1. Repeat Colonoscopy Recommendations
OVERVIEW
Context: Although colonoscopy may have the greatest sensitivity for detecting colorectal cancer (CRC) and precancerous polyps, the procedure also has greater risk than other screening methods. Repeat colonoscopy at inappropriately short intervals may expose patients to unnecessary harms with little or no added benefit. This is a key reason for organizations who issue screening guidelines to not recommend colonoscopy above other screening methods.
Objective: To evaluate the appropriateness of endoscopists’ recommendations for repeat colonoscopy, ascertained from correspondences by endoscopist to the primary care clinician, as compared with guidelines issued by the American Gastroenterological Association.
Design: Retrospective cohort design with medical record abstraction.
Setting: Ten practices located throughout Virginia and Washington, DC: 5 family medicine residency programs within Virginia Commonwealth University / Ambulatory Care Outcomes Network (ACORN) and 5 private practices within the Capital Area Primary Care Research Network (CAPRICORN).
Patients: A total of 3,000 randomly selected men and women (300 per practice) between the ages of 50 and 70 years seen in the participating practices within the past year. Of these patients, those with a record of at least one colonoscopy will be considered in the final sample population.
Instrument: Patient records were reviewed at each practice site. Information was collected on the patients’ risks for CRC, prior CRC screening history, why the most recent colonoscopy was performed, colonoscopy results, and the endoscopist’s recommendation for future follow-up and testing.
Main and Secondary Outcome Measures: The main outcome is whether the endoscopists’ recommendations for future testing are consistent with national guidelines. Factors contributing to potential variations in recommendations will also be explored such as geographic location, individual patient risk, and reason for performing the colonoscopy.
Repeat Colonoscopy Recommendations
Colonoscopy findings
(n=1282)
Repeat colonoscopy recommendations
(n=589 with report and colonoscopy recommendation ) 1
Normal
n=642
61.5%
Mean years to repeat colonoscopy (range)
(n=424) yrs (1-10 yrs)
Repeat in < 5 years %
Repeat in 5-10 years %
Repeat in 10 years %
Hyperplastic polyp(s)
n=121
14.4%
(n=78) yrs (1-10 yrs)
Repeat in < 5 years %
Repeat in 5-10 years %
Repeat in 10 years %
1-2 small (<1cm) tubular adenoma
n=89
8.9%
(n=56) yrs (1-5 yrs)
Repeat in <3 years %
Repeat in 3-5 years %
Repeat in 5 years %
Repeat in 5-10 years %
Repeat in 10 years %
3-10 adenomas or any adenoma ≥1 cm or high grade dysplasia
n=42
4.0%
(n=31) yrs (0.5-5 yrs)
Repeat in <3 years %
Repeat in 3 years %
Repeat in 3-5 years %
Repeat in >5 years %
Notes on Repeat Colonoscopy Table
Endoscopist recommendations in BLUE TEXT are consistent with 2006 Guidelines
Those with a colonoscopy recommendation and unknown polyp pathology are excluded from this table (n=138) as well as those with a
colonscopy recommendation and more than 10 adenomas (n=1)
Endoscopist recommendations on when to repeat a colonoscopy included both intervals (9.2% of recommendations) and single year
recommendations (90.8% of recommendations)
Interval recommendations reported above include both endoscopist interval recommendation and single year recommendations
not separately reported (i.e. for small tubular adenomas repeat in 3-5 years includes a recommendation of “repeat in 3 years” or
“repeat in 4 years” or “repeat in 3 to 5 years”, but does not include a recommendation of “repeat in 5 years”)
* Assumes: 14.2 million colonoscopies per year at a cost of $1200 apiece