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Santos-Jaén JM, Valls Martínez MDC, Palacios-Manzano M, Grasso MS. Analysis of Patient Satisfaction through the Effect of Healthcare Spending on Waiting Times for Consultations and Operations. Healthcare (Basel) 2022; 10:healthcare10071229. [PMID: 35885756 PMCID: PMC9325123 DOI: 10.3390/healthcare10071229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/23/2022] [Accepted: 06/29/2022] [Indexed: 01/14/2023] Open
Abstract
In recent years, public authorities have invested large amounts of public money in trying to reduce waiting times for consultations and operations with the aim of improving the quality of the healthcare system. Our research aims to analyze the effect of these investments on patient satisfaction through the mediating relationship of waiting times for consultations and operations, as well as from a gender perspective. By studying a series of key indicators of the Spanish healthcare system and applying partial least squares structural equation modelling (PLS-SEM), the findings show that the model explains 12.10% of the variance in consultant waiting times, 51.90% in operation waiting times, and 27.00% in patient satisfaction. We found that increased public spending leads to increased patient satisfaction by reducing waiting times. However, no gender-based differences were found. The results provide exciting implications for theory and practice, indicating how policymakers can orient their strategies towards improving patient satisfaction.
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Affiliation(s)
- José Manuel Santos-Jaén
- Department of Accounting and Finance, University of Murcia, 30100 Murcia, Spain; (J.M.S.-J.); (M.P.-M.)
| | - María del Carmen Valls Martínez
- Mediterranean Research Center on Economics and Sustainable Development, 04120 Almería, Spain;
- Economics and Business Department, University of Almeria, 04120 Almería, Spain
- Correspondence: ; Tel.: +34-950-01-55-35
| | - Mercedes Palacios-Manzano
- Department of Accounting and Finance, University of Murcia, 30100 Murcia, Spain; (J.M.S.-J.); (M.P.-M.)
| | - Mayra Soledad Grasso
- Mediterranean Research Center on Economics and Sustainable Development, 04120 Almería, Spain;
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2
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Webber C, Flemming JA, Birtwhistle R, Rosenberg M, Groome PA. Regional variations and associations between colonoscopy resource availability and colonoscopy utilisation: a population-based descriptive study in Ontario, Canada. BMJ Open Gastroenterol 2022; 9:bmjgast-2022-000929. [PMID: 35680174 PMCID: PMC9185399 DOI: 10.1136/bmjgast-2022-000929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/23/2022] [Indexed: 11/25/2022] Open
Abstract
Objective There is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation. Design We conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18–99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex. Results There were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%–55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, p<0.001). Colonoscopy utilisation rates were 4% lower in individuals travelling 50 to <200 km and 11% lower in individuals travelling ≥200 km to colonoscopy, compared to <10 km. There was no association between private clinic access and colonoscopy utilisation. Conclusion The substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decision-makers to address these potential inequalities in access in order to support the use of this medically necessary procedure.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada .,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jennifer A Flemming
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,ICES, Kingston, Ontario, Canada.,Division of Gastroenterology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Richard Birtwhistle
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,ICES, Kingston, Ontario, Canada.,Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mark Rosenberg
- Department of Geography, Queen's University, Kingston, Ontario, Canada
| | - Patti A Groome
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.,Division of Cancer Care and Epidemiology, Queen's Cancer Research Institute, Kingston, Ontario, Canada.,ICES, Kingston, Ontario, Canada
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3
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Bollegala N, Barwick M, Fu N, Griffiths AM, Keefer L, Kohut SA, Kroeker KI, Lawrence S, Lee K, Mack DR, Walters TD, de Guzman J, Tersigni C, Miatello A, Benchimol EI. Multimodal intervention to improve the transition of patients with inflammatory bowel disease from pediatric to adult care: protocol for a randomized controlled trial. BMC Gastroenterol 2022; 22:251. [PMID: 35585484 PMCID: PMC9118697 DOI: 10.1186/s12876-022-02307-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transition in care is defined as the "purposeful and planned movement of adolescents and young adults with a chronic medical condition from pediatric to adult-oriented healthcare systems/care providers." Currently, there are no Level 1 evidence-based interventions to improve the care of transitioning adolescents and young adults (AYAs) with inflammatory bowel disease (IBD). The development of a transition program using a biopsychosocial approach will improve the standards for healthcare delivery to transitioning IBD patients. This is a protocol for a structured randomized controlled trial (RCT) to assess the clinical and implementation effectiveness of a multimodal intervention focused on improving patient function, transition readiness and outcomes among AYA patients with IBD being cared for at pediatric centers in Canada. METHODS This multi-center RCT is a type 1 hybrid effectiveness-implementation trial to evaluate effectiveness of the intervention and how it can be implemented more widely after the trial. We will include patients aged 16.0-17.5 years. The intervention program consists of 4 core components: (1) individualized assessment, (2) transition navigator, (3) virtual patient skills-building with a focus on building resilience, self-management and self-efficacy, and (4) a virtual structured education program. The control group will undergo standard-of-care defined by each participating center. The primary outcome will be the IBD Disability Index, a validated measure to assess patient functioning. Secondary outcomes include transition readiness and success, anxiety and depression scales, and health service utilization rates. Additionally, we will measure implementation outcomes and related barriers and facilitators for the intervention program. DISCUSSION The type 1 hybrid effectiveness-implementation design will allow for the development of a feasible, sustainable, and acceptable final intervention model. The intervention will consist of modules that can be accessed in an online, virtual platform. The implementation will allow centralization of interventions and funding in order to minimize the impact on local clinical practice or hospital resources. The authors anticipate that the main study limitation will relate to study subjects not completely adhering to every component of the intervention, which will be evaluated and addressed using the implementation science approach. TRIAL REGISTRATION NCT05221281. Registry: ClinicalTrials.gov. Date of registration: February 2, 2022. https://clinicaltrials.gov/ct2/show/NCT05221281 .
