Patient time requirements for screening colonoscopy

Health Promotion of Early and Sustained Allergenic Food Introduction for the Prevention of Food Allergy

Observational studies and landmark randomized control trials support early and sustained allergenic food introduction in infancy as an effective preventive strategy against food allergy development. Despite a consensus regarding the intended goals of early and sustained allergenic food introduction, there have been myriad policy recommendations among health authorities in how to achieve both individual and population-level health outcomes for food allergy prevention. This clinical management review provides an overview on the data that informs early and sustained allergenic food introduction strategies, suggestions on how to advise allergenic food introduction, principles of prevention programs as they relate to food allergy prevention, and health promotion and systems-level challenges that impede achievement of food allergy prevention goals.

Economic Pressure and Intention to Complete Colorectal Cancer Screening: A Cross-Sectional Analysis Among U.S. Men

Although men's lives can be saved by colorectal cancer (CRC) screening, its utilization remains below national averages among men from low-income households. However, income has not been consistently linked to men's CRC screening intent. This study tested the hypothesis that men who perceive more economic pressure would have lower CRC screening intent. Cross-sectional data were collected via an online survey in February 2022. Men (aged 45-75 years) living in the U.S. (N = 499) reported their CRC screening intent (outcome) and their perception of their economic circumstances (predictors). Adjusted binary and ordinal logistic analyses were conducted. All analyses were conducted in March 2022. Men who perceived greater difficulty paying bills or affording the type of clothing or medical care they needed (i.e., economic strain) were less likely to have CRC screening intent (OR = 0.67, 95% CI: 0.49, 0.93). This association was no longer significant when prior screening behavior was accounted for (OR = 0.75, 95% CI: 0.52, 1.10). Contrary to our hypothesis, men who reported more financial cutbacks were more likely to report wanting to be screened for CRC within the next year (OR = 1.06, 95% CI: 1.01, 1.11). This is one of the first studies to demonstrate that men's perceptions of their economic circumstances play a role in their intent to complete early-detection screening for CRC. Future research should consider men's perceptions of their economic situation in addition to their annual income when aiming to close the gap between intent and CRC screening uptake.

Examining the relationship between household wealth and colorectal cancer screening behaviors among U.S. men aged 45-75

Colorectal cancer (CRC) is the third leading cause of cancer-related death among men in the United States (U.S.), particularly among men aged 45 years and older. Early-detection screening remains a key method of decreasing CRC-related deaths, yet socioeconomic barriers exist to planning and completing CRC screening. While accumulating evidence shows income disparities in CRC screening prevalence, a dearth of research has investigated wealth disparities. This study aimed to determine whether household wealth was associated with CRC screening uptake and future screening intent. In February 2022, we sent an online survey to potential participants; U.S. men aged 45–75 years were eligible to participate. We examined four CRC screening behaviors as outcomes: ever completing a stool-based or exam-based screening test, current screening status, and future screening intent. Household net wealth, determined by self-reported household wealth and debt, was the primary predictor. We used logistic regression to estimate odds ratios (ORs) and their 95% confidence interval (CI). Of the study participants (N = 499), most self-identified as Non-Hispanic White, were aged 50–64 years, and had previously completed a CRC screening test. Results revealed that, among men aged 45–49 years, higher net wealth decreased the odds of ever completing a stool- or exam-based test (OR = 0.58, 95% CI: 0.33, 0.98; OR = 0.55, 95% CI: 0.31, 0.94, respectively). By contrast, among men aged 50–75 years, higher net wealth increased the odds of being current with CRC screening (OR = 1.40, 95% CI: 1.03, 1.92). Net wealth was unassociated with CRC screening intent. These findings suggest that household net wealth, rather than income, is an important socioeconomic factor to consider in relation to uptake of CRC early-detection screening. The financial and social cognitive mechanisms linking household wealth to CRC screening behaviors merit future research and intervention.

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Wealth was associated with U.S men's adherence to screening for colorectal cancer.

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Age modified the association between wealth and colorectal cancer screening uptake.

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Wealth reduced the odds of past colorectal screening completion for men 45–49 years.

Impact of colonoscopy on working productivity: a prospective multicenter observational study

BACKGROUND AND AIMS

Patients undergoing colonoscopy are often in the workforce. Therefore, colonoscopy may affect patients' work productivity in terms of missed working days and/or reduced working efficiency. We aimed to investigate the impact of colonoscopy on work productivity and factors influencing this impact.

METHODS

We conducted a prospective, observational, multicenter study in 10 Italian hospitals between 2016 and 2017. We collected information on individual characteristics, work productivity, symptoms, and conditions before, during, and after the procedure from patients undergoing colonoscopy for several indications using validated tools. Outcomes were interference of preparation with work, absenteeism, and impaired work performance after the procedure. We fitted multivariate logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for potential predictors of the outcomes.

RESULTS

Among 1137 subjects in the study, 30.5% reported at least 1 outcome. Impaired work performance was associated with bowel preparation regimen (full dose on the day of colonoscopy vs split dose: OR, 4.04; 95% CI, 1.43-11.5), symptoms during bowel preparation (high symptom score: OR, 3.21; 95% CI, 1.15-8.95), and pain during the procedure (OR, 2.47; 95% CI, 1.40-4.35). Increasing number of working hours and less comfortable jobs were associated with absenteeism (P for trend = .06) and impairment of working performance (P for trend = .01) and GI symptoms both before and after colonoscopy.

CONCLUSIONS

Occupational and individual characteristics of patients should be considered when scheduling colonoscopy because this procedure may impair work productivity in up to one-third of patients. Split-dose bowel preparation, performing a painless colonoscopy, and preventing the occurrence of GI symptoms may minimize the impact of colonoscopy on work productivity.

A Teachable Moment: Colorectal Cancer Screening Among Companions Waiting for Outpatients Undergoing a Colonoscopy

To determine colorectal cancer (CRC) screening knowledge, attitudes, behaviors, and preferences for a future CRC screening educational intervention among adults (companions) waiting for outpatients undergoing a colonoscopy. We approached 384 companions at three endoscopy centers associated with one healthcare system to complete a survey from March to July 2017. The survey assessed CRC and CRC screening knowledge, attitudes, behaviors, and preferences for a future CRC screening educational intervention. There were 164 companions at average risk for CRC that completed a self-administered survey. Among average-risk companions, 23% were not within screening guidelines. Additionally, 74% of those not within guidelines reported that they had never completed a CRC screening test. The most frequently reported barriers to CRC screening were the perception of not needing screening because they were asymptomatic and lack of a provider recommendation for screening. Companions suggested that a future CRC screening intervention include a brochure and/or a brief video, featuring men and women from different races/ethnicities, a CRC survivor, and a healthcare professional. Almost one-fourth of average-risk companions waiting at endoscopy centers were not within CRC screening guidelines, providing a teachable moment to recruit companions to participate in an educational intervention to encourage screening. Companions provided suggestions (e.g., content and channel) for a future intervention to promote CRC screening in this population.

Cost-effectiveness analysis of colorectal cancer screening in a low incidence country: The case of Saudi Arabia

BACKGROUND

Colorectal cancer (CRC) screening is cost-effective in many Western countries, and many have successfully implemented CRC screening programs. For countries with a lower CRC incidence, like Saudi Arabia, the value of CRC screening is less evident and requires careful weighing of harms, benefits, and costs.

METHODS

We used the MISCAN-Colon microsimulation model to simulate a male and female cohort with life expectancy and CRC risk as observed in Saudi Arabia. For both cohorts, we evaluated strategies without screening, with annual or biennial faecal immunochemical testing (FIT), and with 10-yearly or once-only colonoscopy. We also considered different start and end ages of screening. For both cohorts, we estimated lifetime costs and effects of each strategy. We then identified a set of potentially cost-effective strategies using incremental cost-effectiveness ratios (ICERs) defined as the additional cost per additional quality-adjusted life year (QALY).

