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

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.

Overtesting and undertesting in primary care: a systematic review and meta-analysis

BACKGROUND

Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste.

OBJECTIVE

To identify overuse and underuse of diagnostic tests in primary care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care.

RESULTS

We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively.

CONCLUSIONS

There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy.

PROSPERO REGISTRATION NUMBER

CRD42016048832.

Appropriateness of endoscopic surveillance recommendations in organised colorectal cancer screening programmes based on the faecal immunochemical test

OBJECTIVES

To assess the appropriateness of recommendations for endoscopic surveillance in organised colorectal cancer (CRC) screening programmes based on the faecal immunochemical test (FIT).

DESIGN

74 Italian CRC screening programmes provided aggregated data on the recommendations given after FIT-positive colonoscopies in 2011 and 2013. Index colonoscopies were divided into negative/no adenoma and low- risk, intermediate-risk and high-risk adenomas. Postcolonoscopy recommendations included a return to screening (FIT after 2 years or 5 years), an endoscopic surveillance after 6 months or after 1 year, 3 years or 5 years, surgery or other. We assessed the deviation from the postcolonoscopy recommendations of the European Guidelines in 2011 and 2013 and the correlation between overuse of endoscopic surveillance in 2011 and the process indicators associated with the endoscopic workload in 2013.

RESULTS

49 704 postcolonoscopy recommendations were analysed. High-risk, intermediate-risk and low-risk adenomas, and no adenomas were reported in 5.9%, 19.3%, 15.3% and 51.5% of the cases, respectively. Endoscopic surveillance was inappropriately recommended in 67.4% and 7%, respectively, of cases with low-risk and no adenoma. Overall, 37% of all endoscopic surveillance recommendations were inappropriate (6696/17 860). Overuse of endoscopic surveillance was positively correlated with the extension of invitations (correlation coefficient (cc) 0.29; p value 0.03) and with compliance with post-FIT+ colonoscopy (cc 0.25; p value 0.05), while it was negatively correlated with total colonoscopy waiting times longer than 60 days (cc -0.26; p value 0.05).

CONCLUSIONS

In organised screening programmes, a high rate of inappropriate recommendations for patients with low risk or no adenomas occurs, affecting the demand for endoscopic surveillance by a third.

The experience of anxiety in colonoscopy outpatients: a mixed-method study

Colonoscopy is commonly used to investigate gastrointestinal symptoms such as pain or changes in bowel habits and may either induce patient anxiety or assist in patient reassurance. Currently, 2 studies investigating negative colonoscopy, reassurance, and anxiety came to conflicting conclusions on this issue. Furthermore, it is possible that differences in coping styles may influence patient anxiety. A mixed-methods study was conducted with 26 precolonoscopy and 24 postcolonoscopy patients to address the conflicting, limited literature regarding colonoscopy, coping, and anxiety. Participants completed postal surveys and interviews were conducted with 16 participants. There was no significant difference between pre- and postcolonoscopy groups on any anxiety measures; however, this was possibly because of individual differences. Significant positive correlations were found between maladaptive coping and state anxiety indicating that healthcare professionals should consider screening for maladaptive coping in patients needing invasive procedures. Neither problem- nor emotion-focused coping showed any significant relationship with state anxiety. Interviews revealed that clinicians and endoscopy nurses should be aware that some patients are not absorbing correct information about colonoscopy, specifically that they may be conscious or experience pain during the procedure. Because of this, clinicians should ensure that patients understand standard practice at their hospital. In addition, interview data suggested that more attention should be given to pain management as it currently may not be adequate during conscious sedation.

Development of a risk score to stratify symptomatic adults referred for colonoscopy

BACKGROUND AND AIM

With an increasing burden on overstretched colonoscopy services, a simple risk score for significant pathology in symptomatic patients may aid in the prioritization of patients.

METHODS

A derivative study of a risk score model for colonic neoplasia (colorectal carcinoma [CRC] and advanced adenoma) and CRC alone was conducted in symptomatic adults referred for an index colonoscopy. The accuracy of the final model was assessed by the area under the curve (AUC) of the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit statistic.

