Clinical validation of the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II criteria in an open-access unit: a prospective study

Appropriateness of colonoscopies in a Tunisian endoscopy center: factors and EPAGE-I/II criteria comparison

BACKGROUND

There is a growing demand for colonoscopy, worldwide, resulting in increased rate of inappropriate referrals. This "overuse" of colonoscopies has become a major burden for health care.

OBJECTIVES

to assess the appropriateness of colonoscopies performed at the endoscopy unit of the university hospital of Sousse and to compare these results of appropriateness according to the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) I and EPAGE II criteria.

PATIENTS AND METHODS

this cross-sectional study included all consecutive patients referred for a diagnostic colonoscopy, between January 2017 and December 2018. Patients referred for exclusively therapeutic indications, those with incomplete colonoscopies were not included. Patients with poor bowel preparation or missing data were also excluded. Indications were assessed using the EPAGE I and EPAGE II criteria.

RESULTS

From 1972 consecutive patients, 1307 were included. Overall, 986 (75.4%) of all referrals were for out-patients. The majority of patients were referred by gastroenterologists (n = 1026 patients; 78.5%), followed by general surgeons (n = 85; 6.5%). The commonest indications were lower abdominal symptoms (275; 21%) followed by uncomplicated diarrhea (152; 11.6%). Relevant findings were present in 363 patients (27.7%). Neoplastic lesions were the dominant finding in 221 patients (16.9%). EPAGE I and EPAGE II criteria were applicable for 1237 (88.8%) and 1276 (97.7%) patients respectively. Hematochezia and abdominal pain recorded the highest inappropriate rates with both sets of criteria. Appropriate colonoscopies increased to 76.4% when EPAGE II criteria were applied; whereas uncertain and inappropriate procedures decreased to 10.3% and 10.9% respectively Appropriateness of indication was significantly higher in hospitalized patients. For the EPAGE II criteria, the specialty of the referring physician was also significantly associated to the appropriate use. The agreement between EPAGE I and EPAGE II criteria was slight using the weighted version of k (k = 0.153).

CONCLUSIONS

The updated and improved EPAGE II guidelines are a simple and valid tool for assessing the appropriateness of colonoscopies. They decreased the inappropriate rate and the possibility of missing potentially severe diagnoses.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%.

DISCUSSION

It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.

Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study

INTRODUCTION

Advances in endoscopy and open-access systems led to an increase in endoscopic procedures. However, overuse of endoscopy has been consistently reported. This study aims to assess the appropriateness of esophagogastroduodenoscopy (EGD) and colonoscopy referral in the private and public setting.

PATIENTS AND METHODS

We conducted a prospective, multicenter study at 2 public and 5 private endoscopy units. Patients scheduled for elective EGD or colonoscopy were enrolled. Clinical data and endoscopy findings were recorded. Appropriateness of endoscopy was defined according to the American Society for Gastrointestinal Endoscopy guidelines (for EGD) and the European Panel on Appropriateness of Gastrointestinal Endoscopy II (for colonoscopy).

RESULTS

Regarding EGD: 215 patients enrolled (43.7% were males) with a mean age of 61.0 ± 15.1 years; 54.0% (n = 116) were in public hospitals. Referral by a gastroenterologist was made for 34.9% (n = 75). Appropriate indications were made for 62.3% (n = 134): 42.4% in private versus 79.3% in public endoscopy units (odds ratio [OR] 5.20; 95% confidence interval [CI] 2.85-9.49; p < 0.01). Rate of appropriate EGD was 74.7% for gastroenterologist referral and 56.1% for other specialties (OR 2.31; 95% CI 1.24-4.28; p < 0.01). Diagnostic yield for relevant findings was 47.9%. No association between indication appropriateness, gastroenterologist referral, and relevant endoscopic findings was found. Regarding colonoscopy: 287 patients enrolled (49.1% were males) with a mean age of 60.4 ± 14.4 years; 48.1% (n = 138) were in public hospitals. Referral by a gastroenterologist was made for 20.6% (n = 59). Appropriate indications were made for 70.0% (n = 201): 53.0% in private vs. 88.4% in public endoscopy units (OR 6.75; 95% CI 3.66-12.47; p < 0.01). Diagnostic yield was 57.1%. Relevant endoscopic diagnosis was associated with indication: 63.2% in the appropriate vs. 43.0% in the nonappropriate indication group (p < 0.05).

DISCUSSION

A significant percentage of endoscopies, mainly in the private setting, were performed without an appropriate indication. This influenced the diagnostic yield. The use of adequate criteria is fundamental for the rational use of an open-access system.

Simple feedback of colonoscopy performance improved the number of adenomas per colonoscopy and serrated polyp detection rate

Background and study aims  High-quality endoscopy requires improvement of not only the adenoma detection rate (ADR) but also the serrated polyp (SP) detection rate and the mean number of adenomas per positive procedure (MAP +). We evaluated whether a simple feedback of colonoscopy performance improves those quality indicators using propensity-score matching. Patients and methods  Eleven endoscopists were evaluated regarding colonoscopy performance including ADRs, SP detection rates, mean numbers of adenomas per procedure (MAPs), and MAPs + with their ranking in the clinic. Endoscopic performance was compared before and after the feedback. Results  Colonoscopies were performed for 874 patients before the feedback and 1,272 patients after the feedback. Using propensity-score matching, 803 patients before the feedback and 803 patients after the feedback were matched. ADR after the feedback was significantly higher than that before the feedback (50.8 % and 40.8 %, respectively). MAP after feedback was significantly larger than that before the feedback (0.92 and 0.69, respectively), as well as MAP + (1.96 and 1.69, respectively). Clinically significant SP detection rate was also improved from 10.0 % to 14.9 %. Conclusions  Feedback including ADR, MAP, MAP +, and clinically significant SR detection rate could improve on those quality indicators. Further studies are needed to effectively prevent colorectal cancer in colonoscopy practice.

