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.
Dr. Gupta has disclosed that he is a consultant for Boston Scientific. The remaining authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.
This study was conducted as part of the NCI-funded consortium Population-Based Research Optimizing Screening through Personalized Regiments (PROSPR) with support from NIH/NCI (U54CA163308-01) and NIH/NCI (P30 CA142543). Research reported in this publication was also supported in part by the National Center for Advancing Translational Sciences of the NIH (UL1TR001105). Dr. Halm was supported in part by the AHRQ Center for Patient-Centered Outcomes Research (R24 HS022418). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or AHRQ.
US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2008;149:627–637.
Elmunzer BJ, Singal AG, Sussman JB et al.. Comparing the effectiveness of competing tests for reducing colorectal cancer mortality: a network meta-analysis. Gastrointest Endosc 2015;81:700–709.e703.
Lieberman DA, Rex DK, Winawer SJ et al.. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844–857.
Saini SD, Schoenfeld P, Vijan S. Surveillance colonoscopy is cost-effective for patients with adenomas who are at high risk of colorectal cancer. Gastroenterology 2010;138:2292–2299.e2291.
Cooper GS, Kou TD, Barnholtz Sloan JS et al.. Use of colonoscopy for polyp surveillance in Medicare beneficiaries. Cancer 2013;119:1800–1807.
Goodwin JS, Singh A, Reddy N et al.. Overuse of screening colonoscopy in the Medicare population. Arch Intern Med 2011;171:1335–1343.
Schoen RE, Pinsky PF, Weissfeld JL et al.. Utilization of surveillance colonoscopy in community practice. Gastroenterology 2010;138:73–81.
le Clercq CM, Bouwens MW, Rondagh EJ et al.. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 2014;63:957–963.
Sint Nicolaas J, de Jonge V, van Baalen O et al.. Optimal resource allocation in colonoscopy: timing of follow-up colonoscopies in relation to adenoma detection rates. Endoscopy 2013;45:545–552.
Seeff LC, Manninen DL, Dong FB et al.. Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States? Gastroenterology 2004;127:1661–1669.
Krist AH, Jones RM, Woolf SH et al.. Timing of repeat colonoscopy: disparity between guidelines and endoscopists' recommendation. Am J Prev Med 2007;33:471–478.
Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004;141:264–271.
Schreuders E, Nicolaas JS, de Jonge V et al.. The appropriateness of surveillance colonoscopy intervals after polypectomy. Can J Gastroenterol 2013;27:33–38.
Kahn B, Freeland Z, Gopal P et al.. Predictors of guideline concordance for surveillance colonoscopy recommendations in patients at a safety-net health system. Cancer Causes Control 2015;26:1653–1660.
Skinner CS, Gupta S, Halm EA et al.. Development of the Parkland-UT Southwestern Colonoscopy Reporting System (CoRS) for evidence-based colon cancer surveillance recommendations. J Am Med Inform Assoc 2016;23:402–406.
Lai EJ, Calderwood AH, Doros G et al.. The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009;69:620–625.
Zhang J, Yu KF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280:1690–1691.
Kim ER, Sinn DH, Kim JY et al.. Factors associated with adherence to the recommended postpolypectomy surveillance interval. Surg Endosc 2012;26:1690–1695.
Johnson MR, Grubber J, Grambow SC et al.. Physician non-adherence to colonoscopy interval guidelines in the Veterans Affairs healthcare system. Gastroenterology 2015;149:938–951.
Ransohoff DF, Yankaskas B, Gizlice Z, Gangarosa L. Recommendations for post-polypectomy surveillance in community practice. Dig Dis Sci 2011;56:2623–2630.
Kingsley J, Karanth S, Revere FL, Agrawal D. Cost effectiveness of screening colonoscopy depends on adequate bowel preparation rates – a modeling study. PLoS One 2016;11:e0167452.
Cohen B, Tang RS, Groessl E et al.. Effectiveness of a simplified “patient friendly” split dose polyethylene glycol colonoscopy prep in Veterans Health Administration patients. J Interv Gastroenterol 2012;2:177–182.
Menees SB, Kim HM, Elliott EE et al.. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013;78:510–516.
Calderwood AH, Jacobson BC. Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc 2010;72:686–692.
Calderwood AH, Thompson KD, Schroy PC III et al.. Good is better than excellent: bowel preparation quality and adenoma detection rates. Gastrointest Endosc 2015;81:691–699.e691.
Lebwohl B, Kastrinos F, Glick M et al.. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointest Endosc 2011;73:1207–1214.
Adler J, Robertson DJ. Interval colorectal cancer after colonoscopy: exploring explanations and solutions. Am J Gastroenterol 2015;110:1657–1664.
Patel N, Tong L, Ahn C et al.. Post-polypectomy guideline adherence: importance of belief in guidelines, not guideline knowledge or fear of missed cancer. Dig Dis Sci 2015;60:2937–2945.
Saini SD, Nayak RS, Kuhn L, Schoenfeld P. Why don't gastroenterologists follow colon polyp surveillance guidelines?: results of a national survey. J Clin Gastroenterol 2009;43:554–558.
Shah TU, Voils CI, McNeil R et al.. Understanding gastroenterologist adherence to polyp surveillance guidelines. Am J Gastroenterol 2012;107:1283–1287.
Cresswell KM, Bates DW, Skeikh A. Ten key considerations for the successful implementation and adoption of large-scale health information technology. J Am Med Inform Assoc 2013;20:e9–13.
American Gastroenterological Association. AGA Institute guidelines for colonoscopy surveillance after cancer resection: clinical decision tool. Gastroenterology 2014;146:1413–1414.
Imler TD, Morea J, Imperiale TF. Clinical decision support with natural language processing facilitates determination of colonoscopy surveillance intervals. Clin Gastroenterol Hepatol 2014;12:1130–1136.
Leiman DA, Metz DC, Ginsberg GG et al.. A novel electronic medical record–based workflow to measure and report colonoscopy quality measures. Clin Gastroenterol Hepatol 2016;14:333–337.e331.
Murphy CC, Sandler RS, Grubber JM et al.. Underuse and overuse of colonoscopy for repeat screening and surveillance in the Veterans Health Administration. Clin Gastroenterol Hepatol 2016;14:436–444.