Colon and Rectal

Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.

Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.

Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.

“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”

The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.

Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.

“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”

There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.

Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.

Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.

“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”

The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.

Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.

“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”

There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

While non-Hispanic white patients had the highest overall rate increase by ethnicity, rising from 5.6 to 10.5 per 100,000 population, rates in non-Hispanic black and Hispanic patients also rose significantly, increasing from 3.5 to 5.8 per 100,000 population, and from 1.1 to 3.7 per 100,000 population, respectively.

Regionally, rates of surgery were higher in the Midwest (10.8 per 100,000) and the South (10.6 per 100,000) than in the Northeast (7.8 per 100,000) and West (7.5 per 100,000). Incidence rates rose equally during the study period for both men and women.

Large urban teaching hospitals were found to have the largest rate increase when data were stratified by teaching status, a finding which caught Dr. Peery and fellow investigators by surprise.

“We had hypothesized that surgery for nonmalignant colorectal polyps would be both uncommon and declining in teaching hospitals where providers are more likely to be familiar with current guidelines and to have access to endoscopic mucosal resection,” wrote the investigators. “Instead, we found that surgery for nonmalignant colorectal polyps is both common and significantly increasing in teaching hospitals.”

The investigators first hypothesized the increased rate in teaching hospitals could be due to a higher concentration of case referrals to these high-volume centers, following a trend of centralizing cancer procedures. However, there has been no other sign that colon and rectal cancer procedures are following this trend.

Another option considered by Dr. Peery and her colleagues was that increased procedures may stem from a rise in colorectal cancer screening; however, the data indicate screenings did not change from 2010 to 2015, leaving investigators with few final guesses to go on.

“It is also conceivable that increasing production pressure and inadequate reimbursement for endoscopic mucosal resection may persuade endoscopists to refer patients with complex nonmalignant colorectal polyps for surgery,” said Dr. Peery and fellow investigators. “Finally, there is the issue of risk ... for endoscopists without additional training in advanced endoscopic resection, these risks may be perceived as too great, especially when they have the option of referring for a surgical resection.”

There is a possibility that the incidence of surgery was over- or underestimated, as investigators were using ICD-9 codes to identify cases, and patients with diverticulitis were also excluded, which may have affected results.

The investigators reported no relevant financial disclosures.

[email protected]

SOURCE: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

LAS VEGAS – Colorectal surgery is rife with potential complications, but there are steps that surgeons can take to improve outcomes, and factors to consider to reduce complications. These strategies and considerations were the focus of a talk by Matthew G. Mutch, MD, at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Prehabilitation

The approach to improve outcomes can begin with prehabilitation – preparing the patient for the difficult process of surgery. “If somebody is going to fight a 15-round heavyweight bout, they train for 6 or 8 weeks before a fight. Why not bring that concept to surgery?” said Dr. Mutch, chief of colon and rectal surgery at the Washington University, St. Louis.

Prehabilitation can include lifestyle changes, such as quitting smoking, but can also incorporate aerobic and/or resistance exercise, dietary counseling and protein supplementation, anxiety reduction, and medical education to prepare the patient for the challenges ahead. “Preoperatively, we try to identify factors to see if we can make meaningful lifestyle changes, because that’s really the grassroots level where a lot of this [improvement in outcomes] is going to occur,” said Dr. Mutch.
 

Frailty

Frailty is a factor driving complications in colorectal surgery. A meta-analysis of 20 studies showed that frailty and prefrailty were associated with worse all-cause mortality during follow-up among older cancer patients. More striking, it showed that frail patients were nearly five times more likely to be intolerant of cancer treatment (odds ratio, 4.86) and more likely to experience postoperative complications (30-day hazard ratio, 3.19) (Ann Oncol. 2015;26[6]:1091-1101).

Hemoglobin A_1c

Dr. Mutch went on to discuss hemoglobin A_1c (HbA_1c) levels as a risk factor in colorectal surgery. HbA_1c levels higher than 6 are associated with worse outcomes, but tight postoperative control is associated with hypoglycemia. “What you want to do is set that patient up before surgery. HbA_1c has a half-life of about a month, so if you start modifying their risk factors 4-6 weeks before you get them into surgery, by 1 month you can see a 50% reduction, and at 2 months a 75% reduction. If you do these things in a preoperative setting it makes a difference,” said Dr. Mutch.

Smoking cessation

Smoking cessation is another key strategy. Two weeks of cessation should lead to a decline in coughing, but a minimum of 4 weeks is needed to significantly reduce overall complications. Lifestyle changes need to be long term. “These are not measures that you’re going to do over a short period of time, and then when surgery is over throw it out the window,” said Dr. Mutch.

Anastomotic leak

Another factor is the detection of anastomotic leak, which can be challenging because its definitions vary significantly, and its causes can be multifactorial. Studies show that predictions of anastomotic leak are not especially successful, Dr. Mutch said, but routine leak testing improves outcomes. In a study of left-side anastomoses in Washington State, hospitals that performed leak tests had lower leak rates at least 90% of the time (OR, 0.23), and hospitals that later implemented leak tests experienced a significant reduction (Arch Surg. 2012:147[4]:345-51).

Venous thromboembolic events

Venous thromboembolic events (VTE), are the leading cause of operative mortality in colorectal surgery patients. This complication can be greatly reduced with prophylaxis, but requires screening for risk factors. Major surgery raises the risk of deep vein thrombosis in 20% of all hospitalized patients to 40%-80%, depending on the surgery type. “We have a lot of room to improve,” said Dr. Mutch.

copyright monkeybusinessimages/Thinkstock

Timing

One factor that may have an impact on complications appears to be timing of surgery, at least at Washington University, where Dr. Mutch practices. The institution found that patients who had surgery the same day they were admitted had a 2.5% VTE risk, compared with 11% in patients who had surgery 5 or more days after admission.

Postop ambulation

Postsurgical ambulation was another critical complication factor. Dr. Mutch cited a study showing that ambulation on the day after surgery was associated with a 1% VTE risk, compared to 6.9% in patients who waited until day 2.

Dr. Mutch had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

LAS VEGAS – Colorectal surgery is rife with potential complications, but there are steps that surgeons can take to improve outcomes, and factors to consider to reduce complications. These strategies and considerations were the focus of a talk by Matthew G. Mutch, MD, at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Prehabilitation

The approach to improve outcomes can begin with prehabilitation – preparing the patient for the difficult process of surgery. “If somebody is going to fight a 15-round heavyweight bout, they train for 6 or 8 weeks before a fight. Why not bring that concept to surgery?” said Dr. Mutch, chief of colon and rectal surgery at the Washington University, St. Louis.

Prehabilitation can include lifestyle changes, such as quitting smoking, but can also incorporate aerobic and/or resistance exercise, dietary counseling and protein supplementation, anxiety reduction, and medical education to prepare the patient for the challenges ahead. “Preoperatively, we try to identify factors to see if we can make meaningful lifestyle changes, because that’s really the grassroots level where a lot of this [improvement in outcomes] is going to occur,” said Dr. Mutch.
 

Frailty

Frailty is a factor driving complications in colorectal surgery. A meta-analysis of 20 studies showed that frailty and prefrailty were associated with worse all-cause mortality during follow-up among older cancer patients. More striking, it showed that frail patients were nearly five times more likely to be intolerant of cancer treatment (odds ratio, 4.86) and more likely to experience postoperative complications (30-day hazard ratio, 3.19) (Ann Oncol. 2015;26[6]:1091-1101).

Hemoglobin A_1c

Dr. Mutch went on to discuss hemoglobin A_1c (HbA_1c) levels as a risk factor in colorectal surgery. HbA_1c levels higher than 6 are associated with worse outcomes, but tight postoperative control is associated with hypoglycemia. “What you want to do is set that patient up before surgery. HbA_1c has a half-life of about a month, so if you start modifying their risk factors 4-6 weeks before you get them into surgery, by 1 month you can see a 50% reduction, and at 2 months a 75% reduction. If you do these things in a preoperative setting it makes a difference,” said Dr. Mutch.