The diagnostic yield of colonoscopy in hospitalized patients. An observational multicenter prospective study

BACKGROUND

Colonoscopy demands a considerable amount of resources, and little is known about its diagnostic yield among inpatients.

AIMS

To assess indications, diagnostic yield and findings of colonoscopy for inpatients, and to identify risk factors for relevant findings and cancer.

METHODS

Multicentre, prospective, observational study including 12 hospitals. Consecutive adult inpatients undergoing colonoscopy were evaluated from February through November 2019.

RESULTS

1,302 inpatients underwent colonoscopy. Diagnostic yield for relevant findings and cancer was 586 (45%) and 112 (8.6%), respectively. Adequate colon cleansing was achieved in 896 (68.8%) patients. Split-dose/same-day regimen was adopted in 847 (65%) patients. Factors associated to relevant findings were age ≥70 years (RR 1.32), male gender (RR 1.11), blood loss (RR 1.22) and adequate cleansing (RR 1.63). Age ≥70 years (RR 2.08), no previous colonoscopy (RR 2.69) and split-dose/same-day regimen (RR 1.59) significantly increased cancer detection. Implementing adequate cleansing and split-dose/same-day regimen in all patients would increase the diagnostic yield for any relevant findings and cancer from 43% to 70% and from 6% to 10%, respectively.

CONCLUSION

Relevant colorectal diseases and cancer were frequent among inpatients. Factors associated with detection of relevant findings were identified. Adequate colon cleansing and split-dose/same-day regimen significantly increased colonoscopy diagnostic yield.

Validation of Australian and Victorian guidelines for colonoscopy triage

BACKGROUND AND AIMS

This study aimed to assess the diagnostic performance of National and Victorian colonoscopy triage guidelines and potential redistribution of triage categories.

METHODS

Diagnostic validation study comparing colonoscopy triage guidelines against a reference colonoscopy dataset.

PARTICIPANTS

reference dataset of 2,378 colonoscopies from 1 October 2014 to 30 June 2016. Comparison with triage categorisation determined using: National Cancer Council Australia guidelines; Victorian triage guidelines; Optimal Cancer Care Pathways recommendations.

MAIN OUTCOME MEASURES

i. Proportion of colonoscopies assigned to each triage category; ii. detection rate (proportion of cancers assigned to triage Category 1); iii. conversion rate (proportion of triage Category 1 colonoscopies which diagnose a cancer).

RESULTS

After adjusting for data absent in referrals, the National and Victorian guidelines reduced the proportion of Category 1 colonoscopies compared with the reference triage (National 76.3% vs 58.6%; 95% CI for difference 15.0 - 20.3% p<0.0001. Victorian 76.3% vs 66.3%; 95% CI for difference 7.4 - 12.6% p<0.0001). Victorian guidelines were associated with the highest detection rate (91.4%) and a conversion rate of 5.4% although the number of cancers limited the power to detect significant differences on these metrics. There was a higher proportion of unclassifiable colonoscopies using the National guidelines than the Victorian ones due to their focus on symptomatic indications.

CONCLUSIONS

The Victorian guidelines could reduce the proportion of Category 1 colonoscopies by 10% without reducing conversion or detection rates. This would require improvements in the quality of referrals and ordering faecal occult blood tests in 6% of symptomatic patients. This article is protected by copyright. All rights reserved.

Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams

BACKGROUND

Colonoscopy is frequently performed in industrialised countries. Inappropriate colonoscopies might lead to unnecessary exams, increasing risks and costs.

AIM

To estimate the impact of colonoscopy appropriateness in terms of gain in additional diagnoses and sparing of unnecessary exams.

METHODS

Systematic review including studies reporting the prevalence of relevant findings, colorectal cancer (CRC) and inflammatory bowel disease (IBD) according to colonoscopy appropriateness as defined by the American Society for Gastrointestinal Endoscopy and European Panel on Appropriateness of Gastrointestinal Endoscopy.

RESULTS

Twenty-one studies with 19,822 patients were included. Colonoscopy was appropriate in 15,162 (71%, CI 64%-78%). Appropriateness significantly increased the probability of relevant findings (34% vs. 18%; RR 1.81, CI 1.53-2.14), CRC (7% vs. 2%; RR 3.62, CI 2.44-5.37) and IBD (6% vs. 4%; RR 1.86, CI 1.09-3.19). Appropriateness had sensitivity 88% (CI 85%-91%), 97% (CI 93%-98%) and 89% (CI 80%-94%), and specificity 24% (CI 20%-29%), 22% (CI 18%-26%) and 24% (CI 20%-28%) for relevant findings, CRC and IBD, respectively. On average, performing colonoscopy with appropriate indication would find 15 (CI 10-21) more relevant findings, five (CI 3-9) more CRCs and three (CI 1-9) more diagnoses of IBD per 100 patients, and save 24 (CI 20-29), 22 (CI 18-26) and 24 (CI 20-28) examinations per 100 patients for relevant findings, CRC and IBD, respectively.

CONCLUSIONS

Appropriateness affects the diagnostic yield of colonoscopy for CRC, IBD and relevant findings. Appropriateness criteria are useful, although integrated with clinical evaluation of the patient.