RESULTS

Without CRC screening, an estimated 14 per 1,000 males would develop CRC during their lifetime and 9 would die from CRC. Several strategies proved potentially cost-effective including biennial FIT at ages 55-65 (ICER of $7,400), once-only colonoscopy at age 55 (ICER of $7,700), and 10-yearly colonoscopy at ages 50-65, 45-65, and 45-75 (ICERs of $34,000, 71,000, and 375,000, respectively). For females, risk of CRC was lower and CRC screening was therefore less cost-effective, but efficient strategies were largely similar.

CONCLUSIONS

Despite low CRC incidence in Saudi Arabia, some FIT or colonoscopy screening strategies may meet reasonable thresholds of cost-effectiveness. The optimal strategy will depend on multiple factors including the willingness to pay per QALY, the colonoscopy capacity, and the accepted budget impact.

Feasibility of sedation on demand in Taiwan using water exchange and air insufflation: A randomized controlled trial

BACKGROUND AND AIM

Completion of colonoscopy without sedation eliminates sedation cost and complications. Reported in the United States and Europe, on-demand sedation is not routine practice in Taiwan. Water exchange (WE), characterized by infusion and nearly complete removal of infused water during insertion, reduces insertion pain compared to air insufflation (AI) during colonoscopy. We evaluated the feasibility of on-demand sedation in Taiwan. In a randomized controlled trial of WE vs AI colonoscopy, we also aimed to determine if WE augmented the implementation by reducing insertion pain and decreasing sedation requirement.

METHODS

This prospective patient-blinded study randomized patients to AI or WE (75 patients/group) to aid insertion. The primary outcome was the proportion of patients completing without sedation.

RESULTS

In the AI and WE groups, 76.0% and 93.3% (P = 0.006) completed without need for sedation, respectively. The WE group had lower insertion pain score (mean [SD]) (4.0 [2.9] vs 2.1 [2.6], P < 0.001), lower doses of propofol (25.7 [52.7] mg vs 9.1 [35.6] mg, P = 0.012), and less time in the recovery room (3.4 [7.4] vs 1.5 [5.5], P = 0.027) than the AI group. Patient satisfaction scores and willingness to repeat if needed in the future were similar.

CONCLUSION

On-demand sedation was feasible in Taiwan. The completion rate without sedation was high in patients (76.0% with standard AI) open to the option (no prior intent to receive the standard of full or minimal sedation). WE augmented the implementation by reducing insertion pain and decreasing sedation requirement without adversely affecting patient satisfaction or willingness to repeat.

Excessive Tums Intake Can Cause Colonoscope Malfunction

During a diagnostic esophagogastroduodenoscopy (EGD) and colonoscopy, a foreign material was found coating a patient’s stomach and proximal colon. Polypectomy with a hot snare and cold forceps proved unsuccessful, as the endoscope channels clogged. Thereafter, the patient confessed to taking one bottle of Tums (GlaxoSmithKline, St. Louis, Missouri, US) daily for an unknown duration. The medication was discontinued and a repeat colonoscopy showed complete resolution. The costs of repeat procedures, reduced efficacy, as well as equipment damage or refurbishment are substantial, and so providers should note that this may be the result of excessive calcium carbonate (similarly to barium) and instruct the patients to adjust intake accordingly.

Analysis of factors associated with extended recovery time after colonoscopy

Background & aims

A common limiting factor in the throughput of gastrointestinal endoscopy units is the availability of space for patients to recover post-procedure. This study sought to identify predictors of abnormally long recovery time after colonoscopy performed with procedural sedation. In clinical research, this type of study would be performed using only one regression modeling approach. A goal of this study was to apply various “machine learning” techniques to see if better prediction could be achieved.

Methods

Procedural data for 31,442 colonoscopies performed on 29,905 adult patients at Massachusetts General Hospital from 2011 to 2015 were analyzed to identify potential predictors of long recovery times. These data included the identities of hospital personnel, and the initial statistical analysis focused on the impact of these personnel on recovery time via multivariate logistic regression. Secondary analyses included more information on patient vitals both to identify secondary predictors and to predict long recoveries using more complex techniques.

Results

In univariate analysis, the endoscopist, procedure room nurse, recovery room nurse, and surgical technician all showed a statistically significant relationship to long recovery times, with p-value below 0.0001 in all cases. In the multivariate logistic regression, the most significant predictor of a long recovery time was the identity of the recovery room nurse, with the endoscopist also showing a statistically significant relationship with a weaker effect. Complex techniques led to a negligible improvement over simple techniques in prediction of long recovery periods.

Conclusion

The hospital personnel involved in performing a colonoscopy show a strong association with the likelihood of a patient spending an abnormally long time recovering from the procedure, with the most pronounced effect for the nurse in the recovery room. The application of more advanced approaches to improve prediction in this clinical data set only yielded modest improvements.

Cost Effectiveness of Screening Patients With Gastroesophageal Reflux Disease for Barrett's Esophagus With a Minimally Invasive Cell Sampling Device

BACKGROUND & AIMS

It is important to identify patients with Barrett's esophagus (BE), the precursor to esophageal adenocarcinoma (EAC). Patients with BE usually are identified by endoscopy, which is expensive. The Cytosponge, which collects tissue from the esophagus noninvasively, could be a cost-effective tool for screening individuals with gastroesophageal reflux disease (GERD) who are at increased risk for BE. We developed a model to analyze the cost effectiveness of using the Cytosponge in first-line screening of patients with GERD for BE with endoscopic confirmation, compared with endoscopy screening only.

METHODS

We incorporated data from a large clinical trial of Cytosponge performance into 2 validated microsimulation models of EAC progression (the esophageal adenocarcinoma model from Massachusetts General Hospital and the microsimulation screening analysis model from Erasmus University Medical Center). The models were calibrated for US Surveillance, Epidemiology and End Results data on EAC incidence and mortality. In each model, we simulated the effect of a 1-time screen for BE in male patients with GERD, 60 years of age, using endoscopy alone or Cytosponge collection of tissue, and analysis for the level of trefoil factor 3 with endoscopic confirmation of positive results. For each strategy we recorded the number of cases of EAC that developed, the number of EAC cases detected with screening by Cytosponge only or by subsequent targeted surveillance, and the number of endoscopies needed. In addition, we recorded the cumulative costs (including indirect costs) incurred and quality-adjusted years of life lived within each strategy, discounted at a rate of 3% per year, and computed incremental cost-effectiveness ratios (ICERs) among the 3 strategies.

RESULTS

According to the models, screening patients with GERD by Cytosponge with follow-up confirmation of positive results by endoscopy would reduce the cost of screening by 27% to 29% compared with screening by endoscopy, but led to 1.8 to 5.5 (per 1000 patients) fewer quality-adjusted life years. The ICERs for Cytosponge screening compared with no screening ranged from $26,358 to $33,307. For screening patients by endoscopy compared with Cytosponge the ICERs ranged from $107,583 to $330,361. These results were sensitive to Cytosponge cost within a plausible range of values.

CONCLUSIONS

In a comparative modeling analysis of screening strategies for BE in patients with GERD, we found Cytosponge screening with endoscopic confirmation to be a cost-effective strategy. The greatest benefit was achieved by endoscopic screening, but with an unfavorable cost margin.

Colorectal Cancer Screening in Average Risk Patients

Colorectal cancer (CRC) contributes a major burden of cancer mortality in the United States. There are multiple effective screening approaches that can reduce CRC mortality. These approaches are supported by different levels of evidence, and each has its own advantages and disadvantages. Implementing a systematic approach to screening that addresses the multiple steps involved in the screening process is essential to improving population-level CRC screening. Offering patients stool-based screening is important for increasing screening uptake. However, programs that offer stool testing must support the population health infrastructure needed to promote adherence to repeat testing and follow-up of abnormal tests.

Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies

Many studies have documented barriers to colorectal cancer screenings. However, there is lack of comprehensive information on the time and costs borne by low-income patients and the persons accompanying the patient (caregiver) for colonoscopies in the United States. We surveyed patients in three health clinics in Philadelphia retrospectively who had undergone free colonoscopies in the previous 18-month period. Participants were asked questions about time and out-of-pockets expenses for themselves and their caregivers. Even when colonoscopies were free to the patient through Colorectal Cancer Control Program funded by the Centers for Disease Control and Prevention, the patient and caregivers still incurred costs in relation to preparing for, undergoing, and recovering from a colonoscopy. These costs can be substantial and may account for some of the low colorectal cancer screening rates especially among the low-income populations. Patients' and caregivers' costs need to be considered when designing and implementing colorectal cancer control programs.

Controlled Dietary Restriction With a Prepackaged Low-Residue Diet Before Colonoscopy Offers Better-Quality Bowel Cleansing and Allows the Use of a Smaller Volume of Purgatives: A Randomized Multicenter Trial

BACKGROUND

Bowel preparation is burdensome, and less-demanding preparation procedures are needed. Few studies have investigated the effects of low-residue diet and prepackaged low-residue diet in combination with low-volume polyethylene glycol-electrolyte lavage solution during colonoscopy preparation.

OBJECTIVE

We compared self-prepared low-residue diets with prepackaged low-residue diets in combination with low-volume polyethylene glycol.

DESIGN

This was a single-blinded, 3-arm, multicenter, randomized controlled trial.

SETTING

Colonoscopies were conducted in outpatient settings at 3 centers in Taiwan.

PATIENTS

The study included 180 patients (age range, 20-75 years) who were scheduled for colonoscopy.

INTERVENTIONS

Three groups were compared: group A included self-prepared, 1-day, low-residue diets with a same-day 2.0-L single-dose of polyethylene glycol; group B included prepackaged low-residue diets plus 2.0 L of polyethylene glycol; and group C included prepackaged low-residue diets plus 1.5 L of polyethylene glycol.

MAIN OUTCOME MEASURES

The outcome measures were adherence, bowel-cleansing level, and patient satisfaction.

RESULTS

One third of the subjects in group A, but none in the prepackaged low-residue diets groups, violated the dietary restrictions. The proportion of right-segment preparation failure was 15.0%, 1.7%, and 6.7% (p = 0.025). Accordingly, treatment B was superior to A (p = 0.008). Among subjects violating the low-residue diets guideline, the right-segment preparation failure rate was 25%. According to a multivariate analysis, low-residue diet compliance (adjusted OR = 6.55 (95% CI, 1.83-23.43)) and BMI were predictors of right-sided preparation adequacy, but the volume of polyethylene glycol ingested was not a predictor. Compared with group A, a greater proportion of subjects in groups B and C reported satisfaction.

LIMITATIONS

Patients with high BMI and severe constipation were excluded from this study. This study included only an Asian population.

CONCLUSIONS

The prepackaged low-residue diet provides excellent adherence, better bowel cleansing, and a better experience than a self-prepared low-residue diet. With good dietary compliance, 1.5 L of polyethylene glycol provides effective preparation.

Colonoscopy without sedation: Patient factors alone are less likely to influence its uptake

BACKGROUND AND STUDY AIMS

Conscious sedation during colonoscopy minimizes discomfort, improves polyp detection rates, and reduces technical failure, but carries medication-related risks and requires dedicated and costly recovery services. Sedation-free procedures may offer a safer alternative. We aimed to compare this group with those receiving sedation to determine differences in patient characteristics, cecal intubation rates, polyp detection rates, discomfort levels and safety in patients for whom anesthesia is high risk.

PATIENTS AND METHODS

Prospectively collected data from all colonoscopies performed over a 1-year period at three district general hospitals were analyzed. Conscious sedation was offered to all patients and outcomes in those who refused were compared with outcomes in those who received sedation.

RESULTS

One hundred ninety-four of 1694 (11 %) colonoscopies were performed without sedation (61 % male, P < 0.001) but rates varied between hospitals. Of these, 55 % were American Society of Anesthesiologists (ASA) grade 3 or more and 5 % experienced moderate discomfort, compared to 40 % (P < 0.0001) and 10 % (P = 0.023) respectively of those receiving sedation. They were more likely to have indications of rectal bleeding or frequency of stool and less likely to have anaemia or macroscopic inflammation at colonoscopy. Complications, completion. and polyp detection rates were similar in both groups.

CONCLUSIONS

Colonoscopy without sedation can be completed successfully in select patients without compromising comfort or polyp detection rates and is safe in those for whom anesthesia is high risk. It is therefore a safe alternative for clinicians concerned about sedation, but the findings suggest that hospital, rather than patient factors, may prevent its uptake.

Does anxiety or waiting time influence patients' tolerance of upper endoscopy?

BACKGROUND/AIMS

Endoscopy is an essential and very commonly used procedure for the evaluation of a multitude of gastrointestinal symptoms. Although it is increasingly required, patients often wait on arrival at the endoscopy unit until they are called for the procedure. It is not clear whether or not this waiting time may have an impact on patient's tolerance during upper endoscopy. Our study attempts to address this.

PATIENTS AND METHODS

We studied consecutive outpatients who underwent endoscopy from September to December, 2013. Gender, age, body mass index (BMI), previous endoscopic experiences, antidepressant therapy, and the time interval between arrival at the endoscopy unit and the onset of examination was recorded. Anxiety before the procedure, pain, and discomfort were rated by a numeric rating scale (0 = no pain/discomfort encountered to 10 = extremely painful/uncomfortable).

RESULTS

One hundred and five consecutive outpatients (male = 52; mean age = 45.3 years; age range = 20-86 years) were included in the study. The mean BMI was 25 ± 4.8; mean waiting time from registration to the procedure was  172 min (time range = 30 - 375 mins). Mean patients' pre-examination anxiety level was 3 ± 3.84, mean discomfort score was 4.3 ± 3.09 and mean pain score was 3.4 ± 3.03. The level of pain and discomfort was significantly higher in patients with higher levels of pre-procedure anxiety. No differences were found in terms of anxiety, pain and discomfort among patients divided according to waiting time.

CONCLUSIONS

According to our data, waiting time does not have a significant impact on the perception of pain and discomfort related to the endoscopic procedure. On the other hand, high pre-procedural levels of anxiety were associated with a low tolerance. Further multicenter randomized trials are needed to clarify the impact of waiting time.

A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy

OBJECTIVES

Minimal sedation obviates patient recovery burdens, but intolerable pain limits success of cecal intubation. Painless or minimally uncomfortable insertion ensures success of cecal intubation, current patient satisfaction, and willingness to repeat future colonoscopy with minimal sedation. Water immersion (WI) and water exchange (WE), when separately compared with air insufflation (AI), significantly reduced insertion pain. To assess comparative effectiveness, we conducted a randomized controlled trial with head-to-head comparison of these three methods. We hypothesized that WE could produce the highest proportion of patients reporting painless insertion.

METHODS

This prospective patient-blinded trial (NCT01535326) enrolled minimally sedated (25 mg intramuscular meperidine) patients randomized to AI, WI, or WE (90 patients/group) to aid insertion. The previously validated primary outcome was the proportion of patients reporting painless insertion.

RESULTS

Painless insertion was reported by 30.0% (AI), 43.3% (WI), and 61.1% (WE) of patients (P<0.001). Multivariate logistic regression analysis revealed that, after adjusting for gender, body mass index, abdominal compression, position change, insertion time to cecum, and length of scope at cecum, only WE was significantly associated with painless insertion compared with AI (odds ratio (OR)=0.08, 95% confidence interval (CI)=0.03-0.24, P<0.001) or WI (OR=0.14, 95% CI=0.05-0.40, P<0.001). Adenoma detection rate (ADR) in the right (cecum and ascending) colon was 11.1% (AI), 14.4% (WI), and 26.7% (WE) (P=0.015). The limitations included single site study with unblinded colonoscopist and assistant.

