Do Explicit Appropriateness Criteria Enhance the Diagnostic Yield of Colonoscopy?

Background and Study Aims: Appropriateness of use of colonoscopy is an important issue in health care in the quest to improve quality of care while at the same time containing costs. This prospective study examined whether detailed and explicit appropriateness criteria significantly improve the diagnostic yield of colonoscopy.
Patients and Methods: Consecutive patients referred for diagnostic colonoscopy at five centers (one university hospital and its outpatient department, two district hospitals, and two gastroenterology practices) were prospectively studied over a 17-month period. The appropriateness of the indications for these colonoscopies was assessed using explicit Swiss criteria developed by the Rand Corporation/University of California at Los Angeles (RAND/UCLA) panel method, and the relationship between appropriateness of use and the presence of clinically relevant endoscopic lesions was analysed.
Results: 1188 patients were included in the study. Indications for 1144 (96.3 %) of the colonoscopies could be evaluated using explicit criteria; 64.1 % of the colonoscopies were judged appropriate, 13.3 % uncertain and 22.6 % inappropriate. Significant endoscopic lesions were found in 23.8 % of the colonoscopies. Colonoscopies judged appropriate or uncertain yielded significantly more relevant lesions than did those judged to be inappropriate (25.6 % vs. 17.4 %; P = 0.007). Of 51 colon cancers, all but one were found in colonoscopies judged to be appropriate or uncertain. In a multivariate analysis, the diagnostic yield of colonoscopy was significantly influenced by appropriateness, patient gender and treatment setting.
Conclusions: The use of detailed and explicit appropriateness criteria for colonoscopy significantly enhances the identification of relevant lesions and in particular of colon cancer. The use of such criteria could therefore improve patient selection for colonoscopy and thus contribute to efforts aimed at enhancing the quality and efficiency of care.