RESULTS

A total of 1013 subjects (mean age 59.9 ± 13.7 years, 52.3% females) from a multi-ethnic Asian background (Chinese 56%, Malay 20.4%, Indian 21.5%) were recruited. Colonic neoplasia and CRC were identified in 175 (17.3%) and 114 (11.3%) cases, respectively. Risk scores were assigned to individual factors identified in a logistic regression model of both demographic (age, gender, ethnicity, education level, smoking history, Aspirin use) and clinical symptoms (change in bowel habit, bloody stool, weight loss, appetite loss, lethargy). The risk score for each patient was the sum of their individual risk factors. The AUC of the risk score for colonic neoplasia and CRC was 0.76 (Hosmer-Lemeshow goodness-of-fit statistic of P = 0.745) and 0.83 (Hosmer-Lemeshow goodness-of-fit statistic of P = 0.982), respectively.

CONCLUSION

A simple risk score for colonic neoplasia and CRC may be able to prioritize colonoscopy referrals in symptomatic subjects from a multi-ethnic background. A further study to validate this scoring system is required.

Split-dose vs same-day reduced-volume polyethylene glycol electrolyte lavage solution for morning colonoscopy

AIM: To compare same-day whole-dose vs split-dose of 2-litre polyethylene glycol electrolyte lavage solution (PEG-ELS) plus bisacodyl for colon cleansing for morning colonoscopy.

METHODS: Consecutive adult patients undergoing morning colonoscopy were allocated into two groups i.e., same-day whole-dose or split-dose of 2-litre PEG-ELS. Investigators and endoscopists were blinded to the allocation. All patients completed a questionnaire that was designed by Aronchick and colleagues to assess the tolerability of the bowel preparation regime used. In addition, patients answered an ordinal five-value Likert scale question on comfort level during bowel preparation. Endoscopists graded the quality of bowel preparation using the Boston bowel preparation scale (BBPS). In addition, endoscopists gave an overall grading of the quality of bowel preparation. Cecal intubation time, withdrawal time, total colonoscopy time, adenoma detection rate and number of adenomas detected for each patient were recorded. Sample size was calculated using an online calculator for binary outcome non-inferiority trial. Analyses was based upon intent-to-treat. Significance was assumed at P-value < 0.05.

RESULTS: Data for 295 patients were analysed. Mean age was 62.0 ± 14.4 years old and consisted of 50.2 % male. There were 143 and 152 patients in the split-dose and whole-dose group, respectively. Split-dose was as good as whole-dose for quality of bowel preparation. The total BBPS score was as good in the split-dose group compared to the whole-dose group [6 (6-8) vs 6 (6-7), P = 0.038]. There was no difference in cecal intubation rate, cecal intubation time, withdrawal time, total colonoscopy time and adenoma detection rate. Median number of adenoma detected was marginally higher in the split-dose group [2 (1-3) vs 1 (1-2), P = 0.010]. Patients in the whole-dose group had more nausea (37.5% vs 25.2%, P = 0.023) and vomiting (16.4% vs 8.4%, P = 0.037), and were less likely to complete the bowel preparation (94.1% vs 99.3%, P = 0.020). Patients in the split-dose group were less likely to refuse the same bowel preparation regime (6.3% vs 13.8%, P = 0.033) and less likely to want to try another bowel preparation regime (53.8% vs 78.9%, P < 0.001).

CONCLUSION: Splitting reduced-volume PEG-ELS for morning colonoscopy is as effective as taking the whole dose on the same morning but is better tolerated and preferred by patients.

"It's a tube up your bottom; it makes people nervous": the experience of anxiety in initial colonoscopy patients

This study aimed to prospectively consider the effect of colonoscopy on patients' experiences of anxiety at 4 time points related to an initial colonoscopy, using a qualitative approach. The study involved a sample of 13 patients undergoing an initial colonoscopy at a public hospital and followed for 12 months. Four exploratory interviews were conducted with each participant: before the procedure, 1 week, 2 weeks, and 12 months after the procedure. Thematic analysis was conducted to summarize patients' responses. In these participants, colonoscopy was associated with stigma. The discussion of the procedure was perceived as stressful and embarrassing and led to anxiety. Irrational expectations regarding the procedure were also contributing to anxiety, as was a doctor-patient relationship based on unequal powers and lack of control. Before the procedure, fear of a serious diagnosis contributed to anxiety; however, postprocedure, an unclear or functional diagnosis also appeared to increase anxiety. Anticipating the preparation for the procedure was also reported as an important factor in preprocedure anxiety. A shift toward a biopsychosocial approach to healthcare, such as providing patients with a greater sense of control by participating in decision making, should be recommended as it may reduce anxiety.

