Colorectal cancer (CRC) screening can reduce CRC incidence and mortality.1 Although CRC screening can be performed using stool-based methods or colonoscopy, many US providers prefer colonoscopy because it is both diagnostic and therapeutic, permitting simultaneous removal of precancerous lesions.2,3
Surveillance colonoscopy is required after polypectomy given an elevated risk of recurrent polyps and cancer.4,5 The long-term effectiveness of colonoscopy-based screening depends on appropriate surveillance intervals; however, previous studies suggest there is substantial overuse and underuse.6–8 Underuse may increase risk of interval cancer and cancer-related mortality,9,10 whereas overuse is associated with unnecessary costs and an increased risk of potential harms.5,11–14 Appropriate surveillance colonoscopy intervals, a focus of healthcare reform in gastroenterology, is one of the Centers for Medicare and Medicaid Services Physician Quality Reporting System measures.
A prior study at Parkland Health and Hospital System, the sole safety-net healthcare system for Dallas County, demonstrated guideline-adherent surveillance intervals in 77.4% of patients who underwent a polypectomy during colonoscopy.15 Recommendations representing potential overuse, underuse, and missing surveillance recommendations were observed in 14.4%, 4.7%, and 3.5% of patients, respectively. To address this, we developed and implemented an electronic medical record (EMR)–based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS) in December 2013. CoRS is a user-friendly, EMR-based template that captures data from colonoscopy and pathology reports and uses a computerized algorithm to generate tailored, guideline-adherent recommendations for the next surveillance colonoscopy after polypectomy.16 The CoRS algorithm is based on published guidelines and produces tailored reporting letters (in English and Spanish) for patients and their referring physicians. Provider acceptance and use in clinical practice exceeded 90% during the first 6 months after implementation. However, prior studies have shown that early provider acceptance of new interventions can decrease over time.16 Further, the impact of CoRS on guideline adherence to surveillance recommendations was unknown.
The goals of our study were to (1) evaluate the impact of CoRS implementation on guideline adherence of surveillance recommendations, (2) identify additional factors associated with guideline-adherent surveillance recommendations among patients who underwent colonoscopy with polypectomy, and (3) identify factors associated with providers' use of CoRS at an academic safety-net health system.
US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med2008;149:627–637.
ElmunzerBJSingalAGSussmanJB. Comparing the effectiveness of competing tests for reducing colorectal cancer mortality: a network meta-analysis. Gastrointest Endosc2015;81:700–709.e703.
LiebermanDARexDKWinawerSJ. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology2012;143:844–857.
SainiSDSchoenfeldPVijanS. Surveillance colonoscopy is cost-effective for patients with adenomas who are at high risk of colorectal cancer. Gastroenterology2010;138:2292–2299.e2291.
le ClercqCMBouwensMWRondaghEJ. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut2014;63:957–963.
Sint NicolaasJde JongeVvan BaalenO. Optimal resource allocation in colonoscopy: timing of follow-up colonoscopies in relation to adenoma detection rates. Endoscopy2013;45:545–552.
SeeffLCManninenDLDongFB. Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?Gastroenterology2004;127:1661–1669.
KristAHJonesRMWoolfSH. Timing of repeat colonoscopy: disparity between guidelines and endoscopists' recommendation. Am J Prev Med2007;33:471–478.
MysliwiecPABrownMLKlabundeCNRansohoffDF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med2004;141:264–271.
SchreudersENicolaasJSde JongeV. The appropriateness of surveillance colonoscopy intervals after polypectomy. Can J Gastroenterol2013;27:33–38.
KahnBFreelandZGopalP. Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system. Cancer Causes Control2015;26:1653–1660.
SkinnerCSGuptaSHalmEA. Development of the Parkland-UT Southwestern Colonoscopy Reporting System (CoRS) for evidence-based colon cancer surveillance recommendations. J Am Med Inform Assoc2016;23:402–406.
LaiEJCalderwoodAHDorosG. The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc2009;69:620–625.
ZhangJYuKF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA1998;280:1690–1691.
KimERSinnDHKimJY. Factors associated with adherence to the recommended postpolypectomy surveillance interval. Surg Endosc2012;26:1690–1695.
JohnsonMRGrubberJGrambowSC. Physician non-adherence to colonoscopy interval guidelines in the Veterans Affairs healthcare system. Gastroenterology2015;149:938–951.
RansohoffDFYankaskasBGizliceZGangarosaL. Recommendations for post-polypectomy surveillance in community practice. Dig Dis Sci2011;56:2623–2630.
KingsleyJKaranthSRevereFLAgrawalD. Cost effectiveness of screening colonoscopy depends on adequate bowel preparation rates – a modeling study. PLoS One2016;11:e0167452.
CohenBTangRSGroesslE. Effectiveness of a simplified “patient friendly” split dose polyethylene glycol colonoscopy prep in Veterans Health Administration patients. J Interv Gastroenterol2012;2:177–182.
MeneesSBKimHMElliottEE. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc2013;78:510–516.
CalderwoodAHThompsonKDSchroyPCIII. Good is better than excellent: bowel preparation quality and adenoma detection rates. Gastrointest Endosc2015;81:691–699.e691.
LebwohlBKastrinosFGlickM. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointest Endosc2011;73:1207–1214.
AdlerJRobertsonDJ. Interval colorectal cancer after colonoscopy: exploring explanations and solutions. Am J Gastroenterol2015;110:1657–1664.
PatelNTongLAhnC. Post-polypectomy guideline adherence: importance of belief in guidelines, not guideline knowledge or fear of missed cancer. Dig Dis Sci2015;60:2937–2945.
SainiSDNayakRSKuhnLSchoenfeldP. Why don't gastroenterologists follow colon polyp surveillance guidelines?: results of a national survey. J Clin Gastroenterol2009;43:554–558.
ShahTUVoilsCIMcNeilR. Understanding gastroenterologist adherence to polyp surveillance guidelines. Am J Gastroenterol2012;107:1283–1287.
CresswellKMBatesDWSkeikhA. Ten key considerations for the successful implementation and adoption of large-scale health information technology. J Am Med Inform Assoc2013;20:e9–13.
American Gastroenterological Association. AGA Institute guidelines for colonoscopy surveillance after cancer resection: clinical decision tool. Gastroenterology2014;146:1413–1414.
ImlerTDMoreaJImperialeTF. Clinical decision support with natural language processing facilitates determination of colonoscopy surveillance intervals. Clin Gastroenterol Hepatol2014;12:1130–1136.
LeimanDAMetzDCGinsbergGG. A novel electronic medical record–based workflow to measure and report colonoscopy quality measures. Clin Gastroenterol Hepatol2016;14:333–337.e331.
MurphyCCSandlerRSGrubberJM. Underuse and overuse of colonoscopy for repeat screening and surveillance in the Veterans Health Administration. Clin Gastroenterol Hepatol2016;14:436–444.