Background The impact of fair bowel preparation on endoscopists' recommendations and adenoma miss rates in average-risk patients undergoing colonoscopy is unknown. Objective To assess the impact of ...fair bowel preparation on endoscopists' interval colonoscopy recommendations and miss rates in colonoscopies performed within 3 years of the index colonoscopy in average-risk patients undergoing colorectal cancer screening. Design Retrospective chart review. Setting Tertiary-care center. Patients Average-risk patients undergoing index colonoscopy for colorectal cancer screening between 2004 and 2006. Intervention Colonoscopy. Main Outcome Measurements Endoscopists' interval recommendations, adenoma miss rates. Results A total of 16,251 colonoscopy records were reviewed over a 2-year period. Of these cases, 1943 colonoscopies were performed for the sole indication of average risk or screening . Of these, fair bowel preparation was reported in 619 patients (31.9%). A repeat colonoscopy within 5 years was recommended in 70.4% of patients. The follow-up colonoscopy compliance rate within 3 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 3 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. Limitations Retrospective design. Conclusion 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. In patients who returned for repeat colonoscopy within 3 years, the overall adenoma miss rate was 28%. Further guidelines on timing for repeat colonoscopy for fair bowel preparation are needed.
Background Current guidelines stratify patients with a personal history of adenomas as low risk (ie, 1-2 small <10 mm adenomas at index colonoscopy) or high risk (≥3 small adenomas or advanced ...adenoma at index colonoscopy) for recurrent advanced adenomas. Guidelines recommend longer intervals between surveillance colonoscopies for low-risk patients, but physicians frequently perform surveillance colonoscopy at shorter intervals for these patients. Objective Our purpose was to perform a meta-analysis about the incidence of advanced adenomas at 3-year surveillance colonoscopy among high- and low-risk patients. Methods Computer searches of MEDLINE, PREMEDLINE, and EMBASE were performed to identify appropriate studies. Study selection criteria were (1) study design—prospective or registry-based study, (2) study population—patients with a personal history of adenomas, and (3) intervention—completion of surveillance colonoscopy at an interval of ≥2 years. Data were extracted on (1) incidence of advanced adenomas at surveillance colonoscopy, (2) interval between colonoscopies, and (3) risk factors associated with recurrent adenomas. After the validity of study design was assessed and independent, duplicate data extraction was performed from selected trials, summary relative risks (RR) for the incidence of advanced adenomas at 3-year colonoscopy were calculated. Results Fifteen studies met study selection criteria, but only 5 studies stratified surveillance colonoscopy results according to findings at the index colonoscopy. Patients with ≥3 adenomas at index colonoscopy were more likely to have recurrent advanced adenomas than were patients with 1 to 2 adenomas: RR 2.52, 95% CI 1.07-5.97. Patients with adenomas with high-grade dysplasia at index colonoscopy were also at increased risk for recurrent advanced adenomas: RR 1.84, 95% CI: 1.06-3.19. In the individual studies, increasing size of adenomas and increasing number of adenomas at index colonoscopy were the most commonly reported risk factors associated with recurrent advanced adenomas. No studies stratified surveillance colonoscopy results according to the definitions of low risk and high risk used in current guidelines. Conclusion Few published studies stratify the incidence of advanced adenomas at surveillance colonoscopy according to index colonoscopy findings. In the future, large prospective studies or studies using pooled data from existing ramdomized controlled trial databases or polyp registries should be used to better define which patients are at low risk for advanced adenoma recurrence. (Gastrointest Endosc 2006;64:•••-•••.)
Background Among average-risk patients, repeat colonoscopy in 5 years is recommended after 1 to 2 small (<1 cm) adenomas are found on screening colonoscopy or in 10 years if hyperplastic polyps are ...found. However, sparse quantitative data are available about adherence to these recommendations or factors that may improve adherence. Objective To quantify adherence to recommended intervals and to identify factors associated with lack of adherence. Design Retrospective endoscopic database analysis. Setting Tertiary-care institution and Veterans Affairs Health System. Patients Average-risk individuals undergoing screening colonoscopy found to have 1 to 2 small polyps on screening colonoscopy. Main Outcome Measurements Frequency of recommending repeat colonoscopy in 5 years if 1 to 2 small adenomas are found and in 10 years if hyperplastic polyps are found. Results Of 922 outpatient screening colonoscopies with 1 to 2 small polyps found, 90.2% received appropriate recommendations for timing of repeat colonoscopy. Eighty-four percent of patients with 1 to 2 small adenomas and 94% of patients with 1 to 2 hyperplastic polyps received recommendations that were consistent with guidelines. Based on logistic regression analysis, patients aged >70 years (odds ratio OR 2.4, 95% confidence interval CI, 1.0-5.7), fair bowel preparation (OR 12.7; 95% CI, 7.3-22.4), poor bowel preparation (OR 10.0; 95% CI, 4.3-23.6), and the presence of 2 small adenomas versus 1 small adenoma (OR 3.6; 95% CI, 2.2-6.0) were factors associated with “overuse” or recommendations inconsistent with guidelines. Limitations Retrospective study design. Conclusion More than 90% of endoscopists' recommendations for timing of surveillance colonoscopy in average-risk patients with 1 to 2 small polyps are consistent with guideline recommendations. Quality of preparation is strongly associated with deviation from guideline recommendations.
