Achieving long-term compliance with colonoscopic surveillance guidelines for patients at increased risk of colorectal cancer in Australia

Surveillance colonoscopy findings in asymptomatic participants over 75 years of age

Background and Aim

Surveillance colonoscopy for colorectal cancer (CRC) is generally not recommended beyond 75 years of age. The study determined incidence and predictors of advanced adenoma and CRC in older individuals undergoing surveillance colonoscopy.

Methods

This was a retrospective cohort study of asymptomatic older participants (≥75 years), enrolled in a South Australian CRC surveillance program who underwent colonoscopy (2015-2020). Clinical records were extracted for demographics, personal or family history of CRC, comorbidities, polypharmacy, and colonoscopy findings. The associations between clinical variables and advanced adenoma or CRC at surveillance were assessed with multivariable Poisson regression analysis.

Results

Totally 698 surveillance colonoscopies were analyzed from 574 participants aged 75-91 years (55.6% male). The incidence of CRC was 1.6% (11/698), while 37.9% (260/698) of procedures had advanced adenoma detected. Previous CRC (incidence rate ratio [IRR] 5.9, 95% CI 1.5-22.5), age ≥85 years (IRR 5.8, 95% CI 1.6-20.1) and active smoking (IRR 4.9, 95% CI 1.0-24.4) were independently associated with CRC diagnosis, while advanced adenoma at immediately preceding colonoscopy (IRR 1.6, 95% CI 1.3-2.0) and polypharmacy (IRR 1.2, 95% CI 1.0-1.5) were associated with advanced adenoma at surveillance colonoscopy in asymptomatic older participants (≥75 years).

Conclusion

Advanced neoplasia was found in more than one third of the surveillance procedures completed in this cohort. Continuation of surveillance beyond age 75 yeasrs may be considered in participants who have previous CRC or are active smokers (provided they are fit to undergo colonoscopy). In other cases, such as past advanced adenoma only, the need for ongoing surveillance should be considered alongside participant preference and health status.

Patient attitudes towards changes in colorectal cancer surveillance: An application of the Health Belief Model

OBJECTIVE

This is to determine whether health beliefs regarding colorectal cancer (CRC) screening could predict discomfort with a change to CRC surveillance proposing regular faecal immunochemical tests (FIT) instead of colonoscopy.

METHODS

Eight hundred individuals enrolled in a South Australian colonoscopy surveillance programme were invited to complete a survey on surveillance preferences. Responses were analysed using binary logistic regression predicting discomfort with a hypothetical FIT-based surveillance change. Predictor variables included constructs based on the Health Belief Model: perceived threat of CRC, perceived confidence to complete FIT and colonoscopy (self-efficacy), perceived benefits from current surveillance and perceived barriers to FIT and colonoscopy.

RESULTS

A total of 408 participants (51%) returned the survey (complete data n = 303; mean age 62 years, 52% male). Most participants (72%) were uncomfortable with FIT-based surveillance reducing colonoscopy frequency. This attitude was predicted by a higher perceived threat of CRC (OR = 1.03 [95% CI 1.01-1.04]), higher colonoscopy self-efficacy (OR = 1.34 [95% CI 1.13-1.59]) and lower perceived barriers to colonoscopy (OR = 0.92 [95% CI 0.86-0.99]).

CONCLUSIONS

Health beliefs regarding colonoscopy and perceived threat of CRC may be important to consider when changing CRC surveillance protocols. If guideline changes were introduced, these factors should be addressed to provide patients reassurance concerning the efficacy of the alternative protocol.

Detection of advanced colorectal neoplasia and relative colonoscopy workloads using quantitative faecal immunochemical tests: an observational study exploring the effects of simultaneous adjustment of both sample number and test positivity threshold

OBJECTIVE

When screening for colorectal cancer (CRC) using quantitative faecal immunochemical tests (FIT), test parameters requiring consideration are the faecal haemoglobin concentration (f-Hb) positivity cut-off and the number of stools sampled. This observational study explored variation in f-Hb between samples and the relationship between sensitivity for advanced neoplasia (AN, cancer or advanced adenoma) and colonoscopy workload across a range of independently-adjusted parameter combinations.

DESIGN

Quantitative FIT data (OC-Sensor) were accessed from individuals undergoing personalised colonoscopic screening with an offer of 2-sample FIT in the intervening years. We estimated variation in f-Hb between samples in 12 710 completing 2-sample FIT, plus test positivity rates (colonoscopy workload) and sensitivity for AN according to parameter combinations in 4037 instances where FIT was done in the year preceding colonoscopy.