Optical imaging technology in colonoscopy: Is there a role for photometric stereo?

Colonoscopy screening for the detection and removal of colonic adenomas is central to efforts to reduce the morbidity and mortality of colorectal cancer. However, up to a third of adenomas may be missed at colonoscopy, and the majority of post-colonoscopy colorectal cancers are thought to arise from these. Adenomas have three-dimensional surface topographic features that differentiate them from adjacent normal mucosa. However, these topographic features are not enhanced by white light colonoscopy, and the endoscopist must infer these from two-dimensional cues. This may contribute to the number of missed lesions. A variety of optical imaging technologies have been developed commercially to enhance surface topography. However, existing techniques enhance surface topography indirectly, and in two dimensions, and the evidence does not wholly support their use in routine clinical practice. In this narrative review, co-authored by gastroenterologists and engineers, we summarise the evidence for the impact of established optical imaging technologies on adenoma detection rate, and review the development of photometric stereo (PS) for colonoscopy. PS is a machine vision technique able to capture a dense array of surface normals to render three-dimensional reconstructions of surface topography. This imaging technique has several potential clinical applications in colonoscopy, including adenoma detection, polyp classification, and facilitating polypectomy, an inherently three-dimensional task. However, the development of PS for colonoscopy is at an early stage. We consider the progress that has been made with PS to date and identify the obstacles that need to be overcome prior to clinical application.

Appropriate referral and selection of patients with chronic pain for spinal cord stimulation: European consensus recommendations and e-health tool

Background

Spinal cord stimulation (SCS) is an established treatment for chronic neuropathic, neuropathic‐like and ischaemic pain. However, the heterogeneity of patients in daily clinical practice makes it often challenging to determine which patients are eligible for this treatment, resulting in undesirable practice variations. This study aimed to establish patient‐specific recommendations for referral and selection of SCS in chronic pain.

Methods

A multidisciplinary European panel used the RAND/UCLA Appropriateness Method (RUAM) to assess the appropriateness of (referral for) SCS for 386 clinical scenarios in four pain areas: chronic low back pain and/or leg pain, complex regional pain syndrome, neuropathic pain syndromes and ischaemic pain syndromes. In addition, the panel identified a set of psychosocial factors that are relevant to the decision for SCS treatment.

Results

Appropriateness of SCS was strongly determined by the neuropathic or neuropathic‐like pain component, location and spread of pain, anatomic abnormalities and previous response to therapies targeting pain processing (e.g. nerve block). Psychosocial factors considered relevant for SCS selection were as follows: lack of engagement, dysfunctional coping, unrealistic expectations, inadequate daily activity level, problematic social support, secondary gain, psychological distress and unwillingness to reduce high‐dose opioids. An educational e‐health tool was developed that combines clinical and psychosocial factors into an advice on referral/selection for SCS.

Conclusions

The RUAM was useful to establish a consensus on patient‐specific criteria for referral/selection for SCS in chronic pain. The e‐health tool may help physicians learn to apply an integrated approach of clinical and psychosocial factors.

Significance

Determining the eligibility of SCS in patients with chronic pain requires careful consideration of a variety of clinical and psychosocial factors. Using a systematic approach to combine evidence from clinical studies and expert opinion, a multidisciplinary European expert panel developed detailed recommendations to support appropriate referral and selection for SCS in chronic pain. These recommendations are available as an educational e‐health tool (https://www.scstool.org/).

Outcomes at follow-up of negative colonoscopy in average risk population: systematic review and meta-analysis

OBJECTIVE

To review and summarise the evidence on the prevalence of colorectal adenomas and cancers at a follow-up screening colonoscopy after negative index colonoscopy, stratified by interval between examinations and by sex.

DESIGN

Systematic review and meta-analysis of all available studies.

DATA SOURCES

PubMed, Web of Science, and Embase. Two investigators independently extracted characteristics and results of identified studies and performed standardised quality ratings.

ELIGIBILITY CRITERIA

Studies assessing the outcome of a follow-up colonoscopy among participants at average risk for colorectal cancer with a negative previous colonoscopy (no adenomas).

RESULTS

28 studies were identified, including 22 cohort studies, five cross sectional studies, and one case-control study. Findings for an interval between colonoscopies of one to five, five to 10, and more than 10 years were reported by 17, 16, and three studies, respectively. Summary estimates of prevalences of any neoplasm were 20.7% (95% confidence interval 15.8% to 25.5%), 23.0% (18.0% to 28.0%), and 21.9% (14.9% to 29.0%) for one to five, five to 10, and more than 10 years between colonoscopies. Corresponding summary estimates of prevalences of any advanced neoplasm were 2.8% (2.0% to 3.7%), 3.2% (2.2% to 4.1%), and 7.0% (5.3% to 8.7%). Seven studies also reported findings stratified by sex. Summary estimates stratified by interval and sex were consistently higher for men than for women.

CONCLUSIONS

Although detection of any neoplasms was observed in more than 20% of participants within five years of a negative screening colonoscopy, detection of advanced neoplasms within 10 years was rare. Our findings suggest that 10 year intervals for colonoscopy screening after a negative colonoscopy, as currently recommended, may be adequate, but more studies are needed to strengthen the empirical basis for pertinent recommendations and to investigate even longer intervals.

STUDY REGISTRATION

Prospero CRD42019127842.

