Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study

Colonoscopy and Subsequent Risk of Parkinson's Disease

Background

Parkinson's disease (PD) is caused by the misfolding and aggregation of α-synuclein in neurons into toxic oligomers and fibrils that have prion-like properties allowing them to infect healthy neurons and to be transmitted to animal models of PD by injection or oral exposure. Given α-synuclein fibrils' potential transmission on the gut-brain axis, α-synuclein may be transmitted through colonoscopy procedures.

Objective

This study examines a possible association between colonoscopy and PD.

Methods

Longitudinal health insurance data of 250,000 individuals aged 50+ from 2004-2019 was analyzed. Cox proportional hazard and competing risk models with death as a competing event were estimated to calculate the risk of PD. Colonoscopy was categorized as never receiving colonoscopy, colorectal cancer (CRC) screening without or with biopsy, destruction or excision (BDE), and diagnostic colonoscopy without or with BDE.

Results

We identified 6,422 new cases of PD among 221,582 individuals. The Cox model revealed a significantly increased risk of PD for patients who ever had a diagnostic colonoscopy without or with BDE (HR = 1.31; 95% CI: [1.23-1.40]; HR = 1.32 [1.22-1.42]) after adjustment for age and sex. After controlling for covariates and death, persons who ever underwent CRC screening had a 40% reduced risk of PD (CRHR = 0.60 [0.54-0.67]), while persons who underwent diagnostic colonoscopy had a 20% reduced risk of PD (CRHR = 0.81 [0.75-0.88]).

Conclusions

Colonoscopy does not increase the risk of PD, after adjusting for death and covariates. Individuals who underwent only CRC screening had the lowest risk of PD, which may be a result of a more health-conscious lifestyle.

Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams

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.

European panel on the appropriateness of gastrointestinal endoscopy II guidelines help in selecting and prioritizing patients referred to colonoscopy--a quality control study

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.

The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures

OBJECTIVE

To summarize the findings of methodological studies on the RAND/University of California Los Angeles (RAND/UCLA) appropriateness method, which was developed to assess if variation in the use of surgical procedures is because of overuse and/or underuse.

STUDY DESIGN AND SETTING

A MEDLINE literature search was performed. Studies were included if they assessed the reliability or validity of the RAND/UCLA appropriateness method for a surgical procedure or the effect of altering panelist composition or eliminating in-person discussion between rating rounds. Information was abstracted on procedure, study design, and findings.

RESULTS

One thousand six hundred one titles were identified, and 37 met the inclusion criteria. The test-retest reliability is good to very good (kappa, 0.64-0.81) for total knee and hip joint replacement, coronary artery bypass grafting (CABG), and carotid endarterectomy (CEA). The interpanel reliability is moderate to very good (kappa, 0.52-0.83) for CABG and hysterectomy. Construct validity has been demonstrated by comparing the appropriateness method with guidelines and/or evidence-based approaches for endoscopy, colonoscopy, CABG, hysterectomy, and CEA. Predictive validity has been studied for cardiac revascularization, in which concordance with appropriateness classification is associated with better clinical outcomes.

CONCLUSION

Our findings support use of the appropriateness method to assess variation in the rates of the procedures studied by identifying overuse and underuse. Further methodological research should be conducted as appropriateness criteria are developed and implemented for a broader range of procedures.

Appropriateness of the indication for colonoscopy: is the endoscopist the 'gold standard'?

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.

Evaluation of French guidelines on the indications of colonoscopy: results of a regional practice survey

BACKGROUND AND AIMS

Compliance with guidelines on colonoscopic indications can improve colorectal cancer screening efficiency. We conducted a regional practice survey of gastroenterologists working in the public and private sectors in France, and compared the results with French national guidelines.

METHODS

Four consecutive yearly questionnaire-based practice surveys were conducted, and remedial measures were recommended on the basis of the results.

