Recommended Follow-up Interval Research Articles

Frequency of colorectal surveillance colonoscopies for adenomatous polyps: systematic review and meta-analysis.

The purpose of this study was to assess evidence on the frequency of polyp surveillance colonoscopies performed earlier than the recommended follow-up intervals in clinical practice guidelines. A systematic review was performed based on electronic searches in PubMed and Embase. Research articles, letters to the editors, and review articles, published before April 2022, were included. Studies that focused on the intervals of polyp surveillance in adult populations were selected. The Risk Of Bias In Non-randomized Studies of Exposure (ROBINS-E) was used to assess the risk of bias. A meta-analysis was performed with Forest plots to illustrate the results. In total, 16 studies, comprising 11172 patients from Australia, Europe, and North America, were included for analysis. The quality of the studies was moderate. Overall, 38% (95% CI: 30-47%) of colonoscopies were undertaken earlier than their respective national clinical guidelines. In risk-stratified surveillance, 10 studies contained data relating to low-risk polyp surveillance intervals and 30% (95% CI: 29-31%) of colonoscopies were performed earlier than recommended. Eight studies contained data relating to intermediate-risk polyp surveillance and 15% (95% CI: 14-17%) of colonoscopies were performed earlier than recommended. One study showed that 6% (95% CI: 4-10%) of colonoscopies performed for high-risk polyp surveillance were performed earlier than recommended. A significant proportion of polyp surveillance was performed earlier than the guidelines suggested. This provides evidence of the potential overuse of healthcare resources and the opportunity to improve hospital efficiency.

Guideline adherent colposcopy completion following abnormal cervical cancer screening.

e17510 Background: Cervical cancer (CC) prevention relies upon timely management of abnormal screening results. Established recommended follow-up intervals for colposcopy after abnormal CC screening results exist for high-grade and low-grade abnormalities. Despite these guidelines, CC incidence is disproportionately higher in Black and Hispanic/Latino women in the US. Differential follow-up of abnormal screening results and delays in diagnosis may contribute to these disparities despite well-defined CC prevention measures. We investigated factors associated with guideline adherent colposcopy scheduling and attendance. Methods: Clinical and demographic medical record data was collected for patients with abnormal CC screening results from 2/2021 to 1/2022 at a large urban OB/GYN clinic in Connecticut. Timely colposcopy was defined as completion within 8 weeks from final CC screening result for high-grade abnormalities and 90 days for low-grade abnormalities. Clinical and demographic characteristics of patients needing colposcopy were examined. Association between these factors and completion of guideline adherent colposcopy was evaluated using univariate and multivariate regression. Colposcopy scheduling and attendance outcomes were compared by Pap grade using univariate regression and the Mann Whitney U test. Results: Overall, most of the 248 patients needing colposcopy identified as Black or Hispanic, spoke English, were publicly insured, had a low-grade Pap abnormality, and never smoked; half had received at least one dose of HPV vaccine. Among them, 215 (87%) received colposcopy ever and 190 (77%) received colposcopy within the guideline recommend interval. Race/ethnicity, preferred language, insurance status, pap grade, and smoking status were not significantly associated with receipt of timely colposcopy. In multivariate analysis only pregnancy was significantly associated with colposcopy receipt within the guideline recommended interval (RR=1.37, 95% CI: 1.11–1.69, p=0.004). There was no difference in receipt of colposcopy by pap grade. Scheduling of an initial colposcopy appointment was significantly lower among women with low-grade vs. high-grade CC screening abnormalities (94% vs. 100%, RR=1.03, 95% CI: 1.01–1.04, p<0.001). Patients with low-grade vs. high-grade abnormalities experienced similar numbers of no shows or cancellations for colposcopy appointments, with a maximum of 4 no shows or cancellations in each group. Conclusions: Evaluation of abnormal CC screening with colposcopy within guideline adherent time intervals can reduce diagnostic delays. Except for pregnancy, when there is increased interaction with healthcare, no other factors were associated with timely receipt of colposcopy. Further research on factors associated with receipt of colposcopy can contribute to implementation strategies to improve rates of timely follow-up for CC prevention.