CONCLUSIONS

This head-to-head comparison of AI vs. WI vs. WE confirmed that WE was superior to WI and AI, with a significantly greater proportion of patients reporting painless insertion. The significantly higher ADR in the right colon in the WE group warrants further investigations.

Sedated vs unsedated colonoscopy: A prospective study

AIM: To compare sedated to unsedated colonoscopy in terms of duration, pain and the patient’s willingness to repeat the procedure.

METHODS: Consecutive patients who underwent colonoscopies over a 2-year period were invited to participate. All patients who were to undergo our endoscopy unit were offered sedation with standard intravenous sedatives and analgesics, or an unsedated colonoscopy was attempted. Demographic details were recorded. The patient anxiety level prior to the procedure, time to reach the cecum, total discharge time, patient and endoscopist pain assessments, satisfaction after the examination and the patient’s willingness to return for the same procedure in the future were recorded.

RESULTS: Among the 403 observed patients, more males were observed in the unsedated group (66.2% vs 55.2%, P = 0.04). Additionally, the unsedated group patients were less anxious prior to the procedure (5.1 vs 6.0, P < 0.01). The colonoscopy completion rates were comparable between the 2 groups (85.9% vs 84.2%, P = 0.66). The time to reach the cecum was also comparable (12.2 min vs 11.8 min); however, the total discharge times were shorter in the unsedated group (20.7 min vs 83.0 min, P < 0.01). Moreover, the average patient pain score (3.4 vs 5.7, P < 0.01) was lower in the sedated group, while the satisfaction score (8.8 vs 7.8, P < 0.01) was significantly higher. There was no significant difference, however, between the groups in terms of willingness to repeat the procedure if another was required in the future (83.3% vs 77.3%, P = 0.17).

CONCLUSION: Unsedated colonoscopy is feasible in willing patients. The option saves the endoscopy units up to one hour per patient and does not affect the patient willingness to return to the same physician again for additional colonoscopies if a repeated procedure is needed.

FIT testing: an overview

Colorectal cancer (CRC) is a common, but preventable, disease and is the second most common cause of cancer-related deaths in the U.S. CRC screening has proven effective at reducing both the incidence and mortality of this disease, using any of a number of screening tests available. The test options range from the least invasive and least expensive to more invasive and costly options. Fecal occult blood testing is the oldest, least expensive, and least invasive of these options and has evolved from the poorly sensitive standard guaiac test to the newer and diagnostically superior fecal immunochemical test (FIT) for hemoglobin. This article explores the evolutionary history of fecal occult blood testing, examines test performance characteristics among different FOBTs, and evaluates the role of the FIT in programmatic CRC screening.

Rapid colonoscopy preparation using bolus lukewarm saline combined with sequential posture changes: a randomized controlled trial

OBJECTIVE

In this randomized clinical trial, we have compared the Shudh™ colon cleanse (SCC) with HalfLytely(®) colon prep (HCP) to evaluate the efficacy, bowel preparation time (BPT), adverse events, electrolyte abnormalities and patient acceptability.

METHODS

Patients were randomized to receive either SCC (n = 65) or HCP (n = 68). All colonoscopies were performed by a single, blinded endoscopist. Colon prep was evaluated on a 5 point grading scale. Statistical non-inferiority was pre-defined as a difference of <15 % in the lower limit of the 95.5 % confidence interval for the treatment difference. Data that were collected include bowel prep score, BPT, adverse events, electrolyte abnormalities and patient acceptability.

RESULTS

Bowel preparation efficacy was rated as "successful" for 59/65 (90.7 %) in SCC versus 66/68 (97.1 %) in HCP. This gave a success difference of -6.4 % with a 1-sided 95 % lower confidence limit (LCI) for the difference = -13.3 % (non-inferiority p = 0.25). This difference fell within the predefined limit for non-inferiority. The average BPT for SCC was 1.9 h versus 10.9 in HCP (p < 0.001). No serious adverse events were reported in either group. None of the patients in either group had any clinically significant electrolyte imbalance. Patient ratings for palatability and willingness to repeat were significantly better for SCC (p < 0.05).

CONCLUSION

SCC was found to not be inferior to PEG with regards to the quality of bowel preparation. It is worth highlighting that a major advantage of SCC is shorter BPT.

[Colonoscopy with carbon dioxide insufflation: luxury or neccesity?]

Colonoscopy is an essential diagnostic and therapeutic tool for many gastrointestinal diseases and is also a key element in the prevention and early diagnosis of colon cancer. Despite numerous technical advances, colonoscopy continues to be uncomfortable for patients, both during and after the procedure. To a large extent, the discomfort of colonoscopy depends on the need to distend the colon, which usually produces abdominal pain. Although ambient air is usually employed to expand and inflate the colon, in the last few years devices that allow carbon dioxide (CO(2)) insufflation in colonoscopy have been developed. This gas is a highly attractive option for pain-free colonoscopy.

Rescreening of persons with a negative colonoscopy result: results from a microsimulation model

BACKGROUND

Persons with a negative result on screening colonoscopy are recommended to repeat the procedure in 10 years.

OBJECTIVE

To assess the effectiveness and costs of colonoscopy versus other rescreening strategies after an initial negative colonoscopy result.

DESIGN

Microsimulation model.

DATA SOURCES

Literature and data from the Surveillance, Epidemiology, and End Results program.

TARGET POPULATION

Persons aged 50 years who had no adenomas or cancer detected on screening colonoscopy.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal.

INTERVENTION

No further screening or rescreening starting at age 60 years with colonoscopy every 10 years, annual highly sensitive guaiac fecal occult blood testing (HSFOBT), annual fecal immunochemical testing (FIT), or computed tomographic colonography (CTC) every 5 years.

OUTCOME MEASURES

Lifetime cases of colorectal cancer, life expectancy, and lifetime costs per 1000 persons, assuming either perfect or imperfect adherence.

RESULTS OF BASE-CASE ANALYSIS

Rescreening with any method substantially reduced the risk for colorectal cancer compared with no further screening (range, 7.7 to 12.6 lifetime cases per 1000 persons [perfect adherence] and 17.7 to 20.9 lifetime cases per 1000 persons [imperfect adherence] vs. 31.3 lifetime cases per 1000 persons with no further screening). In both adherence scenarios, the differences in life-years across rescreening strategies were small (range, 30 893 to 30 902 life-years per 1000 persons [perfect adherence] vs. 30 865 to 30 869 life-years per 1000 persons [imperfect adherence]). Rescreening with HSFOBT, FIT, or CTC had fewer complications and was less costly than continuing colonoscopy.

RESULTS OF SENSITIVITY ANALYSIS

Results were sensitive to test-specific adherence rates.

LIMITATION

Data on adherence to rescreening were limited.