RESULTS

We analyzed 5128 colonoscopies carried out by 65 practitioners. Of these, 4266 (83.2%) conformed to contemporary guidelines, 391 (7.6%) did not conform, and 471 (9.2%) could not be classified, owing to a lack of information. Remedial measures led to a significant increase in the number of colonoscopies conforming to guidelines (p=0.037) and to a significant fall in the number of unclassified procedures (p=0.0018). The distribution of colonic lesions differed between procedures that did and did not conform to guidelines (2.4% versus 0.3% of colorectal cancers, 11.4% vs. 6.9% of advanced adenomas, and 17.5% vs. 14.6% of non-advanced adenomas; p<0.0001).

CONCLUSION

This longitudinal multicenter survey shows that national colonoscopy guidelines are largely respected in France and improve the detection of colonic neoplasia. Practices improved following implementation of remedial measures.

Appropriateness of outpatient gastrointestinal endoscopy in a non-academic hospital

AIM: To assess the appropriate use and the diagnostic yield of upper gastrointestinal endoscopy and colonoscopy in this subgroup of patients.

METHODS: In total, 789 consecutive outpatients referred for gastrointestinal (GI) endoscopy [381 for esophagogastroduodenoscopy (EGD) and 408 for colonoscopy] were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between appropriateness and the presence of relevant endoscopic findings.

RESULTS: The overall inappropriate rate was 13.3%. The indications for EGD and colonoscopy were, respectively, appropriate in 82.7% and 82.6% of the exams, uncertain in 5.8% and 2.4% and inappropriate in 11.5% and 15%. The diagnostic yield was significant higher for EGDs and colonoscopies judged appropriate and uncertain when compared with those considered inappropriate (EGD: 36.6% vs 36.4% vs 11.4%, P = 0.004; Colonoscopy: 24.3% vs 20.0% vs 3.3%, P = 0.001). Of the 25 malignant lesions detected, all but one was detected in exams judged appropriate or uncertain.

CONCLUSION: This study shows a good adherence to ASGE guidelines by the referring physicians and a significant increase of the diagnostic yield in appropriate examinations, namely in detecting neoplastic lesions. It underscores the importance that the appropriateness of the indication assumes in assuring high-quality GI endoscopic procedures.

Second look colonoscopy: indication and requirements

BACKGROUND

There are circumstances when a colonoscopy should be repeated after a short interval following the first endoscopic procedure which has not completely fulfilled its objective.

REVIEW OF THE LITERATURE

A second look colonoscopy is proposed when there remains a doubt about missed neoplastic lesions, either because the intestinal preparation was poor or because the video-endoscope did not achieved a complete course in the colon. The second look colonoscopy is also proposed at a short interval when it is suspected that the endoscopic removal of a single or of multiple neoplastic lesions was incomplete and that a complement of treatment is required. When the initial endoscopic procedure has completely fulfilled its objective, a second look colonoscopy can be proposed at longer intervals in surveillance programs. The intervals in surveillance after polypectomy are now adapted to the initial findings according to established guidelines. This also applies to the surveillance of incident focal cancer in patients suffering from a chronic inflammatory bowel disease.

CONCLUSION

Finally, in most developed countries, a priority is attributed to screening of colorectal cancer and focus is given on quality assurance of colonoscopy which is considered as the gold standard procedure in the secondary prevention of colorectal cancer.

Appropriateness of colonoscopy in a digestive endoscopy unit: a prospective study using ASGE guidelines

RATIONALE, AIMS AND OBJECTIVES

Appropriate indications for colonoscopy (C) are essential for a rational use of resources. The aim of this study is to evaluate the appropriateness of indication for C according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and to evaluate whether appropriate use was correlated with the diagnostic yield of C.

METHODS

We analysed 677 consecutive C performed over an 11-month period in a digestive endoscopy unit with an open access system.

RESULTS

The rate of 'generally indicated' C was 77% and 'generally not indicated' C was 18%. The rate of indication not listed in the ASGE guidelines was 5%. The percentage of generally not indicated C requested by gastroenterologists for outpatients was lower than that requested by primary care surgeons or doctors (9.5%, 29%, 25.3%, respectively). In 38 (7.3%) and in 111 (21.3%) of 520 patients with appropriate C, cancer and polyps larger than 5 mm were found, respectively. Twenty polyps greater than 5 mm were detected in 15 cases (12%) of 122 inappropriate C, with only one case of intramucosal carcinoma; four (12%) polyps measuring over 5 mm were found in C not listed in ASGE guidelines. No advanced stage cancer was detected in the inappropriate group and in C not listed in ASGE guidelines.

