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Sonnenberg A, Yoo ER, Bakis G. Illusion of endoscopic success in instances of spontaneous disease resolution. Gastrointest Endosc 2023; 98:437-440. [PMID: 37150415 DOI: 10.1016/j.gie.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/09/2023]
Affiliation(s)
- Amnon Sonnenberg
- The Portland VA Medical Center; Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Eric R Yoo
- The Portland VA Medical Center; Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Gennadiy Bakis
- The Portland VA Medical Center; Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, USA
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Sonnenberg A, Bakis G. Fortune of Reversals: How Randomized Clinical Trials Shape Medical Practice. Dig Dis Sci 2022; 67:1911-1914. [PMID: 34463886 DOI: 10.1007/s10620-021-07240-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/18/2021] [Indexed: 12/09/2022]
Affiliation(s)
- Amnon Sonnenberg
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA.
- Gastroenterology Section, Portland VA Medical Center, P3-GI, 3710 SW US Veterans Hospital Road, Portland, OR, 97239, USA.
| | - Gennadiy Bakis
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
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Frazzoni L, La Marca M, Radaelli F, Spada C, Laterza L, Zagari RM, Bazzoli F, Hassan C, Frazzoni M, Dinis-Ribeiro M, Fuccio L. Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams. Aliment Pharmacol Ther 2021; 53:22-32. [PMID: 33159359 DOI: 10.1111/apt.16144] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/27/2020] [Accepted: 10/17/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Colonoscopy is frequently performed in industrialised countries. Inappropriate colonoscopies might lead to unnecessary exams, increasing risks and costs. AIM To estimate the impact of colonoscopy appropriateness in terms of gain in additional diagnoses and sparing of unnecessary exams. METHODS Systematic review including studies reporting the prevalence of relevant findings, colorectal cancer (CRC) and inflammatory bowel disease (IBD) according to colonoscopy appropriateness as defined by the American Society for Gastrointestinal Endoscopy and European Panel on Appropriateness of Gastrointestinal Endoscopy. RESULTS Twenty-one studies with 19,822 patients were included. Colonoscopy was appropriate in 15,162 (71%, CI 64%-78%). Appropriateness significantly increased the probability of relevant findings (34% vs. 18%; RR 1.81, CI 1.53-2.14), CRC (7% vs. 2%; RR 3.62, CI 2.44-5.37) and IBD (6% vs. 4%; RR 1.86, CI 1.09-3.19). Appropriateness had sensitivity 88% (CI 85%-91%), 97% (CI 93%-98%) and 89% (CI 80%-94%), and specificity 24% (CI 20%-29%), 22% (CI 18%-26%) and 24% (CI 20%-28%) for relevant findings, CRC and IBD, respectively. On average, performing colonoscopy with appropriate indication would find 15 (CI 10-21) more relevant findings, five (CI 3-9) more CRCs and three (CI 1-9) more diagnoses of IBD per 100 patients, and save 24 (CI 20-29), 22 (CI 18-26) and 24 (CI 20-28) examinations per 100 patients for relevant findings, CRC and IBD, respectively. CONCLUSIONS Appropriateness affects the diagnostic yield of colonoscopy for CRC, IBD and relevant findings. Appropriateness criteria are useful, although integrated with clinical evaluation of the patient.
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Affiliation(s)
- Leonardo Frazzoni
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Marina La Marca
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Poliambulanza, Brescia, Italy
| | - Liboria Laterza
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Rocco Maurizio Zagari
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Franco Bazzoli
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Marzio Frazzoni
- Department of Specialized Medicine, Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy
| | - Mario Dinis-Ribeiro
- Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, Porto, Portugal
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Portugal
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S.Orsola-Malpighi Hospital, Bologna, Italy
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On Structural Entropy and Spatial Filling Factor Analysis of Colonoscopy Pictures. ENTROPY 2019; 21:e21030256. [PMID: 33266971 PMCID: PMC7514738 DOI: 10.3390/e21030256] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/19/2019] [Accepted: 02/27/2019] [Indexed: 12/21/2022]
Abstract
Colonoscopy is the standard device for diagnosing colorectal cancer, which develops from little lesions on the bowel wall called polyps. The Rényi entropies-based structural entropy and spatial filling factor are two scale- and resolution-independent quantities that characterize the shape of a probability distribution with the help of characteristic curves of the structural entropy–spatial filling factor map. This alternative definition of structural entropy is easy to calculate, independent of the image resolution, and does not require the calculation of neighbor statistics, unlike the other graph-based structural entropies.The distant goal of this study was to help computer aided diagnosis in finding colorectal polyps by making the Rényi entropy based structural entropy more understood. The direct goal was to determine characteristic curves that can differentiate between polyps and other structure on the picture. After analyzing the distribution of colonoscopy picture color channels, the typical structures were modeled with simple geometrical functions and the structural entropy–spatial filling factor characteristic curves were determined for these model structures for various parameter sets. A colonoscopy image analying method, i.e., the line- or column-wise scanning of the picture, was also tested, with satisfactory matching of the characteristic curve and the image.
