Gastroenterology

Gastroenterology

Volume 140, Issue 1, January 2011, Pages 65-72
Gastroenterology

Clinical—Alimentary Tract
Analysis of Administrative Data Finds Endoscopist Quality Measures Associated With Postcolonoscopy Colorectal Cancer

https://doi.org/10.1053/j.gastro.2010.09.006Get rights and content

Background & Aims

Most quality indicators for colonoscopy measure processes; little is known about their relationship to patient outcomes. We investigated whether characteristics of endoscopists, determined from administrative data, are associated with development of postcolonoscopy colorectal cancer (PCCRC).

Methods

We identified individuals diagnosed with colorectal cancer in Ontario from 2000 to 2005 using the Ontario Cancer Registry. We determined performance of colonoscopy using Ontario Health Insurance Plan data. Patients who had complete colonoscopies 7 to 36 months before diagnosis were defined as having a PCCRC. Patients who had complete colonoscopies within 6 months of diagnosis had detected cancers. We determined if endoscopist factors (volume, polypectomy and completion rate, specialization, and setting) were associated with PCCRC using logistic regression, controlling for potential covariates.

Results

In the study, 14,064 patients had a colonoscopy examination within 36 months of diagnosis; 584 (6.8%) with distal and 676 (12.4%) with proximal tumors had PCCRC. The endoscopist's specialty (nongastroenterologist/nongeneral surgeon) and setting (non–hospital-based colonoscopy) were associated with PCCRC. Those who underwent colonoscopy by an endoscopist with a high completion rate were less likely to have a PCCRC (distal: odds ratio [OR], 0.73; 95% confidence interval [CI], 0.54–0.97; P = .03; proximal: OR, 0.72; 95% CI, 0.53–0.97; P = .002). Patients with proximal cancers undergoing colonoscopy by endoscopists who performed polypectomies at high rates had a lower risk of PCCRC (OR, 0.61; 95% CI, 0.42–0.89; P < .0001). Endoscopist volume was not associated with PCCRC.

Conclusions

Endoscopist characteristics derived from administrative data are associated with development of PCCRC and have potential use as quality indicators.

Section snippets

Overview of Study Design

This is an observational study of all individuals diagnosed with CRC between January 1, 2000, and December 31, 2005, with a known site of primary who underwent a colonoscopy within 36 months of diagnosis.

Data Sources

We used 5 data sources.

  • 1

    The Ontario Cancer Registry includes information on all incident cancers diagnosed since 1964 in Ontario and is estimated to be more than 95% complete.12

  • 2

    The Ontario Health Insurance Plan database contains information on claims billed by physicians for services, permitting

Results

Of the 34,312 patients in Ontario diagnosed with CRC in our study period, 14,064 had a complete colonoscopy within 36 months of diagnosis and met all study criteria. Of these, 1260 (9.0%) were considered to have a new or missed cancer (PCCRC). Overall, 61.1% of patients with CRC were diagnosed with a distal CRC. Patients with proximal CRC were more likely to have a PCCRC than patients with distal CRC (676 patients with proximal cancer had a PCCRC [12.4%] vs 584 patients [6.8%] with distal

Discussion

Colonoscopy is a common procedure and a key component of CRC control strategies at the population level. Previous studies have documented variation in performance of colonoscopy; adenoma detection rate, for example, is known to vary between endoscopists19, 24 and is associated with factors such as scope withdrawal time,8 a proxy for careful colonoscopy technique. Variation in the quality of colonoscopy likely has an important impact on effectiveness and patient outcomes, and this has led to a

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    Conflicts of interest The authors disclose no conflicts.

    Funding of interest Supported by an American College of Gastroenterology Cancer Prevention Action Plan Grant, the Ontario Institute for Cancer Research, Cancer Care Ontario and by the Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. N.N.B. holds the Cancer Care Ontario Health Services Research Chair and an Early Researchers Award from the Ontario Ministry of Research and Innovation. The funding sources played no role in design, conduct, or reporting of this study. The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by the Institute for Clinical Evaluative Sciences or the Ontario Ministry of Health and Long-Term Care is intended or should be inferred.

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