CONCLUSIONS

Our results showed the high rate of inappropriate procedures, according to ASGE guidelines, requested by surgeons, internists and primary care doctors for both outpatients and inpatients. The proportion of not indicated endoscopic procedures requested by gastroenterologists must be reduced through more carefully application of ASGE guidelines. Endoscopic findings were more stringent in appropriate C.

Cost effectiveness of colonoscopy, based on the appropriateness of an indication

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.

Significant colonic neoplasia prevalence and ASGE recommendations: is it time for a change?

GOALS AND BACKGROUND

To Evaluate the indications versus diagnostic yield of significant colonic neoplasia (SCN) in the open-access era and screening colonoscopy.

STUDY

During 6-year period, all procedural data were obtained from all consecutive patients who underwent colonoscopies. Indications were compared with American Society for Gastrointestinal Endoscopy guidelines.

RESULTS

In all 22,341 procedures were included in the study. Indications were divided into 3 groups: Screening (21.89% of the procedures), surveillance (17.60%) and symptoms/signs (60.51%). A total of 2867 patients (12.83%) had SCNs. Of these, 278 (7.00%) SCNs were found in the group less than 50 years of age and 2589 in the group over the age of 50 years (14.10%). SCN as per indication frequency was 12.69% in the symptom/sign group (subdivided to 7.24% and 14.01% in the under 50 and over 50, age groups, respectively); screening 13.37% (5.48% and 15.09%, respectively); surveillance 12.64% (8.48% and 13.19%, respectively). The indications leading to the highest SCN rate (over 25%) were: abnormal imaging, elevated carcinoembryonic antigen, and rectal pain.

CONCLUSIONS

Colonoscopy is a unique screening tool that can detect neoplastic lesions. SCN prevalence in our study was between 13% and 15% for all indications in patients above 50 years of age. This emphasizes performing a screening colonoscopy for the entire population over the age of 50 years, regardless of the indication. We feel that American Society for Gastrointestinal Endoscopy guidelines should be reassessed. The revised criteria should state that the primary indication, are all people over the age of 50 years, who should have a colonoscopy performed, unless otherwise contraindicated.

Education improves colonoscopy appropriateness

BACKGROUND

Appropriateness in GI endoscopy is critical to face the rising amount of demands. Education of physicians has been advocated to reduce the level of inappropriateness.

OBJECTIVE

Our purpose was to assess the effectiveness of an educational program in determining a reduction of inappropriate colonoscopies in an open access system.

DESIGN

Prospective study.

SETTING

A single endoscopy unit in Italy.

PATIENTS

A total of 495 consecutive outpatients referred to our endoscopy unit by family physicians for diagnostic colonoscopy before the educational course and 522 after its completion, for a total of 1017 patients.

MAIN OUTCOME MEASUREMENTS

Inappropriate colonoscopy reduction rates, cost savings, and reduction of waiting lists were evaluated.

RESULTS

With regard to inappropriate colonoscopies, the post-course group rate of inappropriateness was significantly lower than that of the pre-course group (P < or = .001). The economic savings for 1 year was estimated to be euro19,000. The reduction of the waiting list was about 15% of the original value.

CONCLUSIONS

Education has a high incidence in reducing inappropriate colonoscopies in an open-access system determining reduction of costs and waiting lists.

[Guidelines for the rational use of endoscopy to improve the detection of relevant lesions in an open-access endoscopy unit: a prospective study]

BACKGROUND AND OBJECTIVE

Almost 50% of gastrointestinal endoscopies performed in our Unit correspond to patients coming from primary care. Since resources are finite, adherence to appropriate indications for these procedures is essential. We prospectively assessed the appropriateness of gastrointestinal endoscopies referred from Primary Care according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria.

PATIENTS AND METHOD

From May to June 2005, all consecutive patients referred from Primary care to our unit for open-access endoscopy were included (478 colonoscopies and 264 gastroscopies). Appropriateness of each exploration was established according to the EPAGE criteria. In order to evaluate whether appropriateness of use correlated with the diagnostic yield of endoscopies, relevant endoscopic findings were recorded.