Smoking cessation

Smoking cessation is another key strategy. Two weeks of cessation should lead to a decline in coughing, but a minimum of 4 weeks is needed to significantly reduce overall complications. Lifestyle changes need to be long term. “These are not measures that you’re going to do over a short period of time, and then when surgery is over throw it out the window,” said Dr. Mutch.

Anastomotic leak

Another factor is the detection of anastomotic leak, which can be challenging because its definitions vary significantly, and its causes can be multifactorial. Studies show that predictions of anastomotic leak are not especially successful, Dr. Mutch said, but routine leak testing improves outcomes. In a study of left-side anastomoses in Washington State, hospitals that performed leak tests had lower leak rates at least 90% of the time (OR, 0.23), and hospitals that later implemented leak tests experienced a significant reduction (Arch Surg. 2012:147[4]:345-51).

Venous thromboembolic events

Venous thromboembolic events (VTE), are the leading cause of operative mortality in colorectal surgery patients. This complication can be greatly reduced with prophylaxis, but requires screening for risk factors. Major surgery raises the risk of deep vein thrombosis in 20% of all hospitalized patients to 40%-80%, depending on the surgery type. “We have a lot of room to improve,” said Dr. Mutch.

copyright monkeybusinessimages/Thinkstock

Timing

One factor that may have an impact on complications appears to be timing of surgery, at least at Washington University, where Dr. Mutch practices. The institution found that patients who had surgery the same day they were admitted had a 2.5% VTE risk, compared with 11% in patients who had surgery 5 or more days after admission.

Postop ambulation

Postsurgical ambulation was another critical complication factor. Dr. Mutch cited a study showing that ambulation on the day after surgery was associated with a 1% VTE risk, compared to 6.9% in patients who waited until day 2.

Dr. Mutch had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

LAS VEGAS – Colorectal surgery is rife with potential complications, but there are steps that surgeons can take to improve outcomes, and factors to consider to reduce complications. These strategies and considerations were the focus of a talk by Matthew G. Mutch, MD, at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Prehabilitation

The approach to improve outcomes can begin with prehabilitation – preparing the patient for the difficult process of surgery. “If somebody is going to fight a 15-round heavyweight bout, they train for 6 or 8 weeks before a fight. Why not bring that concept to surgery?” said Dr. Mutch, chief of colon and rectal surgery at the Washington University, St. Louis.

Prehabilitation can include lifestyle changes, such as quitting smoking, but can also incorporate aerobic and/or resistance exercise, dietary counseling and protein supplementation, anxiety reduction, and medical education to prepare the patient for the challenges ahead. “Preoperatively, we try to identify factors to see if we can make meaningful lifestyle changes, because that’s really the grassroots level where a lot of this [improvement in outcomes] is going to occur,” said Dr. Mutch.
 

Frailty

Frailty is a factor driving complications in colorectal surgery. A meta-analysis of 20 studies showed that frailty and prefrailty were associated with worse all-cause mortality during follow-up among older cancer patients. More striking, it showed that frail patients were nearly five times more likely to be intolerant of cancer treatment (odds ratio, 4.86) and more likely to experience postoperative complications (30-day hazard ratio, 3.19) (Ann Oncol. 2015;26[6]:1091-1101).

Hemoglobin A_1c

Dr. Mutch went on to discuss hemoglobin A_1c (HbA_1c) levels as a risk factor in colorectal surgery. HbA_1c levels higher than 6 are associated with worse outcomes, but tight postoperative control is associated with hypoglycemia. “What you want to do is set that patient up before surgery. HbA_1c has a half-life of about a month, so if you start modifying their risk factors 4-6 weeks before you get them into surgery, by 1 month you can see a 50% reduction, and at 2 months a 75% reduction. If you do these things in a preoperative setting it makes a difference,” said Dr. Mutch.

Smoking cessation

Smoking cessation is another key strategy. Two weeks of cessation should lead to a decline in coughing, but a minimum of 4 weeks is needed to significantly reduce overall complications. Lifestyle changes need to be long term. “These are not measures that you’re going to do over a short period of time, and then when surgery is over throw it out the window,” said Dr. Mutch.

Anastomotic leak

Another factor is the detection of anastomotic leak, which can be challenging because its definitions vary significantly, and its causes can be multifactorial. Studies show that predictions of anastomotic leak are not especially successful, Dr. Mutch said, but routine leak testing improves outcomes. In a study of left-side anastomoses in Washington State, hospitals that performed leak tests had lower leak rates at least 90% of the time (OR, 0.23), and hospitals that later implemented leak tests experienced a significant reduction (Arch Surg. 2012:147[4]:345-51).

Venous thromboembolic events

Venous thromboembolic events (VTE), are the leading cause of operative mortality in colorectal surgery patients. This complication can be greatly reduced with prophylaxis, but requires screening for risk factors. Major surgery raises the risk of deep vein thrombosis in 20% of all hospitalized patients to 40%-80%, depending on the surgery type. “We have a lot of room to improve,” said Dr. Mutch.

copyright monkeybusinessimages/Thinkstock

Timing

One factor that may have an impact on complications appears to be timing of surgery, at least at Washington University, where Dr. Mutch practices. The institution found that patients who had surgery the same day they were admitted had a 2.5% VTE risk, compared with 11% in patients who had surgery 5 or more days after admission.

Postop ambulation

Postsurgical ambulation was another critical complication factor. Dr. Mutch cited a study showing that ambulation on the day after surgery was associated with a 1% VTE risk, compared to 6.9% in patients who waited until day 2.

Dr. Mutch had no disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

Colorectal cancer (CRC) is an important concern for the VA, and colonoscopy is one primary screening, surveillance, and diagnostic modality used. The observed reductions in CRC incidence and mortality over the past decade largely have been attributed to the widespread use of CRC screening options.^1,2 Colonoscopy quality is critical to CRC prevention in veterans. However, endoscopy skills to detect and remove colorectal polyps using colonoscopy vary in practice.^3-5

Quality benchmarks, linked to patient outcomes, have been established by specialty societies and proposed by the Centers for Medicare and Medicaid Services as reportable quality metrics.⁶ Colonoscopy quality metrics have been shown to be associated with patient outcomes, such as the risk of developing CRC after colonoscopy. The adenoma detection rate (ADR), defined as the proportion of average-risk screening colonoscopies in which 1 or more adenomas are detected, has the strongest association to interval or “missed” CRC after screening colonoscopy and has been linked to a risk for fatal CRC despite colonoscopy.³

In a landmark study of 314,872 examinations performed by 136 gastroenterologists, the ADR ranged from 7.4% to 52.5%.³ Among patients with ADRs in the highest quintile compared with patients in the lowest, the adjusted hazard ratios (HRs) for any interval cancer was 0.52 (95% confidence interval [CI], 0.39-0.69) and for fatal interval cancers was 0.38 (95% CI, 0.22-0.65).³ Another pooled analysis from 8 surveillance studies that followed more than 800 participants with adenoma(s) after a baseline colonoscopy showed 52% of incident cancers as probable missed lesions, 19% as possibly related to incomplete resection of an earlier, noninvasive lesion, and only 24% as probable new lesions.⁷ These interval cancers highlight the current imperfections of colonoscopy and the focus on measurement and reporting of quality indicators for colonoscopy.^8-12

According to VHA Directive 1015, in December 2014, colonoscopy quality should be monitored as part of an ongoing quality assurance program.¹³ A recent report from the VA Office of the Inspector General (OIG) highlighted colonoscopy-quality deficiencies.¹⁴ The OIG report strongly recommended that the “Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.”¹⁴However, no currently standardized and readily available VHA resource measures, reports, and ensures colonoscopy quality.

The authors hypothesized that colonoscopy quality assurance programs vary widely across VHA sites. The objective of this survey was to assess the measurement and reporting practices for colonoscopy quality and identify both strengths and areas for improvement to facilitate implementation of quality assurance programs across the VA health care system.

