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Abstract
Background Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a high-quality screening program, especially in safety net systems with limited resources. We sought to assess colonoscopy quality and ensure appropriate surveillance in a network of safety net practices. Methods We identified age-eligible patients ages 50-75 within a Federally Qualified Health Center (FQHC) clinic system with evidence of colonoscopy in preceding 10 years. We performed chart reviews to assess key aspects of colonoscopy quality: bowel preparation quality, evidence of cecal intubation, cecal withdrawal time, and the adenoma detection rate. We then utilized established guidelines to assess and revise surveillance colonoscopy intervals, determine whether appropriate surveillance had taken place, and schedule overdue patients as appropriate. Results Of 26,394 age-eligible patients, a total of 3,970 patients had evidence of prior colonoscopy and 1,709 charts were selected and reviewed. Mean age was 57, 54% identified as women and 51% identified as Hispanic. Of 1709 colonoscopies reviewed, 77% had data on bowel preparation, and of those, 85% had adequate preparation quality. Cecal intubation was documented in 89% of procedures. Adequate cecal withdrawal time was documented in 59% of those with documented cecal intubation. Overall adenoma detection rate was 42%. Initial surveillance interval was clearly stated in 72% (n = 1238) of procedures. Of these, initial recommended intervals were too short in 24.5% (n = 304) and too long in 3.6% (n = 45). A total of 132 patients (10.7%) were overdue for appropriate surveillance and were referred for follow-up colonoscopy. Conclusions Overall, the quality of screening colonoscopy was high, but reporting was incomplete. We found fair adherence to evidence-based surveillance guidelines, with significant opportunities to extend surveillance intervals and improve adherence to best practices.
Highlights
Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a highquality screening program, especially in safety net systems with limited resources
In our initiative to understand and improve the quality of colonoscopy within our safety net system, we found overall documented colonoscopy quality to be high, but many data elements were incompletely reported
There were no consistent differences in colonoscopy quality by patient demographic groups, suggesting that the care delivered within this system was not increasing health disparities
Summary
Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a highquality screening program, especially in safety net systems with limited resources. Despite strong evidence supporting the value of screening and surveillance, colorectal cancer (CRC) remains the second leading cause of cancer death in the US [1] Vulnerable patients, including those served by safety net systems, are less likely to receive appropriate screening and surveillance and are at an increased risk of mortality [2,3,4]. High-quality colonoscopy is an important element of an effective colorectal cancer screening and surveillance program; access to high-quality colonoscopy may be especially challenging in safety net settings where many patients have limited or no health insurance In such settings, it is critical to ensure and document that patients are receiving high-quality surveillance at proper intervals, as inadequate surveillance can increase CRC incidence and mortality, while oversurveillance represents waste, and limits access to those who are appropriately due for testing. A high-quality colonoscopy ensures screening efficacy by detection and removal of neoplastic lesions [6]
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