RESULTS

There was large within-subject variability between samples, with the ratio for the second to the first sample f-Hb ranging up to 18-fold for all cases, and up to 56-fold for AN cases. Sensitivity for AN was greatest at lower f-Hb cut-offs and/or using 2-sample FIT. Colonoscopy workload varied according to how parameters were combined. Using different cut-offs for 1-sample FIT and 2-sample FIT to return similar sensitivity, workload was less with 2-sample FIT when the sensitivity goal exceeded 35%.

CONCLUSION

Variation in f-Hb between samples is such that both parameters are crucial determinants of sensitivity and workload; independent adjustment of each should be considered. The 2-sample FIT approach is best for detecting advanced adenomas as well as CRC provided that the colonoscopy workload is feasible.

Uptake of a colorectal cancer screening blood test in people with elevated risk for cancer who cannot or will not complete a faecal occult blood test

Participation rates in colorectal cancer (CRC) screening programmes using faecal occult blood tests (FOBTs) are low. Nonparticipation is commonly attributed to psychosocial factors, but some medical conditions also prevent screening. These barriers might be partially overcome if a blood test for CRC screening was available. This study determined whether people who had always declined screening by FOBT would participate if offered a blood test. An audit of registrants within a personalized CRC screening programme was undertaken to determine the reasons for regular nonparticipation in FOBT. Consistent nonparticipants (n=240) were randomly selected and invited for CRC screening with a blood test. Demographic characteristics and the reasons for prior FOBT nonparticipation were collected by means of a questionnaire. Nonparticipation in the screening programme could be classified as either behavioural (8.6%), with consistent noncompliance, or due to medical contraindications (8.5%), which included chronic rectal bleeding, being deemed unsuitable by a health professional, and needing personal assistance. Blood test uptake was 25%, with participation in the medical contraindications group greater than that in the behavioural group (43 vs. 12%, P<0.001). Reported behavioural reasons for nonparticipation in faecal immunochemical test included procrastination and dislike of the test, but these were not associated with blood test uptake (P>0.05). There is a subgroup of the community who have medical reasons for nonparticipation in CRC screening with FOBT but will participate if offered a blood test. The option of a blood test does not, however, improve uptake in those who admit to behavioural reasons for noncompliance with screening.

Barriers and facilitators to implementing continuous quality improvement programs in colonoscopy services: a mixed methods systematic review

BACKGROUND AND AIM

Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients.

METHODS

We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process.

RESULTS

We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists' perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources.

CONCLUSION

Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.

Colorectal cancer screening

Colorectal cancer is one of the most common malignancies in Australia, and screening to detect it an earlier stage is cost-effective. Furthermore, detection and removal of precursor polyps can reduce incidence. Currently, there are limited data to determine the screening rate in Australia, but it is certainly lower than the 80% screening rate considered desirable. Whether colonoscopy is used as the screening test or to follow up positive results of an initial non-invasive test, it plays a fundamental role. Despite high sensitivity and specificity, it is expensive and invasive with measurable risk and is not acceptable as an initial test to many participants. It does not provide complete protection, and interval cancers between planned colonoscopies are associated with proximal location, origin in sessile serrated adenomas and operator-dependent factors. An essential component of colorectal screening is the measurement of colonoscopy quality indicators, such as caecal intubation and adenoma detection rates, which are known to be associated with the rate of interval cancer. The non-invasive screening test currently recommended in Australia is biennial testing for faecal occult blood between the ages of 50 and 75 using a faecal immunochemical test, with positives evaluated by colonoscopy. This is provided through the National Bowel Cancer Screening Programme, currently for those at the ages of 50, 55, 60 and 65 years, with full implementation of biennial screening by 2020. To improve screening in Australia, the most fruitful approach may be to acknowledge that there is a choice of screening tests and to focus on the goal of improving overall participation rate and being able to measure this.

Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study

OBJECTIVE

To determine adherence to recommended surveillance intervals in clinical practice.

DESIGN

2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ± 3 months of a 1-year recommended interval and ± 6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2-3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1-2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing.

RESULTS

Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4-5%, p<0.01).

CONCLUSIONS

There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.

