy,'Nuovo Regina Margherita' Hospital, Rome, Italy.
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, 'Generale' Hospital, Perugia, Italy
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Giulia Fiorini
- Internal Medicine and Gastroenterology, Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy,'Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Dino Vaira
- Internal Medicine and Gastroenterology, Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| |
Collapse
|
3
|
Rajan S, Amaranathan A, Lakshminarayanan S, Sureshkumar S, Joseph M, Nelamangala Ramakrishnaiah VP. Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study. Cureus 2019; 11:e4062. [PMID: 31016089 PMCID: PMC6464286 DOI: 10.7759/cureus.4062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India. Methods The study was conducted as a prospective analytical study. Indications for endoscopy were classified as “ASGE appropriate” and “ASGE inappropriate”. The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed. Results ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively. Conclusion According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.
Collapse
Affiliation(s)
- Susan Rajan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Anandhi Amaranathan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Subitha Lakshminarayanan
- Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Sathasivam Sureshkumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Manoj Joseph
- Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | | |
Collapse
|
4
|
Restall G, Walker JR, Waldman C, Zawaly K, Michaud V, Moffat D, Singh H. Perspectives of primary care providers and endoscopists about current practices, facilitators and barriers for preparation and follow-up of colonoscopy procedures: a qualitative study. BMC Health Serv Res 2018; 18:782. [PMID: 30333033 PMCID: PMC6191911 DOI: 10.1186/s12913-018-3567-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 09/26/2018] [Indexed: 01/28/2023] Open
Abstract
Background Colonoscopy has become a common medical procedure due to increased use of colonoscopy for evaluation of symptoms, colorectal cancer screening and surveillance of people with higher risks of developing colorectal cancer. Timely access to colonoscopy is essential for diagnosis of colorectal cancer, as well as diagnosis and management of inflammatory bowel disease and gastrointestinal symptoms such as diarrhea. The purpose of this study was to obtain the perspectives of primary care providers and endoscopists about current practices, barriers and facilitators to following recommended practice for preparation and follow-up after colonoscopy. We also aimed to obtain recommendations for approaches to improve the process. Methods Six focus groups (two with gastroenterologists, two with surgeons who perform colonoscopies and two with primary care providers) were held between October 2015 and January 2016. Analysis was performed using inductive qualitative approaches. Results Variations and challenges in communication for continuity of care and understanding the distribution of responsibility were identified, as were perceived benefits and challenges of a central intake system for colonoscopies. Recommendations were made to improve processes including strengthening communication and information sharing. A comprehensive quality improvement plan would facilitate implementation of recommendations. Conclusions Findings emphasize the need for improved patient-focused information resources for each step of the colonoscopy process and improved communication among practitioners. The findings apply to other services requiring collaboration among patients, primary care providers, and medical specialists. Electronic supplementary material The online version of this article (10.1186/s12913-018-3567-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Gayle Restall
- Department of Occupational Therapy, College of Rehabilitation Sciences, Rady Faculty of Health Sciences, University of Manitoba, R106 - 771 McDermot Avenue, Winnipeg, MB, R3E 0T6, Canada.
| | - John R Walker
- Department of Clinical Health Psychology, Rady Faculty of Health Sciences University of Manitoba, Winnipeg, MB, Canada
| | - Celeste Waldman
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Kathleen Zawaly
- Interdisciplinary Studies, Faculty of Graduate Studies, University of Manitoba, Winnipeg, MB, Canada
| | - Valerie Michaud
- Department of Internal Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Dana Moffat
- Department of Internal Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Harminder Singh
- Department of Internal Medicine, College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
5
|
Min JK, Cha JM, Cho YK, Kim JH, Yoon SM, Im JP, Jung Y, Moon JS, Kim JO, Jeen YT. Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea. Clin Endosc 2018; 51:239-252. [PMID: 29874905 PMCID: PMC5997069 DOI: 10.5946/ce.2018.075] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/14/2018] [Indexed: 12/12/2022] Open
Abstract
Gastroscopy and colonoscopy are widely used for the early diagnosis of stomach and colorectal cancer. The present revision integrates recent data regarding previous quality indicators and novel indicators suggested for gastroscopy and colonoscopy procedures for the National Cancer Screening Program in Korea. The new indicators, developed by the Quality Improvement Committee of the Korean Society for Gastrointestinal Endoscopy, vary in the level of supporting evidence, and most are based solely on expert opinion. Updated indicators validated by clinical research were prioritized, but were chosen by expert consensus when such studies were absent. The resultant quality indicators were graded according to the levels of consensus and recommendations. The updated indicators will provide a relevant guideline for high-quality endoscopy. The future direction of quality indicator development should include relevant outcome measures and an evidence-based approach to support proposed performance targets.
Collapse
Affiliation(s)
- Jun Ki Min
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Yonsei University School of Medicine, Seoul, Korea
| | - Soon Man Yoon
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Jin-Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yoon Tae Jeen
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Min JK, Cha JM, Cho YK, Kim JH, Yoon SM, Im JP, Jung Y, Moon JS, Kim JO, Jeen YT. [Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018; 71:269-281. [PMID: 29791986 DOI: 10.4166/kjg.2018.71.5.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Gastroscopy and colonoscopy are widely used for the early diagnosis of stomach and colorectal cancer. The present revision integrates recent data regarding previous quality indicators and novel indicators suggested for gastroscopy and colonoscopy procedures for the National Cancer Screening Program in Korea. The new indicators, developed by the Quality Improvement Committee of the Korean Society for Gastrointestinal Endoscopy, vary in the level of supporting evidence, and most are based solely on expert opinion. Updated indicators validated by clinical research were prioritized, but were chosen by expert consensus when such studies were absent. The resultant quality indicators were graded according to the levels of consensus and recommendations. The updated indicators will provide a relevant guideline for high-quality endoscopy. The future direction of quality indicator development should include relevant outcome measures and an evidence-based approach to support proposed performance targets.
Collapse
Affiliation(s)
- Jun Ki Min
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jie Hyun Kim
- Department of Internal Medicine, Yonsei University School of Medicine, Seoul, Korea
| | - Soon Man Yoon
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jong Pil Im
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jeong Seop Moon
- Department of Internal Medicine, Inje University College of Medicine, Seoul, Korea
| | - Jin Oh Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Yoon Tae Jeen
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| |
Collapse
|
7
|
Shaheen NJ, Fennerty MB, Bergman JJ. Less Is More: A Minimalist Approach to Endoscopy. Gastroenterology 2018; 154:1993-2003. [PMID: 29454789 DOI: 10.1053/j.gastro.2017.12.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/08/2017] [Accepted: 12/04/2017] [Indexed: 12/20/2022]
Abstract
A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.
Collapse
Affiliation(s)
- Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina.
| | - M Brian Fennerty
- Division of Gastroenterology and Hepatology, Oregon Health and Sciences University, Portland, Oregon
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
8
|
López-Picazo J, Alberca de Las Parras F, Sánchez Del Río A, Pérez Romero S, León Molina J, Júdez FJ. Quality indicators in digestive endoscopy: introduction to structure, process, and outcome common indicators. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 109:435-450. [PMID: 28553719 DOI: 10.17235/reed.2017.5035/2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The general goal of the project wherein this paper is framed is the proposal of useful quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. This initial offspring sets forth procedures and indicators common to all digestive endoscopy procedures. First, a diagram of pre- and post-digestive endoscopy steps was developed. A group of health care quality and/or endoscopy experts under the auspices of the Sociedad Española de Patología Digestiva (Spanish Society of Digestive Diseases) carried out a qualitative review of the literature regarding the search for quality indicators in endoscopic procedures. Then, a paired analysis was used for the selection of literature references and their subsequent review. Twenty indicators were identified, including seven for structure, eleven for process (five pre-procedure, three intra-procedure, three post-procedure), and two for outcome. Quality of evidence was analyzed for each indicator using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification.
