Background Studies suggest that advancing age is an independent risk factor for experiencing adverse events during colonoscopy. Yet many of these studies are limited by small sample sizes and/or marked variation in reported outcomes. Objective To determine the incidence rates for specific adverse events in elderly patients undergoing colonoscopy and calculate incidence rate ratios for selected comparison groups. Setting and Patients Elderly patients undergoing colonoscopy. Design Systematic review and meta-analysis. Main Outcome Measurements Perforation, bleeding, cardiovascular (CV)/pulmonary complications, and mortality. Results Our literature search yielded 3328 articles, of which 20 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 colonoscopies) in patients 65 years of age and older were 26.0 (95% CI, 25.0–27.0) for cumulative GI adverse events, 1.0 (95% CI, 0.9–1.5) for perforation, 6.3 (95% CI, 5.7–7.0) for GI bleeding, 19.1 (95% CI, 18.0–20.3) for CV/pulmonary complications, and 1.0 (95% CI, 0.7–2.2) for mortality. Among octogenarians, adverse events (per 1000 colonoscopies) were as follows: cumulative GI adverse event rate of 34.9 (95% CI, 31.9–38.0), perforation rate of 1.5 (95% CI, 1.1–1.9), GI bleeding rate of 2.4 (95% CI, 1.1–4.6), CV/pulmonary complication rate of 28.9 (95% CI, 26.2–31.8), and mortality rate of 0.5 (95% CI, 0.06–1.9). Patients 80 years of age and older experienced higher rates of cumulative GI adverse events (incidence rate ratio 1.7; 95% CI, 1.5–1.9) and had a greater risk of perforation (incidence rate ratio 1.6, 95% CI, 1.2–2.1) compared with younger patients (younger than 80 years of age). There was an increased trend toward higher rates of GI bleeding and CV/pulmonary complications in octogenarians but neither was statistically significant. Limitations Heterogeneity of studies included and not all complications related to colonoscopy were captured. Conclusions Elderly patients, especially octogenarians, appear to have a higher risk of complications during and after colonoscopy. These data should inform clinical decision making, the consent process, public health policy, and comparative effectiveness analyses.
This article provided some insights about the trauma care system by computing the pooled estimate of PDRs over the past 23 years as an indicator. The pooled PDR was estimated as approximately 20 %, with no statistical significance of differences in PDRs over time or by the evaluation methods employed. That left us still room for improvement in trauma care system despite our efforts to reduce PDRs. In addition, when 'statistical approaches' are applied alone to estimate PDRs, we recommend that statistical methods should be applied with caution when the characteristics of trauma patients are heterogeneous. The optimal approach might be to combine both statistical and panel review approaches instead of employing a single approach.
Background Preconsultation exchange is an emerging model of specialty care proposed by the American College of Physicians that seeks to answer a clinical question without a formal patient visit to the specialty clinic. This form of specialty care has been little studied. We sought to determine the appropriateness of preconsultation exchange for ambulatory hepatology consultations within our urban healthcare system. Methods Retrospective study of referrals for ambulatory hepatology consultation in the safety net healthcare system of San Francisco, CA from January 2007 through April 2010. Results Of the 500 referrals reviewed, 87 were excluded as repeat requests. The most common reasons for referral were hepatitis B (34.9%) and hepatitis C (32.0%). 56 referrals (13.6%) were appropriate for preconsultation exchange, and 190 (46.0%) were inappropriate for preconsultation exchange. 167 (40.4%) referrals did not include enough information to determine appropriateness for preconsultation exchange. Most of these (83.8%) were made for hepatitis B or hepatitis C, despite the presence of explicit referral guidelines. Midlevel providers were more likely than physicians to provide enough information to determine appropriateness for preconsultation exchange. Conclusion In our urban healthcare system, preconsultation exchange appears to be an appropriate form of specialty care for some ambulatory hepatology consultations. Communication between primary care provider and specialist appears to be an important barrier to broader implementation of preconsultation exchange. Optimizing the preconsultation exchange is critical to improve the primary-specialty care interface, and to build a true Patient Centered Medical Home Neighborhood.
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