Quality measures improving endoscopic screening of colorectal cancer: a review of the literature

INTRODUCTION

Colorectal cancer (CRC) is a major health-care problem all over the world and CRC screening is effective in reducing mortality and increasing the 5-year survival. Colonoscopy has a central role in CRC screening. It can be performed as a primary test, as a recall policy after a positive result of another screening test, and for surveillance. Since effectiveness of endoscopic screening depends on adequate detection and removal of colonic polyps, consistent quality measures, which are useful in enhancing the diagnostic yield of examination, are essential. Areas covered: The aim of this review is to analyze current evidence from literature supporting quality measures able to refine endoscopic screening of colorectal cancer. Expert commentary: Quality measures namely a) time slot allotted to colonoscopy, b) assessment of indication, c) bowel preparation, d) Cecal intubation, e) withdrawal time, f) adenoma detection rate, g) proper management of lesions (polypectomy technique, polyps retrieval rate and tattooing of resection sites), and h) adequate follow-up intervals play a key role in identifying malignant and at-risk lesions and improving the outcome of screening. Adherence to these quality measures is critical to maximize the effectiveness of CRC screening, as well as, a proper technique of colonoscopy and a quality report of the procedure. Among all recommended measures, adenoma detection rate is the most important and must be kept above the recommended quality threshold by all physicians practicing in the setting of screening.

Management of vertebral fragility fractures: a clinical care pathway developed by a multispecialty panel using the RAND/UCLA Appropriateness Method

BACKGROUND CONTEXT

Vertebral fragility fractures (VFFs), mostly due to osteoporosis, are very common and are associated with significant morbidity and mortality. There is a lack of consensus on the appropriate management of patients with or suspected of having a VFF.

PURPOSE

This work aimed at developing a comprehensive clinical care pathway (CCP) for VFF.

STUDY DESIGN/SETTING

The RAND/UCLA Appropriateness Method was used to develop patient-specific recommendations for the various components of the CCP. The study included two individual rating rounds and two plenary discussion sessions.

METHODS

A multispecialty expert panel (orthopedic and neurosurgeons, interventional [neuro]radiologists and pain specialists) assessed the importance of 20 signs and symptoms for the suspicion of VFF, the relevance of 5 diagnostic procedures, the appropriateness of vertebral augmentation versus nonsurgical management for 576 clinical scenarios, and the adequacy of 6 aspects of follow-up care.

RESULTS

The panel identified 10 signs and symptoms believed to be relatively specific for VFF. In patients suspected of VFF, advanced imaging was considered highly desirable, with MRI being the preferred diagnostic modality. Vertebral augmentation was considered appropriate in patients with positive findings on advanced imaging and in whom symptoms had worsened and in patients with 2 to 4 unfavorable conditions (eg, progression of height loss and severe impact on functioning), dependent on their relative weight. Time since fracture was considered less relevant for treatment choice. Follow-up should include evaluation of bone mineral density and treatment of osteoporosis.

CONCLUSIONS

Using the RAND/UCLA Appropriateness Method, a multispecialty expert panel established a comprehensive CCP for the management of VFF. The CCP may be helpful to support decision-making in daily clinical practice and to improve quality of care.

Direct access cancer testing in primary care: a systematic review of use and clinical outcomes

BACKGROUND

Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay.

AIM

To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations.

DESIGN AND SETTING

Systematic review assessing the effectiveness of GP DA testing in adults.

METHOD

MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively.

RESULTS

The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high.

CONCLUSION

GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction.

"Appropriateness of colonoscopy according to EPAGE II in a low resource setting: a cross sectional study from Sri Lanka"

Background

Due to finite resources, the clinical decision to subject a patient to colonoscopy needs to be based on the evidence, regardless of its availability, affordability and safety. This study assessed the appropriateness of colonoscopies conducted in selected study settings in Sri Lanka. In the absence of local guidelines, audit was based on European Panel on Appropriateness of Gastrointestinal Endoscopy II (EPAGE II) criteria.

Methods

This cross-sectional study assessed consecutive patients who underwent colonoscopy between June to August 2015 at four main hospitals in Sri Lanka. Interviewer administered questionnaire and secondary data were collected by trained health staff. Indications were assessed according to EPAGE II criteria.

Results

Out of 325 patients, male female proportions were 57.2 and 42.8%. Mean (SD) age was 54.9 (12.1) years. Colonoscopies were appropriate in 61.2% (95% CI 55.8–66.3), uncertain in 28.6% (95% CI 23.9–33.7) and inappropriate in 10.2% (95% CI 7.3–13.9). Colonoscopy to evaluate abdominal pain has highest percentage of inappropriateness of 10.0%. However, 9.5% of these colonoscopies revealed Colo-Rectal Cancer (CRC), reflecting differences in the profile of local CRC patients. Colonoscopies with appropriate or uncertain indications are three times more likely to have a relevant finding than inappropriate indications (42.5% vs. 18.2%; OR 3.32, 95% CI 1.33–8.3; P = 0.008).

Conclusions

Majority of colonoscopies are appropriate. However, it cannot be neglected that every one in ten patients undergo inappropriate colonoscopy. Proportion of inappropriateness was highest for the indication of chronic abdominal pain, of which, 9.5% of patients were diagnosed with CRC. This may reflect the different profile of local CRC patients in terms of symptom manifestation and other characteristics. In conclusion, the authors recommend formulation of national guidelines for colonoscopy indications based on current best evidence and local patient profile. Use of such prepared local guidelines will improve the efficient use of finite resources.

Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for lower gastrointestinal endoscopy. We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 rate of adequate bowel preparation (minimum standard 90%); 2 cecal intubation rate (minimum standard 90%); 3 adenoma detection rate (minimum standard 25%); 4 appropriate polypectomy technique (minimum standard 80%); 5 complication rate (minimum standard not set); 6 patient experience (minimum standard not set); 7 appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.

The fecal hemoglobin concentration, age and sex test score: Development and external validation of a simple prediction tool for colorectal cancer detection in symptomatic patients

Prediction models for colorectal cancer (CRC) detection in symptomatic patients, based on easily obtainable variables such as fecal haemoglobin concentration (f-Hb), age and sex, may simplify CRC diagnosis. We developed, and then externally validated, a multivariable prediction model, the FAST Score, with data from five diagnostic test accuracy studies that evaluated quantitative fecal immunochemical tests in symptomatic patients referred for colonoscopy. The diagnostic accuracy of the Score in derivation and validation cohorts was compared statistically with the area under the curve (AUC) and the Chi-square test. 1,572 and 3,976 patients were examined in these cohorts, respectively. For CRC, the odds ratio (OR) of the variables included in the Score were: age (years): 1.03 (95% confidence intervals (CI): 1.02-1.05), male sex: 1.6 (95% CI: 1.1-2.3) and f-Hb (0-<20 µg Hb/g feces): 2.0 (95% CI: 0.7-5.5), (20-<200 µg Hb/g): 16.8 (95% CI: 6.6-42.0), ≥200 µg Hb/g: 65.7 (95% CI: 26.3-164.1). The AUC for CRC detection was 0.88 (95% CI: 0.85-0.90) in the derivation and 0.91 (95% CI: 0.90-093; p = 0.005) in the validation cohort. At the two Score thresholds with 90% (4.50) and 99% (2.12) sensitivity for CRC, the Score had equivalent sensitivity, although the specificity was higher in the validation cohort (p < 0.001). Accordingly, the validation cohort was divided into three groups: high (21.4% of the cohort, positive predictive value-PPV: 21.7%), intermediate (59.8%, PPV: 0.9%) and low (18.8%, PPV: 0.0%) risk for CRC. The FAST Score is an easy to calculate prediction tool, highly accurate for CRC detection in symptomatic patients.

Distribution pattern of colorectal diseases based on 2300 total colonoscopies

AIM

We conducted a cross-sectional study to estimate the prevalence of CRD in our area in East Azerbaijan, Iran.

BACKGROUND

Colorectal diseases (CRD) include a broad spectrum that varies from benign lesions to malignant and cancerous masses. CRD can be investigated by colonoscopy. Some of these diseases are highly preventable with timely screening and appropriate planning by the healthcare system.

METHODS

This is a hospital-based, cross-sectional study by the Gastroenterology Department on patients who underwent colonoscopy between June 2013 and March 2015 in outpatient clinics at private Shahriyar medical center and Imam Reza University Hospital in Tabriz, East Azerbaijan province, Iran. Chi-square analysis and bivariate Pearson correlation coefficient were applied in this study using SPSS 20.

RESULTS

During the study period, we recruited 2300 patients (1230 men, 1070 women) with the mean and median (Standard Deviation=SD) age at presentation of 47.10 (0.338) and 47 (16.195) years. The duration of patients' symptoms ranged from 1 to 480 months, with mean and median (SD) values of 26.99 (0.902) and 12 (40.76) months, respectively. Despite at least 20 types of pathologies seen on colonoscopy, normal cases constituted the majority (32.7%).The most serious diseases in the study were IBD (10.9%), polyps (14.4%) and cancers (4.9%). Colonoscopic findings had a significant correlation with patients' age and gender; also, we detected a significant correlation between patients' chief complaint and colonoscopic findings as well as colonoscopic pathology samples.

CONCLUSION

Despite the ongoing westernization of lifestyle in our country, the distribution of colorectal diseases in Iran is different from Western population. It is important to recognize the prevalence of these diseases in our area to determine exposure factors for management and planning correctly in health system policies.

Information seeking and anxiety among colonoscopy-naïve adults: Direct-to-colonoscopy vs traditional consult-first pathways

AIM

To investigate the effects of direct to colonoscopy pathways on information seeking behaviors and anxiety among colonoscopy-naïve patients.

METHODS

Colonoscopy-naïve patients at two tertiary care hospitals completed a survey immediately prior to their scheduled outpatient procedure and before receiving sedation. Survey items included clinical pathway (direct or consult), procedure indication (cancer screening or symptom investigation), telephone and written contact from the physician endoscopist office, information sources, and pre-procedure anxiety. Participants reported pre-procedure anxiety using a 10 point scale anchored by “very relaxed” (1) and “very nervous” (10). At least three months following the procedure, patient medical records were reviewed to determine sedative dose, procedure indications and any adverse events. The primary comparison was between the direct and consult pathways. Given the very different implications, a secondary analysis considering the patient-reported indication for the procedure (symptoms or screening). Effects of pathway (direct vs consult) were compared both within and between the screening and symptom subgroups.

RESULTS

Of 409 patients who completed the survey, 34% followed a direct pathway. Indications for colonoscopy were similar in each group. The majority of the participants were women (58%), married (61%), and internet users (81%). The most important information source was family physicians (Direct) and specialist physicians (Consult). Use of other information sources, including the internet (20% vs 18%) and Direct family and friends (64% vs 53%), was similar in the Direct and Consult groups, respectively. Only 31% of the 81% who were internet users accessed internet health information. Most sought fundamental information such as what a colonoscopy is or why it is done. Pre-procedure anxiety did not differ between care pathways. Those undergoing colonoscopy for symptoms reported greater anxiety [mean 5.3, 95%CI: 5.0-5.7 (10 point Likert scale)] than those for screening colonoscopy (4.3, 95%CI: 3.9-4.7).