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Sonnenberg A, Pohl H. 'Do no harm': an intuitive decision tool to assess the need for gastrointestinal endoscopy. Endosc Int Open 2019; 7:E384-E388. [PMID: 30834299 PMCID: PMC6395093 DOI: 10.1055/a-0826-4432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2022] Open
Affiliation(s)
- Amnon Sonnenberg
- Gastroenterology Section, Portland VA Medical Center,Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon, United States
| | - Heiko Pohl
- Gastroenterology Section, VA Medical Center, White River Junction, Vermont, United States,Division of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
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"Appropriateness of colonoscopy according to EPAGE II in a low resource setting: a cross sectional study from Sri Lanka". BMC Gastroenterol 2018; 18:72. [PMID: 29843628 PMCID: PMC5975517 DOI: 10.1186/s12876-018-0798-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 05/11/2018] [Indexed: 11/16/2022] Open
Abstract
Background Due to finite resources, the clinical decision to subject a patient to colonoscopy needs to be based on the evidence, regardless of its availability, affordability and safety. This study assessed the appropriateness of colonoscopies conducted in selected study settings in Sri Lanka. In the absence of local guidelines, audit was based on European Panel on Appropriateness of Gastrointestinal Endoscopy II (EPAGE II) criteria. Methods This cross-sectional study assessed consecutive patients who underwent colonoscopy between June to August 2015 at four main hospitals in Sri Lanka. Interviewer administered questionnaire and secondary data were collected by trained health staff. Indications were assessed according to EPAGE II criteria. Results Out of 325 patients, male female proportions were 57.2 and 42.8%. Mean (SD) age was 54.9 (12.1) years. Colonoscopies were appropriate in 61.2% (95% CI 55.8–66.3), uncertain in 28.6% (95% CI 23.9–33.7) and inappropriate in 10.2% (95% CI 7.3–13.9). Colonoscopy to evaluate abdominal pain has highest percentage of inappropriateness of 10.0%. However, 9.5% of these colonoscopies revealed Colo-Rectal Cancer (CRC), reflecting differences in the profile of local CRC patients. Colonoscopies with appropriate or uncertain indications are three times more likely to have a relevant finding than inappropriate indications (42.5% vs. 18.2%; OR 3.32, 95% CI 1.33–8.3; P = 0.008). Conclusions Majority of colonoscopies are appropriate. However, it cannot be neglected that every one in ten patients undergo inappropriate colonoscopy. Proportion of inappropriateness was highest for the indication of chronic abdominal pain, of which, 9.5% of patients were diagnosed with CRC. This may reflect the different profile of local CRC patients in terms of symptom manifestation and other characteristics. In conclusion, the authors recommend formulation of national guidelines for colonoscopy indications based on current best evidence and local patient profile. Use of such prepared local guidelines will improve the efficient use of finite resources.
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Abdelmassih Y, El-Khoury S, Georges S, Guindolet D, Gabison E, Cochereau I. Preoperative spectral-domain optical coherence tomography in patients having cataract surgery. J Cataract Refract Surg 2018; 44:610-614. [DOI: 10.1016/j.jcrs.2018.02.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 02/14/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Marzo-Castillejo M, Almeda J, Mascort JJ, Cunillera O, Saladich R, Nieto R, Piñeiro P, Llagostera M, Cantero F, Segarra M, Puente D. Appropriateness of colonoscopy requests according to EPAGE-II in the Spanish region of Catalonia. BMC FAMILY PRACTICE 2015; 16:154. [PMID: 26498043 PMCID: PMC4620598 DOI: 10.1186/s12875-015-0369-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 10/13/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND In a context of increasing demand and pressure on the public health expenditure, appropriateness of colonoscopy indications is a topic of discussion. The objective of this study is to evaluate the appropriateness of colonoscopy requests performed in a primary care (PC) setting in Catalonia. METHODS Cross-sectional descriptive study. Out-patients >14 years of age, referred by their reference physicians from PC or hospital care settings to the endoscopy units in their reference hospitals, to undergo a colonoscopy. Evaluation of the appropriateness of 1440 colonoscopy requests issued from January to July 2011, according to the EPAGE-II guidelines (European Panel on the Appropriateness of Gastrointestinal Endoscopy). RESULTS The most frequent indications of diagnostic suspicion requests were: rectal bleeding (37.46 %), abdominal pain (26.54 %), and anaemia study (16.78 %). The most frequent indications of disease follow-up were adenomas (58.1 %), and CRC (31.16 %). Colonoscopy was appropriate in 73.68 % of the cases, uncertain in 16.57 %, and inappropriate in 9.74 %. In multivariate analysis, performed colonoscopies reached an OR of 9.9 (CI 95 % 1.16-84.08) for qualifying as appropriate for colorectal cancer (CRC) diagnosis, 1.49 (CI 95 % 1.1-2.02) when requested by a general practitioner, and 1.09 (CI 95 % 1.07-1.1) when performed on women. CONCLUSIONS Appropriateness of colonoscopy requests in our setting shows a suitable situation in accordance with recognized standards. General practitioners contribute positively to this appropriateness level. It is necessary to provide physicians with simple and updated guidelines, which stress recommendations for avoiding colonoscopy requests in the most prevalent conditions in PC.
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Affiliation(s)
- M Marzo-Castillejo
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain.
| | - J Almeda
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain. .,Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent. Catalan Institute of Health (ICS), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
| | - J J Mascort
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain. .,EAP Florida, UGEAP L'Hospitalet Nord, Universitat de Barcelona, Parc dels ocellets s/n L'Hospitalet de Llobregat, 08905, Barcelona, Spain.
| | - O Cunillera
- Unitat de Suport a la Recerca - IDIAP Jordi Gol Direcció d'Atenció Primària Costa de Ponent, Catalan Institute of Health (ICS), c/ Bellaterra, 41 1ª planta, 08940, Cornellà de Llobregat, Barcelona, Spain.
| | - R Saladich
- EAP Vinyets Ronda Sant Ramon, 187 Sant Boi de Llobregat, 08830, Barcelona, Spain.
