Improving the Appropriateness of Direct Access Colonoscopy Referrals

Abstract

Introduction: The goal of this project is to improve the appropriateness of direct access colonoscopy referrals from the primary care practices at an urban academic hospital. In a direct access system, a primary care provider can refer a patient for a screening colonoscopy without a prior gastroenterology evaluation. In the system studied, an endoscopy nurse practitioner must screen each referred patient's age, screening interval, and co-morbidities before the exam can be scheduled. The specific aim of this project is to analyze the errors made in the ordering process and create an intervention to decrease the percentage of inappropriate orders for screening colonoscopies by 20% in one year. Methods: Prospective data was collected as direct access referrals were ordered by primary care physicians. We quantified the number of inappropriate referrals and characterized the most common reasons that referrals were ultimately deemed inappropriate. This data was used to create a novel electronic medical record (EMR) tool which includes all of the necessary criteria for ordering an appropriate screening colonoscopy and provides physicians with a pathway to follow for patients who do not fit the specified parameters. Internal medicine residents and attendings piloted this tool in primary care practice. Results: Initially, 19% of direct access colonoscopy orders from the primary care practices were labeled inappropriate. The most common reasons for orders being labeled inappropriate included: 1) high American Society of Anesthesiologists physical status 2) high risk anticoagulation and 3) incorrect age for screening colonoscopy. The first 44 uses of the novel EMR tool resulted in 0% inappropriate referrals. Utilization of the tool changed management in 27% of cases. Specifically, use of the tool decreased the number of symptomatic patients inappropriately referred for screening colonoscopies. Conclusion: This quality improvement project identified common errors in ordering screening colonoscopies and created a successful EMR tool to guide provider ordering. Decreasing inappropriate colonoscopy referrals improved patient safety by avoiding unnecessary procedures and facilitated access to needed diagnostic procedures. The next phase of this project is to extend this intervention to more primary care practices with the aim of further reducing inappropriate referrals.Figure 1