Effectiveness of open-access endoscopy in routine primary-care practice

Timely Completion of Direct Access Colonoscopy Is Noninferior to Office Scheduled for Screening and Surveillance

GOALS

We aimed to evaluate whether direct access colonoscopy (DAC) is noninferior to office-scheduled colonoscopy (OSC) for achieving successful colonoscopy.

BACKGROUND

DAC may improve access to colonoscopy. We developed an algorithm assessing eligibility, risk for inadequate preparation, and need for nursing/navigator assistance.

STUDY

This was a retrospective, single-center study of DAC and OSC patients from June 5, 2018, to July 31, 2019. Patients were 45 to 75 years old with an indication of screening or surveillance. A successful colonoscopy met 3 criteria: complete colonoscopy (cecum, anastomosis, or ileum), adequate preparation (Boston Score ≥2/segment), and performed <90 days from initial patient contact. Unsuccessful colonoscopy did not meet ≥1 criteria. Secondary end points included days to successful colonoscopy, preparation quality, polyp detection, and 10-year recall rate. Noninferiority against risk ratio value of 0.85 was tested using 1-sided alpha of 0.05.

RESULTS

A total of 1823 DAC and 828 OSC patients were eligible. DAC patients were younger, with a greater proportion of black patients and screening indications. For the outcome of successful colonoscopy, DAC was noninferior to OSC (DAC vs. OSC: 62.7% vs. 57.1%, RR 1.16, 95% LCL 1.09, P=0.001). For DAC, days to colonoscopy were fewer, and likelihood of 10-year recall after negative screening greater. Boston Score and polyp detection were similar for groups. Black patients were less likely to achieve successful colonoscopy; otherwise, groups were similar. For unsuccessful colonoscopies, proportionally more DAC patients canceled or no-showed while more OSC patients scheduled >90 days. DAC remained noninferior to OSC at 180 days.

CONCLUSIONS

DAC was noninferior to OSC for achieving successful colonoscopy, comparing similarly in quality and efficiency outcomes.

Open-Access Oesophagogastroduodenoscopy as an Effective and Safe Strategy for Patients With Non-alarming Symptoms

BACKGROUND

Open-access oesophagogastroduodenoscopy (OAO) is defined as the performance of oesophagogastroduodenoscopy (OGD) requested by referring physicians without a prior specialist consultation. With the increasing demand for specialist appointments, the use of OAO has helped to reduce healthcare utilization by decreasing prior clinic visits. This also allows endoscopies to be scheduled and performed earlier. This study aims to evaluate our experience in providing OAO services to patients with non-alarming dyspepsia symptoms under the age of 60.

METHODS

The records of patients scheduled for OAO from January 2019 to December 2022 at Singapore General Hospital (SGH) Department of Gastroenterology were analyzed.

RESULTS

Five hundred sixty-nine patients were scheduled for OAO, and 436 patients underwent the procedure. The mean age of patients was 45.7 (SD=10.9) years old. Thirty-six percent were males, and there were 80.8% Chinese, 5.3% Malay, 8.6% Indian, and 5.3% others. The median waiting time for endoscopy was 23 days (IQR 16-36), and no major adverse events were reported. Over half of the endoscopies were unremarkable (n=231, 53%). There were 25 (5.7%) patients with major findings; three had upper gastrointestinal adenocarcinoma (one oesophageal and two gastric), one had oesophageal varices, and 21 had peptic ulcer disease (10 gastric and 11 duodenal ulcers). A rapid urease test was conducted on 409 patients, and 55 (13.4%) were positive.

CONCLUSION

OAO is a safe and effective strategy for providing timely diagnostic OGD to normal-risk patients at our center. Primary care physicians are encouraged to refer non-alarming dyspepsia symptoms patients under 60 years for OAO over the conventional route.