Collapse
Affiliation(s)
- Julio López-Picazo
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
| | | | | | - Shirley Pérez Romero
- Servicio de Calidad Asistencial, Hospital Clínico Universitario Virgen de la Arrixaca
| | | | | |
Collapse
|
9
|
Tahir M. Appropriateness of Upper Gastrointestinal Endoscopy: Will the Diagnostic Yield Improve by the use of American Society of Gastroenterology Guidelines? Euroasian J Hepatogastroenterol 2016; 6:143-148. [PMID: 29201747 PMCID: PMC5578583 DOI: 10.5005/jp-journals-10018-1187] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 06/23/2016] [Indexed: 12/13/2022] Open
Abstract
Aim Open access endoscopy allows physicians and general practitioners (GIs) to refer patients for endoscopy without prior outpatient consultation. This system was introduced to reduce waiting time to the procedure and subsequent diagnosis. Concerns have been raised regarding misuse of this system with increasing number of inappropriate referrals and hence more normal examinations, which has implications on a public-funded health system. The aim of this study was to assess the appropriate use of the open access system at a rural New Zealand hospital and to see if the diagnostic yield improves by following the American Society of Gastroenterology (ASGE) guidelines for upper gastrointestinal endoscopy [esophagogastroduodenoscopy (OGD)]. Materials and methods This was a prospective study including all the patients who had OGD at Taranaki Base Hospital between December 2013 and 2014. A total of 1,019 patients had OGD during this time period. The ASGE guidelines were used to see the relationship between appropriateness of OGD and finding of a relevant endoscopic diagnosis. Results Fifty-eight percent of the OGDs were judged to be appropriate and 42% inappropriate by the explicit criteria. No cancer was found in OGDs judged to be inappropriate. Upper gastrointestinal (GI) endoscopies judged appropriate yielded significantly more relevant lesions than those judged to be inappropriate [65% vs 32%; odds ratio 3.94, 99% confidence interval (CI) 2.78, 5.57; p < 0.01]. Conclusion The use of ASGE guidelines increases diagnostic yield of OGDs done, which is crucial to cost-effectiveness of an open access system and makes the system more efficient in selecting and treating patients who need it the most, in an acceptable time span. How to cite this article Tahir M. Appropriateness of Upper Gastrointestinal Endoscopy: Will the Diagnostic Yield Improve by the use of American Society of Gastroenterology Guidelines? Euroasian J Hepato-Gastroenterol 2016;6(2):143-148.
Collapse
Affiliation(s)
- Muazzam Tahir
- Department of Surgery and Gastroenterology, Taranaki Base Hospital, Wellington, New Zealand
| |
Collapse
|
10
|
Most Premature Surveillance Colonoscopy Is Not Attributable to Bowel Preparation or New Clinical Indications. Dig Dis Sci 2016; 61:2496-504. [PMID: 27142669 DOI: 10.1007/s10620-016-4177-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 04/20/2016] [Indexed: 12/13/2022]
Abstract
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.
Collapse
|
11
|
Chandrasekhara V, Eloubeidi MA, Bruining DH, Chathadi K, Faulx AL, Fonkalsrud L, Khashab MA, Lightdale JR, Muthusamy VR, Pasha S, Saltzman JR, Shaukat A, Wang A, Cash B, DeWitt JM. Open-access endoscopy. Gastrointest Endosc 2016; 81:1326-9. [PMID: 25865387 DOI: 10.1016/j.gie.2015.03.1917] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 12/13/2022]
Abstract
OAE is commonly used. The majority of patients referred for OAE are considered appropriate for endoscopy according to ASGE guidelines. Most patients undergoing OAE procedures are knowledgeable about the study and are satisfied with the experience. Several potential problems have been identified, including inappropriate referrals, communication errors, and inadequately prepared or informed patients. OAE can be safely used if preprocedure assessment, informed consent, information transfer, patient safety, and satisfaction are addressed in all cases.
Collapse
|
12
|
Satisfaction in open access versus traditional referral for upper endoscopy in children. J Pediatr Gastroenterol Nutr 2015; 60:637-41. [PMID: 25522310 DOI: 10.1097/mpg.0000000000000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES In traditional access endoscopy (TAE), patients are booked for endoscopy following a gastroenterology clinic assessment. In contrast, open access endoscopy (OAE) patients are seen for the first time on the day of the procedure, providing same day procedural consent. Controversy exists over the use of OAE in adults, both with the consent process and with patient satisfaction. No literature exists describing satisfaction with OAE in pediatrics. We therefore aimed to assess pediatric patient and caregiver satisfaction in OAE compared with TAE. METHODS Consecutive pediatric patients, and their caregivers, undergoing elective upper endoscopy from May to December 2012 at the Stollery Children's Hospital (Edmonton, Alberta, Canada) were consented for a cross-sectional survey. Seven preprocedure and 5 postprocedure questions were completed regarding mood and satisfaction with the wait time and the information provided. Group demographics and endoscopy wait times were collected. RESULTS Median wait time with OAE was less compared with TAE (57 days vs 196 days, P < 0.001). OAE patients reported worse mood preprocedure than TAE patients (35.3% vs 10.7%, P = 0.046). OAE caregivers and patients reported more mood disturbance if required to wait longer for endoscopy by attending clinic preprocedure (OAE caregivers 62.2%, OAE patients 64.7%). CONCLUSIONS OAE is associated with worse preendoscopy patient mood; however, children and caregivers seem concerned about longer wait times associated with TAE. Given the significantly shorter wait times in OAE, identifying methods to minimize present limitations of OAE will be useful to improve clinical practices in pediatric gastroenterology.
Collapse
|
13
|
Rizk MK, Sawhney MS, Cohen J, Pike IM, Adler DG, Dominitz JA, Lieb JG, Lieberman DA, Park WG, Shaheen NJ, Wani S. Quality indicators common to all GI endoscopic procedures. Am J Gastroenterol 2015; 110:48-59. [PMID: 25448874 DOI: 10.1038/ajg.2014.383] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
14
|
|
15
|
Park WG, Shaheen NJ, Cohen J, Pike IM, Adler DG, Inadomi JM, Laine LA, Lieb JG, Rizk MK, Sawhney MS, Wani S. Quality indicators for EGD. Gastrointest Endosc 2015; 81:17-30. [PMID: 25480101 DOI: 10.1016/j.gie.2014.07.057] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 02/07/2023]
|
16
|
Quality indicators common to all GI endoscopic procedures. Gastrointest Endosc 2015; 81:3-16. [PMID: 25480102 DOI: 10.1016/j.gie.2014.07.055] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 12/13/2022]
|
17
|
Wichers CD, van Heel NC, ter Borg F, van Herwaarden MA. Triage of colonoscopies: open access endoscopy versus outpatient consultation with a gastroenterologist. Endosc Int Open 2014; 2:E187-90. [PMID: 27054194 PMCID: PMC4812814 DOI: 10.1055/s-0034-1377325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 05/05/2014] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND AND STUDY AIMS In many Dutch hospitals, open access referral for colonoscopy is authorized by a gastroenterologist after screening a standard referral letter (SRL) without face-to-face contact with the patient. We investigated the added value of a 7.5 min outpatient consultation with a gastroenterologist (OC), regarding the patient indications, priority for colonoscopy, and the frequency of correct information about patient medications and comorbidities on SRLs. PATIENTS AND METHODS In a prospective, blinded, single-center study, gastroenterologists assessed SRLs for the accuracy and priority of the colonoscopy request (SRL). These data were compared to results from the OC, and primary outcomes were the number of patients who were not recommended for colonoscopy and priority scheduling of colonoscopy for suspicion of cancer. RESULTS Patients were analyzed using both SRL and OC and, of 255 patients, 224 of them underwent colonoscopy. Colonoscopy was not recommended for 6.3 % and 11.4 % of patients using the SRL and OC, respectively (P = 0.02). Using the SRL, gastroenterologists did not recommend colonoscopy for seven patients, but the same patients were recommended for colonoscopy when OC was available. This was explained because the indications on the SRL did not match the information obtained from OC. Compared to OC , more colonoscopies were prioritized when the SRL was used to make decisions. Cancer was detected in 7/112 (SRL ) versus 7/65 (OC ) of priority-scheduled patients. SRLs did not report the use of coumarins and insulin in 1.6 % of patients or the prevalence of serious comorbid conditions in 52 % of patients. CONCLUSIONS A 7.5 min outpatient consultation with a gastroenterologist improved the identification of indications for colonoscopy, decreased priority scheduling of patients, and increased the number of patients diagnosed with cancer in the prioritized group. SRLs frequently omitted patients' medications and comorbidities.
