Implementation of a Clinical Decision Support (CDS) Tool to Improve Compliance in Surveillance Colonoscopy

Abstract

Purpose: Noncompliance with guidelines for colonoscopy surveillance of adenomatous polyps is known to occur significantly in gastroenterology practice in North America. Means by which to improve this have been limited. We implemented an EMR clinical decision support tool, based upon guidelines for adenomatous polyp surveillance. Methods: Surveillance colonoscopy practice was evaluated in a large gastroenterology community practice in two stages. First, retrospective analysis was done to establish baseline of noncompliance with surveillance guidelines currently being practiced. The index colonoscopy pathology was reviewed to determine appropriate interval. Patients who underwent colonoscopy earlier than interval recommended by the 2012 USMTF guidelines was considered noncompliant with surveillance. Second part of the study was the prospective analysis of the implementation of a clinical recall tool for polyp surveillance intervals. The recall tool is a web-based application that requires the provider to input whether hyperplastic, adenomatous, or sessile polyps are found in addition to their size and number and then the tool determines the appropriate interval date. Compliance with USMTF guidelines for appropriate interval with and without recall tool was the primary endpoint of the study. Difference between groups was determined by a two-way Fishers exact test with p-value 0.05 determined as significant. Results: First, baseline surveillance compliance was determined by assessment of time from index colonoscopy report in 136 patients with colonoscopy for an indication of surveillance of adenomatous polyps. Colonoscopy intervals were deemed noncompliant in 20% (27/136) patients upon retrospective review. We then proceeded to prospectively evaluate the recall tool impact on compliance. 204 colonoscopies were evaluated in total prospectively. Noncompliance with surveillance guidelines occurred in 9% (7/79) cases that utilized the recall tool. In comparison, amongst the prospectively followed patients, when the gastroenterologist did not utilize the recall tool, noncompliance was 19% (24/125). Thus, the recall tool proved to significantly improve compliance p=0.0477. Amongst 6 gastroentererologists who had at least 5 scopes evaluated in both with and without the recall tool prospectively, 5/6 gastroenterologists had improved compliance with utilization of the recall tool. Conclusion: Compliance with guidelines for colorectal cancer surveillance can be improved by a CDS recall tool when used by a gastroenterologist in a community practice.