Screening Guidelines Needed on Inadequate Bowel Prep

ANN ARBOR, MI — How does less-than-adequate bowel preparation for colonoscopy affect adenoma miss rates and future screening recommendations for average-risk patients?

Researchers from the University of Michigan Health System and the Ann Arbor Veterans Affairs Healthcare System sought to determine that in recent research published in the journal Gastrointestinal Endoscopy.1

Using retrospective chart review at a tertiary-care center, study authors analyzed average-risk patients undergoing index colonoscopy for colorectal cancer screening between 2004 and 2006.

Over a two-year period, 16,251 colonoscopy records were reviewed, with 1,943 colonoscopies performed for the sole indication of average risk or screening.

Of those, only fair bowel preparation was reported in 31.9% (619 patients). Repeat colonoscopy within five years was recommended in 70.4% of patients, and the follow-up colonoscopy compliance rate within three years was 55.9%. Adenoma detection rates at index and follow-up colonoscopy were 20.5% and 28.2%, respectively.

Of the 39 patients with follow-up colonoscopy within three years, the overall adenoma miss rate was 28%. Of the patients with an adenoma identified on follow-up colonoscopy, 13.6% had normal colonoscopy results on index examination.

“Fair bowel preparation led to a deviation from national guidelines with early repeat colonoscopy follow-up recommendations in nearly 60% of average-risk patients with normal colonoscopy results,” the authors noted, adding that, in patients who returned for repeat colonoscopy within three years, the overall adenoma miss rate was 28%.

The researchers suggested additional guidelines on timing for repeat colonoscopy for fair bowel preparation are needed.

  1. Menees SB, Kim HM, Elliott EE, Mickevicius JL, Graustein BB, Schoenfeld PS. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc. 2013 Apr 30. doi:pii: S0016-5107(13)01592-7. 10.1016/j.gie.2013.03.1334. [Epub ahead of print] PubMed PMID: 23642491.

Colorectal Cancer Time to VA Treatment Showed Increase Years

CHICAGO — During a 10-year period, time to treatment for colon and rectal cancers significantly increased at VAMCs, according to a recent study.1

During the study periods of 1998-2000,  compared with 2007-2008, time to treatment for colon cancer rose 68%, while going up 74% for rectal cancer, according to the researchers from the Jesse Brown VAMC in Chicago; VA Center for Management of Complex Chronic Care; the Denver VAMC, University of Colorado in Denver and Northwestern University and University of Illinois, both with medical campuses in Chicago.

“Timeliness of cancer treatment is an important aspect of health care quality,” the authors wrote in the Journal of Oncology Practice. “Veterans Affairs Medical Centers (VAMCs) are expected to treat a growing number of patients with cancer. Our objectives were to examine treatment times from diagnosis to first-course therapy for patients with colon and rectal cancers and assess factors associated with prolonged wait times.”

Using the VA Central Cancer Registry with data from 124 VAMCs, researchers tracked patients who underwent colon or rectal resection for cancer from 1998 to 2008, measuring time from diagnosis to definitive cancer-directed therapy. Multivariable regression methods were used to determine predictors of prolonged wait times for colon (≥ 45 days) and rectal (≥ 60 days) cancers.

During the time reviewed, 14,097 patients underwent colectomy, and 3,390 underwent rectal resection for cancer.

Researchers found, for colon cancer, the median time to treatment increased by 68% over the time period, with the median time to colectomy rising to 32 days. Prolonged wait times were more common in married black patients older than 55 who were seen at high volume centers and sought treatment at a different hospital from where the diagnosis was made.

Similar predictors of prolonged wait times were identified for rectal cancer, where the overall median time to first-course treatment increased by 74%. From 2007 to 2008, the median time to proctectomy was 47 days, the researchers noted.

  1. Merkow RP, Bilimoria KY, Sherman KL, McCarter MD, et. al. Efficiency of Colorectal Cancer Care Among Veterans: Analysis of Treatment Wait Times at Veterans Affairs Medical Centers. Journal of Oncology Practice. Published online before print 26 Feb 26 2013, doi: 10.1200/JOP.2012.000738 JOP 26 Feb 2013 JOP.2012.000738

Electronic Reminder Has Little Effect on VA Colonoscopy Rates

DULUTH, GA — The Colorectal Cancer (CRC) Oncology Watch intervention, a clinical reminder, began in 2008 in Veterans Integrated Service Network (VISN) 7 in an effort to improve colorectal cancer screening rates.

A recent study suggests, however, the reminder had little effect on colonoscopy rates. One possible reason was “fatigue” from the deluge of reminders received by VA physicians, according to the report which was published recently in the Journal of Clinical Oncology.

For the study, eight hospitals in the VA’s Southeast Region served as the intervention sites, and the other 121 hospitals as controls, with 2006 to 2007 as the pre-intervention period and 2009 to 2010 as the post-intervention period.

During the four years, the sample included 4,352,082 veteran-years. During study years of 2006, 2007, 2009 and 2010, adherence rates were 37.6%, 31.6%, 34.4% and 33.2%, respectively, in the intervention sites. Corresponding rates in the controls were at 31.0%, 30.3%, 32.3% and 30.9%.

Researchers noted that, among those eligible for screening, the intervention was associated with a 2.2–percentage point decrease in likelihood of adherence, overall.

“The intervention had little impact on CRC screening rates for the studied population,” according to the authors. “This absence of favorable impact may have been caused by an unintentional shift of limited VA colonoscopy capacity from average-risk screening to higher-risk screening and to CRC surveillance, or by physician fatigue resulting from the large number of clinical reminders implemented in the VA.”

1.     Bian J, Bennett CL, Fisher DA, Ribeiro M, Lipscomb J. Unintended consequences 

of health information technology: evidence from Veterans Affairs colorectal cancer oncology watch intervention. J Clin Oncol. 2012 Nov 10; 30(32):3947-52. doi: 10.1200/JCO.2011.39.7448. Epub 2012 Oct 8. PubMed PMID: 23045582; PubMed Central PMCID: PMC3488268.

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