Collapse
Affiliation(s)
- C. D. Wichers
- Gastroenterology, Deventer Hospital, Deventer, the
Netherlands,Corresponding author Carmen D. Wichers Deventer
Hospital-GastroenterologyNico Bolkestaeinlaan
75Deventer 7416
SENetherlands+31612872053
| | | | - F. ter Borg
- Gastroenterology, Deventer Hospital, Deventer, the
Netherlands
| | | |
Collapse
|
18
|
Kaushal NK, Chang K, Lee JG, Muthusamy VR. Using efficiency analysis and targeted intervention to improve operational performance and achieve cost savings in the endoscopy center. Gastrointest Endosc 2014; 79:637-45. [PMID: 24321391 DOI: 10.1016/j.gie.2013.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 10/21/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND With an increasing demand for endoscopy services, there is a greater need for efficiency within the endoscopy center. A validated methodology is important for evaluating efficiency in the endoscopy unit. OBJECTIVE To use the principles of operations management to establish a validated methodology for evaluating and enhancing operational performance in the endoscopy center. DESIGN Biphasic prospective study with pre-intervention and post-intervention efficiency data and analysis. SETTING Tertiary-care referral teaching hospital. PATIENTS Scheduled outpatients undergoing endoscopy. INTERVENTION Determination of the rate-limiting step, or bottleneck, of the endoscopy unit and reducing inefficiencies. MAIN OUTCOME MEASUREMENTS Staffing costs and a novel performance metric, True Completion Time (TCT). RESULTS Data were prospectively recorded for 2248 patients undergoing a total of 2713 procedures (phase I: 255 EGD, 305 colonoscopy, 91 EGD/colonoscopy, 375 EUS, 44 ERCP, 75 EUS/ERCP; phase II: 243 EGD, 328 colonoscopy, 99 EGD/colonoscopy, 335 EUS, 38 ERCP, 109 EUS/ERCP). The bottleneck of the operation was identified as the 10-bed communal pre-procedure/recovery room. On-time procedure starts increased by 51% (P < .001), and TCT was reduced by 12.2% (P < .001) across all cases studied. Overtime and per diem nursing costs were reduced by 30%, whereas full-time employee staff was reduced by 0.85. Annual cost savings were calculated as $312,618 or 11.02% of total operating expenses. LIMITATIONS This study is not directly tied to quality outcomes, and inpatient procedures transported to the endoscopy unit were not directly studied. CONCLUSION Room turnover time and room-to-endoscopist ratio are not necessarily the driving parameters behind endoscopy unit efficiency. A focus on developing a methodology for identifying factors constraining operational efficiency can improve performance and reduce costs in the endoscopy center.
Collapse
Affiliation(s)
- Neal K Kaushal
- Department of Gastroenterology, David Geffen School of Medicine at UCLA, UCLA Medical Center, Los Angeles, California, USA
| | - Kenneth Chang
- H.H. Chao Comprehensive Digestive Disease Center, Department of Gastroenterology, University of California, Irvine Medical Center, Orange, California, USA
| | - John G Lee
- H.H. Chao Comprehensive Digestive Disease Center, Department of Gastroenterology, University of California, Irvine Medical Center, Orange, California, USA
| | - V Raman Muthusamy
- Department of Gastroenterology, David Geffen School of Medicine at UCLA, UCLA Medical Center, Los Angeles, California, USA
| |
Collapse
|
19
|
Aljebreen AM, Alswat K, Almadi MA. Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system. Saudi J Gastroenterol 2013; 19:219-22. [PMID: 24045595 PMCID: PMC3793473 DOI: 10.4103/1319-3767.118128] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIM Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system. PATIENTS AND METHODS A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis. RESULTS A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "(78.9%),''persistent vomiting of unknown cause "(19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively. CONCLUSION A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected.
Collapse
Affiliation(s)
- Abdulrahman M. Aljebreen
- Department of Internal Medicine, Gastroenterology Divisions, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Khalid Alswat
- Department of Internal Medicine, Gastroenterology Divisions, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid A. Almadi
- Department of Internal Medicine, Gastroenterology Divisions, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Department of Internal Medicine, Gastroenterology Divisions, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada,Address for correspondence: Dr. Majid Abdulrahman Almadi, Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, P.O. Box 2925(59), Riyadh 11461, Saudi Arabia. E-mail:
| |
Collapse
|
20
|
Campbell EJ, Krishnaraj A, Harris M, Saini S, Richter JM. Automated before-procedure electronic health record screening to assess appropriateness for GI endoscopy and sedation. Gastrointest Endosc 2012; 76:786-92. [PMID: 22901989 DOI: 10.1016/j.gie.2012.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 06/06/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopists are performing greater numbers of procedures, often on patients with complex conditions, in ambulatory settings because of changing patient demographics and referral patterns. To assist with the pre-procedure assessment of such patients, we deployed an advanced electronic health record tool, the Queriable Patient Inference Dossier (QPID), to review clinical histories and generate e-mail alerts to providers, based on clinical guidelines. OBJECTIVE Study the feasibility of an automated pre-procedure alert system for outpatient endoscopy. DESIGN We retrospectively reviewed 5 physicians' use of the application and their responses to the alerts. SETTING A hospital-based endoscopy unit and its two satellite outpatient clinics, Boston area, Massachusetts. PATIENTS Adult outpatients referred for endoscopy with moderate sedation. INTERVENTION Pre-procedure alerts automatically sent 7 days before the procedure, highlighting any conditions/clinical history that may affect management of the patient. MAIN OUTCOME MEASUREMENTS Physician use of the pre-procedure alert system and its effect on patient management. RESULTS We studied 1682 procedures that met inclusion criteria for review by QPID and 364 alerts (1.6% of the eligible procedures). Nearly 80% of the alerts were reviewed and responded to by the physicians, and 70 total alerts resulted in a change in patient management (4.2% of eligible procedures). LIMITATIONS The small size of the study group and the low rate of adverse events during the study period limit our findings. We thus plan to conduct a larger follow-up study to demonstrate changes in safety and efficiency. CONCLUSION Use of advanced electronic health record technologies, such as QPID, may improve provider efficiency and patient outcomes in endoscopy units.
Collapse
Affiliation(s)
- Emily J Campbell
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | | | | | | |
Collapse
|
21
|
Park WG, Cohen J. Quality measurement and improvement in upper endoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2011.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
22
|
Mangualde J, Cremers MI, Vieira AM, Freire R, Gamito E, Lobato C, Alves AL, Augusto F, Oliveira AP. Appropriateness of outpatient gastrointestinal endoscopy in a non-academic hospital. World J Gastrointest Endosc 2011; 3:195-200. [PMID: 22013500 PMCID: PMC3196727 DOI: 10.4253/wjge.v3.i10.195] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/25/2011] [Accepted: 08/10/2011] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the appropriate use and the diagnostic yield of upper gastrointestinal endoscopy and colonoscopy in this subgroup of patients.
METHODS: In total, 789 consecutive outpatients referred for gastrointestinal (GI) endoscopy [381 for esophagogastroduodenoscopy (EGD) and 408 for colonoscopy] were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between appropriateness and the presence of relevant endoscopic findings.
RESULTS: The overall inappropriate rate was 13.3%. The indications for EGD and colonoscopy were, respectively, appropriate in 82.7% and 82.6% of the exams, uncertain in 5.8% and 2.4% and inappropriate in 11.5% and 15%. The diagnostic yield was significant higher for EGDs and colonoscopies judged appropriate and uncertain when compared with those considered inappropriate (EGD: 36.6% vs 36.4% vs 11.4%, P = 0.004; Colonoscopy: 24.3% vs 20.0% vs 3.3%, P = 0.001). Of the 25 malignant lesions detected, all but one was detected in exams judged appropriate or uncertain.
CONCLUSION: This study shows a good adherence to ASGE guidelines by the referring physicians and a significant increase of the diagnostic yield in appropriate examinations, namely in detecting neoplastic lesions. It underscores the importance that the appropriateness of the indication assumes in assuring high-quality GI endoscopic procedures.
