Improving compliance with postpolypectomy surveillance guidelines: an interventional study using a continuous quality improvement initiative

doi:10.1016/j.gie.2005.08.048

Gastrointestinal Endoscopy

Volume 63, Issue 1, January 2006, Pages 97-103

https://doi.org/10.1016/j.gie.2005.08.048 Get rights and content

Background

Despite guidelines, physicians tend to perform postpolypectomy surveillance colonoscopies too frequently.

Objective

The objective of the study was to determine the baseline compliance rate with postpolypectomy guidelines in our unit and to determine the influence of a continuous quality improvement (CQI) intervention on improving the compliance rate and on decreasing the potential additional costs because of the scheduling of postpolypectomy surveillance colonoscopies earlier than indicated.

Design

This was a single-arm, pretest-posttest design.

Setting

This study took place at a tertiary care, academic medical center.

Patients

The medical records of all patients who underwent colonoscopy with polypectomy in our unit retrospectively during 6 months preceding (baseline period) and prospectively for 6 months after an intervention (postintervention period) were reviewed for patient demographics, colonoscopy findings, and scheduling of repeat colonoscopies.

Intervention

We used 3 components: (1) distribution of a wallet-size card with a summary of postpolypectomy guidelines to all endoscopists, (2) placement of guideline charts near computers used for typing endoscopy reports, and (3) distribution and reinforcement of the guidelines in a monthly continuous quality improvement meeting.

Main Outcome Measures

The main outcome measures were compliance rates, mean times to repeat colonoscopy, and additional costs from surveillance colonoscopies being scheduled earlier than indicated were compared between the two periods.

Results

There were 278 patients in the baseline period and 242 in the postintervention period, with similar patient and polyp characteristics. After the intervention, the compliance rate with guidelines improved from 57.2% to 81% (p < 0.001). The mean time to a repeat colonoscopy increased from 4.5 to 5.2 years (p = 0.003) (i.e., a 14% reduction in the number of postpolypectomy surveillance colonoscopies performed per year). This would result in a reduction of a total of 73 surveillance colonoscopies per year in our unit, with a projected cost savings of $171,331 per year (cost of a colonoscopy assumed at $2347).

Limitations

The limitation of the study was possible enhanced performance secondary to being observed (Hawthorne effect). Because more than 1 intervention was used, we do not know which one is more effective.

Conclusions

Relatively simple and easy-to-implement quality improvement initiatives can significantly enhance compliance with postpolypectomy guidelines and result in cost savings because of a reduction in the number of postpolypectomy surveillance colonoscopies being scheduled earlier than recommended guidelines.

Section snippets

Material and methods

This CQI intervention study consisted of a single-arm, pretest-posttest design. It was conducted at MetroHealth Medical Center (MHMC) in Cleveland, Ohio, USA. MHMC is a county hospital and a tertiary care, academic medical center, with an Accreditation Council for Graduate Medical Education-approved gastroenterology fellowship program. There are 10 attending gastroenterologists and 8 fellows in training at our institution. All attendings are full-time salaried faculty members of the hospital.

Results

There were a total of 389 patients in the baseline period and 346 in the postintervention period who underwent a colonoscopy with polypectomy, of which 111 and 94, respectively, were excluded from the analysis because of various exclusion criteria (Table 2). Hence, there were 278 patients in the baseline period and 242 patients in the postintervention period who were analyzed. Patient and polyp characteristics were similar in both periods (Table 3, Table 4).

The effects of the CQI intervention

Discussion

The key findings of this study are that there is considerable noncompliance with postpolypectomy surveillance guidelines and that a relatively simple intervention can significantly improve the compliance rates. This improved compliance results in reducing the number of postpolypectomy surveillance colonoscopies being scheduled earlier than suggested by guidelines.