RESULTS

In 146 patients (20%), an endoscopy indication was not listed in the EPAGE guidelines or data were incomplete and they were not evaluated. In the remaining 596 patients, the indication of the procedure was considered appropriate in 401 (67%) patients (253 [69%], colonoscopies and 148 [65%], gastroscopies). The diagnostic yield was significantly higher for appropriate endoscopies (30% vs 7%, p < 0.001). Endoscopies were more appropriate in older patients and in non-foreigners.

CONCLUSIONS

The diagnostic yield of gastrointestinal endoscopies in patients coming from primary Care increases with the appropriateness of indications according to the EPAGE criteria. Since a noteworthy proportion of these patients' endoscopies are considered inappropriate, the implementation of validated guidelines for its appropriate use could improve this situation.

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

BACKGROUND

Open access endoscopy allows reference of patients for endoscopic procedures without prior gastrointestinal consultation, allowing the procedure to be more accessible. This practice is becoming increasingly widespread in the United States and other countries and has become commonplace in clinical practice in Israel. The objective of our study is to bring forward our experience with an open access referral system for colonoscopy and to measure the yield and safety of colonoscopy in this system.

METHODS

Between January 2001 and September 2003, 10,866 colonoscopies were performed. Patient's charts were reviewed for the following data: demographics, indication for endoscopy, endoscopic and histopathologic findings, and complications. The practice guidelines of the American Society for Gastrointestinal Endoscopy were used to assess appropriateness of colonoscopy.

RESULTS

3533 pathologic findings were found, in 2978 colonoscopies. 2336 polyps were removed, including 18% hyperplastic, 26% tubular adenomata, 13% villous adenomata, 11% tubulovillous adenomata. Advanced disease was found in 41% of pathologic findings, 11% were invasive cancer. Rate of colonoscopies "generally indicated" according to American Society for Gastrointestinal Endoscopy guidelines was 78% with a rate of colonoscopies "generally not indicated" of 22%. Colonoscopy was completed successfully to the cecum in 93% of patients. 0.08% had serious complications during or immediately after colonoscopy.

CONCLUSIONS

Our results suggest that open access colonoscopy is a reliable and safe method for screening average risk population. As colonoscopy is becoming the recommended screening model for colorectal cancer this attitude of performing screening in an open access system could both cut costs in the future and improve availability, in an aim to become common practice.

Appropriateness of colonoscopy: Diagnostic yield and safety in guidelines

AIM: To evaluate if the guidelines for the appro-priateness of performing colonoscopy by American Society for Gastrointestinal Endoscopy (AGSE) and Italian Society of Digestive Endoscopy (SIED) yield a good diagnostic efficacy and do not present risks of missing important colonic pathologies in an Italian population sample.

METHODS: A total of 1017 consecutive patients (560 men and 457 women; mean age 64.4 ± 16 years) referred to an open-access endoscopy unit for colonoscopy from July 2004 to May 2006 were evaluated according to ASGE and SIED guidelines for appropriateness of performing the procedure. Diagnostic yield was defined as the percentage of relevant colonic pathologies of the total number of colonoscopies performed.

RESULTS: About 85.2% patients underwent colono-scopy that was considered appropriate based on at least one ASGE or SIED criterion, while it was considered inappropriate for 14.8% of patients. The diagnostic yield of colonoscopy was significantly higher for appropriate colonoscopies (26.94% vs 10.6%, P < 0.001) than for inappropriate colonoscopies (5.3%). There was no missed colorectal cancer following the ASGE/SIED criteria.

CONCLUSION: ASGE/SIED guidelines have shown a good diagnostic yield and the rate of missing relevant colonic pathologies seems very low. Unfortunately, the percentage of inappropriate referrals for colonoscopy in an open-access endoscopy system is still high, despite the number of papers published on the issue and the definition of international guidelines. Further steps are required to update and standardize the guidelines to increase their diffusion and to promote educational programs for general practitioners.

The appropriateness of colonoscopy: a multi-center, international, observational study

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.

