Variation in post-colonoscopy colorectal cancer across colonoscopy providers in English National Health Service: population based cohort study

Abstract

ObjectivesTo quantify post-colonoscopy colorectal cancer (PCCRC) rates in England by using recent World Endoscopy Organisation guidelines, compare incidence among colonoscopy providers, and explore associated factors that could benefit from quality improvement initiatives.DesignPopulation based cohort study.SettingNational Health Service in England between 2005 and 2013.PopulationAll people undergoing colonoscopy and subsequently diagnosed as having colorectal cancer up to three years after their investigation (PCCRC-3yr).Main outcome measuresNational trends in incidence of PCCRC (within 6-36 months of colonoscopy), univariable and multivariable analyses to explore factors associated with occurrence, and funnel plots to measure variation among providers.ResultsThe overall unadjusted PCCRC-3yr rate was 7.4% (9317/126 152), which decreased from 9.0% in 2005 to 6.5% in 2013 (P<0.01). Rates were lower for colonoscopies performed under the NHS bowel cancer screening programme (593/16 640, 3.6%), while they were higher for those conducted by non-NHS providers (187/2009, 9.3%). Rates were higher in women, in older age groups, and in people with inflammatory bowel disease or diverticular disease, in those with higher comorbidity scores, and in people with previous cancers. Substantial variation in rates among colonoscopy providers remained after adjustment for case mix.ConclusionsWide variation exists in PCCRC-3yr rates across NHS colonoscopy providers in England. The lowest incidence was seen in colonoscopies performed under the NHS bowel cancer screening programme. Quality improvement initiatives are needed to address this variation in rates and prevent colorectal cancer by enabling earlier diagnosis, removing premalignant polyps, and therefore improving outcomes.

Unacceptable variation in screening colonoscopy

“…Specifically, they find higher rates of post colonoscopy cancers following privately provided colonoscopy, after controlling for certain confounding factors (adjusted odds ratio 1.63 (95% confidence interval 1.39 to 1.91), P<0.01). Rates were also higher among women, older people (aged ≥80), and in people with inflammatory bowel disease and diverticular disease 3…”

“…In a second paper, Burr and colleagues (doi:10.1136/bmj.l6090) quantify rates of colorectal cancer up to three years after a negative colonoscopy in England 3. They report a decreasing incidence of post-colonoscopy cancers over the period of investigation (from 9.0% in 2005 to 6.5% in 2013), but highlight statistically significant variation between colonoscopy providers.…”

“…Burr and colleagues highlight concerning heterogeneity in the quality of colonoscopies, as evidenced by differences in the incidence of post-colonoscopy cancers among patients using private and NHS providers 3. This heterogeneity is likely to affect outcomes,4 and will be of concern to patients, clinicians, and providers.…”

Post-colonoscopy colorectal cancer: patients can be reassured that UK endoscopy is already engaged in quality assessment and continual improvement

“…Burr and colleagues suggest that quality improvement is needed to reduce variation in colonoscopy performance, as measured by post-colonoscopy colorectal cancer (PCCRC) 1. This inter-hospital variation in colonoscopy quality has been known to UK gastroenterology since being shared by Roland Valori during the 2014 British Society of Gastroenterology (BSG) annual meeting.…”

Rates of colorectal cancer after negative colonoscopies vary by provider, study finds

“…The rate at which people develop colorectal cancer within three years of a colonoscopy negative for cancer differs depending on which provider they use, with NHS screening providers performing better than non-NHS providers, a study has found 1…”