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"Appropriateness of colonoscopy according to EPAGE II in a low resource setting: a cross sectional study from Sri Lanka". BMC Gastroenterol 2018; 18:72. [PMID: 29843628 PMCID: PMC5975517 DOI: 10.1186/s12876-018-0798-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/11/2018] [Indexed: 11/16/2022] Open
Abstract
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.
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Uncertain Diagnostic Language Affects Further Studies, Endoscopies, and Repeat Consultations for Patients With Functional Gastrointestinal Disorders. Clin Gastroenterol Hepatol 2016; 14:1735-1741.e1. [PMID: 27404968 DOI: 10.1016/j.cgh.2016.06.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/05/2016] [Accepted: 06/19/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although guidelines state that functional gastrointestinal disorders (FGIDs) can be diagnosed with minimal investigation, consultations and investigations still have high costs. We investigated whether these are due to specific behaviors of specialist clinicians by examining differences in clinician approaches to organic gastrointestinal diseases vs FGIDs. METHODS We performed a retrospective review of 207 outpatient department letters written from the gastroenterology unit at a tertiary hospital after patient consultations from 2008 through 2011. We collected data from diagnostic letters and case notes relating to patients with organic (n = 108) or functional GI disorders (n = 119). We analyzed the content of each letter by using content analysis and reviewed case files to determine which investigations were subsequently performed. Our primary outcome was the type of diagnostic language used and other aspects of the clinical approach. RESULTS We found gastroenterologists to use 2 distinct types of language, clear vs qualified, which was consistent with their level of certainty (or lack thereof), for example, "the patient is diagnosed with…." vs "it is possible that this patient might have….". Qualified diagnostic language was used in a significantly higher proportion of letters about patients with FGIDs (63%) than organic gastrointestinal diseases (13%) (P < .001). In addition, a higher proportion of patients with FGIDs underwent endoscopic evaluation than patients with organic gastrointestinal diseases (79% vs 63%; P < .05). CONCLUSIONS In an analysis of diagnoses of patients with FGIDs vs organic disorders, we found that gastroenterologists used more qualified (uncertain) language in diagnosing patients with FGIDs. This may contribute to patient discard of diagnoses and lead to additional, unwarranted endoscopic investigations.
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Marzo-Castillejo M, Almeda J, Mascort JJ, Cunillera O, Saladich R, Nieto R, Piñeiro P, Llagostera M, Cantero F, Segarra M, Puente D. Appropriateness of colonoscopy requests according to EPAGE-II in the Spanish region of Catalonia. BMC FAMILY PRACTICE 2015; 16:154. [PMID: 26498043 PMCID: PMC4620598 DOI: 10.1186/s12875-015-0369-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 10/13/2015] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- M Marzo-Castillejo
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain.
| | - J Almeda
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain. .,Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent. Catalan Institute of Health (ICS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
| | - J J Mascort
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain. .,EAP Florida, UGEAP L'Hospitalet Nord, Universitat de Barcelona, Parc dels ocellets s/n L'Hospitalet de Llobregat, 08905, Barcelona, Spain.
| | - O Cunillera
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain.
| | - R Saladich
- EAP Vinyets Ronda Sant Ramon, 187 Sant Boi de Llobregat, 08830, Barcelona, Spain.
| | - R Nieto
- EAP Penedès Rural. Servei Atenció Primària Alt Penedès.Garraf- Baix Llobregat Nord, Catalan Institute of Health (ICS) Pg. Fluvial s/n, 08730, Sta Margarida i els Monjos, Barcelona, Spain.
| | - P Piñeiro
- EAP Penedès Rural. Servei Atenció Primària Alt Penedès.Garraf- Baix Llobregat Nord, Catalan Institute of Health (ICS) Pg. Fluvial s/n, 08730, Sta Margarida i els Monjos, Barcelona, Spain.
| | - M Llagostera
- EAP Penedès Rural Servei d'Atenció Primària (SAP) Penedès-Garraf-Llobregat, Nord Catalan Institute of Health (ICS), Plaça Penedès 3, 1ª planta, 08720, Vilafranca del Penedès, Barcelona, Spain.
| | - Fx Cantero
- EAP Lluis Millet, C/ Lluis Millet, 2-4, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - M Segarra
- EAP Igualada Urbà. Servei Atenció Primària Anoia. Gerència Territorial Catalunya Central, Catalan Institute of Health (ICS), Pg. Verdaguer, 170, 08700, Igualada, Barcelona, Spain.
| | - D Puente
- EAP Bellvitge, C. de l'Ermita de Bellvitge, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain. .,Institut Universitari D'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Gran Via de les Corts Catalanes, 587 àtic, 08007, Barcelona, Spain.