CONCLUSION

Compared with the currently recommended strategy of continuing colonoscopy every 10 years after an initial negative examination, rescreening at age 60 years with annual HSFOBT, annual FIT, or CTC every 5 years provides approximately the same benefit in life-years with fewer complications at a lower cost. Therefore, it is reasonable to use other methods to rescreen persons with negative colonoscopy results.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Patient Time Costs Associated with Sensor-Augmented Insulin Pump Therapy for Type 1 Diabetes

Background. Sensor-augmented pump therapy (SAPT) leads to lower glycated hemoglobin levels than multiple daily injections of insulin (MDI) in patients with type 1 diabetes. Patient time and costs associated with SAPT are not known. Objective. We compared time spent on diabetes-related care, changes in time, and associated patient time costs between patients randomly assigned to SAPT or MDI. Design, Setting, and Participants. During a 52-week clinical trial, participants aged 7 to 70 years (n = 483) reported total time per week spent on diabetes-related care. Measurements. Patient time, including comparisons during pump initiation, 52-week patient time costs, and changes in weekly time estimates after pump initiation. Results. At baseline, patients in the MDI group reported spending an average of 4.0 hours per week on diabetes-related care. During the pump initiation period (weeks 1–7), SAPT patients spent 1.9 hours more per week than MDI patients (95% confidence interval [CI], 1.2–2.6). After the initiation period (weeks 8–52), SAPT patients spent 1 hour more per week (95% CI, 0.4–1.7) than MDI patients (i.e., 4.4 v. 3.4 hours); patients in both groups spent progressively less time on diabetes-related care by 1.2 minutes per week (95% CI, −1.7 to −0.7). Overall, mean time costs per person were $4600 with the SAPT group and $3523 with the MDI group (difference, $1077; 95% CI, $491–$1638). Limitations. Time spent on specific activities was not collected, and the estimates do not explicitly account for caregiver time associated with diabetes care activities. Conclusions. Patients receiving SAPT v. MDI spent approximately 2 hours more per week on diabetes-related care during pump initiation and 1 hour more per week thereafter, resulting in higher patient time costs.

Modestly increased use of colonoscopy when copayments are waived

BACKGROUND & AIMS

Colorectal cancer (CRC) screening with colonoscopy often requires expensive copayments from patients. The 2010 Patient Protection and Affordable Care Act mandated elimination of copayments for CRC screening, including colonoscopy, but little is known about the effects of copayment elimination on use. The University of Texas employee, retiree, and dependent health plan instituted and promoted a waiver of copayments for screening colonoscopies in fiscal year (FY) 2009; we examined the effects of removing cost sharing on colonoscopy use.

METHODS

We conducted a retrospective cohort study of 59,855 beneficiaries of the University of Texas employee, retiree, and dependent health plan, associated with 16 University of Texas health and nonhealth campuses, ages 50-64 years at any point in FYs 2002-2009 (267,191 person-years of follow-up evaluation). The primary outcome was colonoscopy incidence among individuals with no prior colonoscopy. We compared the age- and sex-standardized incidence ratios for colonoscopy in FY 2009 (after the copayment waiver) with the expected incidence for FY 2009, based on secular trends from years before the waiver.

RESULTS

The annual incidence of colonoscopy increased to 9.5% after the copayment was waived, compared with an expected incidence of 8.0% (standardized incidence ratio, 1.18; 95% confidence interval, 1.14-1.23; P < .001). After adjusting for age, sex, and beneficiary status, the copayment waiver remained significantly associated with greater use of colonoscopy, with an adjusted hazard ratio of 1.19 (95% confidence interval, 1.12-1.26).

CONCLUSIONS

Waiving copayments for colonoscopy screening results in a statistically significant, but modest (1.5%), increase in use. Additional strategies beyond removing financial disincentives are needed to increase use of CRC screening.

Magnetic endoscope imaging (ScopeGuide) elucidates the mechanism of action of the pain-alleviating impact of water exchange colonoscopy - attenuation of loop formation

BACKGROUND

The explanation why water exchange colonoscopy produces a significant reduction of pain during colonoscopy is unknown. A recent editorial recommended use of magnetic endoscope imaging (MEI) to elucidate the explanation.

OBJECTIVE

In unselected patients to show that MEI documents less frequent loop formation when water exchange is used.

DESIGN

Observational, performance improvement.

SETTING

Veterans Affairs outpatient endoscopy.

PATIENTS

Routine colonoscopy cases.

INTERVENTIONS

Colonoscopy using air or water exchange method was performed as previously described. The MEI equipment (ScopeGuide, Olympus) with built-in magnetic sensors displays the configuration of the colonoscope inside the patient. During sedated colonoscopy the endoscopist was blinded to the ScopeGuide images which were recorded and subsequently reviewed.

MAIN OUTCOME MEASURES

Loop formation based on a visual guide provided by Olympus.

RESULTS

There were 41 and 32 cases in the water exchange and air group, respectively. The sigmoid N loop was most common, followed by the sigmoid alpha loop, and exaggeration of scope curvature at the splenic flexure/transverse colon. Of these, 20/32 vs. 9/41 patients (p=0.0007) had sigmoid looping, and 17/32 vs. 9/41 patients (p=0.0007) had sigmoid/splenic looping when the scope tip was in the transverse colon, in the air and water exchange group, respectively.

LIMITATIONS

Colonoscopy method was not blinded and non randomized.

CONCLUSION

MEI data objectively demonstrated significantly fewer loops during water exchange colonoscopy, elucidating its mechanism of pain alleviation - attenuation of loop formation. Since MEI feedback enhances cecal intubation by trainees, the role of MEI combined water exchange in speeding up trainee learning curves deserves further evaluations.

Acceptability and side-effects of colonoscopy and sigmoidoscopy in a screening setting

OBJECTIVE

Quantitative information on adverse reactions associated with colorectal cancer (CRC) screening tests is useful to estimate the balance between benefit and risk in different strategies.

SETTING

Six Italian screening centres.

METHODS

Thirty-day active follow-up (interview about side-effects and acceptability of the screening procedure and review of hospital admissions) among average-risk people undergoing flexible sigmoidoscopy (FS), total colonoscopy (TC), fecal immunochemical test (FIT) in a multicentre randomized trial of CRC screening. Multivariable logistic models were used to assess determinants of completion rate and self-reported pain.

RESULTS

The attendance rate following the first invitation and mail reminder was 28.2% (1696/6018) in the FS and 23.0% (1382/6021) in the TC arm. Response rate to the 30-day follow-up questionnaire was 88.6% (1502/1696) among people undergoing FS, and 86.7% (1198/1382) among those undergoing TC. The proportion of people complaining of serious reactions following bowel preparation (odds ratio [OR], 5.17; 95% confidence interval [CI] 3.70-7.24) or reporting severe pain immediately after the exam (OR, 1.86; 95% CI 1.47-2.34) was higher for TC than for FS. The most common post-procedural complaints were abdominal distension and pain. People mentioning pain or bowel distension following preparation were more likely to report severe pain both after FS (OR, 2.13; 95% CI 1.52-2.97) and TC (OR: 2.03; 95% CI 1.41-2.90). The 30-day hospitalization rate was similar after FS, TC and FIT.

CONCLUSIONS

Screenees reported higher pain levels after TC than FS. The proportion of people complaining of severe side effects after discharge was similar. Bowel preparation was poorly tolerated by people undergoing TC. Subjects' reactions to the bowel preparation was predictive of post-procedural discomfort. A commitment of at least 48 hours was required of people undergoing TC, compared with 3-4 for FS.

Conjoint analysis versus rating and ranking for values elicitation and clarification in colorectal cancer screening

PURPOSE

To compare two techniques for eliciting and clarifying patient values for decision making about colorectal cancer (CRC) screening: choice-based conjoint analysis and a rating and ranking task.

METHODS

Using our decision lab registry and university e-mail lists, we recruited average risk adults ages 48-75 for a written, mailed survey. Eligible participants were given basic information about CRC screening and six attributes of CRC screening tests, then randomized to complete either a choice-based conjoint analysis with 16 discrete choice tasks or a rating and ranking task. The main outcome was the most important attribute, as determined from conjoint analysis or participant ranking. Conjoint analysis-based most important attribute was determined from individual patient-level utilities generated using multinomial logistic regression and hierarchical Bayesian modeling.