| | - R Nieto
- EAP Penedès Rural. Servei Atenció Primària Alt Penedès.Garraf- Baix Llobregat Nord, Catalan Institute of Health (ICS) Pg. Fluvial s/n, 08730, Sta Margarida i els Monjos, Barcelona, Spain.
| | - P Piñeiro
- EAP Penedès Rural. Servei Atenció Primària Alt Penedès.Garraf- Baix Llobregat Nord, Catalan Institute of Health (ICS) Pg. Fluvial s/n, 08730, Sta Margarida i els Monjos, Barcelona, Spain.
| | - M Llagostera
- EAP Penedès Rural Servei d'Atenció Primària (SAP) Penedès-Garraf-Llobregat, Nord Catalan Institute of Health (ICS), Plaça Penedès 3, 1ª planta, 08720, Vilafranca del Penedès, Barcelona, Spain.
| | - Fx Cantero
- EAP Lluis Millet, C/ Lluis Millet, 2-4, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - M Segarra
- EAP Igualada Urbà. Servei Atenció Primària Anoia. Gerència Territorial Catalunya Central, Catalan Institute of Health (ICS), Pg. Verdaguer, 170, 08700, Igualada, Barcelona, Spain.
| | - D Puente
- EAP Bellvitge, C. de l'Ermita de Bellvitge, s/n, 08907, L'Hospitalet de Llobregat, Barcelona, Spain. .,Institut Universitari D'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Gran Via de les Corts Catalanes, 587 àtic, 08007, Barcelona, Spain.
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Powell AA, Saini SD, Breitenstein MK, Noorbaloochi S, Cutting A, Fisher DA, Bloomfield HE, Halek K, Partin MR. Rates and correlates of potentially inappropriate colorectal cancer screening in the Veterans Health Administration. J Gen Intern Med 2015; 30:732-41. [PMID: 25605531 PMCID: PMC4441657 DOI: 10.1007/s11606-014-3163-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/01/2014] [Accepted: 12/12/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Inappropriate use of colorectal cancer (CRC) screening procedures can inflate healthcare costs and increase medical risk. Little is known about the prevalence or causes of inappropriate CRC screening. OBJECTIVE Our aim was to estimate the prevalence of potentially inappropriate CRC screening, and its association with patient and facility characteristics in the Veterans Health Administration (VHA) . DESIGN AND PARTICIPANTS We conducted a cross-sectional study of all VHA patients aged 50 years and older who completed a fecal occult blood test (FOBT) or a screening colonoscopy between 1 October 2009 and 31 December 2011 (n = 1,083,965). MAIN MEASURES Measures included: proportion of patients whose test was classified as potentially inappropriate; associations between potentially inappropriate screening and patient demographic and health characteristics, facility complexity, CRC screening rates, dependence on FOBT, and CRC clinical reminder attributes. KEY RESULTS Of 901,292 FOBT cases, 26.1 % were potentially inappropriate (13.9 % not due, 7.8 % limited life expectancy, 11.0 % receiving FOBT when colonoscopy was indicated). Of 134,335 screening colonoscopies, 14.2 % were potentially inappropriate (10.4 % not due, 4.4 % limited life expectancy). Each additional 10 years of patient age was associated with an increased likelihood of undergoing potentially inappropriate screening (ORs = 1.60 to 1.83 depending on screening mode). Compared to facilities scoring in the bottom third on a measure of reliance on FOBT (versus screening colonoscopy), facilities scoring in the top third were less likely to conduct potentially inappropriate FOBTs (OR = 0.,78) but more likely to conduct potentially inappropriate colonoscopies (OR = 2.20). Potentially inappropriate colonoscopies were less likely to be conducted at facilities where primary care providers were assigned partial responsibility (OR = 0.74) or full responsibility (OR = 0.73) for completing the CRC clinical reminder. CONCLUSIONS A substantial number of VHA CRC screening tests are potentially inappropriate. Establishing processes that enforce appropriate screening intervals, triage patients with limited life expectancies, and discourage the use of FOBTs when a colonoscopy is indicated may reduce inappropriate testing.
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Affiliation(s)
- Adam A Powell
- Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, MN, USA,
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Andújar X, Sainz E, Galí A, Loras C, Aceituno M, Espinós JC, Viver JM, Esteve M, Fernández-Bañares F. [Inappropriateness rate for colonoscopy indications in an open access unit]. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:313-9. [PMID: 25744733 DOI: 10.1016/j.gastrohep.2014.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/29/2014] [Accepted: 11/03/2014] [Indexed: 12/15/2022]
Abstract
INTRODUCTION AND OBJECTIVE The suitability of indications for colonoscopy is important to optimize the available resources. The aim of this study was to assess the appropriateness of colonoscopy indications in an open access endoscopy unit using the EPAGE II criteria. METHODS Colonoscopies performed between October 1 and November 30, 2011 were retrospectively included. The appropriateness of the colonoscopy was established according to the EPAGE II criteria. Demographics, medical applicants, indications and relevant findings from these examinations were recorded. RESULTS We included 440 colonoscopies (60.8 ± 016.3 years, 54% women). The indication was appropriate in 75.4% (CI, 71-79.3%), uncertain in 13.1% (CI, 10.2-16.6%) and inappropriate in 11.4% (CI, 8.7-14.8%). In the univariate analysis, the relevant findings in the colonoscopy were associated with age, sex, colonoscopy indications and EPAGE II. In the logistic regression analysis, factors independently associated with the presence of relevant findings were age (≥ 50 years) (OR, 1.84), male sex (OR, 2.7) and two indications, inflammatory bowel disease and post-polypectomy surveillance (P < .03). The diagnostic yield of EPAGE II criteria was 37.3% for appropriate colonoscopies and 28.3% for inappropriate colonoscopies (P = .09). CONCLUSIONS The rate of unnecessary colonoscopy is high, especially in young patients (<50 years) and some colonoscopy indications. Age (≥ 50 years) and male sex are independently associated with the presence of relevant findings in colonoscopy. The diagnostic yield of EPAGE II criteria does not differ between appropriate and inappropriate examinations.