Despite having evidence-based guidelines for screening and postpolypectomy surveillance colonoscopies from professional subspecialty

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Almost one-third of patients with colorectal cancer (CRC) experience recurrence after resection. Adherence to surveillance guidelines largely dictates efficacy in early detection of recurrence. We sought to assess and compare adherence to postoperative surveillance guidelines for colonoscopy, imaging, and Carcinoembryonic Antigen (CEA).
PubMed, Medline, Embase, Scopus, Cochrane, Web of Science, and CINAHL were systematically searched. Random-effects meta-analysis was performed and pooled adherence to each surveillance strategy was assessed for CEA, imaging, and colonoscopy.
Overall 14 studies (55,895 patients) met the inclusion criteria. Adherence to colonoscopy guidelines was the highest (70%, 95%CI 67–73), followed by imaging (63%, 95%CI 47–80), and CEA (54%; 95%CI 42–66). Among 7 (50%) studies that examined adherence to the American Society of Clinical Oncology guidelines, compliance with colonoscopy was the highest (73%; 95% CI 70–76), followed by imaging (58%; 95% CI 37–78), and CEA (45%; 95%CI 37–52). Of note, guideline adherence to CEA testing was much lower than colonoscopy among patients with colon (OR 0.21; 95%CI 0.20–0.22) and rectal cancer (OR 0.25; 95%CI 0.23–0.28) (both p < 0.05). This was also noted when compared with imaging recommendations among older patients (OR = 0.62; 95%CI 0.42–0.93) and patients with stage II, (OR = 0.80; 95%CI 0.76–0.84) and stage III disease (OR = 0.88; 95%CI 0.82–0.94) (all p < 0.05).
While guideline adherence to postoperative surveillance with colonoscopy was high, adherence to CEA testing and imaging surveillance strategies was markedly lower following CRC resection. Future studies should investigate avenues to improve compliance with surveillance guidelines among health care providers and patients to optimize postoperative follow-up for CRC.
Real-world compliance with the 2020 U.S. Multi-Society Task Force on Colorectal Cancer polypectomy surveillance guidelines: an observational study
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Overuse of screening colonoscopy increases cost and procedural adverse events, but inadequate surveillance can miss the development of colorectal cancer. We measured compliance with the 2020 U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF) polypectomy surveillance guidelines in clinical records and a survey.
We performed a retrospective study comparing surveillance intervals for first-time average-risk colonoscopies with the 2020 USMSTF guidelines. Cases were analyzed from 3 intervals (March 2021 to May 2021, November 2021 to January 2022, and April 2022 to May 2022), collectively termed the postguideline period, and a baseline period from November 2019 to January 2020. Real-world compliance rates were compared with results of a survey conducted between November 2020 and February 2021.
Overall compliance was 48.9% among 532 colonoscopies, ranging from 8.3% for low-risk adenomas (LRAs), 88.3% for high-risk adenomas, 63.1% for sessile serrated polyps (SSPs), and 88.6% for hyperplastic polyps. Compliance for LRA increased from the baseline period (.8% vs 8.3%, P = .003), and 95.3% of nonadherent LRA cases followed the 2012 USMSTF guidelines. Compliance for LRAs was 18.6% among respondents who provided a compliant surveillance interval for LRAs in the survey. Noncompliance was associated with finishing training >10 years ago (odds ratio, 1.9; 95% confidence interval, 1.4-2.7) and performing over 800 colonoscopies annually (odds ratio, 2.0; 95% confidence interval, 1.5-2.6).
Adoption of the 2020 USMSTF surveillance guidelines remains low at 2 years. Further research into outcomes for patients with LRAs and SSPs may increase guideline adoption.
Surveillance Colonoscopy After Polypectomy—Current Evidence and Future Directions
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Colorectal cancer (CRC) incidence continues to steadily rise in various parts of the world, and there remains an urgent need for effective interventions to tackle this. Effective and timely implementation of CRC screening interventions and adherence to post polypectomy surveillance recommendations remain paramount. Colonoscopy is the gold standard for timely diagnosis and removal of precursor lesions or polyps to CRC; however, patient uptake and cost effectiveness, especially in the era of noninvasive testing strategies, require closer evaluation. Furthermore, the risk of progression to CRC varies with the morphology, size, and histology of colorectal polyps. Several colonoscopy-based resection techniques have been reported in literature to effectively and safely remove these precursor lesions. In this review, we summarize the current guidelines (US and Europe) and evidence for the effectiveness of post-polypectomy surveillance, resection, and surveillance for sessile serrated lesions. We also appraise the current literature regarding non-colonoscopy options for post colonoscopy surveillance, as well as interventions to boost adherence to surveillance.
What Is Organized Screening and What Is Its Value?
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Organization of surveillance in GI practice
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Citation Excerpt :