RESULTS

Of the 114 eligible participants, 104 completed and returned questionnaires. Mean age was 57 (range 48-73), 70% were female, 88% were white, 71% were college graduates, and 62% were up to date with CRC screening. Ability to reduce CRC incidence and mortality was the most frequent most important attribute for both the conjoint analysis (56% of respondents) and rating/ranking (76% of respondents) groups, and these proportions differed significantly between groups (absolute difference 20%, 95% CI 3%, 37%, p =0.03). There were no significant differences between groups in proportion with clear values (p = 0.352), intent to be screened (p = 0.226) or unlabelled test preference (p = 0.521)

CONCLUSIONS

Choice-based conjoint analysis produced somewhat different patterns of attribute importance than a rating and ranking task, but had little effect on other outcomes.

The safety of same-day endoscopy and percutaneous liver biopsy

BACKGROUND AND AIMS

The aim of this study was to review our experience with same-day endoscopy (SDE) plus percutaneous liver biopsy (PLB) and to evaluate its safety compared to PLB alone.

METHODS

We retrospectively examined records of all patients who underwent PLB between January 2003 and September 2009 and identified those who underwent SDE and matched these patients to those undergoing PLB alone. Serious adverse events (SAEs) were analyzed using our endoscopic database (EndoPro, Pentax) and were divided into those occurring immediately post-procedure and those occurring after discharge.

RESULTS

In the study, 479 patients underwent 507 PLBs and 52 patients (11%) were identified as having SDE. No statistical differences were apparent in terms of sex, age, baseline laboratory values, medical comorbidities, cirrhosis, or liver lesions. The most common indication for PLB was chronic hepatitis C (HCV). A total of 15 patients underwent upper endoscopy (EGD); 37 patients underwent colonoscopy (most for colorectal cancer screening). One (1.9%) SAE occurred in the SDE and PLB group. This patient experienced microperforation of the hepatic flexure secondary to abnormal anatomy and underwent immediate laparoscopic repair with an unremarkable post-op course. Four (0.88%) SAEs occurred with PLB alone, mostly prolonged pain from subcapsular hematoma, with no transfusions or surgery required.

CONCLUSIONS

At our institution, SDE with PLB is often performed and appears to be a safe method of practice. We believe that performance of EGD or colonoscopy on the same day as PLB optimizes medical resources and results in patient satisfaction without sacrificing safety.

A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation

BACKGROUND

Sedation for colonoscopy discomfort imposes a recovery-time burden on patients. The water method permitted 52% of patients accepting on-demand sedation to complete colonoscopy without sedation. On-site and at-home recovery times were not reported.

OBJECTIVE

To confirm the beneficial effect of the water method and document the patient recovery-time burden.

DESIGN

Randomized, controlled trial, with single-blinded, intent-to-treat analysis.

SETTING

Veterans Affairs outpatient endoscopy unit.

PATIENTS

This study involved veterans accepting on-demand sedation for screening and surveillance colonoscopy.

INTERVENTION

Air versus water method for colonoscope insertion.

MAIN OUTCOME MEASUREMENTS

Proportion of patients completing colonoscopy without sedation, cecal intubation rate, medication requirement, maximum discomfort (0 = none, 10 = severe), procedure-related and patient-related outcomes.

RESULTS

One hundred veterans were randomized to the air (n = 50) or water (n = 50) method. The proportions of patients who could complete colonoscopy without sedation in the water group (78%) and the air group (54%) were significantly different (P = .011, Fisher exact test), but the cecal intubation rate was similar (100% in both groups). Secondary analysis (data as Mean [SD]) shows that the water method produced a reduction in medication requirement: fentanyl, 12.5 (26.8) μg versus 24.0 (30.7) μg; midazolam, 0.5 (1.1) mg versus 0.94 (1.20) mg; maximum discomfort, 2.3 (1.7) versus 4.9 (2.0); recovery time on site, 8.4 (6.8) versus 12.3 (9.4) minutes; and recovery time at home, 4.5 (9.2) versus 10.9 (14.0) hours (P = .049; P = .06; P = .0012; P = .0199; and P = .0048, respectively, t test).

LIMITATIONS

Single Veterans Affairs site, predominantly male population, unblinded examiners.

CONCLUSION

This randomized, controlled trial confirms the reported beneficial effects of the water method. The combination of the water method with on-demand sedation minimizes the patient recovery-time burden. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00920751.).

Missed work related to mid-week screening colonoscopy

BACKGROUND

Most screening colonoscopies require patients to miss work on the day of the procedure. Little is known about whether patients are taking additional time off from work, and the reasons for doing so.

AIMS

The purpose of this study was to assess the patterns and reasons for missed work related to screening colonoscopies.

METHODS

All outpatient screening colonoscopy procedures performed at an academic medical center over 6 months were reviewed. Exclusions included procedures performed for other indications, patients age 65 or older, procedures performed on Monday or Friday, and patients who were not working. Patients were interviewed by telephone regarding missed work time and the reasons for doing so.

RESULTS

Sixty-eight patients met all inclusion criteria. Thirty-four percent missed work on more than the day of the procedure. Thirty-two percent took the day prior off, 10% took the day after off, and 9% took both days off. The reason for taking the day before the procedure off was uniformly anticipation of the bowel preparation. Of those who took the day after off, 57% did so as a precautionary measure after moderate sedation, while 43% had symptoms.

CONCLUSIONS

One third of working patients who undergo mid-week screening colonoscopies miss work on additional days to the procedure day. Unanticipated time missed from work could increase the indirect costs of screening colonoscopy.

Unsedated colonoscopy: is it feasible?

Unsedated colonoscopy has been an evolving subject ever since its initial description four decades ago. Failure in unsedated diagnostic cases due to patient pain led to the introduction of sedation. Extension to screening cases, albeit logical, created a sedation-related barrier to colonoscopy screening. In recent years a water method has been developed to combat the pain during unsedated colonoscopy in the US. In randomized controlled trials the water method decreases pain, increases cecal intubation success, and enhances the proportion of patients who complete unsedated colonoscopy. The salvage cleansing of suboptimal bowel preparation by the water method serendipitously may have increased the detection of adenoma in both unsedated and sedated patients. The state-of-the-art lecture concludes that unsedated colonoscopy is feasible. The hypothesis is that recent advances, such as the development of the water method, may contribute to reviving unsedated colonoscopy as a potentially attractive option for colon cancer screening and deserves to be tested.

Is there a place for sedationless colonoscopy?

Usedated colonoscopy is routinely available in many parts of the world. In the US, only educated professionals appear to be knowledgeable enough to request the unsedated option. Colonoscopists have also been willing to perform unsedated colonoscopy when a patient presents without an escort after undergoing bowel purge preparation. While the actual side-effects of sedation are minimal, the escort requirement and time burden of sedation are barriers to the uptake of screening colonoscopy in the US. The recent trend of deep sedation with propofol for screening colonoscopy increases the efficiency of the colonoscopists at significant costs (e.g. anesthetist reimbursement). The options of as needed and on demand sedation permit patients to complete colonoscopy without sedation. The latter appears to be potentially less coercive. Nurses with experience in the unsedated options recognize the benefit of the quick turn-around of the examination room and shortened occupancy of the recovery area. Discharge planning can be optimized due to absence of amnesia. Patients completing unsedated colonoscopy have given their endorsement of the options. Pain and discomfort continue to limit the success rate of cecal intubation to about 80%. A recently described water method (warm water infusion in lieu of air insufflation combined with removal of all residual colonic air by suction and residual feces by water exchange) has the potential of decreasing procedural discomfort and enhancing cecal intubation in unsedated colonoscopy. The availability of the novel water method assures colonoscopists that high success rate of cecal intubation can be achieved in the unsedated patients.

Willingness-to-pay to avoid the time spent and discomfort associated with screening colonoscopy

BACKGROUND

The screening colonoscopy process requires a considerable amount of time and some discomfort for patients.

OBJECTIVE

We sought to use willingness-to-pay (WTP) to value the time required and the discomfort associated with screening colonoscopy. In addition, we aimed to explore some of the differences between and potential uses of the WTP and the human capital methods.