Patient Personality and Illness Perceptions in Relation to Follow-Up Appointment Adherence in Neuro-Ophthalmology.

Improving patient attendance at medical follow-up visits may have a notable impact on disease and overall health outcomes. Understanding factors contributing to poor attendance is important for identifying at-risk patients and designing interventions to improve clinical outcomes. Our objective was to identify personality and illness perception factors associated with attendance at recommended follow-up visits in a neuro-ophthalmology practice. New or established patients (≥18 years) with scheduled neuro-ophthalmology (study) or glaucoma (comparison) appointments at a tertiary care academic medical center completed the Brief Illness Perception Questionnaire and Ten-Item Personality Inventory. Physician recommendations made during the visit were recorded (medications, referrals, follow-up, testing, and procedures). A chart review was performed 18 months after enrollment to assess attendance at follow-up appointment and adherence with other physician recommendations. Multiple variable logistic regression models studied associations between follow-up appointment attendance and demographic factors, appointment factors, and survey responses. Among 152 respondents (97% response rate (152 of 157), aged 19-97 years, 58% female, 34% new, 80 neuro-ophthalmology, 72 glaucoma), neuro-ophthalmology subjects were younger, more likely to be White, non-Hispanic, female and new to the practice than subjects with glaucoma. They reported higher emotional impact, identity, and consequences related to their illness (P = 0.001-0.03). Neuro-ophthalmology physician recommendations included more referrals to other services (17.5% vs 1.4%, P = 0.001, chi-square) and more radiology studies (15% vs 0%, P = 0.001, chi-square), but fewer follow-up visits (75% vs 97%, P < 0.0005, chi-square). Among those with recommended follow-up visits, neuro-ophthalmology subjects had lower rates of on-time appointment attendance (55% vs 77%, P = 0.009, chi-square). In a multiple variable model, on-time follow-up attendance was associated with shorter recommended follow-up interval (≤90 days, P < 0.0005), established (vs new) patient status at enrollment visit (P = 0.04), and glaucoma (P = 0.08), but not subject demographics, illness perception, or personality factors. Patient demographics, illness perception, and personality traits were not associated with follow-up appointment attendance and therefore unlikely to be useful for identifying patients at risk of being lost to follow-up. New neuro-ophthalmology patients with a follow-up recommended ≥90 days in advance may benefit from targeted interventions to improve follow-up appointment adherence.

Lost but not missing: factors associated with loss of follow-up in a paediatric cardiology clinic.

Loss of follow-up is a barrier to providing adequate care to paediatric cardiac patients. The purpose of this study was to determine variables associated with loss of appropriate paediatric cardiology follow-up, including potentially modifiable factors. We hypothesised having earlier recommend follow-up intervals was associated with less likelihood of loss of follow-up. We performed a retrospective cohort study of patients >5 years old seen in a large, outpatient paediatric practice from 2013 to 2016. Subjects were considered to be lost to follow-up if they did not have a subsequent outpatient encounter by 6 months after their recommend follow-up time interval. Of the 8940 eligible patients, 45.9% were lost to follow-up. Recommended follow-up interval of 1 year was associated with less loss of follow-up (41.4%) as compared to 2-year intervals (51.6%) and 3 years (55.7%) (p < 0.001 for both). Other significant predictors of loss of follow-up included less severe heart disease, older age, and non-Hispanic Black race/ethnicity. Sex and payor type were not significant predictors. In the stratified analyses by severity of disease and age, longer recommended follow-up time was associated with greater loss of follow-up among all severity and age categories. Almost half of the patients in our cohort did not return to clinic within the recommended timeline. Shorter follow-up time was associated with less loss of follow-up among all categories of disease severity and age groups. Recommending shorter follow-up intervals may be one initiative for paediatric cardiologists to improve rates of follow-up.

FOLLOW-UP ADHERENCE IN PATIENTS WITH NONPROLIFERATIVE DIABETIC RETINOPATHY PRESENTING TO AN OPHTHALMIC EMERGENCY DEPARTMENT.