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Affiliation(s)
- Natasha Bollegala
- Division of Gastroenterology, Department of Medicine, Women's College Hospital, University of Toronto, Toronto, Canada
| | - Melanie Barwick
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,Department of Psychiatry, University of Toronto, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Nancy Fu
- Division of Gastroenterology, Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Anne M Griffiths
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Laurie Keefer
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Ahola Kohut
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Karen I Kroeker
- Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sally Lawrence
- Division of Gastroenterology, Hepatology and Nutrition, BC Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Kate Lee
- Crohn's and Colitis Canada, Toronto, Canada
| | - David R Mack
- CHEO Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Eastern Ontario (CHEO), Ottawa, Canada.,Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Thomas D Walters
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | | | - Claudia Tersigni
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada.,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Ashleigh Miatello
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Eric I Benchimol
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada. .,SickKids Inflammatory Bowel Disease Centre, Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada. .,Department of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada. .,ICES, Toronto, Canada.
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4
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Payne T, Kevric J, Stelmach W, To H. The Use of Electronic Consultations in Outpatient Surgery Clinics: Synthesized Narrative Review. JMIR Perioper Med 2022; 5:e34661. [PMID: 35436223 PMCID: PMC9052035 DOI: 10.2196/34661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/20/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning. OBJECTIVE We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19. METHODS We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults. RESULTS A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component. CONCLUSIONS The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.
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Affiliation(s)
- Thomas Payne
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
- Department of Surgery, The Northern Hospital, Melbourne, Australia
| | - Jasmina Kevric
- Department of Surgery, The Northern Hospital, Melbourne, Australia
| | - Wanda Stelmach
- Department of Surgery, The Northern Hospital, Melbourne, Australia
| | - Henry To
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
- Department of Surgery, The Northern Hospital, Melbourne, Australia
- Department of Surgery, Werribee Mercy Hospital, Melbourne, Australia
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Regional Variation in Pregnancy Outcomes amongst Women in Inflammatory Bowel Disease: A Population-Based Cohort Study. Can J Gastroenterol Hepatol 2021; 2021:3037128. [PMID: 34881209 PMCID: PMC8648466 DOI: 10.1155/2021/3037128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/11/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Women with inflammatory bowel disease (IBD) are at risk of certain pregnancy outcomes such as preterm delivery, infants small for gestational age (SGA), and Cesarean delivery. Whether regional variation in these outcomes exists remains unknown. We aimed to assess the geographical variation in these pregnancy outcomes in women with IBD. METHODS All pregnancies in women with and without IBD (2002-2013) were identified using Ontario health administrative datasets. Geographical variation in preterm delivery, infants SGA, and Cesarean delivery was assessed using age-adjusted odds ratios (aOR) with 95% confidence intervals (CI) comparing women with and without IBD, stratified by Ontario's 14 health-service regions, known as Local Health Integration Networks (LHINs). RESULTS 1621 women with IBD (2466 pregnancies) and 855,425 women without IBD (1,280,493 pregnancies) were included. Women with IBD were more likely to have preterm delivery (aOR 1.56, 95% CI, 1.35-1.79), infants SGA (aOR 1.52, 95% CI, 1.23-1.88), and Cesarean section (aOR 1.34, 95% CI, 1.22-1.49). Significant geographical variation in these outcomes was detected, with the highest rates observed in the most northern rural areas (aOR for preterm delivery 2.78 (95% CI, 1.03-7.46), aOR for SGA 5.66 (95% CI, 1.67-19.14), and aOR for Cesarean delivery 2.48 (95% CI, 1.11-5.55)). There were no differences in these outcomes in women with and without IBD in more central urban LHINs. CONCLUSION Significant regional variation was detected in rates of adverse pregnancy outcomes and Cesarean delivery in women with IBD. Further study is required to determine specific reasons for this variation.