METHODS

Subjects completed a diary recording time and a questionnaire including WTP questions to value the time and discomfort associated with colonoscopy. We also valued the elapsed time reported in the diaries (but not the discomfort) using the human capital method.

RESULTS

110 subjects completed the study. Mean WTP to avoid the time and discomfort was $263. Human capital values for elapsed time were greater. Linear regressions showed that WTP was influenced most by the difficulty of the preparation, which added $147 to WTP (p=0.03).

CONCLUSIONS

WTP values to avoid the time and discomfort associated with the screening colonoscopy process were substantially lower than most of the human capital values for elapsed time alone. The human capital method may overestimate the value of time in situations that involve an irregular, episodic series of time intervals, such as preparation for or recovery after colonoscopy.

A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

BACKGROUND

An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy.

OBJECTIVE

To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT).

DESIGN

Prospective RCT, intent-to-treat analysis.

SETTING

Veterans Affairs ambulatory care facility.

PATIENTS

Veterans undergoing scheduled unsedated colonoscopy.

INTERVENTIONS

During insertion, the water and traditional air methods were compared.

MAIN OUTCOME MEASUREMENTS

Discomfort and procedure-related outcomes.

RESULTS

Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield.

LIMITATIONS

Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability.

CONCLUSIONS

The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

Cost-effectiveness of computed tomographic colonography screening for colorectal cancer in the medicare population

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) considered whether to reimburse computed tomographic colonography (CTC) for colorectal cancer screening of Medicare enrollees. To help inform its decision, we evaluated the reimbursement rate at which CTC screening could be cost-effective compared with the colorectal cancer screening tests that are currently reimbursed by CMS and are included in most colorectal cancer screening guidelines, namely annual fecal occult blood test (FOBT), flexible sigmoidoscopy every 5 years, flexible sigmoidoscopy every 5 years in conjunction with annual FOBT, and colonoscopy every 10 years.

METHODS

We used three independently developed microsimulation models to assess the health outcomes and costs associated with CTC screening and with currently reimbursed colorectal cancer screening tests among the average-risk Medicare population. We assumed that CTC was performed every 5 years (using test characteristics from either a Department of Defense CTC study or the National CTC Trial) and that individuals with findings of 6 mm or larger were referred to colonoscopy. We computed incremental cost-effectiveness ratios for the currently reimbursed screening tests and calculated the maximum cost per scan (ie, the threshold cost) for the CTC strategy to lie on the efficient frontier. Sensitivity analyses were performed on key parameters and assumptions.

RESULTS

Assuming perfect adherence with all tests, the undiscounted number life-years gained from CTC screening ranged from 143 to 178 per 1000 65-year-olds, which was slightly less than the number of life-years gained from 10-yearly colonoscopy (152-185 per 1000 65-year-olds) and comparable to that from 5-yearly sigmoidoscopy with annual FOBT (149-177 per 1000 65-year-olds). If CTC screening was reimbursed at $488 per scan (slightly less than the reimbursement for a colonoscopy without polypectomy), it would be the most costly strategy. CTC screening could be cost-effective at $108-$205 per scan, depending on the microsimulation model used. Sensitivity analyses showed that if relative adherence to CTC screening was 25% higher than adherence to other tests, it could be cost-effective if reimbursed at $488 per scan.

CONCLUSIONS

CTC could be a cost-effective option for colorectal cancer screening among Medicare enrollees if the reimbursement rate per scan is substantially less than that for colonoscopy or if a large proportion of otherwise unscreened persons were to undergo screening by CTC.

Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening

Unsedated colonoscopy is available worldwide, but is not a routine option in the United States (US). We conducted a literature review supplemented by our experience and expert commentaries to provide data to support the use of unsedated colonoscopy for colorectal cancer screening. Medline data from 1966 to 2009 were searched to identify relevant articles on the subject. Data were summarized and co-authors provided critiques as well as accounts of unsedated colonoscopy for screening and surveillance. Diagnostic colonoscopy was initially developed as an unsedated procedure. Procedure-related discomfort led to wide adoption of sedation in the US, although unsedated colonoscopy remains the usual practice elsewhere. The increased use of colonoscopy for colorectal cancer screening in healthy, asymptomatic individuals suggests a reassessment of the burden of sedation in colonoscopy for screening is appropriate in the US for lowering costs and minimizing complications for patients. A water method developed to minimize discomfort has shown promise to enhance outcomes of unsedated colonoscopy. The use of scheduled, unsedated colonoscopy in the US appears to be feasible for colorectal cancer screening. Studies to assess its applicability in diverse practice settings deserve to be conducted and supported.

Medication-free colonoscopy--factors related to pain and its assessment

AIM

This paper is a report of a study conducted to determine the possibility of performing colonoscopy without medication, elucidate the factors related to a painful colonoscopy experience and compare colonoscopy patients' reported pain assessment to nurses' and endoscopists' observations.

BACKGROUND

Sedation and pain medication are routinely administered for colonoscopies in many countries. However, medication-free colonoscopies have attracted attention because the use of medication requires a time commitment from patients and increases complications. Earlier studies show that, for instance, gender, age and pelvic operations may increase the risk of painful colonoscopy and those healthcare professionals and patients appear to assess pain differently.

METHOD

A cross-sectional descriptive study was conducted in a Finnish university hospital using questionnaires developed for this study and analysed statistically. The sample of 138 colonoscopy patients, 11 nurses and 11 endoscopists was recruited in 2006.

RESULTS

Over three-quarters of patients reported mild pain or no pain at all. Patients' nervousness is a risk factor for experiencing pain during colonoscopy. Both nurses and endoscopists slightly underestimated the intensity of pain experienced by patients.

CONCLUSION

It is possible to perform colonoscopy without medication with most patients and focus sedation and pain medication on at-risk patients, especially those who are nervous. Before the procedure, nurses must devote time to discovering which patients are nervous and at risk of having a painful colonoscopy to present them for sedation. To improve pain management for patients having colonoscopy, endoscopists and nurses should participate systematically in pain education and use pain scales.

Patient time requirements for anticoagulation therapy with warfarin

BACKGROUND

Most patients receiving warfarin are managed in outpatient office settings or anticoagulation clinics that require frequent visits for monitoring.

OBJECTIVE

To measure the amount and value of time required of patients for chronic anticoagulation therapy with warfarin.

DESIGN

/Participants. Prospective observation of a cohort of adult patients treated at a university-based anticoagulation program. Measurements. Participants completed a questionnaire and a prospective diary of the time required for 1 visit to the anticoagulation clinic, including travel, waiting, and the clinic visit. The authors reviewed subjects' medical records to obtain additional information, including the frequency of visits to the anticoagulation clinic. They used the human capital method to estimate the value of time.

RESULTS

Eighty-five subjects completed the study. The mean (median) total time per visit was 147 minutes (123). Subjects averaged 15 visits per year (14) and spent 39.0 hours (29.3) per year on their visits. Other anticoagulation-related activities, such as communication with providers, pharmacy trips, and extra time preparing food, added an average of 52.7 hours (19.0) per year. The mean annual value of patient time spent traveling, waiting, and attending anticoagulation visits was $707 (median $591). The mean annual value when also including other anticoagulation-related activities was $1799 (median $1132).

CONCLUSIONS

The time required of patients for anticoagulation visits was considerable, averaging approximately 2.5 hours per visit and almost 40 hours per year.

METHODS

for reducing patient time requirements, such as home-based testing, could reduce costs for patients, employers, and companions.

A randomized, controlled comparison of warm water infusion in lieu of air insufflation versus air insufflation for aiding colonoscopy insertion in sedated patients undergoing colorectal cancer screening and surveillance

BACKGROUND

Pilot studies using a novel water method to perform screening colonoscopy allowed patients to complete colonoscopy without sedation medications and also significantly increased the cecal intubation success rate.