References

• 1 Rosenberg W, Donald A. Evidence based medicine an approach to clinical problem-solving.  BMJ. 1995;  310 1122- 1126
• 2 Brook R H, Chassin M R, Fink A. et al .A method for the detailed assessment of the appropriateness of medical technologies. Santa Monica, California; Rand 1991
• 3 Brook R H, Chassin M, Fink A. et al . A method for the detailed assessment of the appropriateness of medical technologies.  Int J Technol Assess Health Care. 1986;  21 53-63
• 4 Park R E, Fink A, Brook R H. et al . Physician ratings of appropriate indications for six medical and surgical procedures.  Am J Public Health. 1986;  76 (7) 766-772
• 5 Brook R H. Appropriateness: the next frontier.  BMJ. 1994;  308 218-219
• 6 Brook R H, Park R E, Chassin M R. et al . Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography.  N Engl J Med. 1990;  323 (17) 1173-1177
• 7 DiMagno E P, Bond J H. Colonoscopy in policy and procedure manual for gastrointestinal endoscopy.  The American Society of Gastrointestinal Endoscopy, Manchester (MA), 1992.. 1998;  30 9-12
• 8 Department of Health Care and Promotion CMA . Workshop on Clinical Practice Guidelines: summary of proceedings.  Can Med Assoc J. 1993;  148 1459-1462
• 9 Kahn K L, Park R E, Vennes J. et al . Assigning appropriateness ratings for diagnostic upper gastrointestinal endoscopy using two different approaches.  Med Care. 1992;  30 (11) 1016-1028
• 10 Woolf S H. Practice guidelines, a new reality in medicine. II. Methods of developing guidelines.  Arch Intern Med. 1992;  152 946-952
• 11 Morrissey J F, Reichelderfer M. Gastrointestinal endoscopy-first of two parts.  N Engl J Med. 1991;  325 1142-1149
• 12 Morrissey J F. The problem of the inappropriate endoscopy.  Ann Intern Med. 1988;  109 (8) 605-606
• 13 Gonvers J J, Burnand B, Froehlich F. et al . Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy unit (see comments).  Endoscopy. 1996;  28 (8) 661-666
• 14 Minoli G, Prada A, Gambetta G. et al . The ASGE guidelines for the appropriate use of upper gastrointestinal endoscopy in an open access system.  Gastrointest Endosc. 1995;  42 387-389
• 15 Mahajan R J, Barthel J S, Marshall J B. Appropriateness of referrals for open-access endoscopy.  Arch Intern Med. 1996;  156 2065-2069
• 16 Froehlich F, Burnand B, Pache I. et al . Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care.  Gastrointest Endosc. 1997;  45 (1) 13-19
• 17 Kahn K L, Kosecoff J, Chassin M R. et al . The use and misuse of upper gastrointestinal endoscopy.  Ann Intern Med. 1988;  109 (8) 664-670
• 18 Brook R H, Park R E, Chassin M R. et al . Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography.  N Engl J Med. 1990;  323 (17) 1173-1177
• 19 Quine M A, McCloy R F, Devlin B H. et al . Appropriate use of upper gastrointestinal endoscopy - a prospective audit.  Gut. 1994;  35 1209-1214
• 20 Vader J P, Pache I, Froehlich F. et al . Overuse and underuse of colonoscopy in a European primary care setting.  Gastrointest Endosc. 2000;  52 593-599
• 21 Froehlich F, Pache I, Burnand B. et al . Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study.  Gastrointest Endosc. 1998;  48 128-136
• 22 Mahajan R J, Barthel J S, Marshall J B. Appropriateness of referrals for open-access endoscopy. How do physicians in different medical specialties do?.  Arch Int Med. 1996;  156 (18) 2065-2069
• 23 Minoli G, Meucci G, Bortoli A. et al . The ASGE guidelines for the appropriate use of colonoscopy in an open access system.  Gastrointest Endosc. 2000;  52 39-44
• 24 Morini S, Hassan C, Meucci G. et al . Diagnostic yield of open access colonoscopy according to appropriateness.  Gastrointest Endosc. 2001;  54 175-179
• 25 Naji S A, Brunt P W, Hagen S. et al . Improving the selection of patients for upper gastrointestinal endoscopy.  Gut. 1993;  34 187-191
• 26 Holdstock G, Harman M, Machin D. et al . Prospective testing of a scoring system designed to improve case selection for upper gastrointestinal investigation.  Gastroenterology. 1986;  90 (5:Pt1) 1164-1169
• 27 Chassin M R, Kosecoff J, Solomon D H. et al . How coronary angiography is used. Clinical determinants of appropriateness.  JAMA. 1987;  258 1-5
• 28 Korkis A M, McDougall C J. Rectal bleeding in patients less than 50 years of age.  Dig Dis Sci. 1995;  40 (7) 1520-1523.
• 29 Shinya H, Cwern M, Wolf G. Colonoscopic diagnosis and management of rectal bleeding.  Surg Clin N Am. 1982;  62 (5) 897-903
• 30 Irvine E J, O'Connor J, Frost R A. et al . Prospective comparison of double contrast barium enema plus flexible sigmoidoscopy v colonoscopy in rectal bleeding: barium enema v colonoscopy in rectal bleeding.  Gut. 1988;  29 (9) 1188-1193
• 31 Mulcahy H E, Patel R S, Mokhashi M S. et al . Low yield of significant pathology when colonoscopy is performed for isolated abdominal pain: a multicenter database analysis of 15 550 patients.  Gastrointest Endosc. 2000;  51 (4 part 2) AB135
• 32 Berkowitz I, Kaplan M. Indications for colonoscopy. An analysis based on indications and diagnostic yield (see comments).  S Afr Med J. 1993;  83 (4) 245-248
• 33 Fockens P, Tytgat G N. Role of endoscopy in the follow-up of inflammatory bowel disease.  Endoscopy. 1992;  24 (6) 582-584
• 34 Winawer S J, Zauber A G, O'Brien M J. et al . The National Polyp Study. Design, methods, and characteristics of patients with newly diagnosed polyps. The National Polyp Study Workgroup.  Cancer. 1992;  70 1236-1245
• 35 Jorgensen O D. A randomized surveillance study of patients with pedunculated and small sessile tubular and tubulovillous adenomas. The funen adenoma follow-up study.  Scand J Gastroenterol. 1995;  30 686-692
• 36 Rex D K. Surveillance colonoscopy after resection of colorectal polyps and cancer.  ASGE Clinical Update. 1998;  6 (2) 1-4
• 37 Ibach M B, Grier J F, Goldman D E. et al . Diagnostic considerations in evaluation of patients presenting with melena and nondiagnostic esophagogastro-duodenoscopy.  Dig Dis Sci. 1995;  40 (7) 1459-1462
• 38 Neugut A I, Garbowski G C, Waye J D. et al . Diagnostic yield of colorectal neoplasie with colonoscopy for abdominal pain, change in bowel habits, and rectal bleeding.  Am J Gastroenterol. 1993;  88 1179-1183
• 39 Helfand M, Marton K I, Zimmer-Gembeck M J. et al . History of visible rectal bleeding in a primary care population.  JAMA. 1997;  277 44-48
• 40 European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) . .  Endoscopy. 1999;  31 571-696