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Guglani S, Liddy C, Afkham A, Mitchell R, Keely E. One Service, Two Models: a comparison of direct-to-specialist and managed specialty models in a provincial eConsult service (Preprint). JMIR Form Res 2021; 6:e32101. [PMID: 35451985 PMCID: PMC9077515 DOI: 10.2196/32101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/22/2021] [Accepted: 02/05/2022] [Indexed: 11/25/2022] Open
Abstract
Background The Ontario electronic consultation (eConsult) service allows a primary care provider (PCP) to access specialist advice through 2 models: the direct-to-specialist (DTS) model, where PCPs select a specialist from a directory, and the Building Access to Specialists Through eConsultation (BASE)–managed specialty service, where PCPs choose a specialty group and are assigned a specialist from a qualified pool based on availability. Objective The aim of this study is to examine patterns of use between the 2 models of eConsult delivery. Methods We conducted a cross-sectional analysis of utilization data collected from eConsults completed between October 2018 and September 2019. Cases were grouped based on the model used for submission (ie, BASE or DTS). Each model was assessed for the number of cases over time, specialty distribution, proportion resulting in new or additional information, impact on PCPs’ decisions to refer, and billing time. Results PCPs submitted 26,121 eConsults during the study period. The monthly case volume increased by 43% over the duration of the study, primarily in the BASE model (66% compared to 6% for DTS). PCPs were able to confirm a course of action that they originally had in mind in 41.4% (6373/15,376) of BASE cases and 41.3% (3363/8136) of DTS cases and received advice for a new or additional course of action in 54.7% (8418/15,376) of BASE cases and 56.3% (4582/8136) of DTS cases. A referral was originally contemplated but avoided in 51.3% (7887/15,376) of BASE cases and 53.3% (4336/8136) of DTS cases, originally contemplated and still needed in 19.4% (2986/15,376) of BASE cases and 17.7% (1438/8136) of DTS cases, and neither originally contemplated nor needed in 21.7% (3334/15,376) of BASE cases and 21.9% (1781/8136) of DTS cases. Conclusions Both eConsult models had strong uptake. Use patterns varied between models, with the majority of growth occurring under BASE, but survey responses showed that both models provided similar outcomes in terms of new information offered and impact on decision to refer.
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Affiliation(s)
- Sheena Guglani
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Rhea Mitchell
- eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
| | - Erin Keely
- eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
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7
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Gorin SS. Multilevel Approaches to Reducing Diagnostic and Treatment Delay in Colorectal Cancer. Ann Fam Med 2019; 17:386-389. [PMID: 31501198 PMCID: PMC7032906 DOI: 10.1370/afm.2454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 08/05/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Sherri Sheinfeld Gorin
- Annals of Family Medicine
- Department of Family Medicine, The University of Michigan School of Medicine, Ann Arbor, Michigan
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8
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Independent Heath Facility Meets Cancer Care Ontario and Canadian Association of Gastroenterology Guidelines for Endoscopic Procedure Wait Times While Meeting Quality Indicators: A Retrospective Review. Can J Gastroenterol Hepatol 2018; 2018:4708270. [PMID: 29974039 PMCID: PMC6008741 DOI: 10.1155/2018/4708270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/09/2018] [Accepted: 03/25/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Canadian independent health facilities (IHFs) have been implemented to reduce hospital endoscopy volume and expedite endoscopic evaluations for patients suspected to have underlying colorectal cancer. METHODS We conducted a retrospective review of a prospective database at a large-volume urban IHF. The primary outcomes were wait times, and the secondary outcomes were colonoscopy quality indicators and complication rates. RESULTS Median wait times from referral to colonoscopy met the recommendations set out by the Canadian Association of Gastroenterology and Cancer Care Ontario for all indications: chronic abdominal pain: 43 days; new onset change in bowel habits: 36 days; bright red rectal bleeding: 42 days; documented iron-deficiency anemia: 43 days; fecal occult blood test positive: 38 days; cancer likely based on imaging or physical exam: 23 days; chronic diarrhea and chronic constipation: 42 days; and screening colonoscopies: 55 days. Secondary outcomes of quality indicators and complication rates all met or exceeded the CCO and CAG recommendations. CONCLUSIONS This IHF met the recommended wait times for all indications for colonoscopy while maintaining high procedural quality and safety. IHFs are one solution to help meet the increasing demand for colonoscopy in Ontario.
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Keely E, Canning S, Saloojee N, Afkham A, Liddy C. Improving Access to Gastroenterologist Using eConsultation: A Way to Potentially Shorten Wait Times. J Can Assoc Gastroenterol 2018; 1:124-128. [PMID: 31294353 PMCID: PMC6507275 DOI: 10.1093/jcag/gwy017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background Wait times for gastroenterologists in Canada continue to exceed recommended targets. Electronic consultation (eConsult) may reduce the need for face-to-face gastroenterologist visits. Objective The goal of this study was to identify the cases submitted to gastroenterologists though the Champlain BASE™ (Building Access to Specialists through eConsultation) eConsult service and explore their impact on primary care physicians' (PCPs) courses of action. Methods Gastroenterology cases submitted between June 2013 and January 2015 were categorized using a modification of the International Classification for Primary Care (ICPC-2) taxonomy. Question type (e.g., diagnosis or management) was classified using a validated taxonomy. Results Of the 121 gastroenterology consults reviewed, 33% were related to hepatology, 23% to GI symptoms, and 13% to specific luminal diseases. Among hepatology eConsults (n=40), 47% pertained to abnormal liver function testing. Overall, 51% of eConsults were related to diagnosis, 30% to management, 9% to drug treatments and 7% to procedures. PCPs received a reply within a median of 2.9 days. Only 25% of cases resulted in a face-to-face referral. Conclusions The eConsult service provided timely, highly regarded advice from gastroenterologists directly to PCPs and often eliminated the need for a face-to-face consultation. An evaluation of the most commonly-posed questions could inform future continuing medical education activities for PCPs.
