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Accuracy of Referring Provider and Endoscopist Impressions of Colonoscopy Indication

Mariam Naveed, Meredith Clary, Chul Ahn, Nisa Kubiliun, Deepak Agrawal, Byron Cryer, Caitlin Murphy, and Amit G. Singal

Background: Referring provider and endoscopist impressions of colonoscopy indication are used for clinical care, reimbursement, and quality reporting decisions; however, the accuracy of these impressions is unknown. This study assessed the sensitivity, specificity, positive and negative predictive value, and overall accuracy of methods to classify colonoscopy indication, including referring provider impression, endoscopist impression, and administrative algorithm compared with gold standard chart review. Methods: We randomly sampled 400 patients undergoing a colonoscopy at a Veterans Affairs health system between January 2010 and December 2010. Referring provider and endoscopist impressions of colonoscopy indication were compared with gold-standard chart review. Indications were classified into 4 mutually exclusive categories: diagnostic, surveillance, high-risk screening, or average-risk screening. Results: Of 400 colonoscopies, 26% were performed for average-risk screening, 7% for high-risk screening, 26% for surveillance, and 41% for diagnostic indications. Accuracy of referring provider and endoscopist impressions of colonoscopy indication were 87% and 84%, respectively, which were significantly higher than that of the administrative algorithm (45%; P<.001 for both). There was substantial agreement between endoscopist and referring provider impressions (κ=0.76). All 3 methods showed high sensitivity (>90%) for determining screening (vs nonscreening) indication, but specificity of the administrative algorithm was lower (40.3%) compared with referring provider (93.7%) and endoscopist (84.0%) impressions. Accuracy of endoscopist, but not referring provider, impression was lower in patients with a family history of colon cancer than in those without (65% vs 84%; P=.001). Conclusions: Referring provider and endoscopist impressions of colonoscopy indication are both accurate and may be useful data to incorporate into algorithms classifying colonoscopy indication.

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Sociodemographic Disparities in the Receipt of Adjuvant Chemotherapy Among Patients With Resected Stage I–III Pancreatic Adenocarcinoma

Nina N. Sanford, Todd A. Aguilera, Michael R. Folkert, Chul Ahn, Brandon A. Mahal, Herbert Zeh, Muhammad S. Beg, John Mansour, and David J. Sher

Background: Adjuvant therapy for resected pancreatic adenocarcinoma was given a category 1 NCCN recommendation in 2000, yet many patients do not receive chemotherapy after definitive surgery. Whether sociodemographic disparities exist for receipt of adjuvant chemotherapy is poorly understood. Methods: The National Cancer Database was used to identify patients diagnosed with nonmetastatic pancreatic adenocarcinoma who underwent definitive surgery from 2004 through 2015. Multivariable logistic regression defined the adjusted odds ratio (aOR) and associated 95% CI of receipt of adjuvant chemotherapy. Among patients receiving chemotherapy, multivariable logistic regression assessed the odds of treatment with multiagent chemotherapy. Results: Among 18,463 patients, 11,288 (61.1%) received any adjuvant chemotherapy. Sociodemographic factors inversely associated with receipt of any adjuvant chemotherapy included uninsured status (aOR, 0.61; 95% CI, 0.50–0.74), Medicaid insurance (aOR, 0.66; 95% CI, 0.57–0.77), and lower income (P<.001 for all income levels compared with ≥$46,000). Black race (aOR, 0.72; 95% CI, 0.57–0.90) and female sex (aOR, 0.75; 95% CI, 0.65–0.86) were associated with lower odds of receiving multiagent chemotherapy. There was a statistically significant interaction term between black race and age/comorbidity status (P=.03), such that 26.4% of black versus 35.8% of nonblack young (aged ≤65 years) and healthy (Charlson-Deyo comorbidity score 0) patients received multiagent adjuvant chemotherapy (P=.006), whereas multiagent adjuvant chemotherapy rates were similar among patients who were not young and healthy (P=.15). Conclusions: In this nationally representative study, receipt of adjuvant chemotherapy appeared to be associated with sociodemographic characteristics, independent of clinical factors. Sociodemographic differences in receipt of adjuvant chemotherapy may represent a missed opportunity for improving outcomes and a driver of oncologic disparities.