Appropriateness and Safety of Direct Access Endoscopy in Hospitalized Patients

Background and objective Direct access endoscopy (DAE) allows hospitalists to refer patients for endoscopy without a gastroenterologist (GI) evaluation, potentially decreasing wait time and facilitating earlier discharge from the hospital. This study aimed to evaluate the efficacy and safety of DAE for average-risk endoscopic procedures. Methods A retrospective chart review was performed by comparing patients who underwent a DAE with patients who underwent an endoscopy ordered by GI physicians at a tertiary care hospital. The procedure indications were obtained from the endoscopy reports and hospitalist progress notes. Appropriateness of each procedure was determined based on the guidelines from the American Society for Gastrointestinal Endoscopy (ASGE). Findings, procedure-related complications, and clinical significance were recorded. Results A total of 110 patients were included in this study; 40 were DAE and 70 were ordered by GI. The mean age of the patients was 55.5 years with 69 males and 41 females. In the DAE group, there were 31 esophagogastroduodenoscopies (EGD) and nine colonoscopies performed, while in the GI group, there were 58 EGDs, 11 colonoscopies, and one push enteroscopy. All procedures fulfilled ASGE criteria; 20/40 DAE and 53/70 GI-ordered procedures had clinically significant findings. There was one complication in each group. Conclusion DAE allows a hospitalist to order an endoscopy without consultation with a GI physician. This study showed that all DAE procedures had met ASGE criteria for appropriateness, with 50% having clinically significant findings and no difference in adverse events. These results suggest that DAE is safe and effective in evaluating hospitalized patients for average-risk endoscopy.

Direct access surgery for cholecystectomy - can we speed up the process?

BACKGROUND

In appropriate patients, direct referral from general practitioners to surgery without pre-operative clinic assessment can streamlining the process and allow more efficient use of clinical time. This study aimed to look at the feasibility of a direct access cholecystectomy pathway in patients with symptomatic gallstones and their satisfaction of it.

METHODS

In 2012, Bay of Plenty general practitioners (GP) were invited to refer fit patients (ASA 1 or 2, BMI <35 and <60 years old) with symptomatic cholelithiasis directly to a surgical list. One surgeon oversaw each referral and the process. The patients GP provided written and visual information and pre-operative health preoperative health questionnaire. Patients presented on the day of surgery, were seen, consented and underwent day stay cholecystectomy. Post-operative follow up was GP lead.

RESULTS

41 patients were referred via the Direct Access Surgery pathway. 37 patients were deemed appropriate with 35 proceeded to surgery. Waiting time from referral to operation was reduced from 120 (standard pathway) to 59.3 days. 30 patients (86%) had day stay procedures. Three patients (8%) re-presented with ongoing right upper quadrant pain within one year requiring further investigation. A written voluntary questionnaire was sent to all patients who underwent DAS with an 80% response rate. Overall the majority of patients (24/28; 85%) agreed or strongly agreed that they felt fully informed regarding the operation and were happy with the process.

CONCLUSION

Direct Access Surgery is an effective way to streamline healthy patients' access to operative intervention.

The Direct Access Colonoscopy Clinic: Improving time to colonoscopy for eligible positive faecal occult blood test patients in Broken Hill NSW

OBJECTIVE

This pilot project aimed to assess whether the Direct Access Colonoscopy Clinic is an effective and safe model to reduce the time from a positive faecal occult blood test referral to a gastroenterologist-performed colonoscopy, and its effect on meeting the 120-day recommendation.

DESIGN

Before/after clinical practice and patient file audit.

SETTING

Broken Hill Health Service.

PARTICIPANTS

De-identified data from all positive faecal occult blood test colonoscopies performed in the Broken Hill Health Service in October 2016-January 2017 (Pre-Direct Access Colonoscopy Clinic) and October 2017-January 2018 (Post-Direct Access Colonoscopy Clinic).

MAIN OUTCOME MEASURES

Variables included referral date, indication, initial appointment date, colonoscopy date, colonoscopy finding, bowel preparation and adverse events. Colonoscopies indicated by positive faecal occult blood test results were the focus.