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Affiliation(s)
- Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa Ontario, Canada
| | - Stephanie Canning
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nav Saloojee
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amir Afkham
- The Champlain Local Health Integration Network, Ottawa, Ontario, Canada
| | - Clare Liddy
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Family Medicine University of Ottawa, Ottawa, Ontario, Canada
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10
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Lord AR, Simms LA, Brown A, Hanigan K, Krishnaprasad K, Schouten B, Croft AR, Appleyard MN, Radford-Smith GL. Development and evaluation of a risk assessment tool to improve clinical triage accuracy for colonoscopic investigations. BMC Cancer 2018; 18:229. [PMID: 29486733 PMCID: PMC6389276 DOI: 10.1186/s12885-018-4140-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 02/19/2018] [Indexed: 01/24/2023] Open
Abstract
Background Gastroenterology Departments at hospitals within Australia receive thousands of General Practitioner (GP)-referral letters for gastrointestinal investigations every month. Many of these requests are for colonoscopy. This study aims to evaluate the performance of the current symptoms-based triage system compared to a novel risk score using objective markers. Methods Patients with lower abdominal symptoms referred by their GPs and triaged by a Gastroenterology consultant to a colonoscopy consent clinic were recruited into the study. A risk assessment tool (RAT) was developed using objective data (clinical, demographic, pathology (stool test, FIT), standard blood tests and colonoscopy outcome). Colonoscopy and histology results were scored and then stratified as either significant bowel disease (SBD) or non-significant bowel disease (non-SBD). Results Of the 467 patients in our study, 45.1% were male, the mean age was 54.3 ± 13.8 years and mean BMI was 27.8 ± 6.2. Overall, 26% had SBD compared to 74% with non-SBD (42% of the cohort had a normal colonoscopy). Increasing severity of referral symptoms was related to a higher triage category, (rectal bleeding, P = 2.86*10-9; diarrhoea, P = 0.026; abdominal pain, P = 5.67*10-4). However, there was no significant difference in the prevalence of rectal bleeding (P = 0.991) or diarrhoea (P = 0.843) for SBD. Abdominal pain significantly reduced the risk of SBD (P = 0.0344, OR = 0.52, CI = 0.27-0.95). Conversely, the RAT had a very high specificity of 98% with PPV and NPV of SBD prediction, 74% and 77%, respectively. The RAT provided an odds ratio (OR) of 9.0, 95%CI 4.29-18.75, p = 2.32*10-11), higher than the FIT test (OR = 5.3, 95%CI 2.44-11.69, p = 4.88*10-6), blood score (OR = 2.8, 95%CI 1.72- 4.38, p = 1.47*10-5) or age (OR = 2.5, 95%CI 1.61-4.00, 5.12*10-5) independently. Notably, the ORs of these individual objective measures were higher than the current practice of symptoms-based triaging (OR = 1.4, 95%CI 0.88-2.11, p = 0.153). Conclusions It is critical that individuals with high risk of having SBD are triaged to the appropriate category with the shortest wait time. Here we provide evidence that a combination of blood markers, demographic markers and the FIT test have a higher diagnostic accuracy for SBD than FIT alone.
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Affiliation(s)
- Anton R Lord
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia.
| | - Lisa A Simms
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Allison Brown
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Katherine Hanigan
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Krupa Krishnaprasad
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Belinda Schouten
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Anthony R Croft
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Mark N Appleyard
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Graham L Radford-Smith
- Inflammatory Bowel Diseases, QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Australia.,University of Queensland School of Medicine, Brisbane, Australia
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11
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Silvester JA, Kalkat H, Graff LA, Walker JR, Singh H, Duerksen DR. Information seeking and anxiety among colonoscopy-naïve adults: Direct-to-colonoscopy vs traditional consult-first pathways. World J Gastrointest Endosc 2016; 8:701-708. [PMID: 27909550 PMCID: PMC5114459 DOI: 10.4253/wjge.v8.i19.701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/28/2016] [Accepted: 07/22/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate the effects of direct to colonoscopy pathways on information seeking behaviors and anxiety among colonoscopy-naïve patients.
METHODS Colonoscopy-naïve patients at two tertiary care hospitals completed a survey immediately prior to their scheduled outpatient procedure and before receiving sedation. Survey items included clinical pathway (direct or consult), procedure indication (cancer screening or symptom investigation), telephone and written contact from the physician endoscopist office, information sources, and pre-procedure anxiety. Participants reported pre-procedure anxiety using a 10 point scale anchored by “very relaxed” (1) and “very nervous” (10). At least three months following the procedure, patient medical records were reviewed to determine sedative dose, procedure indications and any adverse events. The primary comparison was between the direct and consult pathways. Given the very different implications, a secondary analysis considering the patient-reported indication for the procedure (symptoms or screening). Effects of pathway (direct vs consult) were compared both within and between the screening and symptom subgroups.