CONCLUSION

Procedure indication (cancer screening or symptom investigation) was more closely associated with information seeking behaviors and pre-procedure anxiety than care pathway.

Appropriateness of endoscopic surveillance recommendations in organised colorectal cancer screening programmes based on the faecal immunochemical test

OBJECTIVES

To assess the appropriateness of recommendations for endoscopic surveillance in organised colorectal cancer (CRC) screening programmes based on the faecal immunochemical test (FIT).

DESIGN

74 Italian CRC screening programmes provided aggregated data on the recommendations given after FIT-positive colonoscopies in 2011 and 2013. Index colonoscopies were divided into negative/no adenoma and low- risk, intermediate-risk and high-risk adenomas. Postcolonoscopy recommendations included a return to screening (FIT after 2 years or 5 years), an endoscopic surveillance after 6 months or after 1 year, 3 years or 5 years, surgery or other. We assessed the deviation from the postcolonoscopy recommendations of the European Guidelines in 2011 and 2013 and the correlation between overuse of endoscopic surveillance in 2011 and the process indicators associated with the endoscopic workload in 2013.

RESULTS

49 704 postcolonoscopy recommendations were analysed. High-risk, intermediate-risk and low-risk adenomas, and no adenomas were reported in 5.9%, 19.3%, 15.3% and 51.5% of the cases, respectively. Endoscopic surveillance was inappropriately recommended in 67.4% and 7%, respectively, of cases with low-risk and no adenoma. Overall, 37% of all endoscopic surveillance recommendations were inappropriate (6696/17 860). Overuse of endoscopic surveillance was positively correlated with the extension of invitations (correlation coefficient (cc) 0.29; p value 0.03) and with compliance with post-FIT+ colonoscopy (cc 0.25; p value 0.05), while it was negatively correlated with total colonoscopy waiting times longer than 60 days (cc -0.26; p value 0.05).

CONCLUSIONS

In organised screening programmes, a high rate of inappropriate recommendations for patients with low risk or no adenomas occurs, affecting the demand for endoscopic surveillance by a third.

Colorectal cancer diagnosis: Pitfalls and opportunities

Colorectal cancer (CRC) is a major health problem in the Western world. The diagnostic process is a challenge in all health systems for many reasons: There are often no specific symptoms; lower abdominal symptoms are very common and mostly related to non-neoplastic diseases, not CRC; diagnosis of CRC is mainly based on colonoscopy, an invasive procedure; and the resource for diagnosis is usually scarce. Furthermore, the available predictive models for CRC are based on the evaluation of symptoms, and their diagnostic accuracy is limited. Moreover, diagnosis is a complex process involving a sequence of events related to the patient, the initial consulting physician and the health system. Understanding this process is the first step in identifying avoidable factors and reducing the effects of diagnostic delay on the prognosis of CRC. In this article, we describe the predictive value of symptoms for CRC detection. We summarize the available evidence concerning the diagnostic process, as well as the factors implicated in its delay and the methods proposed to reduce it. We describe the different prioritization criteria and predictive models for CRC detection, specifically addressing the two-week wait referral guideline from the National Institute of Clinical Excellence in terms of efficacy, efficiency and diagnostic accuracy. Finally, we collected information on the usefulness of biomarkers, specifically the faecal immunochemical test, as non-invasive diagnostic tests for CRC detection in symptomatic patients.

Appropriateness of colonoscopy requests according to EPAGE-II in the Spanish region of Catalonia

BACKGROUND

In a context of increasing demand and pressure on the public health expenditure, appropriateness of colonoscopy indications is a topic of discussion. The objective of this study is to evaluate the appropriateness of colonoscopy requests performed in a primary care (PC) setting in Catalonia.

METHODS

Cross-sectional descriptive study. Out-patients >14 years of age, referred by their reference physicians from PC or hospital care settings to the endoscopy units in their reference hospitals, to undergo a colonoscopy. Evaluation of the appropriateness of 1440 colonoscopy requests issued from January to July 2011, according to the EPAGE-II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy).

RESULTS

The most frequent indications of diagnostic suspicion requests were: rectal bleeding (37.46 %), abdominal pain (26.54 %), and anaemia study (16.78 %). The most frequent indications of disease follow-up were adenomas (58.1 %), and CRC (31.16 %). Colonoscopy was appropriate in 73.68 % of the cases, uncertain in 16.57 %, and inappropriate in 9.74 %. In multivariate analysis, performed colonoscopies reached an OR of 9.9 (CI 95 % 1.16-84.08) for qualifying as appropriate for colorectal cancer (CRC) diagnosis, 1.49 (CI 95 % 1.1-2.02) when requested by a general practitioner, and 1.09 (CI 95 % 1.07-1.1) when performed on women.

CONCLUSIONS

Appropriateness of colonoscopy requests in our setting shows a suitable situation in accordance with recognized standards. General practitioners contribute positively to this appropriateness level. It is necessary to provide physicians with simple and updated guidelines, which stress recommendations for avoiding colonoscopy requests in the most prevalent conditions in PC.

Descriptive analysis of endoscopic findings in patients with a family history of colorectal cancer

BACKGROUND

The presence of a family history implies an increased risk for developing colorectal cancer (CRC), and may require a different screening strategy. The aim of this study was to evaluate lesions found during colonoscopies of patients that had a family history of CRC.