RESULTS

The nurse-consulted Direct Access Colonoscopy Clinic cohort (n = 22) had a significant 139-day reduction from positive faecal occult blood test referral to colonoscopy compared to the Pre-Direct Access Colonoscopy Clinic cohort. All Direct Access Colonoscopy Clinic patients met the new 120-day recommendation for wait-time from referral to colonoscopy. Following the introduction of the Direct Access Colonoscopy Clinic, no immediate adverse events were documented for patients using either the conventional or Direct Access Colonoscopy Clinic pathways.

CONCLUSIONS

The Direct Access Colonoscopy Clinic offers a safe and effective intervention that reduces wait-time to colonoscopy in eligible patients with positive faecal occult blood test within the recommended 120 days. Further research is recommended, but Direct Access Colonoscopy Clinic has the potential to improve timely access to colonoscopy services and outcomes for all positive faecal occult blood test patients.

Diagnostic yield of upper endoscopy according to appropriateness: A systematic review

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.

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.

The Initial Management and Endoscopic Outcomes of Dyspepsia in a Low-Risk Patient Population

BACKGROUND AND AIMS

Dyspepsia is frequently encountered by primary care providers (PCP) and gastroenterologists (GI). While esophagogastroduodenoscopy (EGD) may be useful, current guidelines suggest a proton pump inhibitor (PPI) trial and H. pylori (HP) test-and-treat before EGD for low-risk patients. This study aimed to evaluate pre-EGD management and endoscopic outcomes in this population.

METHODS

This was a retrospective cohort study of low-risk dyspepsia patients (age ≤55, no alarm features) undergoing EGD at an ambulatory endoscopy center from January 2011 to March 2012. Adherences to initial management guidelines (PPI trial and HP test-and-treat strategy before EGD) were compared between PCP and GI. Endoscopic and pathologic outcomes were assessed for all patients. Statistical analyses were performed using Chi-squared test (categorical variables) and Student's t test (continuous variables). This study received IRB approval (2011P001715).

RESULTS

A total of 309 low-risk patients underwent EGD for dyspepsia. Only 202 (65.4 %) had HP testing, and 220 (71.2 %) were trialed on any dose/length PPI pre-EGD, with no differences between PCP and GI. PPI exposure was similar between groups for all dose/duration except for trials ≥8 weeks of any dose (46.9 % GI vs 34.3 % PCP, p = 0.03) and high dose (32 % GI vs 18.7 % PCP, p = 0.01). Overall, only 178 (57.6 %) patients had both HP testing and any PPI exposure pre-EGD (56.6 % GI vs 59 % PCP, p = 0.73). Significant pathology was rare, with gastritis (46.6 %) and HP (17.2 %) being most common. No malignancy was found.

CONCLUSIONS

A significant proportion of low-risk dyspepsia patients did not receive any PPI trial or HP testing before EGD. Within this population, significant finding on EGD was rare, supporting the current noninvasive initial management guidelines for dyspepsia.

Health disparities in colorectal cancer among racial and ethnic minorities in the United States

In the 2010 Census, just over one-third of the United States (US) population identified themselves as being something other than being non-Hispanic white alone. This group has increased in size from 86.9 million in 2000 to 111.9 million in 2010, representing an increase of 29 percent over the ten year period. Per the American Cancer Society, racial and ethnic minorities are more likely to develop cancer and die from it when compared to the general population of the United States. This is particularly true for colorectal cancer (CRC). The primary aim of this review is to highlight the disparities in CRC among racial and ethnic minorities in the United States. Despite overall rates of CRC decreasing nationally and within certain racial and ethnic minorities in the US, there continue to be disparities in incidence and mortality when compared to non-Hispanic whites. The disparities in CRC incidence and mortality are related to certain areas of deficiency such as knowledge of family history, access to care obstacles, impact of migration on CRC and paucity of clinical data. These areas of deficiency limit understanding of CRC's impact in these groups and when developing interventions to close the disparity gap. Even with the implementation of the Patient Protection and Affordable Healthcare Act, disparities in CRC screening will continue to exist until specific interventions are implemented in the context of each of racial and ethnic group. Racial and ethnic minorities cannot be viewed as one monolithic group, rather as different segments since there are variations in incidence and mortality based on natural history of CRC development impacted by gender, ethnicity group, nationality, access, as well as migration and socioeconomic status. Progress has been made overall, but there is much work to be done.