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Affiliation(s)
- Xavier Andújar
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Empar Sainz
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Alex Galí
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Carme Loras
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Montserrat Aceituno
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Jorge C Espinós
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Josep M Viver
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
| | - Maria Esteve
- Servicio de Aparato Digestivo, Hospital Universitari Mutua Terrassa, CIBERehd, Terrassa, España
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Affiliation(s)
| | - Neil A Shepherd
- Gloucestershire Cellular Pathology Laboratory; Cheltenham General Hospital; Cheltenham Gloucestershire UK
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Eskeland SL, Dalén E, Sponheim J, Lind E, Brunborg C, de Lange T. European panel on the appropriateness of gastrointestinal endoscopy II guidelines help in selecting and prioritizing patients referred to colonoscopy--a quality control study. Scand J Gastroenterol 2014; 49:492-500. [PMID: 24597781 DOI: 10.3109/00365521.2014.886715] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To use information from the referral letters to assess the appropriateness of colonoscopies in a primary open-access referral center, according to the criteria from the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II, and to compare with the first EPAGE guidelines. Second, to evaluate how the appropriateness and other patient- or doctor-related factors affected the diagnostic yield (DY). MATERIAL AND METHODS A set of variables; symptoms, referring physician and final diagnosis, for 323 referrals accepted for colonoscopy were recorded prospectively and later on assessed using the EPAGE and EPAGE II criteria, respectively. Patients with incomplete visualization of the entire colon or colonoscopic findings as indication were excluded. RESULTS EPAGE and EPAGE II criteria were applicable in 287 (95.3%) and 295 (98.0%) referrals, respectively. A total of 166 (57.8%) patients were considered appropriate by EPAGE and 240 (81.4%) patients were considered appropriate by EPAGE II. DY for appropriate versus uncertain/inappropriate referrals was 34.9% versus 17.4% for EPAGE (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.8-4.4, p = 0.003) and 31.3% versus 10.9% for EPAGE II (OR = 3.5, 95% CI: 1.4-8.9, p = 0.007). Sensitivity was higher for EPAGE II (92.6% vs. 73.4%). According to EPAGE II, 68 (23.1%) patients were referred due to lesions identified on other diagnostic procedures, producing a DY of 39.7%. In this group, 70% presented symptoms appropriate for a primary referral to colonoscopy. CONCLUSIONS The majority of colonoscopies were found appropriate by EPAGE II. There was a clear association between high appropriateness of the indication and a high DY. EPAGE II is a guideline-improvement that may be useful for both referring physicians and gastroenterologists when considering referrals.
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Affiliation(s)
- Sigrun Losada Eskeland
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust , Sandvika , Norway
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Burri E, Manz M, Schroeder P, Froehlich F, Rossi L, Beglinger C, Lehmann FS. Diagnostic yield of endoscopy in patients with abdominal complaints: incremental value of faecal calprotectin on guidelines of appropriateness. BMC Gastroenterol 2014; 14:57. [PMID: 24679065 PMCID: PMC4021405 DOI: 10.1186/1471-230x-14-57] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 03/24/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria have been developed to increase diagnostic yield, but their predictive value is limited. We investigated the incremental diagnostic value of faecal calprotectin to EPAGE criteria. METHODS In a post-hoc analysis of a prospective study, EPAGE criteria were applied to 298 of 575 (51.8%) patients who had undergone esophagogastroduodenoscopy (EGD), colonoscopy or both for abdominal complaints at the Division of Gastroenterology & Hepatology at the University Hospital Basel in Switzerland. Faecal calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. Final endoscopic diagnoses were blinded to calprotectin values. RESULTS Of 149 EGDs and 224 colonoscopies, 17.6% and 14.7% respectively were judged inappropriate by EPAGE criteria. Appropriate or uncertain indications revealed more endoscopic findings in both EGD (46.3% vs. 23.1%, P = 0.049) and colonoscopy (23.6% vs. 6.1%, P = 0.041) than inappropriate indications. Median calprotectin levels were higher (81.5 μg/g, interquartile range 26-175, vs. 10 μg/g, IQR 10-22, P < 0.001) and testing was more often positive (>50 μg/g) in patients with endoscopic findings, both in EGD (58.2% vs. 33.0%, P = 0.005) and in colonoscopy (57.3% vs. 7.4%, P < 0.001). The use of faecal calprotectin in addition to EPAGE criteria improved the risk reclassification of patients by endoscopic findings. The calculated net reclassification index was 37.8% (P = 0.002) for EGD and 110.9% (P <0.001) for colonoscopy, thus improving diagnostic yield to 56.8% and 70.2%, respectively. CONCLUSIONS The use of faecal calprotectin in addition to EPAGE criteria improved diagnostic yield in patients with abdominal complaints.