MATERIAL AND METHODS

A retrospective study was conducted that included consecutive colonoscopies performed on patients with a family history of CRC at a referral center within the period from April 2000 to January 2012. The colonoscopic findings were analyzed in relation to sex, age, and the presence or absence of symptoms.

RESULTS

Data from 3,792 colonoscopies were collected. The mean age of the patients was 53.14 years (SD 12.22), and 57.4% were women. Colonoscopy was normal in 71.7% of the cases, with hyperplastic polyps being detected in 7.1%, and adenomatous polyps in 19.8% (39.4% of them were high risk). There was a 1.5% presence of adenocarcinomas in the subjects. Polyps and CRC were predominant in men (P=.001 and P=.027, respectively) and there was a linear increase with age. Symptomatic patients had a higher CRC detection rate (P<.001), but no differences were observed in relation to polyp diagnosis.

CONCLUSIONS

Age and male sex increased the risk for presenting with CRC or adenomas in the group of patients with a family history of CRC, and the presence of symptoms was associated with a greater risk for presenting with CRC.

[Inappropriateness rate for colonoscopy indications in an open access unit]

INTRODUCTION AND OBJECTIVE

The suitability of indications for colonoscopy is important to optimize the available resources. The aim of this study was to assess the appropriateness of colonoscopy indications in an open access endoscopy unit using the EPAGE II criteria.

METHODS

Colonoscopies performed between October 1 and November 30, 2011 were retrospectively included. The appropriateness of the colonoscopy was established according to the EPAGE II criteria. Demographics, medical applicants, indications and relevant findings from these examinations were recorded.

RESULTS

We included 440 colonoscopies (60.8 ± 016.3 years, 54% women). The indication was appropriate in 75.4% (CI, 71-79.3%), uncertain in 13.1% (CI, 10.2-16.6%) and inappropriate in 11.4% (CI, 8.7-14.8%). In the univariate analysis, the relevant findings in the colonoscopy were associated with age, sex, colonoscopy indications and EPAGE II. In the logistic regression analysis, factors independently associated with the presence of relevant findings were age (≥ 50 years) (OR, 1.84), male sex (OR, 2.7) and two indications, inflammatory bowel disease and post-polypectomy surveillance (P < .03). The diagnostic yield of EPAGE II criteria was 37.3% for appropriate colonoscopies and 28.3% for inappropriate colonoscopies (P = .09).

CONCLUSIONS

The rate of unnecessary colonoscopy is high, especially in young patients (<50 years) and some colonoscopy indications. Age (≥ 50 years) and male sex are independently associated with the presence of relevant findings in colonoscopy. The diagnostic yield of EPAGE II criteria does not differ between appropriate and inappropriate examinations.

Results of a fast-track referral system for urgent outpatient hepatology visits

OBJECTIVE

In 2011, our regional district adopted an experimental system for fast referral (within 72 h) by general practitioners to several outpatient specialist evaluations including hepatology. The aim of this study was to assess the characteristics and appropriateness of urgent hepatology visits.

DESIGN

Retrospective study.

SETTING

Hospital-based study in Italy.

PARTICIPANTS

A total of 192 subjects referred to our outpatient hepatology clinic classified as 'urgent' were compared with 397 patients evaluated with standard referral. A comparison with 200 patients visited just before the adoption of the new system was also included.

MAIN OUTCOME MEASURES

Patients' features and appropriateness of referral in urgent and non-urgent groups using the new system.

RESULTS

Increase in liver enzymes was the main factor that leads to specialist hepatology consultation and was more frequent in the urgent group (37% vs. 27.1%, P < 0.001). Liver malignancies were identified in 2.6% of patients in the urgent group, whereas this percentage was 10 times lower in the non-urgent group (P = 0.01). Urgent patients required inpatient admission more frequently compared with non-urgent patients (4.2% vs. 0.5%; P = 0.003). Inappropriate referral was recorded in 41% of cases in the urgent group (no reason for urgency 27%; condition not attributable to liver 13.5%). In the non-urgent group, consultations were inappropriate in 20.1% of cases (condition not attributable to liver). In comparison with the old system, the new one allocated >85% of patients with serious illness to urgent group.

CONCLUSIONS

This strategy is helpful in selecting patients with more serious hepatic conditions. Appropriateness of referral represents a crucial issue.

European panel on the appropriateness of gastrointestinal endoscopy II guidelines help in selecting and prioritizing patients referred to colonoscopy--a quality control study

OBJECTIVE

To use information from the referral letters to assess the appropriateness of colonoscopies in a primary open-access referral center, according to the criteria from the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II, and to compare with the first EPAGE guidelines. Second, to evaluate how the appropriateness and other patient- or doctor-related factors affected the diagnostic yield (DY).

MATERIAL AND METHODS

A set of variables; symptoms, referring physician and final diagnosis, for 323 referrals accepted for colonoscopy were recorded prospectively and later on assessed using the EPAGE and EPAGE II criteria, respectively. Patients with incomplete visualization of the entire colon or colonoscopic findings as indication were excluded.

