Abstract
BackgroundGastroenterology Departments at hospitals within Australia receive thousands of General Practitioner (GP)-referral letters for gastrointestinal investigations every month. Many of these requests are for colonoscopy. This study aims to evaluate the performance of the current symptoms-based triage system compared to a novel risk score using objective markers.MethodsPatients with lower abdominal symptoms referred by their GPs and triaged by a Gastroenterology consultant to a colonoscopy consent clinic were recruited into the study. A risk assessment tool (RAT) was developed using objective data (clinical, demographic, pathology (stool test, FIT), standard blood tests and colonoscopy outcome). Colonoscopy and histology results were scored and then stratified as either significant bowel disease (SBD) or non-significant bowel disease (non-SBD).ResultsOf the 467 patients in our study, 45.1% were male, the mean age was 54.3 ± 13.8 years and mean BMI was 27.8 ± 6.2. Overall, 26% had SBD compared to 74% with non-SBD (42% of the cohort had a normal colonoscopy). Increasing severity of referral symptoms was related to a higher triage category, (rectal bleeding, P = 2.86*10-9; diarrhoea, P = 0.026; abdominal pain, P = 5.67*10-4). However, there was no significant difference in the prevalence of rectal bleeding (P = 0.991) or diarrhoea (P = 0.843) for SBD. Abdominal pain significantly reduced the risk of SBD (P = 0.0344, OR = 0.52, CI = 0.27-0.95). Conversely, the RAT had a very high specificity of 98% with PPV and NPV of SBD prediction, 74% and 77%, respectively. The RAT provided an odds ratio (OR) of 9.0, 95%CI 4.29-18.75, p = 2.32*10-11), higher than the FIT test (OR = 5.3, 95%CI 2.44-11.69, p = 4.88*10-6), blood score (OR = 2.8, 95%CI 1.72- 4.38, p = 1.47*10-5) or age (OR = 2.5, 95%CI 1.61-4.00, 5.12*10-5) independently. Notably, the ORs of these individual objective measures were higher than the current practice of symptoms-based triaging (OR = 1.4, 95%CI 0.88-2.11, p = 0.153).ConclusionsIt is critical that individuals with high risk of having SBD are triaged to the appropriate category with the shortest wait time. Here we provide evidence that a combination of blood markers, demographic markers and the FIT test have a higher diagnostic accuracy for SBD than FIT alone.
Highlights
Gastroenterology Departments at hospitals within Australia receive thousands of General Practitioner (GP)-referral letters for gastrointestinal investigations every month
Non-significant bowel disease (SBD) was classified as any adenomas < 10 mm, < 3 adenomas at procedure, hyperplastic polyps, or presence of no dysplasia/ low-grade dysplasia only, other e.g. non-specific focal inflammation related to the bowel preparation, normal colonoscopy
Examining the distribution of symptoms between patients with and without SBD, we found no significant difference between referral symptoms and assigned triage category
Summary
Gastroenterology Departments at hospitals within Australia receive thousands of General Practitioner (GP)-referral letters for gastrointestinal investigations every month. Many of these requests are for colonoscopy. One million Australians who turned 50, 55 and 65 between 1st January 2011 and 31st December 2014 were invited to participate in this programme [2, 3] Individuals in this programme who record a positive faecal immunochemical test (FIT) represent only a small fraction (4.3%) of colonoscopy services undertaken within Australia each year [4, 5]. The majority of colonoscopy services in Australia, including public and private healthcare sectors, are undertaken in the symptomatic population (subjects referred by primary care doctors with a range of symptoms referrable to the gastrointestinal tract) [6]. The increasing public and clinician awareness of both colorectal and upper gastrointestinal malignancies, together with the increasing prevalence of non-malignant (inflammatory bowel disease (IBD), gastro-oesophageal reflux disease), functional gastrointestinal disorders and surveillance colonoscopies has led to an enormous increase in the demand for gastrointestinal endoscopic services [4, 7]
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