Appropriateness of colonoscopy using the ASGE guidelines: experience in a large Asian hospital

BACKGROUND

The is currently a heavy burden on endoscopy services worldwide and although guidelines for the appropriate use of esophagogastroduodenoscopy (EGD) have been well studied, there are few such studies with respect to colonoscopy and none for the Asia-Pacific region. This study aimed, firstly, to determine the 'appropriateness of colonoscopy' for procedures performed in the endoscopy unit of a large Asian hospital using the American Society of Gastrointestinal Endoscopy (ASGE) 2000 guidelines, and secondly, to determine predictive factors including 'appropriateness of colonoscopy' for positive findings and colorectal cancer (CRC).

METHODS

A prospective cross-sectional study was carried out on consecutive colonoscopies performed in the University of Malaya Medical Center. The unit has an open-access endoscopy policy for doctors who work in the hospital. Referrals were from endoscopists (gastroenterologists and surgeon-endoscopists), primary care physicians and other specialists. The indication of a procedure referral was recorded and judged 'appropriate' or 'inappropriate' using the ASGE criteria. The colonoscopic findings were recorded and classified as positive (endoscopies showing any pathology that had direct therapeutic or prognostic consequences) or negative findings (endoscopies showing no pathology or minor pathologies). Predictive factors for positive findings and CRC were determined using multivariate analysis.

RESULTS

Of 380 patients referred for colonoscopy, 220 (57.9%) were classified as appropriate according to the ASGE guidelines, and 49 (12.9%) as inappropriate. The remaining 111 patients (29.2%) presented with complaints and conditions that could not be categorized. The rate of appropriate referral was similar for all three categories of physician (endoscopists: 59.8%, primary care physicians: 48.1%, others: 51.1%). When referrals by endoscopists were substratified according to gastroenterologists and surgeon-endoscopists, the rate of appropriate referral among gastroenterologists (78.4%) was significantly higher than that of surgeon-endoscopists (56.1%) (P = 0.049), primary care physicians (P = 0.013) and 'others' (P = 0.009). The most common appropriate indications were unexplained Rectalbleeding (79 cases, 20.8%) followed by CRC surveillance (45 cases, 11.8%). The most common inappropriate indication was inappropriately timed colonic cancer surveillance (32 cases, 8.4%). Chronic constipation in 36 cases (9.5%) was the most common 'unlisted' indication. A positive colonoscopic finding was detected in 131 (34.5%) examinations and CRC was found in 36 patients (9.5%). Appropriateness of indication was not a predictive factor for positive findings or CRC and there was no difference in the proportion of cases with positive findings or CRC in the three 'appropriateness categories'. Multivariate analysis revealed that only Rectalbleeding and smoking were significant independent positive predictive factors for positive findings and CRC.

CONCLUSION

The appropriateness of colonoscopy was not high among the different sources of referrals except for the subgroup of 'gastroenterologist'. Furthermore, the rates of positive findings and CRC among the cases with appropriate, inappropriate and unlisted indications did not differ. The ASGE guidelines will need to be modified for Asia to be of practical use.

Appropriateness of indication and diagnostic yield of colonoscopy: first report based on the 2000 guidelines of the American Society for Gastrointestinal Endoscopy

AIM

To assess the appropriateness of referrals and to determine the diagnostic yield of colonoscopy according to the 2000 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE).

METHODS

A total of 736 consecutive patients (415 males, 321 females; mean age 43.6+/-16.6 years) undergoing colonoscopy during October 2001-March 2002 were prospectively enrolled in the study. The 2000 ASGE guidelines were used to assess the appropriateness of the indications for the procedure. Diagnostic yield was defined as the ratio between significant findings detected on colonoscopy and the total number of procedures performed for that indication.

RESULTS

The large majority (64%) of patients had colonoscopy for an indication that was considered "generally indicated", it was "generally not indicated" for 20%, and it was "not listed" for 16% in the guidelines. The diagnostic yield of colonoscopy was highest for the "generally indicated" (38%) followed by "not listed" (13%) and "generally not indicated" (5%) categories. In the multivariable analysis, the diagnostic yield was independently associated with the appropriateness of indication that was "generally indicated" (odds ratio=12.3) and referrals by gastroenterologist (odds ratio =1.9).