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Affiliation(s)
- Emanuel Burri
- Department of Gastroenterology & Hepatology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
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Massl R, van Putten PG, Steyerberg EW, van Tilburg AJP, Lai JYL, de Ridder RJJ, Brouwer JT, Verburg RJ, Alderliesten J, Schoon EJ, van Leerdam ME, Kuipers EJ. Comparing quality, safety, and costs of colonoscopies performed by nurse vs physician trainees. Clin Gastroenterol Hepatol 2014; 12:470-7. [PMID: 24036056 DOI: 10.1016/j.cgh.2013.08.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 08/03/2013] [Accepted: 08/22/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We evaluated the quality and safety of colonoscopies performed by nurse and physician endoscopy trainees as well as the cost differences. METHODS We performed a study of 7 nurse and 8 physician (gastroenterology fellows) endoscopy trainees at 2 medical centers in the Netherlands from September 2008 through April 2012. At the beginning of the study, the subjects had no experience in endoscopy; they were trained in gastrointestinal endoscopy according to the regulations of the Dutch Society of Gastroenterology, performing a minimum of 100 colonoscopies. Each trainee then performed 135 consecutive colonoscopies (866 total by nurse trainees and 1080 by physician trainees) under supervision of a gastroenterologist; the colonoscopies were evaluated for quality and safety. We performed statistical analyses of data, assessing multilevel and cost minimization. The mean age of the patients was 57 years, and about half were women in each group. RESULTS The endoscopic quality and safety were comparable between nurse and physician trainees. Overall rates of cecal intubation were 95% for nurses and 93% for physicians (P = .38), including procedures that required assistance from a supervisor; mean withdrawal times were 10.4 and 9.8 minutes, respectively (P = .44). Each group detected 27% of adenomas and had a 0.5% rate of complication. In both groups, the rates of unassisted cecal intubation gradually increased with the number of colonoscopies performed, from 70% for nurses and 74% for physicians at the beginning to 89% and 86%, respectively, at the end of the assessment period. Using a strategy in which 1 gastroenterologist supervises 3 nurses, the personnel costs decreased from $64.65 to $54.58. CONCLUSIONS In a supervised setting, nurse endoscopists perform colonoscopies according to quality and safety standards that are comparable with those of physician endoscopist and can substantially reduce costs.
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Affiliation(s)
- Renate Massl
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands.
| | - Paul G van Putten
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Anthonie J P van Tilburg
- Department of Gastroenterology and Hepatology, Sint Franciscus Gasthuis, Rotterdam, the Netherlands
| | - Jonathan Y L Lai
- Department of Gastroenterology and Hepatology, Groene Hart Hospital, Gouda, the Netherlands
| | - Rogier J J de Ridder
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Johnannes T Brouwer
- Department of Gastroenterology and Hepatology, Reinier de Graaf Medical Center, Delft, the Netherlands
| | - Robert J Verburg
- Department of Gastroenterology and Hepatology, Medical Center Haaglanden, The Hague, the Netherlands
| | - Joyce Alderliesten
- Department of Gastroenterology and Hepatology, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Department of Gastroenterology and Hepatology, Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, the Netherlands; Department of Internal Medicine, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Petruzziello L, Hassan C, Alvaro D, Kohn A, Rossi Z, Zullo A, Cesaro P, Annibale B, Barca A, Di Giulio E, Giorgi Rossi P, Grasso E, Ridola L, Spada C, Costamagna G. Appropriateness of the indication for colonoscopy: is the endoscopist the 'gold standard'? J Clin Gastroenterol 2012; 46:590-4. [PMID: 22178958 DOI: 10.1097/mcg.0b013e3182370b7b] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The appropriate selection of patients for colonoscopy is crucial for an efficient use of endoscopy. The role of endoscopist in filtering out inappropriate referrals is largely unknown. METHODS A multicentre, prospective study was performed in which consecutive patients referred for colonoscopy during a 1-month period were enrolled. Before colonoscopy, the endoscopist assessed appropriateness of the endoscopic referral without directly consulting official guidelines, also collecting clinical and demographic variables. Appropriateness of the indication was eventually assessed by a group of experts based on the American Society for Gastrointestinal Endoscopy guidelines, representing the gold standard. Outcomes of the study were the inappropriateness rate and the main related causes, as well as the concordance rate between the endoscopists and the experts. A multivariate analysis was performed to identify predictors of inappropriateness. RESULTS One thousand seven hundred ninety-nine patients were enrolled in 20 centres, of which 1489 outpatients were included in the final analysis. According to the American Society for Gastrointestinal Endoscopy guidelines, 432 referrals were inappropriate, corresponding to an inappropriateness rate of 29%. At multivariate analysis, prescription of a repeated colonoscopy (≥2 colonoscopies in the same patient) was strongly associated with the inappropriateness of the indication (odds ratio: 8.8; 95% confidence interval: 6.2, 12.7). Postpolypectomy or post-colorectal cancer surveillance accounted for 77% of the inappropriate control procedures. A 79% concordance rate between endoscopist and expert assessment was found. Among the 317 discordant cases, postpolypectomy or post-colorectal cancer surveillance accounted for 51% of the cases, the endoscopists mistakenly classifying it as appropriate in 55% to 61% of the inappropriate cases. CONCLUSIONS Inappropriateness in outpatient colonoscopy referrals remains high, surveillance procedures representing the most frequent source of inappropriateness.
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Argüello L, Pertejo V, Ponce M, Peiró S, Garrigues V, Ponce J. The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria. Gastrointest Endosc 2012; 75:138-45. [PMID: 22100299 DOI: 10.1016/j.gie.2011.08.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 08/20/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care. OBJECTIVES To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria. DESIGN Cross-sectional study. SETTING Endoscopy unit of a teaching hospital in Spain. PATIENTS Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing. MAIN OUTCOME MEASUREMENTS Appropriateness of colonoscopies according to the EPAGE criteria. RESULTS From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer-related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels. LIMITATIONS The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria. CONCLUSIONS Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.