To determine the rate of follow-up after emergent encounters for nonproliferative diabetic retinopathy and to identify patient or visit characteristics associated with follow-up adherence. A retrospective cohort study of patients presenting to an ophthalmic emergency department with nonproliferative diabetic retinopathy between May 2014 and December 2018 was conducted. Demographic and encounter data were gathered. Adherence to follow-up was defined as a completed encounter within 5 weeks of the recommended follow-up. A total of 1,248 patients were included. The overall follow-up rate was 53%. Significantly decreased odds of follow-up adherence were associated with longer physician recommended follow-up intervals (odds ratio: 0.81, P < 0.001), longer interval to scheduled appointment (OR: 0.98, P < 0.001), commercial insurance (OR: 0.76, P = 0.01), and lack of any insurance (OR: 0.57, P < 0.01). Significantly increased odds were associated with a longer emergency department visit duration (OR: 1.002, P = 0.001), farther home distance (1.02, P < 0.01), increased likelihood of living in a higher income area (OR: 1.07, P = 0.04), greater NPDR severity (OR: 1.23, P < 0.01), Medicare (OR: 1.38, P = 0.04), presence of macular edema (OR: 1.66, P < 0.001), and worse vision (OR: 1.73, P < 0.001). Patients presenting emergently with non-proliferative diabetic retinopathy are at high risk for follow-up nonadherence. Several patient and encounter characteristics were associated with follow-up adherence.

S1223 Automated Endoscopy Template Improves Provider Adherence to Esophageal Varices Surveillance Guidelines

INTRODUCTION: Esophageal variceal (EV) hemorrhage is a significant cause of morbidity and mortality in patients with cirrhosis. Though timely endoscopic follow-up for EV surveillance improves outcomes, there remains significant practice variation regarding recommended follow-up interval after variceal detection on esophagogastroduodenoscopy (EGD). In this quality improvement study, we aimed to improve adherence to EV surveillance recommendations per American Association for the Study of Liver Diseases (AASLD) and American Society for Gastrointestinal Endoscopy (ASGE) by implementing prescriptive templates in an endoscopy reporting software. METHODS: A pre-post study was conducted at a single academic center between 1/2018 and 3/2020. Interventions included (1) surveying faculty/fellows to identify barriers of knowledge/adherence to guidelines, (2) disseminating uniform follow-up recommendations derived from AASLD/ASGE best practices, and (3) developing an automated prescriptive template in PENTAX endoPRO software to standardize procedural documentation and follow-up recommendations. Outcomes included adherence to standardized follow-up recommendations of (1) ≤2 years for small varices, (2) ≤3 months for medium/large varices or endoscopic variceal ligation (EVL), or (3) initiation of a non-selective beta blocker. RESULTS: Among 2,363 EGDs performed prior to the intervention in 2018, EV were noted on 218 EGDs with the majority (54%) without documentation of EV size. Of the 127 EGDs with documented EV size and/or EVL, only 63% provided guideline-based follow-up recommendations. On the pre-intervention survey (n = 24), suboptimal adherence was due to variability in provider practices with regards to follow-up intervals due to conflicting guidelines and low satisfaction rate (19%) with the current endoscopy reporting template. Development of an automated template to standardize guideline-based follow-up was implemented on 6/2019. After template implementation, the rate of adherence to guideline-based recommendations improved quarterly from a baseline of 69% to 74%, 80%, and 94%, respectively (Figure 1). CONCLUSION: Suboptimal adherence to recommended guidelines for EV-related care was due to variability in provider practices based on differing recommendations between societal guidelines and inadequate documentation of variceal size. Our intervention utilizing standardized automated prescriptive templates in endoPRO led to improved overall adherence to guideline-based EV surveillance recommendations.Figure 1.: Compliance Rate of Esophageal Varices Surveillance Recommendations.