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Burri E, Manz M, Schroeder P, Froehlich F, Rossi L, Beglinger C, Lehmann FS. Diagnostic yield of endoscopy in patients with abdominal complaints: incremental value of faecal calprotectin on guidelines of appropriateness. BMC Gastroenterol 2014; 14:57. [PMID: 24679065 PMCID: PMC4021405 DOI: 10.1186/1471-230x-14-57] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/24/2014] [Indexed: 01/14/2023] Open
Abstract
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.
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Affiliation(s)
- Emanuel Burri
- Department of Gastroenterology & Hepatology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
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Courtney RJ, Paul CL, Sanson‐Fisher RW, Macrae FA, Carey ML, Attia JR, McEvoy MA. Colorectal cancer screening in Australia: a community‐level perspective. Med J Aust 2012; 196:516-20. [DOI: 10.5694/mja11.10661] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Ryan J Courtney
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW
| | - Christine L Paul
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW
| | | | - Finlay A Macrae
- Department of Colorectal Medicine and Genetics, Royal Melbourne Hospital, Melbourne, VIC
| | - Mariko L Carey
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW
| | - John R Attia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW
| | - Mark A McEvoy
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW
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Argüello L, Pertejo V, Ponce M, Peiró S, Garrigues V, Ponce J. The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria. Gastrointest Endosc 2012; 75:138-45. [PMID: 22100299 DOI: 10.1016/j.gie.2011.08.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/20/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care. OBJECTIVES To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria. DESIGN Cross-sectional study. SETTING Endoscopy unit of a teaching hospital in Spain. PATIENTS Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing. MAIN OUTCOME MEASUREMENTS Appropriateness of colonoscopies according to the EPAGE criteria. RESULTS From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer-related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels. LIMITATIONS The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria. CONCLUSIONS Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.
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Affiliation(s)
- Lidia Argüello
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, Spain
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Puente D, Cantero FX, Llagostera M, Piñeiro P, Nieto R, Saladich R, Mascort J, Marzo M, Almeda J, Segarra M. A cross-sectional study of the appropriateness of colonoscopy requests in the Spanish region of Catalonia. BMJ Open 2012; 2:e002207. [PMID: 23204141 PMCID: PMC3533100 DOI: 10.1136/bmjopen-2012-002207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Diana Puente
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | | | - Maria Llagostera
- Gerència Territorial Metropolitana Sud, Institut Català de la Salut, L'Hospitalet del Llobregat, Spain
| | - Pilar Piñeiro
- Servei d'Atenció Primària (SAP) Penedès-Garraf-Llobregat Nord, ABS Penedès Rural, Institut Català de la Salut, Alt Penedès, Spain
| | - Raquel Nieto
- Servei d'Atenció Primària (SAP) Penedès-Garraf-Llobregat Nord, ABS Penedès Rural, Institut Català de la Salut, Alt Penedès, Spain
| | - Rosa Saladich
- EAP Sant Boi de Llobregat-4 (Vinyets), Institut Català de la Salut, Sant Boi de Llobregat, Spain
| | - Juanjo Mascort
- EAP L'Hospitalet de Llobregat-8 (Florida Sud), Institut Català de la Salut, L'Hospitalet de Llobregat, Spain
- Campus Bellvitge, Universitat de Barcelona, L'Hospitalet del Llobregat, Spain
| | - Mercè Marzo
- Unitat de Suport a la Recerca Costa de Ponent, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Cornellà, Spain
| | - Jesús Almeda
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
- Unitat de Suport a la Recerca Costa de Ponent, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Cornellà, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Manel Segarra
- EAP Hospitalet de Llobregat-1 (Centre), Institut Català de la Salut, L'Hospitalet de Llobregat, Spain
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Jobin G, Gagnon MP, Candas B, Dubé C, Ben Abdeljelil A, Grenier S. User's perspectives of barriers and facilitators to implementing quality colonoscopy services in Canada: a study protocol. Implement Sci 2010; 5:85. [PMID: 21044332 PMCID: PMC2988067 DOI: 10.1186/1748-5908-5-85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 11/02/2010] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) represents a serious and growing health problem in Canada. Colonoscopy is used for screening and diagnosis of symptomatic or high CRC risk individuals. Although a number of countries are now implementing quality colonoscopy services, knowledge synthesis of barriers and facilitators perceived by healthcare professionals and patients during implementation has not been carried out. In addition, the perspectives of various stakeholders towards the implementation of quality colonoscopy services and the need of an efficient organisation of such services have been reported in the literature but have not been synthesised yet. The present study aims to produce a comprehensive synthesis of actual knowledge on the barriers and facilitators perceived by all stakeholders to the implementation of quality colonoscopy services in Canada. METHODS First, we will conduct a comprehensive review of the scientific literature and other published documentation on the barriers and facilitators to implementing quality colonoscopy services. Standardised literature searches and data extraction methods will be used. The quality of the studies and their relevance to informing decisions on colonoscopy services implementation will be assessed. For each group of users identified, barriers and facilitators will be categorised and compiled using narrative synthesis and meta-analytical techniques. The principle factors identified for each group of users will then be validated for its applicability to various Canadian contexts using the Delphi study method. Following this study, a set of strategies will be identified to inform decision makers involved in the implementation of quality colonoscopy services across Canadian jurisdictions. DISCUSSION This study will be the first to systematically summarise the barriers and facilitators to implementation of quality colonoscopy services perceived by different groups and to consider the local contexts in order to ensure the applicability of this knowledge to the particular realities of various Canadian jurisdictions. Linkages with strategic partners and decision makers in the realisation of this project will favour the utilisation of its results to support strategies for implementing quality colonoscopy services and CRC screening programs in the Canadian health system.