A prediction model for colon cancer surveillance data

Dynamic prediction models make use of patient-specific longitudinal data to update individualized survival probability predictions based on current and past information. Colonoscopy (COL) and fecal occult blood test (FOBT) results were collected from two Australian surveillance studies on individuals characterized as high-risk based on a personal or family history of colorectal cancer. Motivated by a Poisson process, this paper proposes a generalized nonlinear model with a complementary log-log link as a dynamic prediction tool that produces individualized probabilities for the risk of developing advanced adenoma or colorectal cancer (AAC). This model allows predicted risk to depend on a patient's baseline characteristics and time-dependent covariates. Information on the dates and results of COLs and FOBTs were incorporated using time-dependent covariates that contributed to patient risk of AAC for a specified period following the test result. These covariates serve to update a person's risk as additional COL, and FOBT test information becomes available. Model selection was conducted systematically through the comparison of Akaike information criterion. Goodness-of-fit was assessed with the use of calibration plots to compare the predicted probability of event occurrence with the proportion of events observed. Abnormal COL results were found to significantly increase risk of AAC for 1 year following the test. Positive FOBTs were found to significantly increase the risk of AAC for 3 months following the result. The covariates that incorporated the updated test results were of greater significance and had a larger effect on risk than the baseline variables.

Ideal colonoscopic surveillance intervals to reduce incidence of advanced adenoma and colorectal cancer

BACKGROUND AND AIMS

There is limited information about the interplay between multiple risk factors contributing to the risk of advanced neoplasia. We determined the actual risk for advanced neoplasia in relation to lapsed time between colonoscopies in people enrolled in a structured surveillance program. This risk information can be used to guide the selection of optimal surveillance intervals.

METHODS

Patients were recruited into programs at two major tertiary hospitals, with a personal or family history of advanced neoplasia. Five thousand one hundred forty-one patients had an index and one or more surveillance colonoscopies. Fifty-one percent had a family history of colorectal neoplasia while the remainder had a personal history.

RESULTS

Patients with an immediately prior colonoscopy result (prior result) of advanced adenoma had a risk for advanced neoplasia 7.1 times greater than those with a normal prior result. Cancer as a prior result did not confer a greater risk than either a hyperplastic polyp or a nonadvanced adenoma. Being female reduced risk, age increased risk. Only a family history of a first-degree relative diagnosed under 55, or definite or suspected hereditary nonpolyposis colorectal cancer (HNPCC) conferred an increased risk over a personal history of advanced neoplasia.

CONCLUSIONS

Most family history categories did not confer excess risk above personal history of advanced neoplasia. A prior cancer poses less of a risk than a prior advanced adenoma. Based on our models, a person with an advanced adenoma should be scheduled for colonoscopy at 3 years, corresponding to a 15% risk of advanced neoplasia for a male aged under 56. Guidelines should be updated that uses a 15% risk as a benchmark for calculating surveillance intervals.

Guideline adherence for the treatment of advanced schistosomiasis japonica in Hubei, China

This study compared physicians’ practices on three treatment procedures and hospitalization days with guideline recommendations to assess guideline adherence in the treatment of advanced schistosomiasis japonica. Descriptive statistics were used to estimate patients’ characteristics and rate of guideline adherence. And chi-square tests were used to assess influences of severity of the disease on guideline adherence. The study found no one (0/173) adhered to adequate diagnosis, treatment regimens, and discharge criteria of guidelines completely. And 2.23 % of patients in group 1 and 4.23 % in group 2 were totally conforming to adequate diagnosis. 91.91 % of patients were conforming to adequate treatment regimens among which group 1 and group 2 were 90.32 and 92.25 %, respectively. And one (2.23 %) patient in group 1 and zero (0 %) in group 2 were conforming to discharge criteria of guidelines, and most of the patients left hospital without symptom checks (151/173), liver function and biochemical tests (169/173), and complication checks (91/173). Among 173 inpatients, rate of adequate hospitalization days was 36.42 % (63/173). And chi-square test suggested no significant difference (P > 0.05) on guideline adherence in two groups, which implied both of critical and general patients’ treatments should be stressed to comply with guidelines. There existed a large gap between guidelines and practices of the treatment of advanced schistosomiasis japonica.

Improving colonoscopy quality through health-care payment reform

Problems with the quality of colonoscopy are well recognized. Variation in colonoscopist performance is compounded by payment structures that reward volume rather than quality. Payment reform has emerged as one strategy to address these and more systemic problems in the quality of health care. Various forms of value-based purchasing might encourage a realignment of incentives, and allow reimbursement to be directly linked with clinically important goals of colonoscopy. This paper proposes criteria for the selection of quality measures, and three candidate indicators to define quality for the purpose of payment reform in colonoscopy: cecal intubation rate, adenoma detection rate, and recommended post-polypectomy surveillance interval. These measures represent valid, credible, and reliable indicators of the quality of colonoscopy for colorectal cancer screening and surveillance. Payment reform should explicitly link public reporting and performance on these quality measures to payment for colonoscopy.