Screening Colonoscopy among Uninsured and Underinsured Urban Minorities

Background/Aims

Uninsured individuals have lower rates of screening colonoscopy (SC), and little is known regarding the pathology results obtained when they undergo colonoscopies. Since 2004, we have participated in a program that offers SC to uninsured New Yorkers; herein, we report our findings.

Methods

Uninsured, average-risk patients who were at least 50 years of age underwent SC at our institution between April 2004 and June 2011. We analyzed polyp pathology, location, size, incidence of adenomas, and incidence of adenomas with advanced pathology (AAP) with respect to ethnicity, gender, and age.

Results

Out of 493 referrals, 222 patients completed the colonoscopies. Polyps were identified in 21.2% of all patients; 14% had adenomas, and 4.5% had AAP. The rates of adenomas among African-Americans, Hispanics, and Whites were 24.3%, 12.1%, and 11.6%, respectively, and the corresponding rates of AAP were 10.8%, 3.5%, and 2.3%. Differences in the polyp type, location, and AAP did not reach statistical significance with respect to ethnicity or gender. Patients aged 60 and older were found to have a higher rate of advanced adenomas compared with younger patients (8.6% vs 2.6%, p=0.047).

Conclusions

Further efforts to fund screening colonoscopies for uninsured individuals will likely result in the identification of advanced lesions of the colon before they progress to colorectal cancer.

Open-access endoscopy

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.

Initial experience of direct-to-test endoscopic ultrasonography for suspected choledocholithiasis

BACKGROUND AND AIMS

Endoscopic ultrasound has become an invaluable tool in the investigation of patients with suspected pancreatobiliary disease. We set out to determine whether a "direct-to-test" endoscopic ultrasound procedure could be offered to selected patients with suspected choledocholithiasis.

METHODS AND RESULTS

We included patients referred to our general gastroenterology service with clinical history, symptomatology and/or laboratory results compatible with choledocholithiais. Almost all patients had already had a transabdominal ultrasound performed at the request of their general practitioner. All patients underwent direct-to-test day-case endoscopic ultrasound under conscious sedation. Procedures were performed by a single practitioner using an oblique-viewing radial echoendoscope. The diagnostic yield and frequencies of discharge, onward referral and follow-up were determined. Overall diagnostic yield of direct-to-test endoscopic ultrasound was 61%. The most common diagnoses were cholelithiasis (18%) and choledocholithiasis (11%); one periampullary cancer was also detected. A definitive outcome (discharge or referral for a therapeutic procedure) occurred in 14 of 28 patients (50%). The remaining 14 patients underwent further out-patient evaluation. Eventual diagnoses in this group included autoimmune hepatitis, primary biliary cirrhosis and drug-induced hepatitis.

CONCLUSIONS

For patients with suspected biliary disease, direct-to-test endoscopic ultrasound has a high diagnostic yield, and may be an appropriate mode of investigation.

Triage of colonoscopies: open access endoscopy versus outpatient consultation with a gastroenterologist

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.

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system

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.

Assessment of a rapid referral pathway for suspected colorectal cancer in Madrid

OBJECTIVE

To assess the results achieved with a rapid referral pathway for suspected colorectal cancer (CRC), comparing with the standard referral pathway.

METHODS

Three-year audit of patients suspected of having CRC routed via a rapid referral pathway, and patients with CRC routed via the standard referral pathway of a health care district serving a population of 498,000 in Madrid (Spain). Outcomes included referral criteria met, waiting times, cancer diagnosed and stage of disease.