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Affiliation(s)
- Gilles Jobin
- Department of Medicine, Université de Montréal, Montréal, Canada
- Maisonneuve-Rosemont Hospital, Montréal, Canada
| | - Marie Pierre Gagnon
- Department of Nursing, Université Laval, Québec, Canada
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada
| | - Bernard Candas
- Department of Medicine, Université Laval, Québec, Canada
- Canadian Partnership Against Cancer, Québec, Canada
| | | | - Anis Ben Abdeljelil
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada
| | - Sonya Grenier
- Research Center of the Centre Hospitalier Universitaire de Québec, Québec, Canada
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Carrión S, Marín I, Lorenzo-Zúñiga V, Moreno De Vega V, Boix J. Adecuación de la indicación de la colonoscopia según los nuevos criterios de EPAGE II. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:484-9. [DOI: 10.1016/j.gastrohep.2010.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Revised: 05/05/2010] [Accepted: 05/06/2010] [Indexed: 12/13/2022]
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Singh H, Kadiyala H, Bhagwath G, Shethia A, El-Serag H, Walder A, Velez M, Petersen LA. Using a multifaceted approach to improve the follow-up of positive fecal occult blood test results. Am J Gastroenterol 2009; 104:942-52. [PMID: 19293786 PMCID: PMC2921791 DOI: 10.1038/ajg.2009.55] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Inadequate follow-up of abnormal fecal occult blood test (FOBT) results occurs in several types of practice settings. Our institution implemented multifaceted quality improvement (QI) activities in 2004-2005 to improve follow-up of FOBT-positive results. Activities addressed precolonoscopy referral processes and system-level factors such as electronic communication, provider education, and feedback. We evaluated their effects on timeliness and appropriateness of positive-FOBT follow-up and identified factors that affect colonoscopy performance. METHODS Retrospective electronic medical record review was used to determine outcomes before and after QI activities in a multispecialty ambulatory clinic of a tertiary care Veterans Affairs facility and its affiliated satellite clinics. From 1869 FOBT-positive cases, 800 were randomly selected from time periods before and after QI activities. Two reviewers used a pretested standardized data collection form to determine whether colonoscopy was appropriate or indicated based on predetermined criteria and if so, the timeliness of colonoscopy referral and performance before and after QI activities. RESULTS In cases where a colonoscopy was indicated, the proportion of patients who received a timely colonoscopy referral and performance were significantly higher post-implementation (60.5% vs. 31.7%, P<0.0001 and 11.4% vs. 3.4%, P=0.0005). A significant decrease also resulted in median times to referral and performance (6 vs. 19 days, P<0.0001 and 96.5 vs. 190 days, P<0.0001) and in the proportion of positive-FOBT test results that had received no follow-up by the time of chart review (24.3% vs. 35.9%, P=0.0045). Significant predictors of absence of the performance of an indicated colonoscopy included performance of a non-colonoscopy procedure such as barium enema or flexible sigmoidoscopy (OR=16.9; 95% CI, 1.9-145.1), patient non-adherence (OR=33.9; 95% CI, 17.3-66.6), not providing an appropriate provisional diagnosis on the consultation (OR=17.9; 95% CI, 11.3-28.1), and gastroenterology service not rescheduling colonoscopies after an initial cancellation (OR=11.0; 95% CI, 5.1-23.7). CONCLUSIONS Multifaceted QI activities improved rates of timely colonoscopy referral and performance in an electronic medical record system. However, colonoscopy was not indicated in over one third of patients with positive FOBTs, raising concerns about current screening practices and the appropriate denominator used for performance measurement standards related to colon cancer screening.