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Affiliation(s)
- Lidia Argüello
- Servicio de Medicina Digestiva, Hospital Universitario La Fe, Valencia, Spain
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17
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Cosentino F, Tumino E, Passoni GR, Morandi E, Capria A. Functional evaluation of the endotics system, a new disposable self-propelled robotic colonoscope: in vitro tests and clinical trial. Int J Artif Organs 2011; 32:517-27. [PMID: 19844894 DOI: 10.1177/039139880903200806] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Currently, the best method for CRC screening is colonoscopy, which ideally (where possible) is performed under partial or deep sedation. This study aims to evaluate the efficacy of the Endotics System, a new robotic device composed of a workstation and a disposable probe, in performing accurate and well-tolerated colonoscopies. This new system could also be considered a precursor of other innovating vectors for atraumatic locomotion through natural orifices such as the bowel. The flexible probe adapts its shape to the complex contours of the colon, thereby exerting low strenuous forces during its movement. These novel characteristics allow for a painless and safe colonoscopy, thus eliminating all major associated risks such as infection, cardiopulmonary complications and colon perforation. METHODS An experimental study was devised to investigate stress pattern differences between traditional and robotic colonoscopy, in which 40 enrolled patients underwent both robotic and standard colonoscopy within the same day. RESULTS The stress pattern related to robotic colonoscopy was 90% lower than that of standard colonoscopy. Additionally, the robotic colonoscopy demonstrated a higher diagnostic accuracy, since, due to the lower insufflation rate, it was able to visualize small polyps and angiodysplasias not seen during the standard colonoscopy. All patients rated the robotic colonoscopy as virtually painless compared to the standard colonoscopy, ranking pain and discomfort as 0.9 and 1.1 respectively, on a scale of O to 10, versus 6.9 and 6.8 respectively for the standard device. CONCLUSIONS The new Endotics System demonstrates efficacy in the diagnosis of colonic pathologies using a procedure nearly completely devoid of pain. Therefore, this system can also be looked upon as the first step toward developing and implementing colonoscopy with atraumatic locomotion through the bowel while maintaining a high level of diagnostic accuracy;
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Affiliation(s)
- Felice Cosentino
- Gastroenterology and Digestive Endoscopy, San Giuseppe Hospital, Milan, Italy.
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18
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Athreya PJ, Owen GN, Wong SW, Douglas PR, Newstead GL. Achieving quality in colonoscopy: bowel preparation timing and colon cleanliness. ANZ J Surg 2010; 81:261-5. [DOI: 10.1111/j.1445-2197.2010.05429.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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19
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Miele E, Giannetti E, Martinelli M, Tramontano A, Greco L, Staiano A. Impact of the Rome II paediatric criteria on the appropriateness of the upper and lower gastrointestinal endoscopy in children. Aliment Pharmacol Ther 2010; 32:582-90. [PMID: 20528827 DOI: 10.1111/j.1365-2036.2010.04383.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The demand for paediatric gastrointestinal (GI) endoscopy has increased, resulting in a significant rise of overall costs. AIM To assess the clinical impact of the Rome II criteria for functional gastrointestinal disorders when selecting paediatric patients who underwent GI endoscopy. METHODS The indications and findings of GI endoscopic procedures performed before and after the publication of the Rome II criteria were evaluated retrospectively. RESULTS Upper GI endoscopy was performed in 1124 children, whereas colonoscopy was performed in 500 subjects. A total of 607 (54%) oesophago-gastro-duodenoscopies (OGDs) were positive and 517 (46%) were negative, whereas 306 (61.1%) colonoscopies were positive and 194 (38.9%) were negative. Of the 1624 procedures, 26% were considered inappropriate according to the Rome II criteria. Inappropriate procedures decreased significantly after publication of the Rome II criteria (OR, 3.7; 95% CI, 1.8-7.5). Of 1202 appropriate GI endoscopies, 502 OGD (62.7%) were significantly contributive, compared with only 105 (32.5%) of the 323 inappropriate procedures (OR, 3.5; 95% CI, 2.6-4.6), whereas 265 (65.8%) colonoscopies were significantly contributive, compared with only 41 (42.3%) of the 97 inappropriate procedures (OR, 2.6; 95% CI, 1.6-4.1). CONCLUSIONS The use of the criteria for functional gastrointestinal disorders makes a significant positive impact, they should reduce unnecessary paediatric GI endoscopy.
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Affiliation(s)
- E Miele
- Department of Pediatrics, University of Naples "Federico II", Naples, Italy
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20
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The effect of nonmedical factors on variations in the performance of colonoscopy among different health care settings. Med Care 2010; 48:101-9. [PMID: 20068487 DOI: 10.1097/mlr.0b013e3181c160ee] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous published studies have shown significant variations in colonoscopy performance, even when medical factors are taken into account. This study aimed to examine the role of nonmedical factors (ie, embodied in health care system design) as possible contributors to variations in colonoscopy performance. METHODS Patient data from a multicenter observational study conducted between 2000 and 2002 in 21 centers in 11 western countries were used. Variability was captured through 2 performance outcomes (diagnostic yield and colonoscopy withdrawal time), jointly studied as dependent variables, using a multilevel 2-equation system. RESULTS Results showed that open-access systems and high-volume colonoscopy centers were independently associated with a higher likelihood of detecting significant lesions and longer withdrawal durations. Fee for service (FFS) payment was associated with shorter withdrawal durations, and so had an indirect negative impact on the diagnostic yield. Teaching centers exhibited lower detection rates and longer withdrawal times. CONCLUSIONS Our results suggest that gatekeeping colonoscopy is likely to miss patients with significant lesions and that developing specialized colonoscopy units is important to improve performance. Results also suggest that FFS may result in a lower quality of care in colonoscopy practice and highlight the fact that longer withdrawal times do not necessarily indicate higher quality in teaching centers.