RESULTS

Two hundred and seventy-two patients (mean age 68.8 years, SD 14.0; 51% male) were routed via the rapid referral pathway for colonoscopy. Seventy-nine per cent of referrals fulfilled the criteria for high risk of CRC. Fifty-two cancers were diagnosed: 26% Stage A (Astler-Coller), 36% Stage B, 24% Stage C and 14% Stage D. Average waiting time to colonoscopy for the rapid referral patients was 18.5 days (SD 19.1) and average waiting time to surgery was 28.6 days (SD 23.9). Colonoscopy was performed within 15 days in 65% of CRC rapid referral patients compared to 43% of standard pathway patients (P = 0.004). Overall waiting time for patients with CRC in the rapid referral pathway was 52.7 days (SD 32.9); while for those in the standard pathway, it was 71.5 days (SD 57.4) (P = 0.002). Twenty-six per cent Stage A CRC was diagnosed in the rapid referral pathway compared to 12% in the standard pathway (P < 0.001).

CONCLUSION

The rapid referral pathway reduced waiting time to colonoscopy and overall waiting time to final treatment and appears to be an effective strategy for diagnosing CRC in its early stages.

Diagnostic Yield of Microscopic Colitis in Open Access Endoscopy Center

Background

The diagnostic yield in open access endoscopy has been evaluated which generally support the effectiveness and efficiency of open access endoscopy. With a few exceptions, diagnostic yield studies have not been performed in open access endoscopy for more specific conditions. Therefore, we conducted a study to determine the efficiency of open access endoscopy in the detection of microscopic colitis as compared to traditional referral via a gastroenterologist.

Methods

A retrospective search of the pathology database at the University of Missouri for specimens from a local open access endoscopy center was conducted via SNOMED code using the terms: “microscopic”, “lymphocytic”, “collagenous”, “spirochetosis”, “focal active colitis”, “melanosis coli” and “histopathologic” in the diagnosis line for the time period between January 1, 2004 and May 25, 2006. Specimens and colonoscopy reports were reviewed by a single pathologist.

Results

Of 266 consecutive patients with chronic diarrhea and normal colonoscopies, the number of patients with microscopic disease are as follows: Lymphocytic colitis (n = 12, 4.5%), collagenous colitis (n = 17, 6.4%), focal active colitis (n = 15, 5.6%), and spirochetosis (n = 2, 0.4%).

Conclusions

The diagnostic yield of microscopic colitis in this study of an open access endoscopy center does not differ significantly from that seen in major medical centers. In terms of diagnostic yield, open access endoscopy appears to be as effective in diagnosing microscopic colitis.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Challenges in the management of positive fecal occult blood tests

BACKGROUND

Many patients with a positive fecal occult blood test (FOBT) do not undergo follow-up evaluations.

OBJECTIVE

To identify the rate of follow-up colonoscopy following a positive FOBT and determine underlying reasons for lack of follow-up.

DESIGN

It is a retrospective chart review.

PARTICIPANTS

The subject group consisted of 1,041 adults with positive FOBTs within a large physician group practice from 2004 to 2006.

MEASUREMENTS

We collected data on reasons for ordering FOBT, presence of prior colonoscopy, completed evaluations, and results of follow-up tests. We fit a multivariable logistic regression model to identify predictors of undergoing follow-up colonoscopy.

RESULTS

Most positive FOBTs were ordered for routine colorectal cancer screening (76%), or evaluation of anemia (13%) or rectal bleeding (7%). Colonoscopy was completed in 62% of cases, with one-third of these procedures identifying a colorectal adenoma (29%) or cancer (4%). Factors associated with higher rates of follow-up colonoscopy included obtaining the FOBT for routine colorectal screening (odds ratio (OR) 1.59, 95% confidence interval (CI) 1.11-2.29) and consultation with gastroenterology (OR 1.99, 95% CI 1.46-2.72). Patients were less likely to undergo colonoscopy if they were older than 80 years old (OR 0.54, 95% CI 0.31-0.92), younger than 50 years old (OR 0.44, 95% CI 0.28-0.70), uninsured (OR 0.50, 95% CI 0.27-0.93), or had undergone colonoscopy within the prior five years (OR 0.32, 95% CI 0.23-0.44).