Mo1678 EVALUATING RECOMMENDATIONS FOR SURVEILLANCE FOR PATIENTS WITH LOW RISK ADENOMAS

Significance: Current practice guidelines recommend surveillance colonoscopies among patients with adenomas removed and intervals vary based on polyp classification. High risk adenomas (HRAs) (≥1 cm, villous features, or high-grade dysplasia) are most likely to progress to cancer and have a recommended 3-year follow-up whereas low risk adenomas (LRAs) (1-2 tubular adenomas ≤1 cm), have a recommended surveillance interval of 5-10 years. Over-performance of surveillance colonoscopies in patients with LRAs increases medical risk and carries significant societal cost. This study examined surveillance recommendations in practice for low risk adenomas. A retrospective chart review in an academic health system of 284 participants [median age: 57.4 (41.6-75.2); 54.6% female] with 1-2 tubular adenomas ≤1 centimeter on index colonoscopy, and a completed surveillance colonoscopy, was performed. Data were collected from exams between January 2011-June 2019. Exclusion criteria included family history of colon cancer, or personal history of polyps, inflammatory bowel disease, adenomas, or colon cancer. The recommended follow-up interval at index colonoscopy and surveillance colonoscopy findings were abstracted. Almost half of participants were recommended to follow up in 5 years (43.3%, n=123). Other recommendations were: 3 years (18.7%), “await pathology results” (19.0%), 5-10 years (8.5%), 3-5 years depending on pathology (3.5%), <3 years (3.2%), 3-5 years (1.4%), 10 years (0.7%), and other (1.8%). The median duration (months) between colonoscopies was 60.07 (12.19 – 88.07). On surveillance, number of LRAs discovered varied: zero (52.1%), one (25.0%), two (12.3%), three (4.6%), four (3.2%), five (0.7%), six or more (1.4%), and uncertain (0.7%). Fifteen participants (5.3%) had one HRA and one (0.4%) had two. No colorectal cancer was detected. Variables significantly associated (p<0.05) with adenomas on surveillance exam included older age, recommendation for follow up after index exam, and worse surveillance exam Boston Bowel Preparation Score (BBPS). Variables with no significant association included sex, race, ethnicity, index exam BBPS, quantity of LRAs and hyperplastic polyps on index exam, LRA size, duration of time between index and surveillance exams, diabetes, smoking history, and body mass index. The majority of participants with LRAs at baseline did not develop HRAs between colonoscopies, supporting a longer surveillance interval. No participants developed colon cancer. Although the current recommended interval is 5-10 years, <10% had a surveillance recommendation of 10 years. Many were told to follow up before 5 years. The findings support the current guidelines of performing a surveillance exam after 5-10 years and suggest that there is low risk in waiting to perform a surveillance exam until closer to the 10 year mark.

Evidence-Based Follow-up for Adults With Cancer.

The objectives of follow-up care for cancer patients include psycho- social assistance and the detection of health problems. The concept of follow-up care rests on the assumption that the early detection of cancer recurrences and disease- or treatment-related complications is beneficial to patients. In this article, we provide an overview of the scientific evidence supporting current recommen- dations for the follow-up care of patients with colorectal cancer, lung cancer, and lymphoma. This review is based on pertinent publications that were retrieved by a selective search in PubMed, supplemented by the authors' own experience in patient care and guideline creation. As recurrences usually arise soon after initial treatment, the recommended follow-up interval is shorter in the first two years (3-6 months) and longer thereafter (6-12 months). The question of which particular follow-up studies should be per- formed has only been systematically analyzed in a few cases. For patients with colorectal cancer, colonoscopy is the most important study. Intensive follow-up care is associated with a statistically non-significant increase in the survival rate compared to minimal follow-up care (77.5% versus 75.8%). Intensive diagnostic follow-up studies have been found to lead to a doubling of the frequency of operations for recurrence with curative intent, yet without any effect on the average survival time. The findings in lung cancer are similar. However, after tumor resection with curative intent, regularly repeated CT scanning leads to a survival advantage. In lymphoma patients, the longer the interval from primary treatment, the greater the likelihood of treatment-related secondary illnesses. It is not yet known how follow-up care should be provided to these patients in order to help them best. The evidence supporting the efficacy of currently recommended modalities of follow-up care for cancer patients is weak. Until more data from clinical studies become available, the current guidelines should be followed.