CONCLUSION

There is a high likelihood of inappropriate referrals for colonoscopy in an open-access endoscopy system. The diagnostic yield of the procedure is dependent on the appropriateness of indication and referring physician's specialty. Certain indications "not listed" in the guidelines have an intermediate diagnostic yield and further studies are required to evaluate whether they should be included in future revisions of the ASGE guidelines.

Do ASGE guidelines for the appropriate use of colonoscopy enhance the probability of finding relevant pathologies in an open access service?

BACKGROUND

This prospective study examined the appropriate use of colonoscopy in an open-access system with the American Society for Gastrointestinal Endoscopy guidelines and determined whether the American Society for Gastrointestinal Endoscopy guidelines were associated with relevant endoscopic findings.

METHODS

In a cohort of 2221 consecutive patients referred for colonoscopy, the proportion of patients who underwent colonoscopy for appropriate indications was prospectively assessed. The relationship between appropriateness and the presence of clinically relevant endoscopic diagnoses was assessed by calculating (1) the positive and negative likelihood ratio of the indications; and (2) the change in the probability of relevant endoscopic diagnoses in the presence of the American Society for Gastrointestinal Endoscopy criteria.

RESULTS

The rate for 'generally not indicated' colonoscopies was 37%. Relevant endoscopic diagnoses were present in 28.5% of cases with American Society for Gastrointestinal Endoscopy indications versus 20.1% of patients without appropriate indications. However, the risk of finding relevant diagnoses was significantly increased by American Society for Gastrointestinal Endoscopy criteria application (odds ratio (OR) 1.58; 99% CI 1.20-2.07; p<0.01). Furthermore, in both endoscopic situations (appropriate and not appropriate), the likelihood ratio, positive and negative, varied very little, suggesting a low predictivity for serious pathologies by the appropriate procedure.

CONCLUSIONS

The use of an appropriateness evaluation system makes it possible to increase the probability of finding relevant endoscopic diseases. However, the exclusive use of such a system for selecting patients to undergo colonoscopy involves a relatively high risk of colorectal neoplasms going undetected.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality assurance and gastrointestinal endoscopy: an audit of 500 colonoscopic procedures

The aim of this study was to assess the quality of colonoscopic procedures in our endoscopy unit with the goal of improving performance.

METHODS

We prospectively audited 500 consecutive colonoscopic procedures and assessed sixty-two process or outcome indicators for each procedure.

RESULTS

Most of the measured indicators were within standard limits: cecal intubation rate (92%), inadequate bowel preparations (24%), inappropriate procedures (9.7%), normal procedures (54%), yield for neoplasia (32%), morbidity (0.4%), and overall patient satisfaction (95.8%). Some indicators were outside standard limits suggesting our practices should be modified: endoscopy withdrawal time less than 6 minutes (78%), forceps removal of polyps (31%), resected polyps not recovered for pathological examination (12%), adenomas with villous elements (22%), patients unsatisfied because of time spent waiting for the procedure (19%), patients unsatisfied because of inadequate explanations (10%). There was no standard for a few indicators: patient discomfort (6.9%), diagnostic success (89%), therapeutic success (92%). Three new indicators were proposed: proportion of patients aged<50 years, number of normal colonoscopic procedures to perform to detect one advanced adenoma or cancer, and proportion of colonoscopic procedures causing discomfort. The diagnostic yield of colonoscopy was dependent on age, gender, indication and appropriateness of indication but not on the prescriber.

CONCLUSION

This audit allowed us to evaluate our endoscopic practices and to detect certain shortcomings and deviations from standards. It enabled us to change some of our practices with the goal of improving the quality of our colonoscopic procedures.