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21
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Eliakim R. The PillCam™ Colon Capsule for Colon Cancer Screening: Comparison Between the First- and Second-Generation Capsules. Hosp Pract (1995) 2010; 38:110-116. [PMID: 20890059 DOI: 10.3810/hp.2010.06.303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Population-based screening for colorectal cancer is widely recommended, with conventional colonoscopy (CC) being considered the preferred modality. However, compliance with colonoscopy screening is low, ranging between 20% and 50%, and manpower capacity for performing CC is limited. Therefore, a new, minimally invasive diagnostic tool, the PillCam™ Colon Capsule Endoscope (PCCE) was developed to become a desirable, patient-friendly, alternative strategy. This article will review the data regarding the 2 available generations of the PCCE.
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Affiliation(s)
- Rami Eliakim
- Rappaport School of Medicine, Technion Israel Institute of Technology, Department of Medicine, Rambam Health Care Campus, Haifa, Israel.
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22
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Van Gossum A, Munoz-Navas M, Fernandez-Urien I, Carretero C, Gay G, Delvaux M, Lapalus MG, Ponchon T, Neuhaus H, Philipper M, Costamagna G, Riccioni ME, Spada C, Petruzziello L, Fraser C, Postgate A, Fitzpatrick A, Hagenmuller F, Keuchel M, Schoofs N, Devière J. Capsule endoscopy versus colonoscopy for the detection of polyps and cancer. N Engl J Med 2009; 361:264-70. [PMID: 19605831 DOI: 10.1056/nejmoa0806347] [Citation(s) in RCA: 264] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND An ingestible capsule consisting of an endoscope equipped with a video camera at both ends was designed to explore the colon. This study compared capsule endoscopy with optical colonoscopy for the detection of colorectal polyps and cancer. METHODS We performed a prospective, multicenter study comparing capsule endoscopy with optical colonoscopy (the standard for comparison) in a cohort of patients with known or suspected colonic disease for the detection of colorectal polyps or cancer. Patients underwent an adapted colon preparation, and colon cleanliness was graded from poor to excellent. We computed the sensitivity and specificity of capsule endoscopy for polyps, advanced adenoma, and cancer. RESULTS A total of 328 patients (mean age, 58.6 years) were included in the study. The capsule was excreted within 10 hours after ingestion and before the end of the lifetime of the battery in 92.8% of the patients. The sensitivity and specificity of capsule endoscopy for detecting polyps that were 6 mm in size or bigger were 64% (95% confidence interval [CI], 59 to 72) and 84% (95% CI, 81 to 87), respectively, and for detecting advanced adenoma, the sensitivity and specificity were 73% (95% CI, 61 to 83) and 79% (95% CI, 77 to 81), respectively. Of 19 cancers detected by colonoscopy, 14 were detected by capsule endoscopy (sensitivity, 74%; 95% CI, 52 to 88). For all lesions, the sensitivity of capsule endoscopy was higher in patients with good or excellent colon cleanliness than in those with fair or poor colon cleanliness. Mild-to-moderate adverse events were reported in 26 patients (7.9%) and were mostly related to the colon preparation. CONCLUSIONS The use of capsule endoscopy of the colon allows visualization of the colonic mucosa in most patients, but its sensitivity for detecting colonic lesions is low as compared with the use of optical colonoscopy. (ClinicalTrials.gov number, NCT00604162.)
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Affiliation(s)
- André Van Gossum
- Department of Gastroenterology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Hassan C, Di Giulio E, Pickhardt PJ, Zullo A, Laghi A, Kim DH, Iafrate F, Morini S. Cost effectiveness of colonoscopy, based on the appropriateness of an indication. Clin Gastroenterol Hepatol 2008; 6:1231-6. [PMID: 18995214 DOI: 10.1016/j.cgh.2008.06.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 06/05/2008] [Accepted: 06/11/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Determination of the appropriateness of an indication for colonoscopy has been advanced as a means to help rationalize the use of endoscopic resources. However, the efficacy and cost effectiveness of the current guidelines used to select patients for colonoscopy are largely unknown. The goal of this study was to assess the clinical and economic impact of American Society for Gastrointestinal Endoscopy and the European Panel on the appropriateness of Gastrointestinal Endoscopy appropriateness guidelines in selecting patients who are referred for colonoscopy, in relation to colorectal cancer (CRC) detection. METHODS A decision-analysis model was constructed to compare colonoscopy strategies for "appropriate" indications with those for which colonoscopy is deemed "inappropriate" or "generally not indicated." A 50% cancer upstaging was modeled to simulate cancer progression for patients not referred for colonoscopy. CRC prevalence was estimated using a pooled data analysis based on a systematic review of the literature. Costs of colonoscopy and cancer care were estimated from Medicare reimbursement data. The number of colonoscopies needed to detect one case of cancer and to prevent one cancer-related death and incremental cost-effectiveness ratios (ICER), according to appropriateness categories, were computed in a simulated population of patients that were 60 years of age and referred for colonoscopy. RESULTS The numbers of appropriate and inappropriate colonoscopies that needed to be performed to detect one patient with cancer were 18 and 93, respectively. Similarly, 115 and 617 colonoscopies would be needed, respectively, to prevent one CRC-related death. The ICER for appropriate and inappropriate colonoscopies, compared with a policy of not referring patients to colonoscopy, was $6154 and $31,807 per life-year gained, respectively. In a sensitivity analysis, only a reduction from the baseline value of 1.1% to 0.2% was associated with an ICER for inappropriate colonoscopy higher than $150,000. CONCLUSIONS Current guidelines regarding the appropriateness of colonoscopy are relatively inefficient in excluding a clinically meaningful CRC risk for patients in whom colonoscopy is generally not indicated, raising serious concerns about their applicability to clinical practice.