Towards evidence-based follow-up intervals for breast cancer survivors: Estimates of the preclinical detectable phase of contralateral second breast cancer

PurposeFollow-up schemes in breast cancer survivors are predominantly consensus-based. To determine evidence-based follow-up intervals, estimates of sensitivity of the screening test(s) and duration of the preclinical detectable phase (PCDP) are key. We estimated the sensitivity and the duration of the PCDP of clinical breast examination (CBE) and mammography for the detection of contralateral second breast cancers (CBC) in breast cancer survivors. MethodsWomen with a CBC (N = 589) diagnosed in Florence between 1980 and 2005 were included. Test sensitivity and the duration of PCDP were estimated using a simple exponential model of PCDP duration. Analyses were stratified by follow-up period (0–5 vs. >5 years after primary diagnosis) and age at CBC diagnosis (<50 vs. ≥50 years). ResultsFor CBE, test sensitivity was 55% and the duration of the PCDP 16 months. Mammography sensitivity was 91% and duration of the PCDP 35 months. Stratified analyses showed a higher test sensitivity for CBE for women aged <50 (70% vs. 51%). No difference in the duration of PCDP of CBE was found. For mammography, test sensitivity and the duration of the PCDP were higher for women with longer follow-up and in older women. ConclusionsPoor test sensitivity for CBE with a shorter duration of the PCDP compared with mammography were observed. Mammography had high test sensitivity and the potential to detect CBCs early. The estimated duration of the PCDP (35 months) was considerably longer than the recommended follow-up interval (12 months). Future studies are needed to determine whether a longer follow-up interval is appropriate.

Management Strategies of Pulmonary Ground Galss Nodule

肺部磨玻璃结节（ground glass nodule, GGN）是一种影像学表现，可能是肺部恶性肿瘤或良性病变。目前对于肺部磨玻璃结节的诊疗仍存在争议。2017年Fleischner协会和美国国立综合癌症网络（National Comprehensive Cancer Network, NCCN）都更新了GGN诊疗的指南，与之前的版本相比，手术或活检的指征更严，随访的间隔时间更长。临床工作中，GGN的大小、实性成分大小、动态随访变化和CT值都是判断手术介入时机的因素。GGN的诊疗中还存在一些误区：抗生素的使用、正电子发射型计算机断层显像（positron emission tomographycomputed tomography, PET-CT）检查、贴近胸膜的纯GGN和进入GGN的血管都是值得注意的问题。总之，GGN是一种发展缓慢的病灶，可以安全地进行随访。

Disease progression and variation in clinical practice for isolated bicuspid aortic valve in children.

Disease progression of an isolated bicuspid aortic valve (BAV) in children is poorly understood and adult management guidelines may not be applicable. Thus, we sought to evaluate disease progression of pediatric isolated BAV and its relationship to current management practices. Children with a BAV and ≤mild aortic stenosis (AS) and/or aortic regurgitation (AR) at the time of initial evaluation were included in this retrospective cohort study (1/2005-12/2014). Outcomes included change in z-scores for aortic root and ascending aorta diameters, cardiac interventions, adverse outcomes, recommended follow-up interval, and frequency of cardiac imaging studies at each follow up evaluation, as well as AS/AR severity at final evaluation. Outcomes were analyzed using generalized mixed-effect models with subject and provider clustering. BAV disease progression was evaluated in 294 subjects over 4.1 ± 2.4 (range 0.2-9.5) years. Ascending aorta z-scores increased by 0.1/year (P < .001) but aortic root diameter z-scores were unchanged. AS and/or AR progressed to >mild in 9 (3%), 1 subject underwent cardiac intervention, and none had a major complication. Management was evaluated in 454 subjects (1343 encounters) with 27 different cardiologists. The average recommended follow-up interval was 1.5 ± 0.9 years. Younger age at diagnosis, greater aortic root or ascending aorta z-score at diagnosis, ≥mild AS/AR at follow-up, and earlier diagnosis era were associated with shorter recommended follow-up interval (P < .001 for all). Imaging was obtained at 87% of follow-up encounters and was associated with age at encounter with children ≥12 years most frequently imaged (P < .001). Provider accounted for 14% of variability in recommended follow-up interval and 24% of imaging variability (P < .001 for both). We found little to no evidence of disease progression in children with an isolated BAV. Given the low risk, close follow-up and frequent cardiac imaging for BAV surveillance may not be warranted for children.