Évaluer la spécificité d’un centre hospitalo-universitaire

OBJECTIVE

The specificity of a University Hospital Centre is usually assessed from its teaching and research capacity. The EPAGE survey, an instrument used to help decision making available on the Internet, permitted us to compare the prescription of a routine exploration, gastrointestinal endoscopy, between the University Hospital Center in Clermont-Ferrand and the Hospital Centre in Moulins. The aim was to demonstrate the differences in daily practice between these two geographically close hospital centres and hence to underline the specificity of a University Hospital Centre that is not taken into account in the financing systems of such hospitals. Method The data collected were taken from the EPAGE trial, a prospective mutlicentre study that included 21 European and Canadian centres. Data was collected from the University Hospital centre in Clermont-Ferrand over two periods: from December 2000 to March 2001, then from December 2001 to February 2002, and from the Hospital Centre in Moulins, from December 2000 to the end of November 2001. For this Article, only the patients' characteristics, indications for gastrointestinal endoscopy and opportunity rate were analysed. Comparison of patients' categories from the 2 centres was conducted according to their DRG (diagnostic related group) (homogeneous patient group) classification, thus allowing calculation of the mean of the SIA (synthetic index of activity) points in the two centres.

RESULTS

221 cases of gastrointestinal endoscopy performed in the University Hospital centre and 292 in the Hospital Centre were included in the survey. No statistically significant difference was found in the reasons motivating a gastrointestinal endoscopy, with regard to the indications listed on the EPAGE website. There were 18% of unlisted indications in the University Hospital Centre versus 4.8% in the Hospital Centre (p<1.10-6). Using the DRG nomenclature, calculation of the mean SIA points at the University Hospital Centre per patient was of 1161 versus 1147: non significant deviation of 1.2% in favour of the University Hospital Centre.

DISCUSSION

- Conclusion The difference in reasons motivating a gastrointestinal endoscopy found between the two centres concerned rare, complex or innovating situations. This illustrates the role of a Regional Reference University Hospital Centre, an aspect clearly underestimated when measuring mixed cases according to the HPG. Study of the financing and/or information systems is warranted and might resolve the apparent underestimation of the current financing system.

Appropriateness of Colonoscopy in a Tertiary Referral Centre

The aim of this study was to determine the appropriateness of colonoscopy in relation to its diagnostic yield, with reference to the guidelines set by the American Society of Gastrointestinal Endoscopy (ASGE). A prospective 90-day audit was performed at Hospital Kualal Lumpur, which is a tertiary referral centre in Malaysia, to examine the appropriateness of colonoscopy by indication. During that time, 257 colonoscopies were performed in 244 patients. The predominant indications for colonoscopy were altered bowl habit (37%) and rectal bleeding (18%). Of the 257 colonoscopies, 216 (84%) were judged to be appropriate by ASGE guidelines. Only 43% of all colonoscopies had positive findings. Positive findings were found in 93% of cases judged appropriate compared with only 7% found in cases deemed inappropriate. There were statistically significant relationships between appropriateness and overall positive yield and between appropriateness and neoplastic findings (p < 0.05). Colonoscopy performed for appropriate indications yield more significant findings, this, we advocate the use of accepted guidelines to maintain or improve the standard colonoscopy services.

Diagnostic yield of open access colonoscopy according to appropriateness

BACKGROUND

Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. Evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this study was to assess the appropriate use of colonoscopy in an open-access system and to establish the yield of diagnostic information relevant to patient care.

METHODS

Overall, 1123 consecutive patients referred for open-access colonoscopy were prospectively enrolled in the study. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relationship between the appropriate use of colonoscopy and the presence of relevant endoscopic findings.

RESULTS

The rate of colonoscopies "generally not indicated" according to ASGE guidelines was 29% (39% for primary care physicians and 23% for specialists; p < 0.0001). A relevant endoscopic finding was detected in 338 examinations (35%). The diagnostic yield was significantly higher for "generally indicated" colonoscopies (43%) compared with "generally not indicated" procedures (16%) (p < 0.001).

CONCLUSIONS

Although the rate of inappropriate use of colonoscopy was high, open-access colonoscopy was effective in detecting neoplastic lesions. Because most of these were detected during examinations performed for appropriate indications, the appropriateness of the indication emerges as crucial to the cost-effectiveness of an open-access system.

Is the diagnostic yield of upper GI endoscopy improved by the use of explicit panel-based appropriateness criteria?

BACKGROUND

Increasing the appropriateness of use of upper gastrointestinal (GI) endoscopy is important to improve quality of care while at the same time containing costs. This study explored whether detailed explicit appropriateness criteria significantly improve the diagnostic yield of upper GI endoscopy.

