Evidence Of Colonoscopy Research Articles

Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center.

Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC. As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes. We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%). Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.

The Effect of Nomenclature Revision of Streptococcus bovis to Streptococcus gallolyticus on Subsequent Colon Cancer Screening.

BackgroundLack of awareness of the taxonomic revision from the familiar Streptococcus bovis to the less familiar Streptococcus gallolyticus may be associated with a decrease in recommended colon cancer screening in patients with bacteremia from this organism. This could subsequently lead to a delay in diagnosis or underdiagnosis of colon cancer and other serious underlying gastrointestinal diseases. The aim of this study was to determine whether the nomenclature change of S. bovis to S. gallolyticus resulted in decreased colon cancer screening.MethodsThis study was a retrospective, observational, nationwide analysis of patients who had positive blood cultures for S. bovis/S. gallolyticus from any Veterans Affairs Medical Center (VAMC) between January 1, 2002, and December 31, 2017.ResultsThere was no difference in the primary end point of intent for colonoscopy between the S. gallolyticus and S. bovis groups (66.5% [117/176] vs 62.1% [624/1005], respectively; P = .26). The overall mortality rate was 33.8% among 1181 patients included in the study, with a significantly lower mortality in patients with evidence of intent for colonoscopy (29.6% vs 42.5%; P ≤ .001), gastroenterology (GI) consultation (29.8% vs 41.4%; P < .001), infectious diseases (ID) consultation (29.4% vs 39.0%; P = .001), or either consultation (31.9% vs 40.7%; P = .013), compared to those that did not.ConclusionsThere was no difference in colon cancer screening rates between patients with episodes of bacteremia reported as S. bovis and those reported as S. gallolyticus. Overall mortality was lower in patients who had ID consultation, GI consultation, or evidence of colonoscopy.

Colonoscopy Quality and Adherence to Postpolypectomy Surveillance Guidelines in an Underinsured Clinic System.

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.

S0270 Repeat Endoscopies in Patients With Suboptimal Bowel Prep in a Safety Net Setting

INTRODUCTION: Colorectal cancer is the 3rd leading cause of death in the US. Colonoscopy is the most commonly used diagnostic tool in our arsenal and more than 15 million are performed annually in the US. In 2012, The US Multi-Society Task Force on Colorectal Cancer guidelines for the first time mentioned poor preparation and recommended repeat examination within 1 year in most cases of poor bowel preparation. METHODS: We performed a retrospective review of inpatient and outpatient electronic health records at Dell Seton Medical Center and CommUnityCare (CUC), a large safety net health care system in Austin, Texas to describe rates of inadequate bowel preparation. We identified 1709 eligible patients between ages 50 and 75 within the safety net system who had evidence of colonoscopy within the past 10 years. 204 of 1709 (12%) patients had suboptimal bowel prep, identified as fair or poor. Each chart was reviewed to determine what the recommended interval was for repeat testing was, whether it was performed, and whether any further intervention was necessary. RESULTS: Of the 204 patient who had suboptimal prep, 109 (53%) were deemed to be in need of a colonoscopy or fecal immunochemical test (FIT) as no follow-up was done.Those patients were classified into increased risk (personal or family history of CRC, adenomatous polyps or polyps with dysplasia or FIT positive) or average risk (no risk factors). Average risk patients were sent FIT test kits, while increased risk patients were contacted and scheduled for colonoscopies. Of the 109, 67 (61%) were deemed to need FIT testing, 24 (22%) were in need of colonoscopies now, 9 (8%) were in need of colonoscopies in the future, 6 (5%) patients were out of CUC system, and 3 (3%) were >75 years old and over age of recommended screening. Of the 41 patients overdue for colonoscopy that we were able to contact, 4 (0.1%) of those patients were found with cancer or high-grade dysplasia. CONCLUSION: Healthcare providers must be aware of patients with poor bowel prep, particularly in a safety net setting. Poorly prepared colons result in a longer cecal intubation time, a lower cecal intubation rate, higher adenoma miss rate (AMR), as well as increase in total costs to healthcare system. Therefore, gastroenterologists should develop a call back or a reminder system and should educate patients about need for repeat colonoscopies in those poor prep.Figure 1.: Schematic Representation of Follow-up for Patients with History of Poor Prep Colonoscopy.

Sa1135 Comparative Effectiveness of Initial Therapy for Ulcerative Proctitis in Real-World Clinical Practice: A Retrospective Study

Background: Ulcerative colitis is a common chronic inflammatory disease of the colon. In approximately 30% of patients, the disease is limited to the rectum as ulcerative proctitis (UP). While the principal medications used to treat UP have been studied extensively in randomized trials, their comparative effectiveness in real-world settings has been examined only in a few small head-to-head studies. This retrospective study examines the comparative effectiveness of oral 5-ASAs, mesalamine suppository (MS), and mesalamine enema (ME) as initial therapy for ulcerative proctitis. Methods: Using a large US integrated healthcare claims database, we identified all persons, aged ≥14 years, with evidence of newly diagnosed UP (ICD-9-CM 556.2, 556.3) between January 1, 2004 and December 31, 2008, based on: (1) ≥2 encounters with diagnoses of UP ≤90 days apart; (2) evidence of colonoscopy within 60 days of first encounter for UP (index visit); (3) evidence of receipt of either oral 5ASAs, MS, or ME as monotherapy on their index visit; and (4) no evidence of receipt of any pharmacotherapy for UP within 365 days preceding their index visit. Patients were followed for 365 days after their index visit for treatment of UP, especially evidence of treatment escalation (a proxy measure of the lack of effectiveness of initial therapy) and/or new encounters with diagnoses of more extensive disease (ICD-9-CM 556.X, excluding 556.2 and 556.3). We also examined total costs of pharmacotherapy for UP over this period. Results: We identified 548 patients with new onset UP who began monotherapy with oral 5-ASAs, MS, or ME. Mean (SD) age was 48 (16) years, and there were approximately equal numbers of men and women. Forty-five percent of patients were seen by a gastroenterologist at their index visit. At their index visit, 327 patients received MS as initial therapy; 138, an oral 5-ASA; and 83, ME. Men were more likely to have received oral 5-ASA as initial therapy than women. By day 90, 21% of patients receiving oral 5-ASAs as initial therapy had evidence of treatment escalation, compared with 9.5% of MS patients and 12% of ME patients; corresponding figures by day 365 were 34.1%, 20.8%, and 20.5%, respectively. By day 365, 9.8% of MS patients, 18.1% of ME patients, and 20.3% of oral 5-ASA patients had new encounters with evidence of more extensive disease. There were no differences in the mean numbers of emergency room visits or hospitalizations among the 3 groups. Mean total costs of pharmacotherapy for UP to day 365 in relation to initial therapy for UP were $526 for MS, $559 for ME, and $1251 for oral 5-ASAs. Summary & Conclusions: Our retrospective study confirms findings from the few existing head-to-head clinical trials that topical mesalamine (suppositories, enema) may yield better treatment outcomes than oral 5-ASAs as initial therapy for UP.