Follow-up intervals in patients with Cushing's disease: recommendations from a panel of experienced pituitary clinicians.

Follow-up guidelines are needed to assess qualityofcare and to ensure best long-term outcomes for patients with Cushing's disease (CD). The purpose of this study was to assess agreement by experts on recommended follow-up intervals for CD patients at different phases in their treatment course. The RAND/UCLA modified Delphi process was used to assess expert consensus. Eleven clinicians who regularly manage CD patients rated 79 hypothetical patient scenarios before and after ("second round") an in-person panel discussion to clarify definitions. Scenarios described CD patients at various time points after treatment. For each scenario, panelists recommended follow-up intervals in weeks. Panel consensus was assigned as follows: "agreement" if no more than two responses were outside a 2 week window around the median response; "disagreement" if more than two responses were outside a 2 week window around the median response. Recommendations were developed based on second round results. Panel agreement was 65.9% before and 88.6% after the in-person discussion. The panel recommended follow-up within 8 weeks for patients in remission on glucocorticoid replacement and within 1 year of surgery; within 4 weeks for patients with uncontrolled persistent or recurrent disease; within 8-24 weeks in post-radiotherapy patients controlled on medical therapy; and within 24 weeks in asymptomatic patients with stable plasma ACTH concentrations after bilateral adrenalectomy. With a high level of consensus using the Delphi process, panelists recommended regular follow-up in most patient scenarios for this chronic condition. These recommendations may be useful for assessment of CD care both in research and clinical practice.

Impact of reassessment of colonic hyperplastic polyps by expert GI pathologists.

Recommended follow-up intervals after endoscopic removal of hyperplastic polyps (HP) and sessile serrated adenomas (SSA) differ because of assumed differences in biological behaviour. However, histopathologic differentiation is difficult, with higher SSA rates reported from specialist GI histopathologists. The objective of this study was to clarify the relevance of histologic reassessment of HP. From a prospective screening colonoscopy study relevant serrated lesions (excluding distal small HP ≤5 mm) diagnosed by private practice pathologists were reassessed by four specialized GI pathologists One thousand sixty-nine screening colonoscopies were performed in patients. In terms of main outcome measurements, there is a likelihood of changes of the HP diagnosis on reassessment, as well as interrater variability. SSA were initially diagnosed in 7 cases (0.7%) and relevant HP in 83 (7.8%; 101 lesions). Of the latter, the chance of a change in diagnosis from HP to SSA by any of the four specialist histopathologists was higher for larger (>5 mm) and right-sided lesions (19.1 vs 1.3%, OR 18.4, p = 0.04) including a higher likelihood to change recommended follow-up intervals (32.1 vs 3.3%, p < 0.01). However, follow-up intervals were determined by concomitant adenomas in 41%. Interrater variability was also higher for these lesions (p = 0.04), with an overall kappa value of 0.48. However, this issue related to only 1.2% of the 1069 study cases. The limitations this study are the limited case number as well as limited retrospective assessment. Right-sided HP >5 mm had a higher chance of change in diagnosis to SSA; therefore, they should probably be treated like adenomas and be removed. However, reliable data for recommendations on follow-up intervals of HP or SSA will require follow-up studies.

A proposed set of metrics for standardized outcome reporting in the management of low back pain

Background and purpose - Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set. Patients and methods - An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions. Results - Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on preexisting tools. Interpretation - The outcome measures recommended here are structured around specific etiologies of LBP, span a patient's entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.