Methods

The authors performed an online survey of VA sites to assess current colonoscopy quality assurance practices. The institutional review boards (IRBs) at the University of Utah and VA Salt Lake City Health Care System and University of California, San Francisco and San Francisco VA Health Care System classified the study as a quality improvement project that did not qualify for human subjects’ research requiring IRB review.

The authors iteratively developed and refined the questionnaire with a survey methodologist and 2 clinical domain experts. The National Program Director for Gastroenterology, and the National Gastroenterology Field Advisory Committee reviewed the survey content and pretested the survey instrument prior to final data collection. The National Program Office for Gastroenterology provided an e-mail list of all known VA gastroenterology section chiefs. The authors administered the final survey via e-mail, using the Research Electronic Data Capture (REDCap; Vanderbilt University Medical Center) platform beginning January 9, 2017.¹⁵

A follow-up reminder e-mail was sent to nonresponders after 2 weeks. After this second invitation, sites were contacted by telephone to verify that the correct contact information had been captured. Subsequently, 50 contacts were updated if e-mails bounced back or the correct contact was obtained. Points of contact received a total of 3 reminder e-mails until the final closeout of the survey on March 28, 2017; 65 of 89 (73%) of the original contacts completed the survey vs 31 of 50 (62%) of the updated contacts.

Analysis

Descriptive statistics of the responses were calculated to determine the overall proportion of VA sites measuring colonoscopy quality metrics and identification of areas in need of quality improvement. The response rate for the survey was defined as the total number of responses obtained as a proportion of the total number of points of contact. This corresponds to the American Association of Public Opinion Research’s RR1, or minimum response rate, formula.¹⁶ All categoric responses are presented as proportions. Statistical analyses were performed using STATA SE12.0 (College Station, TX).

Results

Of the 139 points of contact invited, 96 completed the survey (response rate of 69.0%), representing 93 VA facilities (of 141 possible facilities) in 44 different states. Three sites had 2 responses. Sites used various and often a combination of methods to measure quality (Table 1). 

A majority of sites’ (63.5%) quality reports represented individual provider data, whereas fewer provided quality reports for physician groups (22.9%) or for the entire facility (40.6%). Provider quality information was de-identified in 43.8% of reporting sites’ quality reports and identifiable in 37.5% of reporting sites’ quality reports. A majority of sites (74.0%) reported that the local gastroenterology section chief or quality manager has access to the quality reports. Fewer sites reported providing data to individual endoscopists (44.8% for personal and peer data and 32.3% for personal data only). One site (1%) responded that quality reports were available for public access. Survey respondents also were asked to provide the estimated time (hours required per month) to collect the data for quality metrics. Of 75 respondents providing data for this question, 28 (29.2%) and 17 (17.7%), estimated between 1 to 5 and 6 to 10 hours per month, respectively. Ten sites estimated spending between 11 to 20 hours, and 7 sites estimated spending more than 20 hours per month collecting quality metrics. A total of 13 respondents (13.5%) stated uncertainty about the time burden.

As shown in the Figure,  numerous quality metrics were collected across sites with more than 80% of sites collecting information on bowel preparation quality (88.5%), cecal intubation rate (87.5%), and complications (83.3%). A majority of sites also reported collecting data on appropriateness of surveillance intervals (62.5%), colonoscopy withdrawal times (62.5%), and ADRs (61.5%). Seven sites (7.3%) did not collect quality metrics.

Information also was collected on colonoscopy procedure documentation to inform future efforts at standardization. A small majority (53.1%) of sites reported using endoscopic software to generate colonoscopy procedure documentation. Within these sites, 6 different types of endoscopic note writing software were used to generate procedure notes (Table 2). 

Most sites (85.4%) were aware of VHA Directive 1015 recommendations for colonoscopy quality assurance programs. A significant majority (89.5%) of respondents also indicated interest in a centralized automatic reporting system to measure and report colonoscopy quality in some form, either with aggregate data, provider data, or both (Table 3).

Discussion

This survey on colonoscopy quality assurance programs is the first assessment of the VHA’s efforts to measure and report colonoscopy quality indicators. The findings indicated that the majority of VA sites are measuring and reporting at least some measures of colonoscopy quality. However, the programs are significantly variable in terms of methods used to collect quality metrics, specific quality measures obtained, and how quality is reported.

The authors’ work is novel in that this is the first report of the status of colonoscopy quality assurance programs in a large U.S. health care system. The VA health care system is the largest integrated health system in the U.S., serving more than 9 million veterans annually. This survey’s high response rate further strengthens the findings. Specifically, the survey found that VA sites are making a strong concerted effort to measure and report colonoscopy quality. However, there is significant variability in documentation, measurement, and reporting practices. Moreover, the majority of VA sites do not have formal performance improvement plans in place for endoscopists who do not meet thresholds for colonoscopy quality.

Screening colonoscopy for CRC offers known mortality benefits to patients.^1,17-19 Significant prior work has described and validated the importance of colonoscopy quality metrics, including bowel preparation quality, cecal intubation rate, and ADR and their association with interval colorectal cancer and death.^20-23 Gastroenterology professional societies, including the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy, have recommended and endorsed measurement and reporting of colonoscopy metrics.²⁴ There is general agreement among endoscopists that colonoscopy quality is an important aspect of performing the procedure.

The lack of formal performance improvement programs is a key finding of this survey. Recent studies have shown that improvements in quality metrics, such as the ADR, by individual endoscopists result in reductions in interval colorectal cancer and death.²⁵ Kahi and colleagues previously showed that providing a quarterly report card improves colonoscopy quality.²⁶ Keswani and colleagues studied a combination of a report card and implementation of standards of practice with resultant improvement in colonoscopy quality.²⁷ Most recently, in a large prospective cohort study of individuals who underwent a screening colonoscopy, 294 of the screening endoscopists received annual feedback and quality benchmark indicators to improve colonoscopy performance.²⁵ The majority of the endoscopists (74.5%) increased their annual ADR category over the study period. Moreover, patients examined by endoscopists who reached or maintained the highest ADR quintile (> 24.6%) had significantly lower risk of interval CRC and death. The lack of formal performance improvement programs across the VHA is concerning but reveals a significant opportunity to improve veteran health outcomes on a large scale.

This study’s findings also highlight the intense resources necessary to measure and report colonoscopy quality. The ability to measure and report quality metrics requires having adequate documentation and data to obtain quality metrics. Administrative databases from electronic health records offer some potential for routine monitoring of quality metrics.²⁸ However, most administrative databases, including the VA Corporate Data Warehouse (CDW), contain administrative billing codes (ICD and CPT) linked to limited patient data, including demographics and structured medical record data. The actual data required for quality reporting of important metrics (bowel preparation quality, cecal intubation rates, and ADRs) are usually found in clinical text notes or endoscopic note documentation and not available as structured data. Due to this issue, the majority of VA sites (79.2%) are using manual chart review to collect quality metric data, resulting in widely variable estimates on time burden. A minority of sites in this study (39.6%) reported using automated endoscopic software reporting capability that can help with the time burden. However, even in the VA, an integrated health system, a wide variety of software brands, documentation practices, and photo documentation was found.

Future endoscopy budget and purchase decisions for the individual VA sites should take into account how new technology and software can more easily facilitate accurate quality reporting. A specific policy recommendation would be for the VA to consider a uniform endoscopic note writer for procedure notes. Pathology data, which is necessary for the calculation of ADR, also should be available as structured data in the CDW to more easily measure colonoscopy quality. Continuous measurement and reporting of quality also requires ongoing information technology infrastructure and quality control of the measurement process.

Limitations

This survey was a cross-section of VA sites’ points of contact regarding colonoscopy quality assurance programs, so the results are descriptive in nature. However, the instrument was carefully developed, using both subject matter and survey method expertise. The questionnaire also was refined through pretesting prior to data collection. The initial contact list was found to have errors, and the list had to be updated after launching the survey. Updated information for most of the contacts was available.