Collapse
Affiliation(s)
- João Mangualde
- João Mangualde, Marie I Cremers, Ana M Vieira, Ricardo Freire, Élia Gamito, Cristina Lobato, Ana L Alves, Fátima Augusto, Ana P Oliveira, Gastrenterology Department Setúbal Hospital Center, São Bernardo Hospital, Setúbal 2910-446, Portugal
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
A nine-year audit of open-access upper gastrointestinal endoscopic procedures: results and experience of a single centre. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:83-8. [PMID: 21321679 DOI: 10.1155/2011/379014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
Collapse
|
24
|
Nguyen VX, Le Nguyen VT, Nguyen CC. Appropriate use of endoscopy in the diagnosis and treatment of gastrointestinal diseases: up-to-date indications for primary care providers. Int J Gen Med 2010; 3:345-57. [PMID: 21116340 PMCID: PMC2990396 DOI: 10.2147/ijgm.s14555] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The field of endoscopy has revolutionized the diagnosis and treatment of gastrointestinal (GI) diseases in recent years. Besides the ‘traditional’ endoscopic procedures (esophagogastroduodenoscopy, colonoscopy, flexible sigmoidoscopy, and endoscopic retrograde cholangiopancreatography), advances in imaging technology (endoscopic ultrasonography, wireless capsule endoscopy, and double balloon enteroscopy) have allowed GI specialists to detect and manage disorders throughout the digestive system. This article reviews various endoscopic procedures and provides up-to-date endoscopic indications based on the recommendations of American Society for Gastrointestinal Endoscopy and American Cancer Society for primary care providers in order to achieve high-quality and cost-effective care.
Collapse
Affiliation(s)
- Vien X Nguyen
- Department of Gastroenterology, Mayo Clinic, Scottsdale, AZ, USA
| | | | | |
Collapse
|
25
|
Buri L, Bersani G, Hassan C, Anti M, Bianco MA, Cipolletta L, Di Giulio E, Di Matteo G, Familiari L, Ficano L, Loriga P, Morini S, Pietropaolo V, Zambelli A, Grossi E, Intraligi M, Tessari F, Buscema M. How to predict a high rate of inappropriateness for upper endoscopy in an endoscopic centre? Dig Liver Dis 2010; 42:624-8. [PMID: 20308024 DOI: 10.1016/j.dld.2010.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Revised: 02/04/2010] [Accepted: 02/15/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND Inappropriateness of upper endoscopy (EGD) indication causes decreased diagnostic yield. Our aim of was to identify predictors of appropriateness rate for EGD among endoscopic centres. METHODS A post-hoc analysis of two multicentre cross-sectional studies, including 6270 and 8252 patients consecutively referred to EGD in 44 (group A) and 55 (group B) endoscopic Italian centres in 2003 and 2007, respectively, was performed. A multiple forward stepwise regression was applied to group A, and independently validated in group B. A <70% threshold was adopted to define inadequate appropriateness rate clustered by centre. RESULTS discrete variability of clustered appropriateness rates among the 44 group A centres was observed (median: 77%; range: 41-97%), and a <70% appropriateness rate was detected in 11 (25%). Independent predictors of centre appropriateness rate were: percentage of patients referred by general practitioners (GP), rate of urgent examinations, prevalence of relevant diseases, and academic status. For group B, sensitivity, specificity and area under receiver operating characteristic curve of the model in detecting centres with a <70% appropriateness rate were 54%, 93% and 0.72, respectively. CONCLUSIONS A simple predictive rule, based on rate of patients referred by GPs, rate of urgent examinations, prevalence of relevant diseases and academic status, identified a small subset of centres characterised by a high rate of inappropriateness. These centres may be presumed to obtain the largest benefit from targeted educational programs.
Collapse
Affiliation(s)
- L Buri
- Gastroenterology and Digestive Endoscopy Unit, Cattinara Hospital, Trieste, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Nekhlyudov L, Latosinsky S. The interface of primary and oncology specialty care: from symptoms to diagnosis. J Natl Cancer Inst Monogr 2010; 2010:11-7. [PMID: 20386049 DOI: 10.1093/jncimonographs/lgq001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Symptomatic individuals presenting to their primary care providers may need further evaluation and/or testing to determine whether a cancer is present. A number of issues arise in determining who needs further testing, what tests are needed, which specialists need to be involved, and how the testing can be organized and supported within a specific health-care system within a timely, coordinated, and cost-efficient manner. This article explores the challenges in the interface of primary care providers and specialists, includes evidence from prior research, and proposes research opportunities to understand and improve this phase of care.
Collapse
Affiliation(s)
- Larissa Nekhlyudov
- Department of Population Medicine, Harvard Medical School, 133 Brookline Ave, 6th Floor, Boston, MA 02215, USA.
| | | |
Collapse
|
27
|
Prospective assessment of inpatient gastrointestinal consultation requests in an academic teaching hospital. Am J Gastroenterol 2010; 105:484-9. [PMID: 20203634 DOI: 10.1038/ajg.2009.686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess the completeness of gastrointestinal (GI) inpatient consultations at an academic teaching hospital. METHODS We conducted a prospective, cross-sectional study of 278 inpatient GI consultation requests evaluated from 1 July 2005 to 31 May 2007. A questionnaire assessing multiple aspects of the requesting health-care providers' knowledge and documentation of patient information was completed by first-year GI fellows. Completeness of the consultation was evaluated by the GI consultation attending physician. RESULTS The most frequent consultation requests pertained to patients with GI hemorrhage (52.5%) and were made by first-year residents (56.8%). In 15% of requests, health-care providers lacked basic knowledge about the patients for whom consultations were sought. Conversely, in 17% of consultations, pertinent information could not be located in patients' paper medical chart/electronic medical record. The strongest predictors for a complete consultation were requesters' knowledge of patients' past medical history (P < 0.001), documentation of patients' current illness (P < 0.001), and presence of the providers' admission note in the paper medical chart (P = 0.002). Consultations requested between 5 and 10 PM were assessed to be more complete (P = 0.02), and more incomplete consultations occurred in the first 3 months of the academic year (P = 0.04). CONCLUSIONS In 16% of inpatient GI consultation requests analyzed, crucial patient data were missing or were unknown by the requesting provider. Several aspects of requesting providers' knowledge and documentation of patient information were strongly associated with completeness of inpatient GI consultations.
Collapse
|
28
|
Identification of patients at increased risk for colorectal cancer in an open access endoscopy center. J Clin Gastroenterol 2008; 42:1025-31. [PMID: 18719509 DOI: 10.1097/mcg.0b013e3181468613] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS To determine whether patients referred for open access endoscopy (OAE) are being appropriately identified as "increased risk" or "average risk" for colorectal cancer (CRC) by referring physicians. BACKGROUND OAE allows nongastroenterologists to schedule elective endoscopies without prior consultation with a gastroenterologist. It is unknown how accurately referring physicians identify CRC risk of such patients. METHODS We retrospectively reviewed the records of outpatients referred to a single OAE center for screening or surveillance colonoscopy from July 1, 2001 to November 8, 2002. Before colonoscopy, a 3-question tool was used to stratify each patient as average risk or increased risk for CRC. CRC risk assessment was compared with the referring physician's indication for colonoscopy. Chi-square testing was used to compare the incidence of neoplastic polyps between average risk and increased risk patients. RESULTS Two hundred eighty-eight patients met inclusion criteria. Referring physicians accurately identified 61% of 126 increased risk patients, including 13 of 19 patients (68%) with a personal history of CRC, 29 of 61 patients (48%) with a family history of CRC, 47 of 61 patients (77%) with a personal history of colonic polyps, and 0 of 8 patients (0%) who met clinical criteria for hereditary nonpolyposis colorectal cancer. Adenomatous polyps were found in 24% of average risk patients compared with 41% of increased risk patients (P<0.01). CONCLUSIONS In an OAE system, referring physicians often fail to correctly identify patients at increased risk for CRC. Our 3-question tool for risk assessment helps to better identify patients at increased risk of CRC and can be used by gastroenterologists to stratify patients referred for OAE.