RESULTS Of 409 patients who completed the survey, 34% followed a direct pathway. Indications for colonoscopy were similar in each group. The majority of the participants were women (58%), married (61%), and internet users (81%). The most important information source was family physicians (Direct) and specialist physicians (Consult). Use of other information sources, including the internet (20% vs 18%) and Direct family and friends (64% vs 53%), was similar in the Direct and Consult groups, respectively. Only 31% of the 81% who were internet users accessed internet health information. Most sought fundamental information such as what a colonoscopy is or why it is done. Pre-procedure anxiety did not differ between care pathways. Those undergoing colonoscopy for symptoms reported greater anxiety [mean 5.3, 95%CI: 5.0-5.7 (10 point Likert scale)] than those for screening colonoscopy (4.3, 95%CI: 3.9-4.7).
CONCLUSION Procedure indication (cancer screening or symptom investigation) was more closely associated with information seeking behaviors and pre-procedure anxiety than care pathway.
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Lee JY, Park HW, Kim MJ, Lee JS, Lee HS, Chang HS, Choe J, Hwang SW, Yang DH, Myung SJ, Yang SK, Byeon JS. Prediction of the Risk of a Metachronous Advanced Colorectal Neoplasm Using a Novel Scoring System. Dig Dis Sci 2016; 61:3016-3025. [PMID: 27358228 DOI: 10.1007/s10620-016-4237-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 06/21/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM This study aimed to develop and validate a risk score model to estimate the probability of a metachronous advanced colorectal neoplasm (ACRN) at surveillance colonoscopy. METHODS A retrospective analysis of a prospectively obtained database of 11,042 asymptomatic subjects who underwent surveillance colonoscopy after a screening colonoscopy was conducted. Subjects were randomly divided into derivation (n = 7730) and validation sets (n = 3312). From the derivation cohort, risk factors for a metachronous ACRN were identified by a multivariable analysis. Risk points were allocated to each risk factor based on the hazard ratio to develop the Metachronous Advanced colorectal neoplasm Prediction Scoring (MAPS) model, the performance of which was assessed in the validation cohort. RESULTS In the derivation cohort, age, male, sessile serrated adenoma/polyp, and a high-risk CRN (ACRN or ≥3 adenomas) at screening colonoscopy were independent risk factors for a metachronous ACRN. These variables were incorporated into the MAPS model, and the risk score ranged 0-17 (high MAPS risk arbitrarily defined as 10-17). At the 3-year surveillance colonoscopy, ACRN was found in 5.1 % of the high MAPS risk group versus 3.9 % of the high-risk CRN group. The colonoscopy number needed to detect one metachronous ACRN at the 3-year surveillance was 19.5 (95 % CI 11.7-33.2) for the high MAPS risk group versus 25.8 (95 % CI 15.4-44.0) for the high-risk CRN group. These findings were similarly confirmed in the validation cohort. CONCLUSIONS Our MAPS model based on clinical and colonoscopic parameters effectively predicts the risk of a metachronous ACRN.
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Affiliation(s)
- Ji Young Lee
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Hye Won Park
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Jong-Soo Lee
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho-Su Lee
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Hye-Sook Chang
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Jaewon Choe
- Health Screening and Promotion Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43 gil, Songpa-gu, Seoul, 05505, Korea.
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van Heijningen EMB, Lansdorp-Vogelaar I, Steyerberg EW, Goede SL, Dekker E, Lesterhuis W, ter Borg F, Vecht J, Spoelstra P, Engels L, Bolwerk CJM, Timmer R, Kleibeuker JH, Koornstra JJ, de Koning HJ, Kuipers EJ, van Ballegooijen M. Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study. Gut 2015; 64:1584-92. [PMID: 25586057 PMCID: PMC4602240 DOI: 10.1136/gutjnl-2013-306453] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 09/29/2014] [Accepted: 10/18/2014] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To determine adherence to recommended surveillance intervals in clinical practice. DESIGN 2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ± 3 months of a 1-year recommended interval and ± 6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2-3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1-2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing. RESULTS Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4-5%, p<0.01). CONCLUSIONS There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.