Another limitation was the inability to survey nongastroenterologist-run endoscopy centers, because many centers use surgeons or other nongastroenterology providers. The authors speculate that quality monitoring may be less likely to be present at these facilities as they may not be aware of the gastroenterology professional society recommendations. The authors did not require or insist that all questions be answered, so some data were missing from sites. However, 93.7% of respondents completed the entire survey.

Conclusion

The authors have described the status of colonoscopy quality assurance programs across the VA health care system. Many sites are making robust efforts to measure and report quality especially of process measures. However, there are significant time and manual workforce efforts required, and this work is likely associated with the variability in programs. Importantly, ADR, which is the quality metric that has been most strongly associated with risk of colon cancer mortality, is not being measured by 38% of sites.

These results reinforce a critical need for a centralized, automated quality reporting infrastructure to standardize colonoscopy quality reporting, reduce workload, and ensure veterans receive high-quality colonoscopy.

Acknowledgments
The authors acknowledge the support and feedback of the National Gastroenterology Program Field Advisory Committee for survey development and testing. The authors coordinated the survey through the Salt Lake City Specialty Care Center of Innovation in partnership with the National Gastroenterology Program Office and the Quality Enhancement Research Initiative: Quality Enhancement Research Initiative, Measurement Science Program, QUE15-283. The work also was partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award UL1TR001067 and Merit Review Award 1 I01 HX001574-01A1 from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development.

Colorectal cancer (CRC) is an important concern for the VA, and colonoscopy is one primary screening, surveillance, and diagnostic modality used. The observed reductions in CRC incidence and mortality over the past decade largely have been attributed to the widespread use of CRC screening options.^1,2 Colonoscopy quality is critical to CRC prevention in veterans. However, endoscopy skills to detect and remove colorectal polyps using colonoscopy vary in practice.^3-5

Quality benchmarks, linked to patient outcomes, have been established by specialty societies and proposed by the Centers for Medicare and Medicaid Services as reportable quality metrics.⁶ Colonoscopy quality metrics have been shown to be associated with patient outcomes, such as the risk of developing CRC after colonoscopy. The adenoma detection rate (ADR), defined as the proportion of average-risk screening colonoscopies in which 1 or more adenomas are detected, has the strongest association to interval or “missed” CRC after screening colonoscopy and has been linked to a risk for fatal CRC despite colonoscopy.³

In a landmark study of 314,872 examinations performed by 136 gastroenterologists, the ADR ranged from 7.4% to 52.5%.³ Among patients with ADRs in the highest quintile compared with patients in the lowest, the adjusted hazard ratios (HRs) for any interval cancer was 0.52 (95% confidence interval [CI], 0.39-0.69) and for fatal interval cancers was 0.38 (95% CI, 0.22-0.65).³ Another pooled analysis from 8 surveillance studies that followed more than 800 participants with adenoma(s) after a baseline colonoscopy showed 52% of incident cancers as probable missed lesions, 19% as possibly related to incomplete resection of an earlier, noninvasive lesion, and only 24% as probable new lesions.⁷ These interval cancers highlight the current imperfections of colonoscopy and the focus on measurement and reporting of quality indicators for colonoscopy.^8-12

According to VHA Directive 1015, in December 2014, colonoscopy quality should be monitored as part of an ongoing quality assurance program.¹³ A recent report from the VA Office of the Inspector General (OIG) highlighted colonoscopy-quality deficiencies.¹⁴ The OIG report strongly recommended that the “Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.”¹⁴However, no currently standardized and readily available VHA resource measures, reports, and ensures colonoscopy quality.

The authors hypothesized that colonoscopy quality assurance programs vary widely across VHA sites. The objective of this survey was to assess the measurement and reporting practices for colonoscopy quality and identify both strengths and areas for improvement to facilitate implementation of quality assurance programs across the VA health care system.

Methods

The authors performed an online survey of VA sites to assess current colonoscopy quality assurance practices. The institutional review boards (IRBs) at the University of Utah and VA Salt Lake City Health Care System and University of California, San Francisco and San Francisco VA Health Care System classified the study as a quality improvement project that did not qualify for human subjects’ research requiring IRB review.

The authors iteratively developed and refined the questionnaire with a survey methodologist and 2 clinical domain experts. The National Program Director for Gastroenterology, and the National Gastroenterology Field Advisory Committee reviewed the survey content and pretested the survey instrument prior to final data collection. The National Program Office for Gastroenterology provided an e-mail list of all known VA gastroenterology section chiefs. The authors administered the final survey via e-mail, using the Research Electronic Data Capture (REDCap; Vanderbilt University Medical Center) platform beginning January 9, 2017.¹⁵

A follow-up reminder e-mail was sent to nonresponders after 2 weeks. After this second invitation, sites were contacted by telephone to verify that the correct contact information had been captured. Subsequently, 50 contacts were updated if e-mails bounced back or the correct contact was obtained. Points of contact received a total of 3 reminder e-mails until the final closeout of the survey on March 28, 2017; 65 of 89 (73%) of the original contacts completed the survey vs 31 of 50 (62%) of the updated contacts.

Analysis

Descriptive statistics of the responses were calculated to determine the overall proportion of VA sites measuring colonoscopy quality metrics and identification of areas in need of quality improvement. The response rate for the survey was defined as the total number of responses obtained as a proportion of the total number of points of contact. This corresponds to the American Association of Public Opinion Research’s RR1, or minimum response rate, formula.¹⁶ All categoric responses are presented as proportions. Statistical analyses were performed using STATA SE12.0 (College Station, TX).

Results

Of the 139 points of contact invited, 96 completed the survey (response rate of 69.0%), representing 93 VA facilities (of 141 possible facilities) in 44 different states. Three sites had 2 responses. Sites used various and often a combination of methods to measure quality (Table 1). 

A majority of sites’ (63.5%) quality reports represented individual provider data, whereas fewer provided quality reports for physician groups (22.9%) or for the entire facility (40.6%). Provider quality information was de-identified in 43.8% of reporting sites’ quality reports and identifiable in 37.5% of reporting sites’ quality reports. A majority of sites (74.0%) reported that the local gastroenterology section chief or quality manager has access to the quality reports. Fewer sites reported providing data to individual endoscopists (44.8% for personal and peer data and 32.3% for personal data only). One site (1%) responded that quality reports were available for public access. Survey respondents also were asked to provide the estimated time (hours required per month) to collect the data for quality metrics. Of 75 respondents providing data for this question, 28 (29.2%) and 17 (17.7%), estimated between 1 to 5 and 6 to 10 hours per month, respectively. Ten sites estimated spending between 11 to 20 hours, and 7 sites estimated spending more than 20 hours per month collecting quality metrics. A total of 13 respondents (13.5%) stated uncertainty about the time burden.

As shown in the Figure,  numerous quality metrics were collected across sites with more than 80% of sites collecting information on bowel preparation quality (88.5%), cecal intubation rate (87.5%), and complications (83.3%). A majority of sites also reported collecting data on appropriateness of surveillance intervals (62.5%), colonoscopy withdrawal times (62.5%), and ADRs (61.5%). Seven sites (7.3%) did not collect quality metrics.

Information also was collected on colonoscopy procedure documentation to inform future efforts at standardization. A small majority (53.1%) of sites reported using endoscopic software to generate colonoscopy procedure documentation. Within these sites, 6 different types of endoscopic note writing software were used to generate procedure notes (Table 2). 

Most sites (85.4%) were aware of VHA Directive 1015 recommendations for colonoscopy quality assurance programs. A significant majority (89.5%) of respondents also indicated interest in a centralized automatic reporting system to measure and report colonoscopy quality in some form, either with aggregate data, provider data, or both (Table 3).

Discussion

This survey on colonoscopy quality assurance programs is the first assessment of the VHA’s efforts to measure and report colonoscopy quality indicators. The findings indicated that the majority of VA sites are measuring and reporting at least some measures of colonoscopy quality. However, the programs are significantly variable in terms of methods used to collect quality metrics, specific quality measures obtained, and how quality is reported.