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Alcohol Use Among Patients With Cancer and Survivors in the United States, 2000–2017

Nina N. Sanford, David J. Sher, Xiaohan Xu, Chul Ahn, Anthony V. D’Amico, Ayal A. Aizer, and Brandon A. Mahal

Background: Alcohol use is an established risk factor for several malignancies and is associated with adverse oncologic outcomes among individuals diagnosed with cancer. The prevalence and patterns of alcohol use among cancer survivors are poorly described. Methods: We used the National Health Interview Survey from 2000 to 2017 to examine alcohol drinking prevalence and patterns among adults reporting a cancer diagnosis. Multivariable logistic regression was used to define the association between demographic and socioeconomic variables and odds of self-reporting as a current drinker, exceeding moderate drinking limits, and engaging in binge drinking. The association between specific cancer type and odds of drinking were assessed. Results: Among 34,080 survey participants with a known cancer diagnosis, 56.5% self-reported as current drinkers, including 34.9% who exceeded moderate drinking limits and 21.0% who engaged in binge drinking. Younger age, smoking history, and more recent survey period were associated with higher odds of current, exceeding moderate, and binge drinking (P<.001 for all, except P=.008 for excess drinking). Similar associations persisted when the cohort was limited to 20,828 cancer survivors diagnosed ≥5 years before survey administration. Diagnoses of melanoma and cervical, head and neck, and testicular cancers were associated with higher odds of binge drinking (P<.05 for all) compared with other cancer diagnoses. Conclusions: Most cancer survivors self-report as current alcohol drinkers, including a subset who seem to engage in excessive drinking behaviors. Given that alcohol intake has implications for cancer prevention and is a potentially modifiable risk factor for cancer-specific outcomes, the high prevalence of alcohol use among cancer survivors highlights the need for public health strategies aimed at the reduction of alcohol consumption.

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Impact of a Clinical Decision Support System on Guideline Adherence of Surveillance Recommendations for Colonoscopy After Polypectomy

Melissa Magrath, Edward Yang, Chul Ahn, Christian A. Mayorga, Purva Gopal, Caitlin C. Murphy, Samir Gupta, Deepak Agrawal, Ethan A. Halm, Eric K. Borton, Celette Sugg Skinner, and Amit G. Singal

Background: Surveillance colonoscopy is required in patients with polyps due to an elevated colorectal cancer (CRC) risk; however, studies suggest substantial overuse and underuse of surveillance colonoscopy. The goal of this study was to characterize guideline adherence of surveillance recommendations after implementation of an electronic medical record (EMR)–based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS). Methods: We performed a retrospective cohort study of patients who underwent colonoscopy with polypectomy at a safety-net healthcare system before (n=1,822) and after (n=1,320) implementation of CoRS in December 2013. Recommendations were classified as guideline-adherent or nonadherent according to the US Multi-Society Task Force on CRC. We defined surveillance recommendations shorter and longer than guideline recommendations as potential overuse and underuse, respectively. We used multivariable generalized linear mixed models to identify correlates of guideline-adherent recommendations. Results: The proportion of guideline-adherent surveillance recommendations was significantly higher post-CoRS than pre-CoRS (84.6% vs 77.4%; P<.001), with fewer recommendations for potential overuse and underuse. In the post-CoRS period, CoRS was used for 89.8% of cases and, compared with cases for which it was not used, was associated with a higher proportion of guideline-adherent recommendations (87.0% vs 63.4%; RR, 1.34; 95% CI, 1.23–1.42). In multivariable analysis, surveillance recommendations were also more likely to be guideline-adherent in patients with adenomas but less likely among those with fair bowel preparation and those with family history of CRC. Of 203 nonadherent recommendations, 70.4% were considered potential overuse, 20.2% potential underuse, and 9.4% were not provided surveillance recommendations. Conclusions: An EMR-based CoRS was widely used and significantly improved guideline adherence of surveillance recommendations.