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Affiliation(s)
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - S Lucas Goede
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Wilco Lesterhuis
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands Department of Gastroenterology, Albert Schweitzer hospital, Dordrecht, the Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and Hepatology, Deventer Hospital, Deventer, the Netherlands
| | - Juda Vecht
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Pieter Spoelstra
- Department of Gastroenterology and Hepatology, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Leopold Engels
- Department of Gastroenterology and Hepatology, Orbis Medical Centre, Sittard, the Netherlands
| | - Clemens J M Bolwerk
- Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Robin Timmer
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan H Kleibeuker
- Department of Gastroenterology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Jan J Koornstra
- Department of Gastroenterology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Harry J de Koning
- Department of Public Health, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
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14
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The 2012 SAGE wait times program: Survey of Access to GastroEnterology in Canada. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:83-9. [PMID: 23472243 DOI: 10.1155/2013/143018] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Periodically surveying wait times for specialist health services in Canada captures current data and enables comparisons with previous surveys to identify changes over time. METHODS During one week in April 2012, Canadian gastroenterologists were asked to complete a questionnaire (online or by fax) recording demographics, reason for referral, and dates of referral and specialist visits for at least 10 consecutive new patients (five consultations and five procedures) who had not been seen previously for the same indication. Wait times were determined for 18 indications and compared with those from similar surveys conducted in 2008 and 2005. RESULTS Data regarding adult patients were provided by 173 gastroenterologists for 1374 consultations, 540 procedures and 293 same-day consultations and procedures. Nationally, the median wait times were 92 days (95% CI 85 days to 100 days) from referral to consultation, 55 days (95% CI 50 days to 61 days) from consultation to procedure and 155 days (95% CI 142 days to 175 days) (total) from referral to procedure. Overall, wait times were longer in 2012 than in 2005 (P<0.05); the wait time to same-day consultation and procedure was shorter in 2012 than in 2008 (78 days versus 101 days; P<0.05), but continued to be longer than in 2005 (P<0.05). The total wait time remained longest for screening colonoscopy, increasing from 201 days in 2008 to 279 days in 2012 (P<0.05). DISCUSSION Wait times for gastroenterology services continue to exceed recommended targets, remain unchanged since 2008 and exceed wait times reported in 2005.
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Nguyen GC, Devlin SM, Afif W, Bressler B, Gruchy SE, Kaplan GG, Oliveira L, Plamondon S, Seow CH, Williams C, Wong K, Yan BM, Jones J. Defining quality indicators for best-practice management of inflammatory bowel disease in Canada. Can J Gastroenterol Hepatol 2014; 28:275-85. [PMID: 24839622 PMCID: PMC4049258 DOI: 10.1155/2014/941245] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 02/23/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND There is a paucity of published data regarding the quality of care of inflammatory bowel disease (IBD) in Canada. Clinical quality indicators are quantitative end points used to guide, monitor and improve the quality of patient care. In Canada, where universal health care can vary significantly among provinces, quality indicators can be used to identify potential gaps in the delivery of IBD care and standardize the approach to interprovincial management. METHODS The Emerging Practice in IBD Collaborative (EPIC) group generated a shortlist of IBD quality indicators based on a comprehensive literature review. An iterative voting process was used to select quality indicators to take forward. In a face-to-face meeting with the EPIC group, available evidence to support each quality indicator was presented by the EPIC member aligned to it, followed by group discussion to agree on the wording of the statements. The selected quality indicators were then ratified in a final vote by all EPIC members. RESULTS Eleven quality indicators for the management of IBD within the single-payer health care system of Canada were developed. These focus on accurate diagnosis, appropriate and timely management, disease monitoring, and prevention or treatment of complications of IBD or its therapy. CONCLUSIONS These quality indicators are measurable, reflective of the evidence base and expert opinion, and define a standard of care that is at least a minimum that should be expected for IBD management in Canada. The next steps for the EPIC group involve conducting research to assess current practice across Canada as it pertains to these quality indicators and to measure the impact of each of these indicators on patient outcomes.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario
| | - Shane M Devlin
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta
| | - Waqqas Afif
- Department of Gastroenterology and Hepatology, McGill University Health Centre, Royal Victoria Hospital, Montreal, Quebec
| | - Brian Bressler
- Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia
| | - Steven E Gruchy
- Division of Gastroenterology, Dalhousie University, Halifax, Nova Scotia
| | - Gilaad G Kaplan
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta
| | | | - Sophie Plamondon
- Division of Gastroenterology, Centre Hospitalier Universitaire de Sherbrooke and Centre de Recherche Étienne-LeBel, Université de Sherbrooke, Sherbrooke, Québec
| | - Cynthia H Seow
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta
| | - Chadwick Williams
- Division of Gastroenterology, Saint John Regional Hospital, Saint John, New Brunswick
| | - Karen Wong
- Mount Saint Joseph Hospital, Vancouver, British Columbia
| | - Brian M Yan
- Division of Gastroenterology, Department of Medicine, Western University, London, Ontario
| | - Jennifer Jones
- Multidisciplinary IBD Program, Division of Gastroenterology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan
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The appropriateness of surveillance colonoscopy intervals after polypectomy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:33-8. [PMID: 23378981 DOI: 10.1155/2013/279897] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload. OBJECTIVE To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC. METHODS Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval. RESULTS A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared. CONCLUSION Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.