The findings of higher proportion of correct surveillance timing among examinations performed within organised population based screening programmes, as compared to community practice [31], would support the role of practice organisation in enabling implementation of guidelines and in reinforcing clinicians adherence with recommendations. Indeed, interventions combining the dissemination of guidelines (using wallet-size cards, printed schemes displayed in the clinic) with supervision of the application by a nurse coordinator [41], or with a monthly continuous quality improvement meeting [68], resulted in an increase from 37% to 96% or from 57% to 81% in the proportion of indications for post-polypectomy surveillance matching the guidelines. Patients compliance with recommended post-polypectomy surveillance intervals ranges between 30% and 80% [42], with low levels of compliance, also among patients detected with HR lesions [1].
Several reports documented an inefficient utilisation of available resources, as well as a suboptimal compliance with surveillance recommendations. Although, evidence suggests that organisational issues can influence the quality of care delivered, surveillance protocols are usually based on non-organized approaches.
We conducted a literature search (publication date: 01/2000-06/2016) on PubMed and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Cochrane Central Register of Controlled Trials for guidelines, or consensus statements, for surveys of practice, reporting information about patients, or providers attitudes and behaviours, for intervention studies to enhance compliance with guidelines. Related articles were also scrutinised. Based on the clinical relevance and burden on endoscopy services this review was focused on surveillance for Barrett's oesophagus, IBD and post-polypectomy surveillance of colonic adenomas.
Existing guidelines are generally recognising structure and process requirements influencing delivery of surveillance interventions, while less attention had been devoted to transitions and interfaces in the care process. Available evidence from practice surveys is suggesting the need to design organizational strategies aimed to enable patients to attend and providers to deliver timely and appropriate care. Well designed studies assessing the effectiveness of specific interventions in this setting are however lacking. Indirect evidence from screening settings would suggest that the implementation of automated standardized recall systems, utilisation of clinical registries, removing financial barriers, could improve appropriateness of use and compliance with recommendations.
Lack of sound evidence regarding utility and methodology of surveillance can contribute to explain the observed variability in providers and patients attitudes and in compliance with the recommended surveillance.
Pre- and post-procedural quality indicators for colonoscopy: A nationwide survey
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The provision of high-quality colonoscopy can be assessed by evaluating technical aspects of the procedure and, at individual center level, by comparing structural indicators and institutional policies for managing peri-procedural issues with guideline recommendations.
To assess the colonoscopy quality (CQ) in Italy at center level.
Gastroenterologists participating in a nationwide colonoscopy education initiative provided information on structural indicators of their centers and on institutional policies by answering 10 multiple-choice clinical scenarios. Practice variation across centers and compliance with guidelines were analyzed.
Data from 282 Italian centers were evaluated. Overall, a significant proportion of centers did not meet CQ standards as concerns endoscopy facilities and equipments (e.g., dedicated recovery room, dirty-to-clean path, reporting software). CQ assurance programs were implemented in only 25% of centers. Concerning peri-procedural issues, main discrepancies with guidelines were recorded in the underuse of split-dose preparation (routinely adopted by 18% of centers), the routine request of coagulation tests prior to colonoscopy (30%), the routine interruption of aspirin for polypectomy (18%), and the adoption of 3-year surveillance for low-risk adenoma (49%).
Present survey shows a significant variation in the CQ of endoscopy centers in Italy on many items of colonoscopy practice that should be targeted for future interventions.

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This study was presented as a poster at the 69th annual scientific meeting of American College of Gastroenterology, October 29-November 3, 2004, Orlando, Florida (Am J Gastroenterol 2004;99:S329).

This study was supported, in part, by an NIH grant (#MOIRR000080) provided to General Clinical Research Center at Case Western Reserve University/MetroHealth Medical Center, Cleveland, Ohio.

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Original ArticleImproving compliance with postpolypectomy surveillance guidelines: an interventional study using a continuous quality improvement initiative

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measures

Results

Limitations

Conclusions

Section snippets

Material and methods

Results

Discussion

Gastroenterology

Am J Gastroenterol

Am J Med

Gastroenterology

Gastroenterology

Am J Gastroenterol

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastroenterology

Am J Gastroenterol

J Clin Epidemiol

Feasibility of colonoscopy screening: discussion of issues and recommendations regarding implementation

Gastrointest Endosc

Original Article
Improving compliance with postpolypectomy surveillance guidelines: an interventional study using a continuous quality improvement initiative