Collapse
|
29
|
Abstract
GOALS AND BACKGROUND To Evaluate the indications versus diagnostic yield of significant colonic neoplasia (SCN) in the open-access era and screening colonoscopy. STUDY During 6-year period, all procedural data were obtained from all consecutive patients who underwent colonoscopies. Indications were compared with American Society for Gastrointestinal Endoscopy guidelines. RESULTS In all 22,341 procedures were included in the study. Indications were divided into 3 groups: Screening (21.89% of the procedures), surveillance (17.60%) and symptoms/signs (60.51%). A total of 2867 patients (12.83%) had SCNs. Of these, 278 (7.00%) SCNs were found in the group less than 50 years of age and 2589 in the group over the age of 50 years (14.10%). SCN as per indication frequency was 12.69% in the symptom/sign group (subdivided to 7.24% and 14.01% in the under 50 and over 50, age groups, respectively); screening 13.37% (5.48% and 15.09%, respectively); surveillance 12.64% (8.48% and 13.19%, respectively). The indications leading to the highest SCN rate (over 25%) were: abnormal imaging, elevated carcinoembryonic antigen, and rectal pain. CONCLUSIONS Colonoscopy is a unique screening tool that can detect neoplastic lesions. SCN prevalence in our study was between 13% and 15% for all indications in patients above 50 years of age. This emphasizes performing a screening colonoscopy for the entire population over the age of 50 years, regardless of the indication. We feel that American Society for Gastrointestinal Endoscopy guidelines should be reassessed. The revised criteria should state that the primary indication, are all people over the age of 50 years, who should have a colonoscopy performed, unless otherwise contraindicated.
Collapse
|
30
|
Chen LA, Santos S, Jandorf L, Christie J, Castillo A, Winkel G, Itzkowitz S. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol 2008; 6:443-50. [PMID: 18304882 DOI: 10.1016/j.cgh.2007.12.009] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although colonoscopy is becoming the preferred screening test for colorectal cancer, screening rates, particularly among minorities, are low. Little is known about the uptake of screening colonoscopy or the factors that predict colonoscopy completion among minorities. This study investigated the use of patient navigation within an open-access referral system and its effects on colonoscopy completion rates among urban minorities. METHODS This was a cohort study that took place at a teaching hospital in New York. Participants were mostly African Americans and Hispanics directly referred for screening colonoscopy by primary care clinics from November 2003 to May 2006. Once referred, a bilingual Hispanic female patient navigator facilitated the colonoscopy completion. Completion rates, demographic factors associated with completing colonoscopy, endoscopic findings, and patient satisfaction were analyzed. RESULTS Of 1169 referrals, 688 patients qualified for and 532 underwent navigation. Two thirds (66%) of navigated patients completed screening colonoscopies, 16% had adenomas, and only 5% had inadequate bowel preps. Women were 1.31 times more likely to complete the colonoscopy than men (P = .014). Hispanics were 1.67 times more likely to complete the colonoscopy than African Americans (P = .013). Hispanic women were 1.50 times more likely to complete the colonoscopy than Hispanic men (P = .009). Patient satisfaction was 98% overall, with 66% reporting that they definitely or probably would not have completed their colonoscopy without navigation. CONCLUSIONS By using a patient navigator, the majority of urban minorities successfully completed their colonoscopies, clinically significant pathology was detected, and patient satisfaction was enhanced. This approach may help increase adherence with screening colonoscopy efforts in other clinical settings.
Collapse
Affiliation(s)
- Lea Ann Chen
- Division of Gastroenterology, Department of Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA
| | | | | | | | | | | | | |
Collapse
|
31
|
Atkinson RJ, Hurlstone DP. Techniques for the treatment of submucosal rectal tumors: the role of ESMRL. J Gastroenterol Hepatol 2008; 23:165-6. [PMID: 18289348 DOI: 10.1111/j.1440-1746.2007.04974.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
|
32
|
Mashimo Y, Matsuda T, Uraoka T, Saito Y, Sano Y, Fu K, Kozu T, Ono A, Fujii T, Saito D. Endoscopic submucosal resection with a ligation device is an effective and safe treatment for carcinoid tumors in the lower rectum. J Gastroenterol Hepatol 2008; 23:218-21. [PMID: 18289355 DOI: 10.1111/j.1440-1746.2008.05313.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Various methods for complete endoscopic resection of rectal carcinoid tumors have been reported; however, the number of cases investigated in each study has been limited. The aim of the present study was to clarify the clinical usefulness of a novel technique named endoscopic submucosal resection with a ligation device (ESMR-L) in a large number of rectal carcinoid tumors. PATIENTS AND METHODS Between January 1999 and March 2005, a total of 61 patients with 63 rectal carcinoid tumors estimated at 10 mm or less in diameter, without atypical features and resected by ESMR-L were recruited for this analysis. The complete resection rate, complications associated with the procedure, local recurrence, and distant metastases were evaluated. RESULTS Sixty-one patients were 36 males and 25 females with a mean age of 59 +/- 11 years (24-76 years). Tumor size ranged from 2 to 12 mm in diameter, with an average size of 6.4 +/- 2.4 mm. Fifty-nine lesions (93.6%) were located in the lower rectum (Rb), three in the upper rectum (Ra) and one in the recto-sigmoid colon (Rs). In total, 60 out of 63 lesions (95.2%) were histologically determined to be completely resected. The complete resection rate for lesions located in the Rb was 98.3%, which was significantly higher than that for lesions in Ra and Rs (50%). Minor bleeding associated with the procedure occurred in five lesions (7.9%), but all cases were successfully managed with hemoclips. Histopathologically, all tumors were located in the submucosal layer, and all were classified as classical-type carcinoids without lymphovascular invasion. Neither local recurrence nor distant metastasis was detected during a median follow-up period of 24 months. CONCLUSION In a large number of cases, ESMR-L proved to be a useful and safe procedure to resect rectal carcinoid tumors 10 mm or less in diameter, especially for those located in the Rb.
Collapse
Affiliation(s)
- Yumi Mashimo
- Division of Endoscopy, National Cancer Center Hospital, Tokyo, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Hassan C, Bersani G, Buri L, Zullo A, Anti M, Bianco MA, Di Giulio E, Ficano L, Morini S, Di Matteo G, Loriga P, Pietropaolo V, Cipolletta L, Costamagna G. Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy. Gastrointest Endosc 2007; 65:767-74. [PMID: 17466196 DOI: 10.1016/j.gie.2006.12.058] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2006] [Accepted: 12/26/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. An evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this Italian multicenter study was to assess the appropriate use of upper endoscopy (EGD) in an open-access system and to establish the yield of diagnostic information relevant to patient care. DESIGN AND SETTING Cross-sectional, prospective, multicenter study. PATIENTS A total of 6270 patients referred to 44 Italian centers for open-access EGD during 1 month were prospectively enrolled. INTERVENTIONS The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relation between the appropriate use of EGD and the presence of relevant endoscopic findings. MAIN OUTCOME MEASUREMENTS AND RESULTS The rate for "generally not indicated" EGDs was 22.9%: 29.4% for primary care physicians and 12.9% for specialists (P < .01). A relevant endoscopic finding was detected in 2929 examinations (46.7%). The diagnostic yield was significantly higher for "generally indicated" EGDs compared with "generally not indicated" procedures (52% vs 29%; odds ratio [OR] 2.65, 99% confidence interval [CI] 2.23-3.20; P < .01). Of the 133 malignant lesions diagnosed, all but 1 were diagnosed in patients with an appropriate indication (OR >20, 99% CI 3 to >100; P < .01). CONCLUSIONS Open-access EGD is an useful procedure for clinical practice. Because most of the relevant findings were detected during examinations performed for appropriate indications, the use of ASGE guidelines emerges as crucial to the cost-effectiveness of an open-access system.
Collapse
Affiliation(s)
- Cesare Hassan
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Rainis T, Keren D, Goldstein O, Stermer E, Lavy A. Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system. J Clin Gastroenterol 2007; 41:394-9. [PMID: 17413609 DOI: 10.1097/01.mcg.0000225573.27643.3d] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Open access endoscopy allows reference of patients for endoscopic procedures without prior gastrointestinal consultation, allowing the procedure to be more accessible. This practice is becoming increasingly widespread in the United States and other countries and has become commonplace in clinical practice in Israel. The objective of our study is to bring forward our experience with an open access referral system for colonoscopy and to measure the yield and safety of colonoscopy in this system. METHODS Between January 2001 and September 2003, 10,866 colonoscopies were performed. Patient's charts were reviewed for the following data: demographics, indication for endoscopy, endoscopic and histopathologic findings, and complications. The practice guidelines of the American Society for Gastrointestinal Endoscopy were used to assess appropriateness of colonoscopy. RESULTS 3533 pathologic findings were found, in 2978 colonoscopies. 2336 polyps were removed, including 18% hyperplastic, 26% tubular adenomata, 13% villous adenomata, 11% tubulovillous adenomata. Advanced disease was found in 41% of pathologic findings, 11% were invasive cancer. Rate of colonoscopies "generally indicated" according to American Society for Gastrointestinal Endoscopy guidelines was 78% with a rate of colonoscopies "generally not indicated" of 22%. Colonoscopy was completed successfully to the cecum in 93% of patients. 0.08% had serious complications during or immediately after colonoscopy. CONCLUSIONS Our results suggest that open access colonoscopy is a reliable and safe method for screening average risk population. As colonoscopy is becoming the recommended screening model for colorectal cancer this attitude of performing screening in an open access system could both cut costs in the future and improve availability, in an aim to become common practice.