Factors influencing long-term adherence to two previously implemented hospital guidelines

OBJECTIVE AND SETTING

After successful implementation, adherence to hospital guidelines should be sustained. Long-term adherence to two hospital guidelines was audited. The overall aim was to explore factors accounting for their long-term adherence or non-adherence.

DESIGN AND PARTICIPANTS

A fluid balance guideline (FBG) and body temperature guideline (BTG) were developed and implemented in our hospital in 2000. Long-term adherence was determined retrospectively based on data from patient files. Focus groups were launched to explore nurses' perceptions of barriers and facilitators regarding long-term adherence. The predominant themes from the nurses' focus groups were posed to clinicians in questionnaires.

RESULTS

Nurses involved in the FBG (overall adherence 100%) stated that adherence has immediate advantages in terms of safety and a gain in time. Nurses and oncologists acted unanimously which was thought to enhance adherence. On the other hand, opinions differed on the BTG within the nursing teams and medical staff (overall adherence 50%). Although the guideline discourages routine postoperative body temperature measurements, temperature should be measured according to the guideline in a considerable number of cases due to changes in patient characteristics since the year 2000. Therefore, adherence was judged to be rather complex.

CONCLUSIONS

To secure adherence to hospital guidelines after their successful implementation, guidelines should preferably be comprehensive in terms of being applicable to the majority of the patients in that particular setting and to the most common clinical situations. All healthcare professionals involved should be aware of its immediate benefits for themselves or to their patients.

Adherence to guidelines for surveillance colonoscopy in patients with ulcerative colitis at a Canadian quaternary care hospital

BACKGROUND

Patients with ulcerative colitis (UC) are at high risk of colonic dysplasia. Therefore, surveillance colonoscopy to detect early dysplasia has been endorsed by many professional organizations.

OBJECTIVES

To determine whether gastroenterologists at Hamilton Health Sciences (Hamilton, Ontario) adhere to recommendations for UC surveillance issued by the Canadian Association of Gastroenterology and to retrospectively assess the incidence and type of dysplasia found and the subsequent outcome of patients with dysplasia (ie, colorectal cancer [CRC], colectomy, dysplasia recurrence).

METHODS

A retrospective chart review of all patients with UC undergoing colonoscopy screening at Hamilton Health Sciences from January 1980 to January 2005, was performed. Patients were classified by the extent of colonic disease: limited left-sided colitis (LSC), pancolitis and any disease extent with concurrent primary sclerosing cholangitis.

RESULTS

A total of 141 patients fulfilled eligibility criteria. They underwent 921 endoscopies, including 453 for surveillance, which were performed by 20 endoscopists. Overall, screening was performed on 90% of patients, and surveillance at the appropriate time in 74%. There was a statistically significant increase in the mean number of biopsies per colonoscopy after the guidelines were published (P<0.01 for all categories). Colonic dysplasia was detected in 24 of 141 patients (17.0%), with 17 of 24 (70.8%) found at surveillance. Two patients (8.3%) had CRC successfully treated. The average age of patients with dysplasia was 56.1 years, with a mean disease duration of 10.9 years in LSC versus 11.8 years in pancolitis (P not significant). Colectomy was not recommended for any patient with flat dysplasia. No patients progressed to high-grade dysplasia or CRC. Patients with pancolitis had a higher incidence of neoplasia (21% [18 of 86]) than patients with LSC (12% [6 of 49]; P=0.24). Forty-one patients (29.5%) had at least one hyperplastic or inflammatory polyp.

CONCLUSIONS

For the majority of patients who underwent surveillance colonoscopies, their procedures were performed within the recommended time intervals, and biopsy compliance has improved. Dysplasia tended to arise after approximately 10 years of disease duration and in middle age, with flat dysplasia being rare. Interventions resulted in no dysplasia progressing to CRC, implying successful prevention.

Colorectal cancer screening tests: pros and cons, and for whom?

The past decade has seen major advances internationally in the implementation of colorectal cancer screening, influenced in differing ways by the profession, the public and by government. Relatively unique to colorectal cancer screening is the availability of so many test alternatives, which have substantial variation in methodology. While perhaps spoilt for choice, discerning the key advantages and disadvantages of each test is often difficult, depending on the perspective from which screening is viewed. Accordingly, this article provides an evaluation of screening tests as might be perceived by governments, the patient and the profession. Aligned issues such as choosing a screening test and provision of informed consent are discussed. Finally, the article identifies current problems with various screening tests that, if attended to, might change the perception of a test's value to a particular interest group.