The authors’ work is novel in that this is the first report of the status of colonoscopy quality assurance programs in a large U.S. health care system. The VA health care system is the largest integrated health system in the U.S., serving more than 9 million veterans annually. This survey’s high response rate further strengthens the findings. Specifically, the survey found that VA sites are making a strong concerted effort to measure and report colonoscopy quality. However, there is significant variability in documentation, measurement, and reporting practices. Moreover, the majority of VA sites do not have formal performance improvement plans in place for endoscopists who do not meet thresholds for colonoscopy quality.

Screening colonoscopy for CRC offers known mortality benefits to patients.^1,17-19 Significant prior work has described and validated the importance of colonoscopy quality metrics, including bowel preparation quality, cecal intubation rate, and ADR and their association with interval colorectal cancer and death.^20-23 Gastroenterology professional societies, including the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy, have recommended and endorsed measurement and reporting of colonoscopy metrics.²⁴ There is general agreement among endoscopists that colonoscopy quality is an important aspect of performing the procedure.

The lack of formal performance improvement programs is a key finding of this survey. Recent studies have shown that improvements in quality metrics, such as the ADR, by individual endoscopists result in reductions in interval colorectal cancer and death.²⁵ Kahi and colleagues previously showed that providing a quarterly report card improves colonoscopy quality.²⁶ Keswani and colleagues studied a combination of a report card and implementation of standards of practice with resultant improvement in colonoscopy quality.²⁷ Most recently, in a large prospective cohort study of individuals who underwent a screening colonoscopy, 294 of the screening endoscopists received annual feedback and quality benchmark indicators to improve colonoscopy performance.²⁵ The majority of the endoscopists (74.5%) increased their annual ADR category over the study period. Moreover, patients examined by endoscopists who reached or maintained the highest ADR quintile (> 24.6%) had significantly lower risk of interval CRC and death. The lack of formal performance improvement programs across the VHA is concerning but reveals a significant opportunity to improve veteran health outcomes on a large scale.

This study’s findings also highlight the intense resources necessary to measure and report colonoscopy quality. The ability to measure and report quality metrics requires having adequate documentation and data to obtain quality metrics. Administrative databases from electronic health records offer some potential for routine monitoring of quality metrics.²⁸ However, most administrative databases, including the VA Corporate Data Warehouse (CDW), contain administrative billing codes (ICD and CPT) linked to limited patient data, including demographics and structured medical record data. The actual data required for quality reporting of important metrics (bowel preparation quality, cecal intubation rates, and ADRs) are usually found in clinical text notes or endoscopic note documentation and not available as structured data. Due to this issue, the majority of VA sites (79.2%) are using manual chart review to collect quality metric data, resulting in widely variable estimates on time burden. A minority of sites in this study (39.6%) reported using automated endoscopic software reporting capability that can help with the time burden. However, even in the VA, an integrated health system, a wide variety of software brands, documentation practices, and photo documentation was found.

Future endoscopy budget and purchase decisions for the individual VA sites should take into account how new technology and software can more easily facilitate accurate quality reporting. A specific policy recommendation would be for the VA to consider a uniform endoscopic note writer for procedure notes. Pathology data, which is necessary for the calculation of ADR, also should be available as structured data in the CDW to more easily measure colonoscopy quality. Continuous measurement and reporting of quality also requires ongoing information technology infrastructure and quality control of the measurement process.

Limitations

This survey was a cross-section of VA sites’ points of contact regarding colonoscopy quality assurance programs, so the results are descriptive in nature. However, the instrument was carefully developed, using both subject matter and survey method expertise. The questionnaire also was refined through pretesting prior to data collection. The initial contact list was found to have errors, and the list had to be updated after launching the survey. Updated information for most of the contacts was available.

Another limitation was the inability to survey nongastroenterologist-run endoscopy centers, because many centers use surgeons or other nongastroenterology providers. The authors speculate that quality monitoring may be less likely to be present at these facilities as they may not be aware of the gastroenterology professional society recommendations. The authors did not require or insist that all questions be answered, so some data were missing from sites. However, 93.7% of respondents completed the entire survey.

Conclusion

The authors have described the status of colonoscopy quality assurance programs across the VA health care system. Many sites are making robust efforts to measure and report quality especially of process measures. However, there are significant time and manual workforce efforts required, and this work is likely associated with the variability in programs. Importantly, ADR, which is the quality metric that has been most strongly associated with risk of colon cancer mortality, is not being measured by 38% of sites.

These results reinforce a critical need for a centralized, automated quality reporting infrastructure to standardize colonoscopy quality reporting, reduce workload, and ensure veterans receive high-quality colonoscopy.

Acknowledgments
The authors acknowledge the support and feedback of the National Gastroenterology Program Field Advisory Committee for survey development and testing. The authors coordinated the survey through the Salt Lake City Specialty Care Center of Innovation in partnership with the National Gastroenterology Program Office and the Quality Enhancement Research Initiative: Quality Enhancement Research Initiative, Measurement Science Program, QUE15-283. The work also was partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award UL1TR001067 and Merit Review Award 1 I01 HX001574-01A1 from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development.

Colorectal cancer (CRC) is an important concern for the VA, and colonoscopy is one primary screening, surveillance, and diagnostic modality used. The observed reductions in CRC incidence and mortality over the past decade largely have been attributed to the widespread use of CRC screening options.^1,2 Colonoscopy quality is critical to CRC prevention in veterans. However, endoscopy skills to detect and remove colorectal polyps using colonoscopy vary in practice.^3-5

Quality benchmarks, linked to patient outcomes, have been established by specialty societies and proposed by the Centers for Medicare and Medicaid Services as reportable quality metrics.⁶ Colonoscopy quality metrics have been shown to be associated with patient outcomes, such as the risk of developing CRC after colonoscopy. The adenoma detection rate (ADR), defined as the proportion of average-risk screening colonoscopies in which 1 or more adenomas are detected, has the strongest association to interval or “missed” CRC after screening colonoscopy and has been linked to a risk for fatal CRC despite colonoscopy.³

In a landmark study of 314,872 examinations performed by 136 gastroenterologists, the ADR ranged from 7.4% to 52.5%.³ Among patients with ADRs in the highest quintile compared with patients in the lowest, the adjusted hazard ratios (HRs) for any interval cancer was 0.52 (95% confidence interval [CI], 0.39-0.69) and for fatal interval cancers was 0.38 (95% CI, 0.22-0.65).³ Another pooled analysis from 8 surveillance studies that followed more than 800 participants with adenoma(s) after a baseline colonoscopy showed 52% of incident cancers as probable missed lesions, 19% as possibly related to incomplete resection of an earlier, noninvasive lesion, and only 24% as probable new lesions.⁷ These interval cancers highlight the current imperfections of colonoscopy and the focus on measurement and reporting of quality indicators for colonoscopy.^8-12

According to VHA Directive 1015, in December 2014, colonoscopy quality should be monitored as part of an ongoing quality assurance program.¹³ A recent report from the VA Office of the Inspector General (OIG) highlighted colonoscopy-quality deficiencies.¹⁴ The OIG report strongly recommended that the “Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.”¹⁴However, no currently standardized and readily available VHA resource measures, reports, and ensures colonoscopy quality.

The authors hypothesized that colonoscopy quality assurance programs vary widely across VHA sites. The objective of this survey was to assess the measurement and reporting practices for colonoscopy quality and identify both strengths and areas for improvement to facilitate implementation of quality assurance programs across the VA health care system.

Methods

The authors performed an online survey of VA sites to assess current colonoscopy quality assurance practices. The institutional review boards (IRBs) at the University of Utah and VA Salt Lake City Health Care System and University of California, San Francisco and San Francisco VA Health Care System classified the study as a quality improvement project that did not qualify for human subjects’ research requiring IRB review.