Collapse
Affiliation(s)
- Tova Rainis
- Gastroenterology Unit, Bnai-Zion Medical Center, Haifa, Israel.
| | | | | | | | | |
Collapse
|
35
|
Grassini M, Verna C, Niola P, Navino M, Battaglia E, Bassotti G. Appropriateness of colonoscopy: Diagnostic yield and safety in guidelines. World J Gastroenterol 2007; 13:1816-9; discussion 1819. [PMID: 17465472 PMCID: PMC4149958 DOI: 10.3748/wjg.v13.i12.1816] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate if the guidelines for the appro-priateness of performing colonoscopy by American Society for Gastrointestinal Endoscopy (AGSE) and Italian Society of Digestive Endoscopy (SIED) yield a good diagnostic efficacy and do not present risks of missing important colonic pathologies in an Italian population sample.
METHODS: A total of 1017 consecutive patients (560 men and 457 women; mean age 64.4 ± 16 years) referred to an open-access endoscopy unit for colonoscopy from July 2004 to May 2006 were evaluated according to ASGE and SIED guidelines for appropriateness of performing the procedure. Diagnostic yield was defined as the percentage of relevant colonic pathologies of the total number of colonoscopies performed.
RESULTS: About 85.2% patients underwent colono-scopy that was considered appropriate based on at least one ASGE or SIED criterion, while it was considered inappropriate for 14.8% of patients. The diagnostic yield of colonoscopy was significantly higher for appropriate colonoscopies (26.94% vs 10.6%, P < 0.001) than for inappropriate colonoscopies (5.3%). There was no missed colorectal cancer following the ASGE/SIED criteria.
CONCLUSION: ASGE/SIED guidelines have shown a good diagnostic yield and the rate of missing relevant colonic pathologies seems very low. Unfortunately, the percentage of inappropriate referrals for colonoscopy in an open-access endoscopy system is still high, despite the number of papers published on the issue and the definition of international guidelines. Further steps are required to update and standardize the guidelines to increase their diffusion and to promote educational programs for general practitioners.
Collapse
Affiliation(s)
- Mario Grassini
- Gastroenterology and Endoscopy Unit, Cardinal Massaja Hospital, Asti, Italy
| | | | | | | | | | | |
Collapse
|
36
|
Gurudu SR, Fry LC, Fleischer DE, Jones BH, Trunkenbolz MR, Leighton JA. Factors contributing to patient nonattendance at open-access endoscopy. Dig Dis Sci 2006; 51:1942-5. [PMID: 17009114 DOI: 10.1007/s10620-006-9215-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 12/23/2005] [Indexed: 12/09/2022]
Abstract
Patients who miss endoscopy appointments cause inefficient utilization of medical resources. Because national nonattendance rates are as high as 27% and reasons for nonattendance have not been well studied, we sought to quantitate nonattendance at our tertiary care institution. We conducted a retrospective records review of the institutional database to identify patients who did not attend a scheduled endoscopy appointment between January 2000 and December 2003. Nonattendance was defined as either not showing up for an appointment or canceling it on the day it was scheduled. At our institution, patient care assistants contact such patients to document their reasons in the database. Of 36,480 patients scheduled for outpatient endoscopy, 1,490 (4.1%) did not show up because of either facility-related (44.3%; e.g., scheduling errors) or patient-related (55.7%; e.g., noncancellation, illness, or hospitalization) reasons. Our 4.1% nonattendance rate over 4 years is considerably lower than that reported by other endoscopy centers.
Collapse
Affiliation(s)
- Suryakanth R Gurudu
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona 85259, USA.
| | | | | | | | | | | |
Collapse
|
37
|
Abstract
The increased demand over the past decade for gastrointestinal endoscopy, particularly colonoscopy, has led to a greater use of open-access scheduling models in gastroenterology practices. Open-access procedures help to increase the overall capacity of a gastroenterology practice. Eliminating preprocedure office visits in selected patients provides an efficient means to meet the growing need for colorectal cancer screening and possibly other endoscopic services, such as screening for Berrett's esophagus; however, it also presents unique challenges with regards to assuring proper procedure indication, minimizing medicolegal risks, and communicating with patients and referring providers before and after the procedure. When done properly, there is a high degree of satisfaction among patients and referring physicians with open-access models.
Collapse
Affiliation(s)
- Irving M Pike
- Department of Clinical Medicine, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, VA 23507, USA.
| |
Collapse
|
38
|
Siddique I, Mohan K, Hasan F, Memon A, Patty I, Al-Nakib B. Appropriateness of indication and diagnostic yield of colonoscopy: first report based on the 2000 guidelines of the American Society for Gastrointestinal Endoscopy. World J Gastroenterol 2006; 11:7007-13. [PMID: 16437607 PMCID: PMC4717045 DOI: 10.3748/wjg.v11.i44.7007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the appropriateness of referrals and to determine the diagnostic yield of colonoscopy according to the 2000 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE). METHODS A total of 736 consecutive patients (415 males, 321 females; mean age 43.6+/-16.6 years) undergoing colonoscopy during October 2001-March 2002 were prospectively enrolled in the study. The 2000 ASGE guidelines were used to assess the appropriateness of the indications for the procedure. Diagnostic yield was defined as the ratio between significant findings detected on colonoscopy and the total number of procedures performed for that indication. RESULTS The large majority (64%) of patients had colonoscopy for an indication that was considered "generally indicated", it was "generally not indicated" for 20%, and it was "not listed" for 16% in the guidelines. The diagnostic yield of colonoscopy was highest for the "generally indicated" (38%) followed by "not listed" (13%) and "generally not indicated" (5%) categories. In the multivariable analysis, the diagnostic yield was independently associated with the appropriateness of indication that was "generally indicated" (odds ratio=12.3) and referrals by gastroenterologist (odds ratio =1.9). CONCLUSION There is a high likelihood of inappropriate referrals for colonoscopy in an open-access endoscopy system. The diagnostic yield of the procedure is dependent on the appropriateness of indication and referring physician's specialty. Certain indications "not listed" in the guidelines have an intermediate diagnostic yield and further studies are required to evaluate whether they should be included in future revisions of the ASGE guidelines.
Collapse
Affiliation(s)
- Iqbal Siddique
- Department of Medicine, Faculty of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait.
| | | | | | | | | | | |
Collapse
|
39
|
Al-Romaih WR, Al-Shehri AM. Appropriateness of upper gastrointestinal endoscopy referrals from primary health care. Ann Saudi Med 2006; 26:224-7. [PMID: 16861869 PMCID: PMC6074446 DOI: 10.5144/0256-4947.2006.224] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Wafa R Al-Romaih
- Department of Family & Community Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | | |
Collapse
|
40
|
Cohen J, Safdi MA, Deal SE, Baron TH, Chak A, Hoffman B, Jacobson BC, Mergener K, Petersen BT, Petrini JL, Rex DK, Faigel DO, Pike IM. Quality indicators for esophagogastroduodenoscopy. Gastrointest Endosc 2006; 63:S10-5. [PMID: 16564907 DOI: 10.1016/j.gie.2006.02.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Jonathan Cohen
- ASGE Communications Department, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
41
|
Menees SB, Scheiman J, Carlos R, Mulder A, Fendrick AM. Gastroenterologists utilize the referral for EGD to enhance colon cancer screening more effectively than primary care physicians. Aliment Pharmacol Ther 2006; 23:953-62. [PMID: 16573798 DOI: 10.1111/j.1365-2036.2006.02844.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Colorectal cancer screening rates among patients with upper gastrointestinal symptoms undergoing oesophagogastroduodenoscopy have not been previously established. We hypothesize that gastroenterologists seize this opportunity more frequently than primary care providers. AIMS To assess colorectal cancer screening rates at the time of direct access oesophagogastroduodenoscopy and gastrointestinal clinic evaluation for upper gastrointestinal symptoms. To compare rates in the 6 months following the oesophagogastroduodenoscopy in both cohorts of patients. METHODS Retrospective review. primary care physician group: direct access oesophagogastroduodenoscopy (n = 247) vs. gastrointestinal group (n = 278). Multivariable regression analysis utilized to assess predictors of screening outcome. RESULTS Colorectal cancer screening at the time of referral was 54%. Among the 243 unscreened patients, an additional 29% in the primary care physician group vs. 59% in the gastrointestinal group completed colorectal cancer screening in 6 months of follow-up. Nearly 60% patients evaluated in gastrointestinal clinic for upper symptoms had documented discussion, and 99% of those patients underwent colonoscopy (P < 0.001). Gastrointestinal consultation increased the probability of colorectal cancer screening completion eightfold (95% CI 3.69-18.96). CONCLUSIONS At the time of evaluation for upper symptoms, half of patients were not current with colorectal cancer screening recommendations. Referrals for the direct access oesophagogastroduodenoscopy and, more importantly, the gastroenterology consult represent key opportunities for colorectal cancer screening education and improved compliance.
