Can we better target colonoscopies using standard "appropriateness" guides?

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Background:
> There is a heavy referral burden on endoscopic services
worldwide as colorectal cancer screening programs are
embraced.
> To best target colonoscopy, it is proposed that
“appropriate” indications for colonoscopy be used to
restrict procedures and maximise the limited endoscopic
resources.
> We aim to estimate the
• proportion of colonoscopies classified as inappropriate &
• the detection rate of clinically relevant findings in them,
using the guidelines developed by the American Society for
Gastrointestinal Endoscopy (ASGE) and the European Panel on
the Appropriateness of Gastrointestinal Endoscopy (EPAGE-II);
AND to compare the performance of a custom alarms-based
approach to ASGE and EPAGE-I criteria, in the subset referred
for colonoscopy with likely functional disorders.
> According to current clinical practice 25% of the
uncodeable colonoscopies were appropriate
> EPAGE-II criteria judged 72% to be appropriate, 10%
inappropriate, 11% uncodeable and 7% had insufficient
information
> According to current clinical practice 52% of the
uncodeable colonoscopies were appropriate
> Of note, there appeared to be no difference in the rate of
relevant findings in appropriate versus inappropriate
colonoscopies using these published criteria; with clinically
relevant findings in 42% of appropriate vs. 50% of
inappropriate cases using ASGE and in 45.4% of
appropriate vs. 20% of inappropriate cases with EPAGE-II
> Functional symptoms were identified on referral in 12%
(n=23), and almost half (n=11) were judged inappropriate
using our custom alarms-based approach
> Clinically relevant findings did not occur in any of the 11
colonoscopies judged inappropriate, but were seen in 25%
of those judged appropriate
> Of note, 4 of these 11 procedures judged inappropriate
with our alarm-based criteria were judged appropriate by
ASGE and 9 by EPAGE.
Results:
> A total of 196 colonoscopies were reviewed (52% male;
88% outpatients)
> ASGE criteria judged the majority to be appropriate (88%)
with 2% inappropriate and 10% uncodeable
Methods:
> Consecutive medical records of patients with completed
colonoscopies at one Australian public hospital were
reviewed (December 2014-October 2014)
> Indications for colonoscopies were judged as appropriate or
inappropriate according to the ASGE and necessary /
appropriate or uncertain / inappropriate using EPAGE-II
criteria
> The clinical relevance of findings was judged by a
gastroenterology registrar and senior gastroenterologist
> A subset analysis of colonoscopies performed on patients
with likely functional symptoms were then additionally
categorised as appropriate/inappropriate according to a
custom alarms-based approach, and pick up rate of
relevant abnormalities determined
> The sample was powered to detect an inappropriateness
rate of 15%.
Table 3. Custom alarms-based criteria for judging “Appropriateness” of
colonoscopy
Conclusion:
> Surprisingly, ASGE criteria do not appear to target
colonoscopy well as clinically relevant findings are
no higher in those judged to be appropriate
compared with inappropriate.
> EPAGE II appears to do better with a lower rate of
findings (but still 20%) in those judged
inappropriate.
> In patients with likely functional symptoms neither
ASGE nor EPAGE-II perform adequately and a larger
trial of the use of our custom alarms-based criteria
in patients with likely functional symptoms seems
justified on these preliminary data.
Q. Rizvi1, E . C. Linedale2, A. Mikocka-Walus3, P. Gibson4, J. M. Andrews5
1. Lyell McEwin Hospital, South Australia, Australia. 2. University of Adelaide, South Australia, Australia. 3. University of York.
4. Monash University, Melbourne. 5. Royal Adelaide Hospital / University of Adelaide, South Australia.
www.ausgoal.gov.au/creative-commons
Can We Better Target Colonoscopies
Using Standard “Appropriateness” Guides?
Table 1. ASGE guidelines for Appropriate Colonoscopies
A. Evaluation of an abnormality on barium
enema or other imaging study that is likely to
be clinically significant, such as a filling defect
and stricture
C. Unexplained iron deficiency anemia
E. For dysplasia and cancer surveillance in select
patients with long-standing ulcerative or
Crohn’s colitis.