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Affiliation(s)
- Cesare Hassan
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
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Axon A. Is diagnostic and therapeutic endoscopy currently appropriate?: suggestions for improvement. Best Pract Res Clin Gastroenterol 2008; 22:959-70. [PMID: 18790441 DOI: 10.1016/j.bpg.2008.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Endoscopy is the driving force in gastroenterology today, and recent exciting advances in technology have extended its frontiers at an unprecedented rate. We have a wider range of diagnostic and therapeutic possibilities at our disposal with more detailed methods available to analyse what we see on our video screens. We can access the small bowel lumen with consistency and intra-abdominal operations have been performed through the mouth and anus so where are the current limitations of the procedure? In spite of these remarkable advances many challenges remain for both the endoscopist and for industry, they are mainly ones associated with human weakness. Endoscopy is an art, performed by individuals who require training and continued education and it is done to patients who are vulnerable, afraid and often seriously unwell. It is human aspects of endoscopy that require improvement. This chapter addresses the areas where endoscopy is falling short and suggests what can be done to improve practice. Changes are needed in management, information technology, education, team working, quality, patient comfort and safety. There also remain a number of areas where improved technology may be able to reduce human error.
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Affiliation(s)
- Anthony Axon
- Department of Gastroenterology, Room 234 D Floor Clarendon Wing, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK.
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25
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Eliakim R. The PillCam COLON capsule—A promising new tool for the detection of colonic pathologies. CURRENT COLORECTAL CANCER REPORTS 2008. [DOI: 10.1007/s11888-008-0002-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Park WG, Triadafilopoulos G. Colonoscopy appropriateness: education is important to identify the right patient, at the right time, for the right reason. Gastrointest Endosc 2008; 67:94-6. [PMID: 18155429 DOI: 10.1016/j.gie.2007.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 09/15/2007] [Indexed: 02/08/2023]
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Harris JK, Froehlich F, Wietlisbach V, Burnand B, Gonvers JJ, Vader JP. Factors associated with the technical performance of colonoscopy: An EPAGE Study. Dig Liver Dis 2007; 39:678-89. [PMID: 17434349 DOI: 10.1016/j.dld.2007.02.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 02/15/2007] [Accepted: 02/15/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Variations in colonoscopy practice exist, which may be related to healthcare quality. AIMS To determine factors associated with three performance indicators of colonoscopy: complete colonoscopy, adenomatous polyp diagnosis, and duration. PATIENTS Consecutive patients referred for colonoscopy from 21 centres in 11 countries. METHODS This prospective observational study used multiple variable regression analyses to identify determinants of the quality indicators. RESULTS Six thousand and four patients were included in the study. Patients from private, open-access centres (odds ratio: 3.17, 95% confidence interval: 1.87-5.38) were more likely to have a complete colonoscopy than patients from public, gatekeeper centres. Patients from centres where over 50% of the endoscopists were of senior rank were roughly twice as likely to have an adenoma diagnosed, and longer average withdrawal duration (odds ratio: 1.08, 95% confidence interval: 1.07-1.09) was associated with more frequent adenoma diagnoses. Patients who had difficulty during colonoscopy had longer durations to caecum (time ratio: 2.87, 95% confidence interval: 2.72-3.01) and withdrawal durations (time ratio: 1.26, 95% confidence interval: 1.18-1.33) than patients who had no difficulties. CONCLUSIONS Multiple factors have been identified as being associated with key quality indicators. The non-modifiable factors permit the identification of patients who may be at greater risk of not having quality colonoscopy, while changes to the modifiable factors may help improve the quality of colonoscopy.
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Affiliation(s)
- J K Harris
- Institute of Social & Preventive Medicine, University of Lausanne, Rue du Bugnon 17, CH-1005 Lausanne, Switzerland
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Harris JK, Froehlich F, Gonvers JJ, Wietlisbach V, Burnand B, Vader JP. The appropriateness of colonoscopy: a multi-center, international, observational study. Int J Qual Health Care 2007; 19:150-7. [PMID: 17347317 DOI: 10.1093/intqhc/mzm008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To examine the appropriateness and necessity of colonoscopy across Europe. DESIGN Prospective observational study. SETTING A total of 21 gastrointestinal centers from 11 countries. PARTICIPANTS Consecutive patients referred for colonoscopy at each center. INTERVENTION Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy. MAIN OUTCOME MEASURE Appropriateness of colonoscopy. RESULTS A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45-54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia [OR: 30.84, 95% CI: 19.79-48.06] or change in bowel habits [OR: 3.69, 95% CI: 2.74-4.96] were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain [OR: 0.64, 95% CI: 0.49-0.83] or chronic diarrhea [OR: 0.54, 95% CI: 0.40-0.75] were less likely to have an appropriate or necessary indication. CONCLUSIONS This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptoms.
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Affiliation(s)
- J K Harris
- Institute of Social and Preventive Medicine, University of Lausanne, Lausanne, Switzerland
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