CONCLUSIONS

Clinical decisions and patient factors available at the time of ordering an FOBT impact performance of colonoscopy. Targeting physicians' understanding of the use of this test may improve follow-up and reduce inappropriate use of this test.

Identification of patients at increased risk for colorectal cancer in an open access endoscopy center

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.

[Continuity of medical care. Evaluation of a collaborative program between hospital and Primary Care]

The patients being treated in our health care system are becoming increasingly older and have a greater prevalence of chronic diseases. Due to these factors, these patients require greater and easier accessibility to the system as well as continuity of medical care. Collaboration between the different levels of health care has been instrumental in the success of the system and has produced changes in the hospital medical care protocol. Our hospital has developed a care model oriented towards the patient's needs, resulting in a higher grade of satisfaction among the medical professionals. In this paper, we have given a detailed description of part of our medical model, illustrating its different components and indicating several parameters of its evaluation. We have also reviewed the current state of the various models published on this topic. In summary, we believe that this medical care model presents a different approach to management that benefits patients, medical professionals and the health system alike.

Satisfaction of the referring physician: a quality control study focusing on EUS

INTRODUCTION

Utilization of endoscopic ultrasonography (EUS) is becoming more widespread. Largely in control of use of EUS, as a primary consumer of EUS, are the physicians who refer patients. This quality control study aimed to uncover remedial impediments to ideal utilization of EUS.

METHODS

Two thousand patient EUS reports, all by one endoscopist, were screened. One hundred forty referring physicians were identified. One hundred of these physicians completed extensive feedback survey questionnaires.

RESULTS

Overall satisfaction with EUS procedures was generally high. The level of satisfaction was comparable to satisfaction with gastroscopy procedures, both being significantly higher than for endoscopic retrograde cholongio-pancreatography. Sixty-nine percent of the physicians indicated their desire for more information regarding EUS, this being significantly higher among residents (vs. specialists). The open access system in current practice was seen as acceptable by less than half of physicians, both from the community and from within the hospital. Waiting time for EUS procedures and for biopsy results were rated as acceptable within the hospital, but more often as too long for outpatients.

CONCLUSIONS

Overall satisfaction with EUS procedures is high. More information should be brought to the referring physicians, in print and lectures. Improving communication and interacting with endoscopist-initiated feedback led to improved feelings of teamwork, uncovered remedial weak points in the EUS service, and was thus found to be valuable.

Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system

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.

Factors contributing to patient nonattendance at open-access endoscopy

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.

Open-access endoscopy

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.

[Study of the gastroscopies requested at a health centre]

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.

The European panel on the appropriateness of gastrointestinal endoscopy guidelines colonoscopy in an open-access endoscopy unit: a prospective study

BACKGROUND

The demand for gastrointestinal endoscopy is increasing in most developed countries, resulting in an important rise in overall costs and waiting lists for endoscopic procedures. Therefore, adherence to appropriate indications for these procedures is essential for the rational use of finite resources in an open-access system.

AIM

To assess indications and appropriateness of colonoscopy according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria.

METHODS

From May to June 2004, all consecutive patients referred to our Unit for open-access colonoscopy were considered for inclusion in this prospective study. Appropriateness of each colonoscopy was established according to the EPAGE criteria. In order to evaluate whether appropriateness of use correlated with the diagnostic yield of colonoscopy, relevant endoscopic findings were also recorded.

RESULTS

A total of 350 consecutive patients were included in the study. In 38 of them, the colonoscopy indication was not listed in the EPAGE guidelines and, consequently, they were not evaluated. In the remaining 312 patients, the indication for the procedure was considered inappropriate in 73 (23%) patients. Both referring doctor characteristics (specialty and health care setting) and patient data (age) correlated with appropriateness of endoscopy. The diagnostic yield was significantly higher for appropriate colonoscopies (42%) than in those judged inappropriate (21%) (P = 0.001).