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 patient satisfaction of an outpatient colonoscopy service in an asian tertiary care hospital

Aim. To evaluate patient satisfaction towards an outpatient colonoscopy service and analyze areas of dissatisfaction for potential improvement. Method. Consecutive patients attending the outpatient diagnostic colonoscopy service in University of Malaya Medical Centre between 1st February and 31th July 2010 were interviewed using a questionnaire modified from the modified Group Health Association of America-9 (mGHAA-9) questionnaire. Favorable/unfavorable responses to each question, contribution of each question to unfavorable responses, and effect of waiting times on favorable/unfavorable response rates were analyzed. Results. Interview was carried out on 426 patients (52.1% men). Mean age ± standard deviation was 61.3 ± 12.9 years old. Mean waiting times for colonoscopy appointment and on colonoscopy day were 3.8 ± 2.7 months and 1.1 ± 0.8 hours, respectively. The main factors that contributed to unfavorable responses were bowel preparation followed by waiting times for colonoscopy appointment and on colonoscopy day (32.3%, 27.5%, and 19.6%, resp.). Favorable responses diminished to undesirable levels when waiting times for colonoscopy appointment and on colonoscopy day exceeded 1 month and 1 hour, respectively. Conclusion. Bowel preparation and waiting times were main factors for patient dissatisfaction. Waiting times for colonoscopy appointment and on colonoscopy day should not exceed 1 month and 1 hour, respectively, to maintain acceptable levels of patient satisfaction.

Appointment waiting times and education level influence the quality of bowel preparation in adult patients undergoing colonoscopy

Background

Risk factors for poor bowel preparation are recognized to be independent of the type of bowel preparation method used. Patient and administrative factors influencing bowel preparation are known to vary in different healthcare systems.

Methods

A prospective, cross-sectional study of patients undergoing colonoscopy in an Asian tertiary centre was conducted to identify risk factors associated with poor bowel preparation, and to evaluate the impact of poor bowel preparation on technical performance and patient comfort.

Results

Data on 501 patients (mean age 60.1 ± 14.0 years old, 51.2% males, 60.9% with secondary education or higher) was available for analysis. Poor bowel preparation was present in 151 patients (30.1%). Lower education level (OR = 2.35, 95% CI = 1.54 - 3.60), colonoscopy appointment waiting time beyond 16 weeks (OR = 1.86, 95% CI = 1.04 - 3.37) and non-adherence to bowel preparation instructions (OR = 4.76, 95% CI = 3.00 - 7.55) were identified as independent risk factors for poor bowel preparation. Poor bowel preparation was associated with a lower cecal intubation rate (78.1% versus 98.3%, p < 0.001), prolonged total colonoscopy time (25.4 ± 12.6 minutes versus 16.7 ± 10.2 minutes, p < 0.001), and increased patient discomfort during colonoscopy (patient with moderate to severe abdominal discomfort 31.8% versus 3.2%, p < 0.001).

Conclusions

Education levels and appointment waiting times, in addition to non-adherence to bowel preparation instructions, increase the risk of poor bowel preparation in adult patients undergoing colonoscopy. The latter has a significant impact on colonoscopy performance and patient comfort.

The interface of primary and oncology specialty care: from symptoms to diagnosis

Symptomatic individuals presenting to their primary care providers may need further evaluation and/or testing to determine whether a cancer is present. A number of issues arise in determining who needs further testing, what tests are needed, which specialists need to be involved, and how the testing can be organized and supported within a specific health-care system within a timely, coordinated, and cost-efficient manner. This article explores the challenges in the interface of primary care providers and specialists, includes evidence from prior research, and proposes research opportunities to understand and improve this phase of care.

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.

Is diagnostic and therapeutic endoscopy currently appropriate?: suggestions for improvement

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.

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.

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.