Background Although split-dose bowel regimen is recommended in colon cancer screening and surveillance guidelines, implementation in clinical practice has seemingly lagged because of concerns of ...patient compliance. Objectives To assess patient compliance with the split-dose bowel regimen and assess patient- and preparation process–related factors associated with compliance and bowel preparation adequacy. Design Prospective survey cohort. Setting Tertiary care setting. Patients Average-risk patients undergoing colonoscopy for colorectal cancer screening between August 2011 and January 2013. Main Outcome Measurements Split-dose bowel regimen patient-reported compliance and bowel preparation adequacy with the Boston Bowel Preparation Scale score. Results Surveys and Boston Bowel Preparation Scale score data were completed in 462 participants; 15.4% were noncompliant with the split-dose bowel regimen, and suboptimal bowel preparation (score <5) was reported in 16% of all procedures. White ( P = .009) and married ( P = .01) subjects were least likely to be noncompliant, whereas Hispanic subjects and those who reported incomes of US$75,000 or less were most likely to be noncompliant ( P = .004). Participants who were noncompliant with split-dosing were less likely to follow the other laxative instructions and more likely to have their colonoscopy appointment before 10:30 am . Compliance differed by bowel preparation type ( P = .003, χ2 test), with those who used MiraLAX showing the highest compliance, followed by polyethylene glycol electrolyte solution and other bowel preparations. Noncompliance with split-dose bowel preparation (odds ratio 6.7; 95% confidence interval, 3.2-14.2) was the strongest predictor of suboptimal bowel preparation. Limitations Patient self-report, performed at tertiary care center. Conclusions Overall, 1 in 7 patients do not comply with a split-dose bowel regimen. Ensuring compliance with the split-dose bowel regimen will reduce the risk of a suboptimal bowel preparation.
Background Per current guidelines, patients with a first-degree relative (FDR) with adenomas should get screened at age 40. Data on the prevalence of adenomas and advanced adenomas (AAs) in these ...patients are lacking. Objective To examine the prevalence of adenomas and AAs in 40- to 49-year-old individuals undergoing screening colonoscopy because of a family history (FH) of polyps and to compare these data with those of a control population of similar age. Design Retrospective cross-sectional study. Setting Tertiary care academic medical center and Veterans Affairs medical center. Patients Study subjects included all 40- to 49-year-old asymptomatic individuals undergoing initial screening colonoscopy at our institution from January 1, 2006, to June 1, 2009, because of an FDR with polyps. The control population consisted of all 40- to 49-year-old individuals who underwent their first colonoscopy during the same period because of abdominal pain, diarrhea, or constipation without an FH of polyps or colorectal cancer. Intervention Colonoscopy. Main Outcome Measurements The prevalence of adenomas of any size, AAs, and risk factors associated with adenomas. Results The prevalence of adenomas was greater in the FH of polyps group (n = 176) compared with the control sample (n = 178) (26.7% vs 13.5%; P = .002) but was not statistically greater for AAs (5.7% vs 3.4%; P = .3). After adjusting for confounders, FH of a polyp was associated with an increased prevalence of adenomas (odds ratio 2.8 95% CI, 1.4–5.5). Limitations Limited data on polyp histology in FDRs and limited sample size. Conclusions Among 40- to 49-year-old patients undergoing screening colonoscopy because of an FDR with polyps, the prevalence of adenomas was greater than in a control population. Prospective research is needed to quantify the prevalence of AAs in this group and to determine whether these individuals should undergo screening colonoscopy at age 40.
Background Per current guidelines, patients with a first-degree relative (FDR) with colorectal cancer (CRC) should get screened at least at age 40. Data about the prevalence of adenomas and advanced ...adenomas (AAs) in these patients are lacking. Objective To examine the prevalence of adenomas and AAs in 40- to 49-year-old individuals undergoing screening colonoscopy for family history of CRC. Design Retrospective chart review. Patients Asymptomatic patients 40 to 49 years of age undergoing their first screening colonoscopy at the University of Michigan during the period 1999 to 2009 because of an FDR with CRC. Main Outcome Measurements Prevalence of adenomas (any size), AAs, and risk factors associated with adenomas. Results Among 640 study patients, the prevalence of adenomas (any size) was 15.4% and 3.3% for AAs. Adenoma prevalence was lower if the FDR with CRC was younger than 60 years of age versus an FDR with CRC older than 60 years of age (12.4% vs 19%, P = .034). Male sex (odds ratio 2.6; 95% CI, 1.06-4.4) and advancing age (odds ratio 1.16; 95% CI, 1.03-1.31) were associated with adenomas. Limitations Limited data on risk factor exposure and insufficient sample size to assess risk factors for AAs. Conclusions Among 40- to 49-year-old patients undergoing screening colonoscopy because of an FDR with CRC, the prevalence of adenomas and AAs is low. Further research should determine whether these individuals have a higher prevalence of adenomas compared with average-risk individuals.
Abstract The growing importance of colonoscopy in the prevention of colorectal cancer has stimulated an effort to identify and track quality indicators for this procedure. Several factors have been ...identified so far which are readily measurable and in many cases have been associated with improved patient outcomes. There is also ample evidence of variations in performance of this procedure. As a result, gathering data about quality indicators may play a vital role in the process of continuous quality improvement. Quality indicators for colonoscopy in colorectal cancer prevention are described along with the evidence that supports their use in benchmarking, quality reporting, and continuous quality improvement.
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