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Affiliation(s)
- Hardeep Singh
- Health Policy and Quality Program, Houston VA HSR&D Center of Excellence, and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Himabindu Kadiyala
- Section of General Medicine, Michael E. DeBakey Veterans Affairs Medical Center Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Gayathri Bhagwath
- Section of General Medicine, Michael E. DeBakey Veterans Affairs Medical Center Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Anila Shethia
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Hashem El-Serag
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA, Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Annette Walder
- Houston VA HSR&D Center of Excellence, Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Maria Velez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center Department of Medicine, Baylor College of Medicine, Houston, Texas USA
| | - Laura A. Petersen
- Health Policy and Quality Program, Houston VA HSR&D Center of Excellence, and The Center of Inquiry to Improve Outpatient Safety Through Effective Electronic Communication, both at the Michael E. DeBakey Veterans Affairs Medical Center and the Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas USA
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Abstract
PURPOSE OF REVIEW Iron deficiency anemia (IDA) still remains universally problematic worldwide. The primary focus of this review is to critique articles published over the past 18 months that describe strategies for the diagnosis and management of this prevalent condition. RECENT FINDINGS The medical community continues to lack consensus when identifying the optimal approach for the diagnosis and management of IDA. Current diagnostic recommendations revolve around the validity and practicality of current biomarkers such as soluble transferrin-receptor concentrations and others, and cause-based diagnostics that potentially include endoscopy. Management of IDA is based on supplementation combined with effective etiological treatment. Advances in oral and parenteral low-molecular-weight iron preparations has expanded and improved treatment modalities for IDA. Since the introduction of low versus high-molecular-weight intravenous iron administration, there have been fewer serious adverse events associated with parenteral iron preparations. SUMMARY Best practice guidelines for diagnosing and managing IDA should include the design of an algorithm that is inclusive of multiple biomarkers and cause-based diagnostics, which will provide direction in managing IDA, and distinguish between IDA from the anemia of chronic disease.
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Suriani R, Rizzetto M, Mazzucco D, Grosso S, Gastaldi P, Marino M, Sanseverinati S, Venturini I, Borghi A, Zeneroli ML. Appropriateness of colonoscopy in a digestive endoscopy unit: a prospective study using ASGE guidelines. J Eval Clin Pract 2009; 15:41-5. [PMID: 19239580 DOI: 10.1111/j.1365-2753.2008.00950.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Appropriate indications for colonoscopy (C) are essential for a rational use of resources. The aim of this study is to evaluate the appropriateness of indication for C according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and to evaluate whether appropriate use was correlated with the diagnostic yield of C. METHODS We analysed 677 consecutive C performed over an 11-month period in a digestive endoscopy unit with an open access system. RESULTS The rate of 'generally indicated' C was 77% and 'generally not indicated' C was 18%. The rate of indication not listed in the ASGE guidelines was 5%. The percentage of generally not indicated C requested by gastroenterologists for outpatients was lower than that requested by primary care surgeons or doctors (9.5%, 29%, 25.3%, respectively). In 38 (7.3%) and in 111 (21.3%) of 520 patients with appropriate C, cancer and polyps larger than 5 mm were found, respectively. Twenty polyps greater than 5 mm were detected in 15 cases (12%) of 122 inappropriate C, with only one case of intramucosal carcinoma; four (12%) polyps measuring over 5 mm were found in C not listed in ASGE guidelines. No advanced stage cancer was detected in the inappropriate group and in C not listed in ASGE guidelines. CONCLUSIONS Our results showed the high rate of inappropriate procedures, according to ASGE guidelines, requested by surgeons, internists and primary care doctors for both outpatients and inpatients. The proportion of not indicated endoscopic procedures requested by gastroenterologists must be reduced through more carefully application of ASGE guidelines. Endoscopic findings were more stringent in appropriate C.
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Affiliation(s)
- Renzo Suriani
- Department of Gastroenterology, Ospedale degli Infermi, Rivoli, Italy
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Axon A. Is diagnostic and therapeutic endoscopy currently appropriate?: suggestions for improvement. Best Pract Res Clin Gastroenterol 2008; 22:959-70. [PMID: 18790441 DOI: 10.1016/j.bpg.2008.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endoscopy is the driving force in gastroenterology today, and recent exciting advances in technology have extended its frontiers at an unprecedented rate. We have a wider range of diagnostic and therapeutic possibilities at our disposal with more detailed methods available to analyse what we see on our video screens. We can access the small bowel lumen with consistency and intra-abdominal operations have been performed through the mouth and anus so where are the current limitations of the procedure? In spite of these remarkable advances many challenges remain for both the endoscopist and for industry, they are mainly ones associated with human weakness. Endoscopy is an art, performed by individuals who require training and continued education and it is done to patients who are vulnerable, afraid and often seriously unwell. It is human aspects of endoscopy that require improvement. This chapter addresses the areas where endoscopy is falling short and suggests what can be done to improve practice. Changes are needed in management, information technology, education, team working, quality, patient comfort and safety. There also remain a number of areas where improved technology may be able to reduce human error.
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Affiliation(s)
- Anthony Axon
- Department of Gastroenterology, Room 234 D Floor Clarendon Wing, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK.
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