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

Abstract

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.

Optimizing Timing of Follow-Up Colonoscopy: A Pilot Cluster Randomized Trial of a Knowledge Translation Tool

“…Our results on baseline adherence with colonoscopy surveillance guideline recommendations are consistent with other studies. A study from Austin, Texas, that included 1,709 patient charts (26) found that interval surveillance was clearly stated in 72% of the procedures and that recommended intervals were too short in 24.5% of cases and too long in 3.6% of cases. A multicenter retrospective observational study in 2015 based on US veterans found that the rate of nonadherence to guideline recommendations was 35.8%; this increased to 45%-52% for colonoscopies with hyperplastic or adenomatous polyps (27).…”

Pharmacokinetics of oral mannitol for bowel preparation for colonoscopy

“… 4 Unfortunately, up to one‐third of patients have unsatisfactory bowel cleansing, 5 , 6 with detrimental effects on colonoscopy completion, endoscopic accuracy, patient tolerance, and healthcare costs. 7 , 8 , 9 , 10 , 11 …”

“…4 Unfortunately, up to one-third of patients have unsatisfactory bowel cleansing, 5,6 with detrimental effects on colonoscopy completion, endoscopic accuracy, patient tolerance, and healthcare costs. [7][8][9][10][11] Many products for bowel preparation are available, with polyethylene glycol (PEG)-based formulations the most commonly used in United States and Europe. However, PEG formulations have some disadvantages, including a large volume of solution, unpleasant taste, complicated timing, nocturnal problems (because of the split-dose regimen), and high cost.…”

The unmet needs for identifying the ideal bowel preparation

“…Many factors affect colonoscopy quality, including the type of health service organization, type of facility, staff, equipment, patient characteristics, and the bowel preparation (BP) process (Table 2). High‐quality colonoscopy is essential for successful screening programs and effective diagnosis 7,8 . The BP process is especially important 9–11 .…”

“…High‐quality colonoscopy is essential for successful screening programs and effective diagnosis. 7 , 8 The BP process is especially important. 9 , 10 , 11 Inadequate BP results in a lengthy procedure, incomplete colonoscopy, incorrect diagnosis or diagnostic delay, increased costs due to the need to repeat the procedure, adverse events, and patient unwillingness to repeat the examination.…”