RESULTS

EPAGE and EPAGE II criteria were applicable in 287 (95.3%) and 295 (98.0%) referrals, respectively. A total of 166 (57.8%) patients were considered appropriate by EPAGE and 240 (81.4%) patients were considered appropriate by EPAGE II. DY for appropriate versus uncertain/inappropriate referrals was 34.9% versus 17.4% for EPAGE (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.8-4.4, p = 0.003) and 31.3% versus 10.9% for EPAGE II (OR = 3.5, 95% CI: 1.4-8.9, p = 0.007). Sensitivity was higher for EPAGE II (92.6% vs. 73.4%). According to EPAGE II, 68 (23.1%) patients were referred due to lesions identified on other diagnostic procedures, producing a DY of 39.7%. In this group, 70% presented symptoms appropriate for a primary referral to colonoscopy.

CONCLUSIONS

The majority of colonoscopies were found appropriate by EPAGE II. There was a clear association between high appropriateness of the indication and a high DY. EPAGE II is a guideline-improvement that may be useful for both referring physicians and gastroenterologists when considering referrals.

Diagnostic yield of endoscopy in patients with abdominal complaints: incremental value of faecal calprotectin on guidelines of appropriateness

BACKGROUND

European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria have been developed to increase diagnostic yield, but their predictive value is limited. We investigated the incremental diagnostic value of faecal calprotectin to EPAGE criteria.

METHODS

In a post-hoc analysis of a prospective study, EPAGE criteria were applied to 298 of 575 (51.8%) patients who had undergone esophagogastroduodenoscopy (EGD), colonoscopy or both for abdominal complaints at the Division of Gastroenterology & Hepatology at the University Hospital Basel in Switzerland. Faecal calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. Final endoscopic diagnoses were blinded to calprotectin values.

RESULTS

Of 149 EGDs and 224 colonoscopies, 17.6% and 14.7% respectively were judged inappropriate by EPAGE criteria. Appropriate or uncertain indications revealed more endoscopic findings in both EGD (46.3% vs. 23.1%, P = 0.049) and colonoscopy (23.6% vs. 6.1%, P = 0.041) than inappropriate indications. Median calprotectin levels were higher (81.5 μg/g, interquartile range 26-175, vs. 10 μg/g, IQR 10-22, P < 0.001) and testing was more often positive (>50 μg/g) in patients with endoscopic findings, both in EGD (58.2% vs. 33.0%, P = 0.005) and in colonoscopy (57.3% vs. 7.4%, P < 0.001). The use of faecal calprotectin in addition to EPAGE criteria improved the risk reclassification of patients by endoscopic findings. The calculated net reclassification index was 37.8% (P = 0.002) for EGD and 110.9% (P <0.001) for colonoscopy, thus improving diagnostic yield to 56.8% and 70.2%, respectively.

CONCLUSIONS

The use of faecal calprotectin in addition to EPAGE criteria improved diagnostic yield in patients with abdominal complaints.

Standardized endoscopic reporting

The need for standardized language is increasingly obvious, also within gastrointestinal endoscopy. A systematic approach to the description of endoscopic findings is vital for the development of a universal language, but systematic also means structured, and structure is inherently a challenge when presented as an alternative to the normal spoken word. The efforts leading to the "Minimal Standard Terminology" (MST) of gastrointestinal endoscopy offer a standardized model for description of endoscopic findings. With a combination of lesion descriptors and descriptor attributes, this system gives guidance to appropriate descriptions of lesions and also has a normative effect on endoscopists in training. The endoscopic report includes a number of items not related to findings per se, but to other aspects of the procedure, formal, technical, and medical. While the MST sought to formulate minimal lists for some of these aspects (e.g. indications), they are not all well suited for the inherent structure of the MST, and many are missing. Thus, the present paper offers a recommended standardization also of the administrative, technical, and other "peri-endoscopic" elements of the endoscopic report; important also are the numerous quality assurance initiatives presently emerging. Finally, the image documentation of endoscopic findings is becoming more obvious-and accessible. Thus, recommendations for normal procedures as well as for focal and diffuse pathology are presented. The recommendations are "minimal," meaning that expansions and subcategories will likely be needed in most centers. Still, with a stronger common grounds, communication within endoscopy will still benefit.

A cross-sectional study of the appropriateness of colonoscopy requests in the Spanish region of Catalonia

INTRODUCTION

Colonoscopies are being requested with increasing frequency in the last few years, as they are used both as a diagnostic and therapeutic procedure in several gastrointestinal diseases. Our purpose is to describe the appropriateness of colonoscopy requests issued both from primary care centres and from hospitals, according to the EPAGE II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy).

METHODS AND ANALYSIS

Cross-sectional study. Colonoscopy requests issued since January 2011 and received at the endoscopy units of all six reference hospitals serving the primary care centres of the South Metropolitan and Central Catalonia districts will be collected (total=1500 requests). Variables to be collected include gender, date of birth, origin of the request and reference hospital, priority of the procedure, type of clinician requesting the procedure, date and indication of request, abdominal examination performed, anal inspection examination performed, date of last colonoscopy if applicable, diagnosis and date of diagnosis. Using the available information and the EPAGE II website, colonoscopy requests will be assigned as an appropriateness score. The association between the variables collected and the EPAGE II scores will be assessed using a Student's t test and a χ(2) test. A multilevel logistic model will be generated on the factors associated with the appropriateness of the requests.

ETHICS AND DISSEMINATION

Colonoscopy is a costly procedure and not free from complications. In order to increase cost effectiveness, reduce waiting lists and optimise resources, it is necessary to use tools such as the EPAGE II guidelines, which establish criteria to assess the appropriateness of colonoscopies. The purpose of this study is to describe the current situation and to discuss whether current clinical practice is appropriate. The results of the study will be published in the next few years. In consideration of the ethical principles and methods of the research study, approval was granted for the project.