METHODS

Consecutive patients referred for upper GI endoscopy at 6 centers (1 university hospital, 2 district hospitals, 3 gastroenterology practices) were prospectively included over a 6-month period. After controlling for disease presentation and patient characteristics, the relationship between the appropriateness of upper GI endoscopy, as assessed by explicit Swiss criteria developed by the RAND/UCLA panel method, and the presence of relevant endoscopic lesions was analyzed.

RESULTS

A total of 2088 patients (60% outpatients, 57% men) were included. Analysis was restricted to the 1681 patients referred for diagnostic upper GI endoscopy. Forty-six percent of upper GI endoscopies were judged to be appropriate, 15% uncertain, and 39% inappropriate by the explicit criteria. No cancer was found in upper GI endoscopies judged to be inappropriate. Upper GI endoscopies judged appropriate or uncertain yielded significantly more relevant lesions (60%) than did those judged to be inappropriate (37%; odds ratio 2.6: 95% CI [2.2, 3.2]). In multivariate analyses, the diagnostic yield of upper GI endoscopy was significantly influenced by appropriateness, patient gender and age, treatment setting, and symptoms.

CONCLUSIONS

Upper GI endoscopies performed for appropriate indications resulted in detecting significantly more clinically relevant lesions than did those performed for inappropriate indications. In addition, no upper GI endoscopy that resulted in a diagnosis of cancer was judged to be inappropriate. The use of such criteria improves patient selection for upper GI endoscopy and can thus contribute to efforts aimed at enhancing the quality and efficiency of care. (Gastrointest Endosc 2000;52:333-41).

The ASGE guidelines for the appropriate use of colonoscopy in an open access system

BACKGROUND

Appropriateness of indications is essential to the rational utilization of resources. The aim of this study was to evaluate the appropriate use of colonoscopy in an open access system and to assess whether the American Society for Gastrointestinal Endoscopy (ASGE) guidelines are useful in clinical practice.

METHODS

The indication for colonoscopy was assessed on 3000 consecutive examinations performed at 7 institutions.

RESULTS

The rate of colonoscopies "generally not indicated" according to the ASGE guidelines was 24.5% for outpatients and 15.5% for inpatients; the rates of examinations performed for an indication not listed in the ASGE guidelines were 12% and 20.1%, respectively. Generally not indicated colonoscopies were significantly less frequent for procedures requested by gastroenterologists or family physicians than those requested by other specialists, but were similar. Most generally not indicated examinations requested by gastroenterologists were for routine follow-up of patients with inflammatory bowel disease; when these patients were excluded, the rate of generally not indicated endoscopies requested by gastroenterologists was also lower than the corresponding rate for examinations requested by family physicians.

CONCLUSIONS

In Italy, the rate of colonoscopies performed for generally not indicated reasons is high, particularly among examinations not requested by a gastroenterologist. Many colonoscopies are performed for indications not listed in the ASGE guidelines.

Prediction of colonoscopic yield of neoplasia

OBJECTIVE

To identify criteria which may predict yield of neoplasia at colonoscopy.

PATIENTS AND METHODS

Clinicopathological characteristics of patients undergoing colonoscopy for either surveillance for neoplasia or investigation of colorectal symptoms were reviewed. Logistic regression was used to analyse risks for detection of adenoma and carcinoma.

RESULTS

A total of 493 consecutive colonoscopies was reviewed. In the surveillance group, risk for detection of adenoma was two-fold greater in the elderly (>65 years), in male patients and in those with a previous history of adenoma as opposed to carcinoma. In symptomatic patients, risk for detection of any neoplasm was three-fold greater in the elderly but was independent of gender and presence or absence of rectal bleeding.

CONCLUSION

These data support a case for prioritization of elderly patients for colonoscopy. The value of surveillance colonoscopy in preventing colorectal cancer appears greater in patients with a previous history of adenoma as opposed to carcinoma. Strict selection of patients with non-bleeding symptoms may result in a colonoscopic yield of neoplasia comparable to that in patients with rectal bleeding.