For evaluation of patients with chronic
inflammatory bowel disease of the colon, if
more precise diagnosis or determination of the
extent of activity of disease will influence
management
G. Intraoperative identification of a lesion not
apparent at surgery (e.g. polypectomy site,
location of a bleeding site)
I. Intraoperative evaluation of anastomotic
reconstructions typical of surgery to treat
diseases of the colon and rectum
(e.g. evaluation for anastomotic leak and
patency, bleeding, pouch formation)
K. Management or evaluation of operative
complications (e.g. dilation of anastomotic
strictures)
M. Excision or ablation of lesions
O. Balloon dilation of stenotic lesions
(e.g. anastomotic strictures)
Q. Marking a neoplasm for localization.
B. Evaluation of unexplained GI bleeding:
1. Hematochezia
2. Melena after an upper GI source has been
excluded
3. Presence of fecal occult blood
D. Screening and surveillance for colonic
neoplasia:
F. Clinically significant diarrhea of unexplained
origin
H. Treatment of bleeding from such lesions as
vascular malformation, ulceration, neoplasia,
and polypectomy site
J. As an adjunct to minimally invasive surgery for
the treatment of diseases of the colon and
rectum
L. Foreign body removal
N. Decompression of acute megacolon or
sigmoid volvulus
P. Palliative treatment of stenosing or bleeding
neoplasms (e.g. laser, electrocoagulation,
stenting).
Table 2. EPAGE (European Panel on the Appropriateness Gastronintestinal
Endoscopies)
New onset symptoms Within 6 months and over age 50
Unexplained weight loss Greater than 3 kg or 5% body weight
Overt GI bleeding Positive FHH, melaena, haematemesis
Unexplained fever
Abdominal pain awaking patient from sleep
Nocturnal diarrhoea
Family history of colon cancer One FDR* < 60
More than one 1 FDR any age
Family History of IBD One FDR
Family History of Coeliac Disease One FDR
1. Iron-deficiency anemia (malabsorption
syndrome excluded).
3. Lower abdominal symptoms (chronic
constipation / lower abdominal pain /
bloating) of at least 3 months duration,
without known inflammatory bowel
disease, without anemia and without
FOBT positive stools, with or without
empirical IBS therapy. No risk factors for
colorectal cancer.
5. Evaluation of known ulcerative colitis
(UC), excluding surveillance for cancer.
7. Surveillance for colorectal cancer in
patients with known inflammatory
bowel diseases.
9. Surveillance after curative intent
resection of colorectal cancer.
11. Miscellaneous indications.
2. Hematochezia (without IBD).
Patient hemodynamically stable.
4. Uncomplicated diarrhea (infectious or
malabsorption origin excluded and
without known IBD). No anemia. No
bleeding. No risk factors for colorectal
cancer. No HIV / AIDS. With or without
empirical treatment.
6. Evaluation of known Crohn's disease
(CD), excluding surveillance for cancer.
8. Surveillance after colonic polypectomy;
follow-up colonoscopy (complete
colonoscopy, bowel preparation
adequate, patient actually
asymptomatic, life expectancy >10
years). Familial polyposis, HNPCC and
hyperplastic polyposis syndrome
excluded.
10. Screening for colorectal cancer.
1. Screening of asymptomatic, average-risk
patients for colonic neoplasia
2. Examination to evaluate the entire colon
for synchronous cancer or neoplastic polyps
in a patient with treatable cancer or
neoplastic polyp
3. Colonoscopy to remove synchronous
neoplastic lesions at or around the time of
curative resection of cancer followed by
colonoscopy at 1 year and, if normal, then
3 years, and, if normal, then 5 years
thereafter to detect metachronous cancer.
4. Surveillance of patients with neoplastic
polyps
5. Surveillance of patients with a significant
family history of colorectal neoplasia
Table 4. Comparing the performance of ASGE/EPAGE Criteria on Colonoscopy
Procedures
A = Appropriate, I = Inappropriate, N/A = Necessary or Appropriate, U/I = Uncertain or Inappropriate.
Total
n
196
ASGE Criteria
A
173
(88.3%)
73
(42.2%)
I
4
(2.0%)
2
(50.0%)
Uncodeable
19
(9.7%)
EPAGE Criteria
N/A
141
(71.9%)
64
(45.4%)
U/I
20
(10.2%)
4
(20.0%)
Uncodeable
35
(17.9%)
Colonoscopies
Clinically
Relevant Finding
Table 5. Comparing the performance of ASGE/EPAGE and Custom Alarm-based
Criteria for Possible Functional Gastrointestinal Disorders
Total
n A I N/A U/I A I
23
3
16
3
7
0
21
3
2
0
12
3
11
0
ASGE Criteria EPAGE Criteria Custom Criteria
Colonoscopies
Clinically
Relevant Finding