OBJECTIVE

To perform a randomized, controlled trial comparing air insufflation (conventional method) and water infusion in lieu of air insufflation (study method) colonoscopy in minimally sedated patients.

HYPOTHESIS

Compared with the conventional method, patients examined by the study method had lower pain scores and required less medication but had a similar cecal intubation rate and willingness to undergo colonoscopy in the future.

SETTING

Outpatient colonoscopy in a single Veterans Affairs hospital.

METHODS

After informed consent and standard bowel preparation, patients received premedications administered as 0.5-increments of fentanyl (25 microg) and 0.5-increments of Versed (midazolam) (1 mg) plus 50 mg of diphenhydramine. The conventional and the study methods for colonoscopy were implemented as previously described. Additional pain medications were administered at the patients' request.

MAIN OUTCOME MEASUREMENTS

Increments of medications, pain scores, cecal intubation, and willingness to repeat colonoscopy.

RESULTS

Increments of medications used before reaching the cecum (1.6 +/- 0.2 vs 2.4 +/- 0.2, P < .0027), total increments used (1.8 +/- 0.2 vs 2.5 +/- 0.2, P < .014), and the maximum pain scores (1.3 +/- 0.3 vs 4.1 +/- 0.6, P < .0002) were significantly lower with the water method. Cecal intubation rate (100%) and willingness to undergo a repeat colonoscopy (96%) were similar.

LIMITATIONS

Single Veterans Affairs hospital, older male population.

CONCLUSION

Water infusion in lieu of air insufflation is superior to air insufflation during colonoscopy in the minimally sedated patients (ClinicalTrials.gov Identifier NCT00785889).

Same day endoscopy and percutaneous liver biopsy: safety and cost-effectiveness

Routine upper and/or lower endoscopy and percutaneous liver biopsy in the same patient are rarely performed on the same day. The aim of this study was to determine the safety, cost savings, and patient satisfaction of these same day procedures. A retrospective cohort study of patients undergoing same day endoscopy and percutaneous liver biopsy between February 2003 and July 2006 at Brooke Army Medical Center was performed. Eighty-nine patients were identified as having same day endoscopy and percutaneous liver biopsy during the study period. No study endpoint complications were identified. A cost savings of $333 per patient for a same day diagnostic upper endoscopy, colonoscopy, and percutaneous liver biopsy was found. More patients in both groups preferred same day procedures (P < 0.001). In conclusion, endoscopy and percutaneous liver biopsy can safely be performed in the same patient on the same day, which simultaneously increases patient satisfaction and is cost-effective.

Completing costs: patients' time

OBJECTIVES

To show the importance of patients' time as a cost of health and medical care and to explain how to include it in costing studies without greatly increasing the work required for such studies.

BACKGROUND

Despite the decade-old recommendation of the Panel on Cost-Effectiveness in Health and Medicine, patients' time is rarely included in costing or cost-effectiveness analyses (CEAs). Studies of cancer care, smoking cessation, and diabetes self-management show that it can be a large part of an intervention's costs, sometimes larger than direct medical costs, and can potentially affect patients' willingness to undertake the intervention. MEASURING AND VALUING TIME: Good costing practice follows 2 principles: measure all important uses of a resource; and value it appropriately and in a way that is consistent with the valuation of other resources. Counts of formal medical services, already measured in most studies, can serve as the starting point for valuing patients' time, and would be a major step toward recognizing time costs, even when analysts cannot measure other uses of time. The concept of opportunity cost, often approximated by a market price, is the basis for valuing all resources. The reasons why the wage is a reasonable proxy for the value patients place on their own time are explained. Wage data are well measured and readily available.

CONCLUSIONS

Ignoring patients' time underestimates disease burden and biases cost-effectiveness results toward interventions that use more time. The tools and data to include patients' time are available and will improve if they are routinely used.

The use of carbon dioxide for insufflation during GI endoscopy: a systematic review

BACKGROUND

Insufflation of the lumen is required for visualization during GI endoscopy. Carbon dioxide (CO(2)) has been proposed as an alternative to room air for insufflation.

OBJECTIVES

To assess the safety and efficacy of CO(2) insufflation for endoscopy.

DESIGN

Systematic review that focuses on evidence from randomized controlled trials (RCT).

METHODS

Two investigators independently searched MEDLINE from 1950 to February 13, 2008, to identify all articles that reported the use of CO(2) in a GI endoscopy application. Bibliographies of relevant articles were also hand searched to identify other pertinent reports. Data from RCTs, as well as from nonrandomized studies, were extracted.

RESULTS

Nine RCTs were identified that compared CO(2) and air insufflation for GI endoscopy. Fifteen other nonrandomized studies or reports were also reviewed. In the 8 RCTs in which postprocedural pain was assessed, pain was lower in the CO(2) insufflation group compared with the air group. Two RCTs found decreased flatus in the CO(2) group compared with the air group, and 3 RCTs showed there was decreased bowel distention on abdominal radiography in the CO(2) group compared with the air group. Also, in all 9 RCTs and 6 additional studies in which safety was assessed, there was no CO(2) retention and no adverse pulmonary events related to CO(2) insufflation.

LIMITATIONS

Because of study heterogeneity, meta-analytic techniques could not be used.

CONCLUSIONS

Consistent RCT evidence indicates that CO(2) insufflation is associated with decreased postprocedural pain, flatus, and bowel distention. CO(2) insufflation also appears to be safe in patients without severe underlying pulmonary disease.

A simplified, noninvasive stool DNA test for colorectal cancer detection

BACKGROUND

As a noninvasive colorectal cancer (CRC) screening test, a multi-marker first generation stool DNA (sDNA V 1.0) test is superior to guaiac-based fecal occult blood tests. An improved sDNA assay (version 2), utilizing only two markers, hypermethylated vimentin gene (hV) and a two site DNA integrity assay (DY), demonstrated in a training set (phase 1a) an even higher sensitivity (88%) for CRC with a specificity of 82%.

AIM

To validate in an independent set of patients (phase 1b) the sensitivity and specificity of sDNA version 2 for CRC.

METHODS

Forty-two patients with CRC and 241 subjects with normal colonoscopy (NC) provided stool samples, to which they immediately added DNA stabilizing buffer, and mailed their specimen to the laboratory. DNA was purified using gel-based capture, and analyzed for hV and DY using methods identical to those previously published.

RESULTS

Using the same cutpoints as the 1a training set (N = 162; 40 CRCs, 122 normals), hV demonstrated a higher and DY a slightly lower sensitivity, for a combined sensitivity of hV + DY of 86%. Optimal cutpoints based on the combined phase 1a + 1b dataset (N = 445; 82 CRCs, 363 normals) yielded a CRC sensitivity of 83%. The vast majority of cancers were detected regardless of tumor stage, tumor location, or patient age. Assay specificity in the phase 1b dataset for hV, DY, and hV + DY was 82%, 85%, and 73%, respectively, using the phase 1a cutpoints. Optimal cutpoints based on the combined phase 1a + 1b dataset yield a specificity of 82%.

CONCLUSIONS

This study provides validation of a simplified, improved sDNA test that incorporates only two markers and that demonstrates high sensitivity (83%) and specificity (82%) for CRC. Test performance is highly reproducible in a large set of patients. The use of only two markers will make the test easier to perform, reduce the cost, and facilitate distribution to local laboratories.

The pre- and postprocedure assessment of patients undergoing sedation for gastrointestinal endoscopy

A thorough and efficient pre-procedure evaluation of the patient's readiness to undergo sedation for endoscopy is essential. This evaluation will allow the formulation of an appropriate sedation plan for the patient, resulting in a safe and effective examination. The post procedure assessment of the patient confirms readiness for discharge and allows for appropriate patient education and follow-up planning.