Collapse
Affiliation(s)
- S B Menees
- Division of Gastroenterology, University of Michigan, Ann Arbor, 48109, USA.
| | | | | | | | | |
Collapse
|
42
|
Faigel DO, Pike IM, Baron TH, Chak A, Cohen J, Deal SE, Hoffman B, Jacobson BC, Mergener K, Petersen BT, Petrini JL, Rex DK, Safdi MA. Quality indicators for gastrointestinal endoscopic procedures: an introduction. Gastrointest Endosc 2006; 63:S3-9. [PMID: 16564906 DOI: 10.1016/j.gie.2006.02.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Douglas O Faigel
- ASGE Communications Department, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Cohen J, Safdi MA, Deal SE, Baron TH, Chak A, Hoffman B, Jacobson BC, Mergener K, Petersen BT, Petrini JL, Rex DK, Faigel DO, Pike IM. Quality indicators for esophagogastroduodenoscopy. Am J Gastroenterol 2006; 101:886-91. [PMID: 16635232 DOI: 10.1111/j.1572-0241.2006.00676.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
44
|
Faigel DO, Pike IM, Baron TH, Chak A, Cohen J, Deal SE, Hoffman B, Jacobson BC, Mergener K, Petersen BT, Petrini JL, Rex DK, Safdi MA. Quality indicators for gastrointestinal endoscopic procedures: an introduction. Am J Gastroenterol 2006; 101:866-72. [PMID: 16635230 DOI: 10.1111/j.1572-0241.2006.00677.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
45
|
Bersani G, Rossi A, Ricci G, Pollino V, Defabritiis G, Suzzi A, Alvisi V. Do ASGE guidelines for the appropriate use of colonoscopy enhance the probability of finding relevant pathologies in an open access service? Dig Liver Dis 2005; 37:609-14. [PMID: 15996629 DOI: 10.1016/j.dld.2005.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2004] [Accepted: 03/20/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND This prospective study examined the appropriate use of colonoscopy in an open-access system with the American Society for Gastrointestinal Endoscopy guidelines and determined whether the American Society for Gastrointestinal Endoscopy guidelines were associated with relevant endoscopic findings. METHODS In a cohort of 2221 consecutive patients referred for colonoscopy, the proportion of patients who underwent colonoscopy for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the positive and negative likelihood ratio of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the American Society for Gastrointestinal Endoscopy criteria. RESULTS The rate for 'generally not indicated' colonoscopies was 37%. Relevant endoscopic diagnoses were present in 28.5% of cases with American Society for Gastrointestinal Endoscopy indications versus 20.1% of patients without appropriate indications. However, the risk of finding relevant diagnoses was significantly increased by American Society for Gastrointestinal Endoscopy criteria application (odds ratio (OR) 1.58; 99% CI 1.20-2.07; p<0.01). Furthermore, in both endoscopic situations (appropriate and not appropriate), the likelihood ratio, positive and negative, varied very little, suggesting a low predictivity for serious pathologies by the appropriate procedure. CONCLUSIONS The use of an appropriateness evaluation system makes it possible to increase the probability of finding relevant endoscopic diseases. However, the exclusive use of such a system for selecting patients to undergo colonoscopy involves a relatively high risk of colorectal neoplasms going undetected.
Collapse
Affiliation(s)
- G Bersani
- Gastrointestinal Endoscopy Service of Malatesta Novello Hospital, Cesena, Italy; Post-graduate School of Gastroenterology, University of Ferrara, Ferrara, Italy.
| | | | | | | | | | | | | |
Collapse
|
46
|
Trillo Sallán E, López Fañanás MS, Villaverde Royo MV, Isanta Pomar C. [Study of the gastroscopies requested at a health centre]. Aten Primaria 2005; 35:375-7. [PMID: 15871800 PMCID: PMC8207891 DOI: 10.1157/13074298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objetivos Determinar los motivos por los que se solicita una gastroscopia y los diagnósticos endoscópicos más frecuentes obtenidos, así como valorar la aceptación de este medio diagnóstico por los médicos de nuestro centro de salud, entendida como la utilización de dicha prueba durante el período de estudio. Diseño Estudio descriptivo, retrospectivo. Emplazamiento Centro de Atención Primaria de San José de Zaragoza que atiende a una población de edad ≥ 14 años de 34.190 personas. Población Todas las gastroscopias solicitadas en el período comprendido entre enero de 1995 y diciembre de 2003. Medición La unidad de análisis utilizada es la endoscopia digestiva alta, dado que a un mismo paciente podrían habérsele realizado distintas gastroscopias en momentos diferentes del período de estudio. Se incluyen las gastroscopias solicitadas, tanto con finalidad diagnóstica como de seguimiento de enfermedades ya conocidas. Las endoscopias se realizan en el centro de especialidadess de referencia, utilizando para esta valoración los registros informatizados de dicho centro de los que se obtienen los siguientes datos: edad y sexo del paciente, médico que realizó la solicitud, motivo de petición de gastroscopia, hallazgos endoscópicos, realización o no de biopsia y hallazgos anatomopatológicos. Se incluyó a todos los médicos que han trabajado en el centro de salud durante el período de estudio, pero hay que recalcar que no todos han contribuido de igual manera, según la fecha de entrada o abandono del centro de salud. La contribución temporal de cada profesional se ha reflejado en la tabla 1. Resultados El total de gastroscopias solicitadas fue de 192. En la tabla 1 se exponen las solicitadas por cada uno de los médicos. Siete médicos no han solicitado ninguna durante el período de estudio (no los incluimos en la tabla) y en los médicos restantes hay grandes diferencias. Del total de gastroscopias solicitadas, 106 (56%) se realizaron en varones frente a 84 (46%) en mujeres. La edad media fue de 52,99 ± 15,54 años y rango de edad de 18-83 años. Los motivos por los que se solicitaron las gastroscopias fueron epigastralgia (54%), seguida de enfermedad por reflujo gastroesofágico (12,1%) y la dispepsia (11,6%). Con menor frecuencia se solicitaron por control, disfagia, estudio o por diagnóstico de sospecha en otra prueba. Los diagnósticos endoscópicos encontrados con más frecuencia fueron gastritis en 57 casos (30%), seguida de ausencia de enfermedad en 52 casos (28%) y hernia de hiato en 21 casos (11%) y esofagitis por reflujo en 19 casos (5,3%); con menor frecuencia se encontraron: ulcus duodenal en 15 casos (8%), ulcus gástrico (2,7%) y esófago de Barret en 5 casos. Otros diagnósticos fueron pólipo gástrico, acantosis, candidiasis esofágica, engrosamiento de pliegues, no realización por intolerancia, hipotonía de cardias, anillo de Schatzki, divertículo esofágico y varices esofágicas. Se realizó biopsia en 85 gastroscopias frente a 104 en las que no llegó a realizarse. No aparecía reflejado el diagnóstico anatomopatológico en 9 de los 85 informes. Los hallazgos resultantes de las 76 biopsias informadas ponen de manifiesto el predominio de gastritis crónica en 62 casos (81%) con respecto al resto de los diagnósticos anatomopatológicos, que por orden de frecuencia fueron: normalidad, cambios inflamatorios inespecíficos, gastritis erosiva, esófago de Barret y acantosis glucogénica. Del total de biopsias realizadas, la presencia de Helicobacter pylori se observó en 52 casos (69%). Aparecía metaplasia en 29 casos (47%) y displasia en 2. La inflamación era severa en 34 casos (58%) y la atrofia estaba presente en 16 casos (26%). Discusión y conclusiones Los motives más frecuentes de solicitud de gastroscopia y los diagnósticos endoscópicos encontrados en nuestro estudio coinciden con los resultados obtenidos en otros estudios, con metodología similar a la nuestra1-3. Según los resultados obtenidos, podemos afirmar que hay gran variabilidad entre los médicos del centro a la hora de solicitar esta prueba, hecho que puede estar justificado por la escasez de guías claras y de protocolos para las enfermedades digestivas, y por el importante porcentaje de población polimedicada y con pluripatología que quizá en otro contexto nos llevaría a realizar dicha solicitud. También observamos que el número de gastroscopias solicitadas parece insuficiente en relación con la elevada prevalencia de enfermedades digestivas susceptibles de ser estudiadas mediante dicha prueba. Algunos autores han intentado comparar el rendimiento de la endoscopia según se acceda a ella desde el médico de familia o mediante consulta previa con el especialista, y podemos observar que se van obteniendo resultados distintos conforme pasan los años4,5. Podemos concluir que este método diagnóstico es una herramienta muy útil para atención primaria, hasta el punto de que sólo en el 7% de los casos se necesita seguimiento por el especialista6 y se ha demostrado que los pacientes tienen un elevado grado de confianza en su medico de familia.