CONCLUSIONS

A noteworthy proportion of patients referred for colonoscopy to an open-access endoscopy unit are considered inappropriate because of their indication, with significant differences among specialties. These results suggest that implementation of validated guidelines for its appropriate use could improve this situation and, considering the correlation between appropriateness and diagnostic yield, even contribute to improve the prognosis of patients with colorectal diseases.

Open-access gastroscopy in primary health-care offices to prevent peptic ulcer-related hospitalization and mortality

BACKGROUND

Open-access gastroscopy performed by general practitioners is available at some primary care health centres in our Central Finland hospital referral area. The aim of the present study was to examine whether this practice influences peptic ulcer-related hospitalization and mortality.

METHODS

Data on peptic ulcer-related hospitalization were obtained from discharge registries of the hospitals. Cause of death statistics were obtained from Statistics Finland Bureau.

RESULTS

In 1996--2001, 896 inhabitants living in our hospital referral area were hospitalized owing to peptic ulcer. Of these, 265 (29.6%) had an ulcer related to the use of aspirin (ASA) or non-steroidal anti-inflammatory drugs (NSAIDs). Among the hospitalized patients, mortality was 11.6% (n = 104). In municipalities with or without an open-access gastroscopy service, the rates of hospitalization were 49.1 cases/100,000/year (95% CI 44.8-53.4) versus 77.5 cases/100,000/year (95% CI 72.0-83.0), and ulcer-related mortality 5.6 cases/100,000/year (95% CI 4.1-7.1) versus 9.4/100,000/year (95% CI 7.5-11.3). In municipalities without the service, inhabitants were older and their overall morbidity and mortality higher than in municipalities offering open-access gastroscopy. Of patients under 75 years of age (n = 582), 48 (8.2%) died, compared with 56 (17.8%, P < 0.001) of patients aged 75 years or older (n = 314). Age was the only independent risk factor for death (odds ratio (OR) 1.03 per year (95% CI 1.02-1.05)). Among patients with ASA-NSAID-related ulcer, open-access endoscopy was protective against ulcer-related death (OR 0.17 (95% CI 0.03-0.85)).

CONCLUSIONS

Open-access gastroscopy in primary health-care offices significantly reduces ASA-NSAID-related ulcer mortality and may also reduce overall ulcer-related hospitalizations. The present results may, however, be biased by demographic factors. Age is a risk factor for death during ulcer-related hospitalization.

Strategies to address increased demand for colonoscopy: Guidelines in an open endoscopy practice

BACKGROUND AND AIMS

Since Medicare approval for reimbursement of screening colonoscopies, the number of colonoscopy requests has increased. Physician resources have often been inadequate to meet the demand. We sought to reduce the demand for colonoscopy in an open endoscopy system by using a guideline-based triage system to eliminate inappropriate procedures and to align the timing of surveillance colonoscopies with recommendations made by national organizations.

METHODS

This was a cohort study with primary care outpatients. From October 2002 to February 2003, 498 consecutive patients on a waiting list of 2400 awaiting colonoscopy for all indications were triaged and are the focus of the study. Selection of patients for appropriate colonoscopy was based on consensus guidelines developed for institutional use by using established published guidelines for appropriate colonoscopy indications.

RESULTS

Of the 498 consecutive patients triaged, 139 (28%) were deemed inappropriate. The most common reason was inappropriate referral for surveillance of colorectal polyps. The percentage of inappropriate referrals by the 3 largest referring specialties (internal medicine, family medicine, and gastroenterology) combined was also 28% with no statistically significant differences between specialties.

CONCLUSIONS

Most referrals for colonoscopy in an open-access endoscopy system were appropriate, although about 1 in 4 were not. Use of triage and further education of physicians regarding colonoscopy may optimize colonoscopy utilization.