The authors iteratively developed and refined the questionnaire with a survey methodologist and 2 clinical domain experts. The National Program Director for Gastroenterology, and the National Gastroenterology Field Advisory Committee reviewed the survey content and pretested the survey instrument prior to final data collection. The National Program Office for Gastroenterology provided an e-mail list of all known VA gastroenterology section chiefs. The authors administered the final survey via e-mail, using the Research Electronic Data Capture (REDCap; Vanderbilt University Medical Center) platform beginning January 9, 2017.¹⁵

A follow-up reminder e-mail was sent to nonresponders after 2 weeks. After this second invitation, sites were contacted by telephone to verify that the correct contact information had been captured. Subsequently, 50 contacts were updated if e-mails bounced back or the correct contact was obtained. Points of contact received a total of 3 reminder e-mails until the final closeout of the survey on March 28, 2017; 65 of 89 (73%) of the original contacts completed the survey vs 31 of 50 (62%) of the updated contacts.

Analysis

Descriptive statistics of the responses were calculated to determine the overall proportion of VA sites measuring colonoscopy quality metrics and identification of areas in need of quality improvement. The response rate for the survey was defined as the total number of responses obtained as a proportion of the total number of points of contact. This corresponds to the American Association of Public Opinion Research’s RR1, or minimum response rate, formula.¹⁶ All categoric responses are presented as proportions. Statistical analyses were performed using STATA SE12.0 (College Station, TX).

Results

Of the 139 points of contact invited, 96 completed the survey (response rate of 69.0%), representing 93 VA facilities (of 141 possible facilities) in 44 different states. Three sites had 2 responses. Sites used various and often a combination of methods to measure quality (Table 1). 

A majority of sites’ (63.5%) quality reports represented individual provider data, whereas fewer provided quality reports for physician groups (22.9%) or for the entire facility (40.6%). Provider quality information was de-identified in 43.8% of reporting sites’ quality reports and identifiable in 37.5% of reporting sites’ quality reports. A majority of sites (74.0%) reported that the local gastroenterology section chief or quality manager has access to the quality reports. Fewer sites reported providing data to individual endoscopists (44.8% for personal and peer data and 32.3% for personal data only). One site (1%) responded that quality reports were available for public access. Survey respondents also were asked to provide the estimated time (hours required per month) to collect the data for quality metrics. Of 75 respondents providing data for this question, 28 (29.2%) and 17 (17.7%), estimated between 1 to 5 and 6 to 10 hours per month, respectively. Ten sites estimated spending between 11 to 20 hours, and 7 sites estimated spending more than 20 hours per month collecting quality metrics. A total of 13 respondents (13.5%) stated uncertainty about the time burden.

As shown in the Figure,  numerous quality metrics were collected across sites with more than 80% of sites collecting information on bowel preparation quality (88.5%), cecal intubation rate (87.5%), and complications (83.3%). A majority of sites also reported collecting data on appropriateness of surveillance intervals (62.5%), colonoscopy withdrawal times (62.5%), and ADRs (61.5%). Seven sites (7.3%) did not collect quality metrics.

Information also was collected on colonoscopy procedure documentation to inform future efforts at standardization. A small majority (53.1%) of sites reported using endoscopic software to generate colonoscopy procedure documentation. Within these sites, 6 different types of endoscopic note writing software were used to generate procedure notes (Table 2). 

Most sites (85.4%) were aware of VHA Directive 1015 recommendations for colonoscopy quality assurance programs. A significant majority (89.5%) of respondents also indicated interest in a centralized automatic reporting system to measure and report colonoscopy quality in some form, either with aggregate data, provider data, or both (Table 3).

Discussion

This survey on colonoscopy quality assurance programs is the first assessment of the VHA’s efforts to measure and report colonoscopy quality indicators. The findings indicated that the majority of VA sites are measuring and reporting at least some measures of colonoscopy quality. However, the programs are significantly variable in terms of methods used to collect quality metrics, specific quality measures obtained, and how quality is reported.

The authors’ work is novel in that this is the first report of the status of colonoscopy quality assurance programs in a large U.S. health care system. The VA health care system is the largest integrated health system in the U.S., serving more than 9 million veterans annually. This survey’s high response rate further strengthens the findings. Specifically, the survey found that VA sites are making a strong concerted effort to measure and report colonoscopy quality. However, there is significant variability in documentation, measurement, and reporting practices. Moreover, the majority of VA sites do not have formal performance improvement plans in place for endoscopists who do not meet thresholds for colonoscopy quality.

Screening colonoscopy for CRC offers known mortality benefits to patients.^1,17-19 Significant prior work has described and validated the importance of colonoscopy quality metrics, including bowel preparation quality, cecal intubation rate, and ADR and their association with interval colorectal cancer and death.^20-23 Gastroenterology professional societies, including the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy, have recommended and endorsed measurement and reporting of colonoscopy metrics.²⁴ There is general agreement among endoscopists that colonoscopy quality is an important aspect of performing the procedure.

The lack of formal performance improvement programs is a key finding of this survey. Recent studies have shown that improvements in quality metrics, such as the ADR, by individual endoscopists result in reductions in interval colorectal cancer and death.²⁵ Kahi and colleagues previously showed that providing a quarterly report card improves colonoscopy quality.²⁶ Keswani and colleagues studied a combination of a report card and implementation of standards of practice with resultant improvement in colonoscopy quality.²⁷ Most recently, in a large prospective cohort study of individuals who underwent a screening colonoscopy, 294 of the screening endoscopists received annual feedback and quality benchmark indicators to improve colonoscopy performance.²⁵ The majority of the endoscopists (74.5%) increased their annual ADR category over the study period. Moreover, patients examined by endoscopists who reached or maintained the highest ADR quintile (> 24.6%) had significantly lower risk of interval CRC and death. The lack of formal performance improvement programs across the VHA is concerning but reveals a significant opportunity to improve veteran health outcomes on a large scale.

This study’s findings also highlight the intense resources necessary to measure and report colonoscopy quality. The ability to measure and report quality metrics requires having adequate documentation and data to obtain quality metrics. Administrative databases from electronic health records offer some potential for routine monitoring of quality metrics.²⁸ However, most administrative databases, including the VA Corporate Data Warehouse (CDW), contain administrative billing codes (ICD and CPT) linked to limited patient data, including demographics and structured medical record data. The actual data required for quality reporting of important metrics (bowel preparation quality, cecal intubation rates, and ADRs) are usually found in clinical text notes or endoscopic note documentation and not available as structured data. Due to this issue, the majority of VA sites (79.2%) are using manual chart review to collect quality metric data, resulting in widely variable estimates on time burden. A minority of sites in this study (39.6%) reported using automated endoscopic software reporting capability that can help with the time burden. However, even in the VA, an integrated health system, a wide variety of software brands, documentation practices, and photo documentation was found.

Future endoscopy budget and purchase decisions for the individual VA sites should take into account how new technology and software can more easily facilitate accurate quality reporting. A specific policy recommendation would be for the VA to consider a uniform endoscopic note writer for procedure notes. Pathology data, which is necessary for the calculation of ADR, also should be available as structured data in the CDW to more easily measure colonoscopy quality. Continuous measurement and reporting of quality also requires ongoing information technology infrastructure and quality control of the measurement process.

Limitations

This survey was a cross-section of VA sites’ points of contact regarding colonoscopy quality assurance programs, so the results are descriptive in nature. However, the instrument was carefully developed, using both subject matter and survey method expertise. The questionnaire also was refined through pretesting prior to data collection. The initial contact list was found to have errors, and the list had to be updated after launching the survey. Updated information for most of the contacts was available.

Another limitation was the inability to survey nongastroenterologist-run endoscopy centers, because many centers use surgeons or other nongastroenterology providers. The authors speculate that quality monitoring may be less likely to be present at these facilities as they may not be aware of the gastroenterology professional society recommendations. The authors did not require or insist that all questions be answered, so some data were missing from sites. However, 93.7% of respondents completed the entire survey.

Conclusion

The authors have described the status of colonoscopy quality assurance programs across the VA health care system. Many sites are making robust efforts to measure and report quality especially of process measures. However, there are significant time and manual workforce efforts required, and this work is likely associated with the variability in programs. Importantly, ADR, which is the quality metric that has been most strongly associated with risk of colon cancer mortality, is not being measured by 38% of sites.