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General anesthetic versus light sedation: effect on pediatric endoscopy wait times. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:519-22. [PMID: 24078936 DOI: 10.1155/2013/201025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Wait times are an important measure of health care system effectiveness. There are no studies describing wait times in pediatric gastroenterology for either outpatient visits or endoscopy. Pediatric endoscopy is performed under light sedation or general anesthesia. The latter is hypothesized to be associated with a longer wait time due to practical limits on access to anesthesia in the Canadian health care system. OBJECTIVE To identify wait time differences according to sedation type and measure adverse clinical outcomes that may arise from increased wait time to endoscopy in pediatric patients. METHODS The present study was a retrospective review of medical charts of all patients <18 years of age who had been assessed in the pediatric gastroenterology clinic and were scheduled for an elective outpatient endoscopic procedure at McMaster Children's Hospital (Hamilton, Ontario) between January 2006 and December 2007. The primary outcome measure was time between clinic visit and date of endoscopy. Secondary outcome measures included other defined waiting periods and complications while waiting, such as emergency room visits and hospital admissions. RESULTS The median wait time to procedure was 64 days for general anesthesia patients and 22 days for patients who underwent light sedation (P<0.0001). There was no significant difference between the two groups with regard to the number of emergency room visits or hospital admissions, both pre- and postendoscopy. CONCLUSIONS Due to the lack of pediatric anesthetic resources, patients who were administered general anesthesia experienced a longer wait time for endoscopy compared with patients who underwent light sedation. This did not result in adverse clinical outcomes in this population.
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Colorectal cancer surveillance after index colonoscopy: guidance from the Canadian Association of Gastroenterology. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 27:224-8. [PMID: 23616961 DOI: 10.1155/2013/232769] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Differences between American (United States [US]) and European guidelines for colonoscopy surveillance may create confusion for the practicing clinician. Under- or overutilization of surveillance colonoscopy can impact patient care. METHODS The Canadian Association of Gastroenterology (CAG) convened a working group (CAG-WG) to review available guidelines and provide unified guidance to Canadian clinicians regarding appropriate follow-up for colorectal cancer (CRC) surveillance after index colonoscopy. A literature search was conducted for relevant data that postdated the published guidelines. RESULTS The CAG-WG chose the 2012 US Multi-Society Task Force (MSTF) on Colorectal Cancer to serve as the basis for the Canadian position, primarily because the US approach was the simplest and comprehensively addressed the issue of serrated polyps. Aspects of other guidelines were incorporated where relevant. The CAG-WG recommendations differed from the US MSTF guidelines in three main areas: patients with negative index colonoscopy should be followed-up at 10 years using any of the appropriate screening tests, including colonoscopy, for average-risk individuals; among patients with >10 adenomas, a one-year interval for subsequent colonoscopy is recommended; and for long-term follow-up, patients with low-risk adenomas on both the index and first follow-up procedures can undergo second follow-up colonoscopy at an interval of five to 10 years. DISCUSSION The CAG-WG adapted the US MSTF guidelines for colonoscopy surveillance to the Canadian health care environment with a few modifications. It is anticipated that the present article will provide unified guidance that will enhance physician acceptance and encourage appropriate utilization of recommended surveillance intervals.
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Sewitch MJ, Jiang M, Joseph L, Hilsden RJ, Bitton A. Developing model-based algorithms to identify screening colonoscopies using administrative health databases. BMC Med Inform Decis Mak 2013; 13:45. [PMID: 23574795 PMCID: PMC3637812 DOI: 10.1186/1472-6947-13-45] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 04/05/2013] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Algorithms to identify screening colonoscopies in administrative databases would be useful for monitoring colorectal cancer (CRC) screening uptake, tracking health resource utilization, and quality assurance. Previously developed algorithms based on expert opinion were insufficiently accurate. The purpose of this study was to develop and evaluate the accuracy of model-based algorithms to identify screening colonoscopies in health administrative databases. METHODS Patients aged 50-75 were recruited from endoscopy units in Montreal, Quebec, and Calgary, Alberta. Physician billing records and hospitalization data were obtained for each patient from the provincial administrative health databases. Indication for colonoscopy was derived using Bayesian latent class analysis informed by endoscopist and patient questionnaire responses. Two modeling methods were used to fit the data, multivariate logistic regression and recursive partitioning. The accuracies of these models were assessed. RESULTS 689 patients from Montreal and 541 from Calgary participated (January to March 2007). The latent class model identified 554 screening exams. Multivariate logistic regression predictions yielded an area under the curve of 0.786. Recursive partitioning using the latent outcome had sensitivity and specificity of 84.5% (95% CI: 81.5-87.5) and 63.3% (95% CI: 59.7-67.0), respectively. CONCLUSIONS Model-based algorithms using administrative data failed to identify screening colonoscopies with sufficient accuracy. Nevertheless, the approach of constructing a latent reference standard against which model-based algorithms were evaluated may be useful for validating administrative data in other contexts where there lacks a gold standard.
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Affiliation(s)
- Maida J Sewitch
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Mengzhu Jiang
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lawrence Joseph
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Robert J Hilsden
- Departments of Medicine/Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Alain Bitton
- Department of Medicine, McGill University, Montreal, Quebec, Canada
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
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Wait times for diagnostic colonoscopy among outpatients with colorectal cancer: a comparison with Canadian Association of Gastroenterology targets. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:894-6. [PMID: 23248790 DOI: 10.1155/2012/494797] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Timely access to colonoscopy is a nationally recognized issue in Canada, with previous studies documenting significant wait times for a variety of indications. However, specific wait times for colonoscopy among patients diagnosed with colorectal cancer remain unknown. METHODS A review of all outpatient cases of colorectal cancer diagnosed at colonoscopy in London, Ontario, in 2010 was performed. Wait times from the date of referral to colonoscopy were reviewed and compared with maximal wait times established by the Canadian Association of Gastroenterology (CAG) stratified according to indication. Cancer stage at the time of diagnosis was compared with colonoscopy wait times. RESULTS A total of 106 colorectal cancer patients meeting the inclusion and exclusion criteria were included in the study. Forty-six per cent of patients waited longer than CAG targets, with a mean (± SD) wait time of 79 ± 101 days. Higher cancer stage was associated with shorter wait time, likely as a result of triaging. CONCLUSION Long wait times for diagnostic colonoscopy among patients with colorectal cancer remain an issue, with a significant proportion of cases not meeting maximal CAG wait time targets.