A proposed set of metrics for standardized outcome reporting in the management of low back pain

Background and purpose — Outcome measurement has been shown to improve performance in several fields of healthcare. This understanding has driven a growing interest in value-based healthcare, where value is defined as outcomes achieved per money spent. While low back pain (LBP) constitutes an enormous burden of disease, no universal set of metrics has yet been accepted to measure and compare outcomes. Here, we aim to define such a set.Patients and methods — An international group of 22 specialists in several disciplines of spine care was assembled to review literature and select LBP outcome metrics through a 6-round modified Delphi process. The scope of the outcome set was degenerative lumbar conditions.Results — Patient-reported metrics include numerical pain scales, lumbar-related function using the Oswestry disability index, health-related quality of life using the EQ-5D-3L questionnaire, and questions assessing work status and analgesic use. Specific common and serious complications are included. Recommended follow-up intervals include 6, 12, and 24 months after initiating treatment, with optional follow-up at 3 months and 5 years. Metrics for risk stratification are selected based on pre-existing tools.Interpretation — The outcome measures recommended here are structured around specific etiologies of LBP, span a patient’s entire cycle of care, and allow for risk adjustment. Thus, when implemented, this set can be expected to facilitate meaningful comparisons and ultimately provide a continuous feedback loop, enabling ongoing improvements in quality of care. Much work lies ahead in implementation, revision, and validation of this set, but it is an essential first step toward establishing a community of LBP providers focused on maximizing the value of the care we deliver.

Impact of clinical follow-up and diagnostic testing on intervention for tetralogy of Fallot

ObjectiveOur purpose was to evaluate yield of tools commonly advocated for surveillance of tetralogy of Fallot (TOF).MethodsAll patients (pts) with TOF, seen at any time from 1/2008 to 9/2013 in...

Development and Validation of a Prospective Point-of-Care Registry for Recall, Communication and Quality Reporting of Colonoscopy Findings

Purpose: Recently, there has been development of endoscopy registry and reporting tools (example: GI Quality Improvement Consortium or GIQuIC), which seeks to standardize documentation within and between institutions, as well as provide comparative analysis regarding documentation and procedure related metrics. The major challenge towards greater adoption of such registry and reporting tools is that the pathology reporting and its interpretation do not integrate with the main electronic health record (EHR) or GIQuIC in a way that allows for discreet data capture. This forces the physician to enter data redundantly greatly affecting work flow and efficiency in quality improvement initiatives. Methods: This prospective pilot study presents a programming solution, SmartLetter, which is able to marry patient communication with capturing of discreet data within EHR, which can be bundled with quality metrics captured within endoscopy records, and can be uploaded to GIQUIC in an automated fashion. Additionally, the programming solution automatically populates a recall registry, which can be used to generate reminder letters to patients, all without any change to physician work flow, or decrease in efficiency. Results: A total of 648 patients underwent screening or surveillance colonoscopy with three pilot physicians between September 2011 and May 2012. All but 5 patients with polypectomy had SmartLetter generated by the pilot physicians and routed to the referring provider and patient. Overall Adenoma Detection Rate (ADR) and Advanced Adenoma Detection Rate was 39.7% and 3.54% respectively. 6% of patients (n=31) had earlier than recommended follow-up interval due to suboptimal bowel preparation. The recall process picked up 4 out of 15 high-risk patients who were recommended colonoscopy within 3 months but did not have repeat procedure completed or scheduled. This data from the SmartLetter is then merged with the data from Endoscopic Electronic Records to automate GIQuIC upload and populate an on-the-fly registry for colonoscopy recall. Conclusion: The usual process for recall is suboptimal and likely to miss some high-risk patients requiring surveillance colonoscopy. A standardized point-of-care solution, such as SmartLetter, can fulfill the tripartite aim of patient communication, recall process for high-risk patients and quality reporting requirements in a one-stop solution. We are partnering with GIQuIC to deploy this solution to other private practices and academic institutions nationally.