These results reinforce a critical need for a centralized, automated quality reporting infrastructure to standardize colonoscopy quality reporting, reduce workload, and ensure veterans receive high-quality colonoscopy.

Acknowledgments
The authors acknowledge the support and feedback of the National Gastroenterology Program Field Advisory Committee for survey development and testing. The authors coordinated the survey through the Salt Lake City Specialty Care Center of Innovation in partnership with the National Gastroenterology Program Office and the Quality Enhancement Research Initiative: Quality Enhancement Research Initiative, Measurement Science Program, QUE15-283. The work also was partially supported by the National Center for Advancing Translational Sciences of the National Institutes of Health Award UL1TR001067 and Merit Review Award 1 I01 HX001574-01A1 from the United States Department of Veterans Affairs Health Services Research & Development Service of the VA Office of Research and Development.

JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.

SOURCE: Wiener JG et al. Abstract 76.03

JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.

SOURCE: Wiener JG et al. Abstract 76.03

JACKSONVILLE, FLA. – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data to monitor and improve their outcomes.

SOURCE: Wiener JG et al. Abstract 76.03

JACKSONVILLE, FLA. – An enhanced recovery protocol for colorectal surgery patients was implemented to not only limit in-hospital opioid use, but also to reduce postdischarge opioid prescriptions.

The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).

Copyright thegoodphoto/Thinkstock

[email protected]

JACKSONVILLE, FLA. – An enhanced recovery protocol for colorectal surgery patients was implemented to not only limit in-hospital opioid use, but also to reduce postdischarge opioid prescriptions.

The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).

Copyright thegoodphoto/Thinkstock

[email protected]

JACKSONVILLE, FLA. – An enhanced recovery protocol for colorectal surgery patients was implemented to not only limit in-hospital opioid use, but also to reduce postdischarge opioid prescriptions.

The results of the enhanced recovery after surgery (ERAS) study were reported at the Association for Academic Surgical/Society of Academic Surgeons Academic Congress by Kathryn Hudak, a fourth-year medical student at the University of Alabama at Birmingham (UAB).

Copyright thegoodphoto/Thinkstock

[email protected]

LAS VEGAS – Delayed creation of an ileal pouch anal anastomosis in patients with ulcerative colitis (UC) was associated with a lower risk of postoperative events, compared with creating the pouch at the time of initial surgery, results from an analysis of national data demonstrated.

“More than 600,000 Americans have UC, and 20%-30% of them require surgical management,” Bharati Kochar, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “The surgical procedure of choice for many UC patients is total proctocolectomy with ileal pouch anal anastomosis creation.”

According to Dr. Kochar, an advanced fellow in inflammatory bowel diseases at the University of North Carolina at Chapel Hill, existing American medical literature regarding ileal pouch anal anastomosis (IPAA) comes mostly from quaternary care centers and compares one-stage procedures with multistage procedures.

“The risks between two- to three-stage procedures are not described, and there are no prospective national reports of postoperative adverse events after IPAA creation,” she said.

Using data from the National Surgical Quality Improvement Program, Dr. Kochar and her associates conducted an observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC who underwent IPAA procedures between 2011 and 2015. Their aims were to evaluate adverse events within 30 days after an IPAA creation and to compare adverse events between pouch creation at the time of colectomy and delayed pouch creation.

They also performed a subanalysis of total abdominal colectomy with ileostomy (TAC), the first stage in the delayed pouch procedures, versus pouch creation at the time of colectomy. Multivariable modified Poisson regression models were used to estimate risk ratios adjusted for age, sex, race, body mass index, smoking status, diabetes, preoperative albumin, and American Society of Anesthesiologists class.

Of the 2,390 patients, 1,571 had pouches created at the time of colectomy (group A), and 819 had delayed pouch creation (group B).

Compared with patients in group B, those in group A were older (a median age of 40 years vs. 37 years, respectively; P less than .01), were more likely to be on an immunosuppressant (51% vs. 15%; P less than .01), have a lower median preoperative albumin level (3.9 vs. 4.2; P less than .01), and a longer median length of stay (6 days vs. 5 days; P less than .01).

On unadjusted analyses, the researchers also observed that, at 30 days, patients in group A had significantly more major complications, such as mortality and cardiac arrest (12.4% vs. 8.7%; P less than .01); minor complications, such as superficial surgical site infections and pneumonia (11.8% vs. 6.1%; P less than .01); unplanned readmissions (statistically similar at 23.3% vs. 21.3%), and unplanned reoperations (7.7% vs. 3.8%; P less than .01).

After controlling for confounders, patients in group B were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42).

In the subgroup analysis, Dr. Kochar and her associates observed that patients who underwent TAC were significantly older, compared with patients in group A (a median of 46 years vs. 40 years, respectively; P less than .01), and a higher proportion were on immunosuppressants (69% vs. 51%; P less than .01). “Despite these factors, the risk of adverse events after TAC was lower,” Dr. Kochar said.

She acknowledged certain limitations of the study, including the inability to accurately determine the risk of linked surgeries together and the inability to assess institution and operator factors. Also, data were not collected for the purposes of studying inflammatory bowel disease.

“This is the first prospective assessment of morbidity following IPAA creation in UC patients from a national database,” Dr. Kochar concluded. “Delayed pouch procedures are associated with a lower risk of unplanned reoperations and major and minor complications. Immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively. The findings can be valuable for preoperative risk assessment and postoperative management.”

Dr. Kochar reported having no financial disclosures.

*This story was updated on 3/26.

[email protected]

SOURCE: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11.

LAS VEGAS – Delayed creation of an ileal pouch anal anastomosis in patients with ulcerative colitis (UC) was associated with a lower risk of postoperative events, compared with creating the pouch at the time of initial surgery, results from an analysis of national data demonstrated.

“More than 600,000 Americans have UC, and 20%-30% of them require surgical management,” Bharati Kochar, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “The surgical procedure of choice for many UC patients is total proctocolectomy with ileal pouch anal anastomosis creation.”

According to Dr. Kochar, an advanced fellow in inflammatory bowel diseases at the University of North Carolina at Chapel Hill, existing American medical literature regarding ileal pouch anal anastomosis (IPAA) comes mostly from quaternary care centers and compares one-stage procedures with multistage procedures.

“The risks between two- to three-stage procedures are not described, and there are no prospective national reports of postoperative adverse events after IPAA creation,” she said.

Using data from the National Surgical Quality Improvement Program, Dr. Kochar and her associates conducted an observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC who underwent IPAA procedures between 2011 and 2015. Their aims were to evaluate adverse events within 30 days after an IPAA creation and to compare adverse events between pouch creation at the time of colectomy and delayed pouch creation.

They also performed a subanalysis of total abdominal colectomy with ileostomy (TAC), the first stage in the delayed pouch procedures, versus pouch creation at the time of colectomy. Multivariable modified Poisson regression models were used to estimate risk ratios adjusted for age, sex, race, body mass index, smoking status, diabetes, preoperative albumin, and American Society of Anesthesiologists class.

Of the 2,390 patients, 1,571 had pouches created at the time of colectomy (group A), and 819 had delayed pouch creation (group B).

Compared with patients in group B, those in group A were older (a median age of 40 years vs. 37 years, respectively; P less than .01), were more likely to be on an immunosuppressant (51% vs. 15%; P less than .01), have a lower median preoperative albumin level (3.9 vs. 4.2; P less than .01), and a longer median length of stay (6 days vs. 5 days; P less than .01).

On unadjusted analyses, the researchers also observed that, at 30 days, patients in group A had significantly more major complications, such as mortality and cardiac arrest (12.4% vs. 8.7%; P less than .01); minor complications, such as superficial surgical site infections and pneumonia (11.8% vs. 6.1%; P less than .01); unplanned readmissions (statistically similar at 23.3% vs. 21.3%), and unplanned reoperations (7.7% vs. 3.8%; P less than .01).