Collapse
|
47
|
Denis B, Weiss AM, Peter A, Bottlaender J, Chiappa P. Quality assurance and gastrointestinal endoscopy: an audit of 500 colonoscopic procedures. ACTA ACUST UNITED AC 2004; 28:1245-55. [PMID: 15671936 DOI: 10.1016/s0399-8320(04)95218-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
UNLABELLED The aim of this study was to assess the quality of colonoscopic procedures in our endoscopy unit with the goal of improving performance. METHODS We prospectively audited 500 consecutive colonoscopic procedures and assessed sixty-two process or outcome indicators for each procedure. RESULTS Most of the measured indicators were within standard limits: cecal intubation rate (92%), inadequate bowel preparations (24%), inappropriate procedures (9.7%), normal procedures (54%), yield for neoplasia (32%), morbidity (0.4%), and overall patient satisfaction (95.8%). Some indicators were outside standard limits suggesting our practices should be modified: endoscopy withdrawal time less than 6 minutes (78%), forceps removal of polyps (31%), resected polyps not recovered for pathological examination (12%), adenomas with villous elements (22%), patients unsatisfied because of time spent waiting for the procedure (19%), patients unsatisfied because of inadequate explanations (10%). There was no standard for a few indicators: patient discomfort (6.9%), diagnostic success (89%), therapeutic success (92%). Three new indicators were proposed: proportion of patients aged<50 years, number of normal colonoscopic procedures to perform to detect one advanced adenoma or cancer, and proportion of colonoscopic procedures causing discomfort. The diagnostic yield of colonoscopy was dependent on age, gender, indication and appropriateness of indication but not on the prescriber. CONCLUSION This audit allowed us to evaluate our endoscopic practices and to detect certain shortcomings and deviations from standards. It enabled us to change some of our practices with the goal of improving the quality of our colonoscopic procedures.
Collapse
Affiliation(s)
- Bernard Denis
- Service de Médecine A, Hôpitaux civils de Colmar, Haut-Rhin.
| | | | | | | | | |
Collapse
|
48
|
Kartsonis AP. Scheduling and preparation for endoscopic procedures: a biased perspective from a private practice. Gastrointest Endosc Clin N Am 2004; 14:629-34, vii. [PMID: 15363767 DOI: 10.1016/j.giec.2004.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Our ability to function successfully as efficient physicians depends substantially on our employees who surround us in our practices. It is our office associates who initially come into contact with our patients, generally spend more time with them than we do, and clearly play the major role in the scheduling of, and preparation for, endoscopic examinations. In this article we discuss ways in which we can improve scheduling and preparation for endoscopic procedures.
Collapse
|
49
|
Abstract
BACKGROUND The appropriateness has become an important issue as the use of EGD becomes more widespread. No study of the appropriateness of EGD has been performed in the Asia-Pacific region. This study examined the appropriateness of EGD in a large Asian hospital by using the American Society for Gastrointestinal Endoscopy 2000 guidelines. A secondary aim was to correlate appropriateness with the presence of positive findings at EGD. METHODS A cross-sectional study was conducted of consecutive diagnostic EGDs performed at a university-affiliated, teaching hospital, which has an open-access endoscopy system for doctors who work in the hospital. The main indication(s) for EGD was recorded and assessed as appropriate or inappropriate by using American Society for Gastrointestinal Endoscopy criteria. EGD findings were recorded and classified as positive or negative. Referrals were categorized as being from endoscopists, primary care physicians, and others. RESULTS Of 1076 referrals for EGD, 88.3% were deemed appropriate. The group with the highest rate of appropriate referral was endoscopists (90.2%), followed by primary care physicians (89.6%) and "others" (81.9%). The rate of appropriate referrals was significantly higher for endoscopists and primary care physicians compared with "others" (respectively, p=0.001 and p=0.022). The most common appropriate indication was "upper abdominal distress that persists despite an appropriate trial of therapy" (35.4%). The most common inappropriate indication was "dyspepsia in patients aged 45 years or below without adequate empirical medical treatment" (48.4%); 42.2% with an appropriate indication had positive findings compared with only 25.6% of those with inappropriate indications (p=0.006). On multivariate analysis, the following were identified as independent predictive factors for positive findings at EGD: male gender (p=0.005), age over 45 years (p=0.011), smoking (p=0.005), none/primary education (p<0.001), and secondary education (p=0.026). CONCLUSIONS The proportion of patients referred for open-access EGD with an appropriate indication(s) was high for all doctor groups in a large university-affiliated medical center in Asia. EGDs performed for appropriate indications had a higher yield of positive findings. Independent predictive factors of positive findings were male gender, age over 45 years, lower education level, and referral by an endoscopist.
Collapse
Affiliation(s)
- Yee-Ming Chan
- Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | |
Collapse
|
50
|
Charles RJ, Cooper GS, Wong RCK, Sivak MV, Chak A. Effectiveness of open-access endoscopy in routine primary-care practice. Gastrointest Endosc 2003; 57:183-6. [PMID: 12556781 DOI: 10.1067/mge.2003.55] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Direct referral of patients for endoscopic procedures without prior consultation (open-access endoscopy) has become commonplace. However, the effect of open-access endoscopy on the care of patients in routine clinical practice has not been studied. METHODS The impact of open-access endoscopy was examined in 168 consecutive patients referred from 8 primary-care practices to our tertiary hospital-based endoscopy center. The effectiveness of open-access endoscopy was assessed by review of office medical records at the primary-care practice sites for a minimum follow-up period of 6 months. Outcome measures evaluated included postprocedure communication between primary-care physician and patient, primary-care physician adherence to postprocedure recommendations, and the need for subsequent diagnostic evaluation and/or consultation. RESULTS The mean age of the 168 patients was 60 years; 56 (33%) underwent EGD and 112 (67%) had colonoscopy; 65% were from hospital-based practices and 35% from community practices. The indication(s) for 77% of the procedures met American Society for Gastrointestinal Endoscopy guidelines for the appropriate use of endoscopy. An office follow-up was noted for 82% of patients after the open-access procedure. Discussion of results was documented in 61% of the patient charts. Compliance with diagnostic and therapeutic recommendations was documented, respectively, in 75% and 90% of patient charts. A follow-up GI consultation was requested for only 7% of the patients. CONCLUSION Open-access endoscopy in the primary-care setting is effective to the extent that subsequent GI consultations are rare and the level of compliance with endoscopist recommendations is high. However, documentation of communication of the results of endoscopy with the patient can be improved.
Collapse
Affiliation(s)
- Roger J Charles
- The Division of Gastroenterology, University Hospitals of Cleveland, Case Western Reserve University, Ohio 44106, USA
| | | | | | | | | |
Collapse
|