Annual rupture risk of growing unruptured cerebral aneurysms detected by magnetic resonance angiography

In this paper, the authors' goals were to clarify the characteristics of growing unruptured cerebral aneurysms detected by serial MR angiography and to establish the recommended follow-up interval. A total of 1002 patients with 1325 unruptured cerebral aneurysms were retrospectively identified. These patients had undergone follow-up evaluation at least twice. Aneurysm growth was defined as an increase in maximum aneurysm diameter by 1.5 times or the appearance of a bleb. Aneurysm growth was observed in 18 patients during the period of this study (1.8%/person-year). The annual rupture risk after growth was 18.5%/person-year. The proportion of females among patients with growing aneurysms was significantly larger than those without growing aneurysms (p=0.0281). The aneurysm wall was reddish, thin, and fragile on intraoperative findings. Frequent follow-up examination is recommended to detect aneurysm growth before rupture. Despite the relatively short period, the annual rupture risk of growing unruptured cerebral aneurysms detected by MR angiography was not as low as previously reported. Surgical or endovascular treatment can be considered if aneurysm growth is detected during the follow-up period.

Reexamining the Recommended Follow-up Interval After Obtaining an In-Range International Normalized Ratio Value: Results from the Veterans Affairs Study to Improve Anticoagulation

Patients receiving oral anticoagulation therapy should be tested often enough to optimize control, but excessive testing increases burden and cost. We examined the relationship between follow-up intervals after obtaining an in-range (2.0-3.0) international normalized ratio (INR) and anticoagulation control.We studied 104,451 patients who were receiving anticoagulation therapy from 100 anticoagulation clinics in the US Veterans Health Administration. Most patients (98,877) had at least one in-range INR followed by another INR within 56 days. For each such patient, we selected the last in-range INR and characterized the interval between this index value and the next INR. The independent variable was the site mean follow-up interval after obtaining an in-range INR. The dependent variable was the site mean risk-adjusted percentage of time in the therapeutic range (TTR).The site mean follow-up interval varied from 25 to 38 days. As the site mean follow-up interval became longer, the risk-adjusted TTR was worse (-0.51% per day, P = .004). This relationship persisted when the index value was the first consecutive in-range INR (-0.63%, P < .001) or the second (-0.58%, P < .001), but not the third or greater (-0.12%, P = .46).Sites varied widely regarding follow-up intervals after obtaining an in-range INR (25-38 days). Shorter intervals were generally associated with better anticoagulation control, but after obtaining a third consecutive in-range value, this relationship was greatly attenuated and no longer statistically significant. Our results suggest that a maximum interval of 28 days after obtaining the first or second in-range value and consideration of a longer interval after obtaining the third or greater consecutive in-range value may be appropriate.

Patient Follow-up in an Urban Resident Continuity Clinic: An Initiative to Improve Scheduling Practices

Failure to schedule timely follow-up appointments may impair continuity and quality of care, especially for patients with low health literacy and unstable living situations. Resident continuity clinics face particular challenges in scheduling patient follow-up because of residents' complex schedules and limited time in clinic. As part of a structured quality-improvement curriculum, residents initiated discussions with clinical supervisors and clerical staff to evaluate and improve scheduling practices in an urban continuity clinic. The problem-solving process emphasized feasibility (rapid implementation/evaluation cycle, low time/resource burden) and measurable outcomes. These discussions led to design of a new scheduling form. We evaluated the short-term impact of awareness raising by comparing scheduling rates before (month 1) versus after (months 2-3) implementation, and of the form itself by randomly selecting 2 afternoon clinics to implement the new form, with a third serving as control. We analyzed all patient encounters over a 3-month period (n = 910), excluding patients with a recommended follow-up interval of greater than 4months. The proportion of appointments "never scheduled" (at 1month after provider-requested follow-up date) declined from 18.8% (95% confidence interval [CI], 14.5%-23.9%) in month 1 to 11.4% (CI, 8.1%-15.5%) in month 3. This proportion was significantly higher before than after implementation of the form (multivariable relative risk, 1.49; 95% CI, 1.08-2.03; P = .02), both in clinics that used and did not use the form (P = .93 for difference). We describe a model resident-led, team-based intervention that addressed core competencies in graduate medical education while improving outpatient scheduling practices.