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The 'natural history' of declined outpatient gastroenterology referrals. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:785-90. [PMID: 23166900 DOI: 10.1155/2012/507174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the 'natural history' of outpatients who were referred to the Division of Gastroenterology at the University of Alberta Hospital (Edmonton, Alberta) for gastrointestinal problems and were subsequently declined. METHODS Patients were tracked for 12 months after they were referred and declined for the following indications: abdominal pain, rectal bleeding, fecal occult blood test-positive stools and iron deficiency. For each patient, data regarding consultations by other gastroenterologists or surgeons working in the region, clinically relevant diagnoses and the number of gastrointestinal-related x-rays performed were obtained. RESULTS Of a total sample size of 230 patients, 110 (47.8%) were seen by another gastroenterologist or surgeon after decline. A significant diagnosis was made in 21 patients (9.1%), which had immediate clinical consequences in 29%. Forty per cent of patients underwent one or more gastointestinal-related x-rays before being declined, which increased to 55% after decline. CONCLUSION Approximately 50% of declined patients were seen by other gastroenterologists or surgeons in the region. In 9.1% of these patients, a clinically important diagnosis was made, of which one-quarter had immediate medical consequences.
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Awareness of postpolypectomy surveillance guidelines: a nationwide survey of colonoscopists in Canada. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:79-84. [PMID: 22312606 DOI: 10.1155/2012/919615] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Due to the increasing demand for colonoscopy, adherence to postpolypectomy surveillance guidelines is important. Suboptimal compliance can lead to unnecessary risks and ineffective use of resources. OBJECTIVE To determine the awareness of and adherence to postpolypectomy surveillance guidelines among members of the Canadian Association of Gastroenterology (CAG). METHODS A survey describing 14 clinical cases was mailed to all physician members (n=411) of the CAG. Respondents were required to recommend a surveillance interval and a reason for his or her choice. RESULTS A total of 150 colonoscopists (37%) completed the survey. Adherence to the guidelines varied from 23% to 96% per clinical scenario (median 63%). Recommended surveillance intervals were too short in 0% to 60% of the different cases (median 8%). The recommended interval was most often (60%) too short for a patient with one tubular adenoma with high-grade dysplasia. Surveillance intervals were too long in 4% to 75% of the cases (median 9%). The recommended interval was most often too long in a patient with a villous adenoma 15 mm in size and removed piecemeal (75%). Most often, recommendations were reported to be based on guidelines (median 74%; range 31% to 94%). However, in nine of 14 cases, more than 10% (median 18%; range 12% to 38%) of the respondents stated that their recommendation was based on guidelines, but did not provide the appropriate surveillance interval. CONCLUSIONS Compliance to colonoscopy surveillance guidelines is suboptimal and reflects both overuse and underuse. The results show that awareness about the content of guidelines needs to be raised and strategies implemented to increase adherence.
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Lansdorp-Vogelaar I, Knudsen AB, Brenner H. Cost-effectiveness of colorectal cancer screening. Epidemiol Rev 2011; 33:88-100. [PMID: 21633092 PMCID: PMC3132805 DOI: 10.1093/epirev/mxr004] [Citation(s) in RCA: 208] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Colorectal cancer is an important public health problem. Several screening methods have been shown to be effective in reducing colorectal cancer mortality. The objective of this review was to assess the cost-effectiveness of the different colorectal cancer screening methods and to determine the preferred method from a cost-effectiveness point of view. Five databases (MEDLINE, EMBASE, the Cost-Effectiveness Analysis Registry, the British National Health Service Economic Evaluation Database, and the lists of technology assessments of the Centers for Medicare and Medicaid Services) were searched for cost-effectiveness analyses published in English between January 1993 and December 2009. Fifty-five publications relating to 32 unique cost-effectiveness models were identified. All studies found that colorectal cancer screening was cost-effective or even cost-saving compared with no screening. However, the studies disagreed as to which screening method was most effective or had the best incremental cost-effectiveness ratio for a given willingness to pay per life-year gained. There was agreement among studies that the newly developed screening tests of stool DNA testing, computed tomographic colonography, and capsule endoscopy were not yet cost-effective compared with the established screening options.
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Affiliation(s)
- Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC, University Medical Center, PO Box 2040, 3000 CA Rotterdam, the Netherlands.
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Bridges RJ, Paterson WG, Sinclair P, Morgan DG. Summary of the Canadian Association of Gastroenterology 2004 strategic plan. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2010; 24:164-172. [PMID: 20352144 PMCID: PMC2852220 DOI: 10.1155/2010/949146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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