After controlling for confounders, patients in group B were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42).

In the subgroup analysis, Dr. Kochar and her associates observed that patients who underwent TAC were significantly older, compared with patients in group A (a median of 46 years vs. 40 years, respectively; P less than .01), and a higher proportion were on immunosuppressants (69% vs. 51%; P less than .01). “Despite these factors, the risk of adverse events after TAC was lower,” Dr. Kochar said.

She acknowledged certain limitations of the study, including the inability to accurately determine the risk of linked surgeries together and the inability to assess institution and operator factors. Also, data were not collected for the purposes of studying inflammatory bowel disease.

“This is the first prospective assessment of morbidity following IPAA creation in UC patients from a national database,” Dr. Kochar concluded. “Delayed pouch procedures are associated with a lower risk of unplanned reoperations and major and minor complications. Immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively. The findings can be valuable for preoperative risk assessment and postoperative management.”

Dr. Kochar reported having no financial disclosures.

*This story was updated on 3/26.

[email protected]

SOURCE: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11.

LAS VEGAS – Delayed creation of an ileal pouch anal anastomosis in patients with ulcerative colitis (UC) was associated with a lower risk of postoperative events, compared with creating the pouch at the time of initial surgery, results from an analysis of national data demonstrated.

“More than 600,000 Americans have UC, and 20%-30% of them require surgical management,” Bharati Kochar, MD, said at the Crohn’s & Colitis Congress, a partnership of the Crohn’s & Colitis Foundation and the American Gastroenterological Association. “The surgical procedure of choice for many UC patients is total proctocolectomy with ileal pouch anal anastomosis creation.”

According to Dr. Kochar, an advanced fellow in inflammatory bowel diseases at the University of North Carolina at Chapel Hill, existing American medical literature regarding ileal pouch anal anastomosis (IPAA) comes mostly from quaternary care centers and compares one-stage procedures with multistage procedures.

“The risks between two- to three-stage procedures are not described, and there are no prospective national reports of postoperative adverse events after IPAA creation,” she said.

Using data from the National Surgical Quality Improvement Program, Dr. Kochar and her associates conducted an observational cohort analysis of 2,390 adult patients with a postoperative diagnosis of UC who underwent IPAA procedures between 2011 and 2015. Their aims were to evaluate adverse events within 30 days after an IPAA creation and to compare adverse events between pouch creation at the time of colectomy and delayed pouch creation.

They also performed a subanalysis of total abdominal colectomy with ileostomy (TAC), the first stage in the delayed pouch procedures, versus pouch creation at the time of colectomy. Multivariable modified Poisson regression models were used to estimate risk ratios adjusted for age, sex, race, body mass index, smoking status, diabetes, preoperative albumin, and American Society of Anesthesiologists class.

Of the 2,390 patients, 1,571 had pouches created at the time of colectomy (group A), and 819 had delayed pouch creation (group B).

Compared with patients in group B, those in group A were older (a median age of 40 years vs. 37 years, respectively; P less than .01), were more likely to be on an immunosuppressant (51% vs. 15%; P less than .01), have a lower median preoperative albumin level (3.9 vs. 4.2; P less than .01), and a longer median length of stay (6 days vs. 5 days; P less than .01).

On unadjusted analyses, the researchers also observed that, at 30 days, patients in group A had significantly more major complications, such as mortality and cardiac arrest (12.4% vs. 8.7%; P less than .01); minor complications, such as superficial surgical site infections and pneumonia (11.8% vs. 6.1%; P less than .01); unplanned readmissions (statistically similar at 23.3% vs. 21.3%), and unplanned reoperations (7.7% vs. 3.8%; P less than .01).

After controlling for confounders, patients in group B were significantly less likely to have major complications (relative risk, 0.72), minor complications (RR, 0.48), unplanned readmissions (RR, 0.95), and unplanned reoperations (RR, 0.42).

In the subgroup analysis, Dr. Kochar and her associates observed that patients who underwent TAC were significantly older, compared with patients in group A (a median of 46 years vs. 40 years, respectively; P less than .01), and a higher proportion were on immunosuppressants (69% vs. 51%; P less than .01). “Despite these factors, the risk of adverse events after TAC was lower,” Dr. Kochar said.

She acknowledged certain limitations of the study, including the inability to accurately determine the risk of linked surgeries together and the inability to assess institution and operator factors. Also, data were not collected for the purposes of studying inflammatory bowel disease.

“This is the first prospective assessment of morbidity following IPAA creation in UC patients from a national database,” Dr. Kochar concluded. “Delayed pouch procedures are associated with a lower risk of unplanned reoperations and major and minor complications. Immunosuppression at the time of pouch creation may result in an increased risk of adverse events postoperatively. The findings can be valuable for preoperative risk assessment and postoperative management.”

Dr. Kochar reported having no financial disclosures.

*This story was updated on 3/26.

[email protected]

SOURCE: Kochar et al. Crohn’s & Colitis Congress 2018 Clinical Abstract 11.

LAS VEGAS – Emergent colectomies for ulcerative colitis in the United States decreased more than 7% annually between 2000 and 2014, a large database analysis has shown.

“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the  Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.

In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.

*This story was updated on 3/26.

[email protected]

SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.

LAS VEGAS – Emergent colectomies for ulcerative colitis in the United States decreased more than 7% annually between 2000 and 2014, a large database analysis has shown.

“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the  Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.

In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.

*This story was updated on 3/26.

[email protected]

SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.

LAS VEGAS – Emergent colectomies for ulcerative colitis in the United States decreased more than 7% annually between 2000 and 2014, a large database analysis has shown.

“Despite advances in medical therapy for ulcerative colitis (UC), many patients still need surgery,” Ryan C. Ungaro, MD, said at the Crohn’s & Colitis Congress, a partnership of the  Crohn’s & Colitis Foundation and the American Gastroenterological Association. “Prior epidemiologic studies have demonstrated a decline in colectomy rates over time, particularly comparing the pre- and postbiologic eras, but less is known about rates of emergent colectomy over time,” he said. In particular, he continued, data on UC colectomy and ileal pouch anal anastomosis (IPAA) surgery rates in the United States are limited.

In an effort to examine UC emergent colectomy rates and IPAA over time, Dr. Ungaro, of the division of gastroenterology at the Icahn School of Medicine at Mount Sinai, New York, and his associates analyzed data from the U.S. Nationwide Inpatient Sample from 2000 through 2014. They defined emergent colectomy cases as admission through the emergency department and used the ICD-9-CM code for subtotal colectomy (45.8) as the outcome variable, and defined a second cohort of UC patients admitted electively with an outcome variable of ICD-9-CM code for IPAA (45.95). To evaluate temporal trends of colectomy and IPAA, the researchers used joinpoint regression analysis with calculation of annual percentage change.

*This story was updated on 3/26.

[email protected]

SOURCE: Ungaro RC et al. Crohn’s & Colitis Congress, Clinical Abstract 23.

Enhanced recovery protocols for elective colectomy shortened length of stay (LOS) by more than a day and decreased complications without increasing readmissions, at 15 hospitals in a pilot study of the Enhanced Recovery in National Surgical Quality Improvement Program.

Guidance from experts, engaged multidisciplinary team leadership, continuous data collection and auditing, and collaboration across institutions were all key to success. “The pilot may serve to inform future implementation efforts across hospitals varied in size, location, and resource availability,” investigators led by Julia R. Berian, MD, a surgery resident at the University of Chicago, wrote in a study published online in JAMA Surgery.

[email protected]

SOURCE: Berian J et. al. JAMA Surg. 2017 Dec 20. doi: 10.1001/jamasurg.2017.4906

Enhanced recovery protocols for elective colectomy shortened length of stay (LOS) by more than a day and decreased complications without increasing readmissions, at 15 hospitals in a pilot study of the Enhanced Recovery in National Surgical Quality Improvement Program.

Guidance from experts, engaged multidisciplinary team leadership, continuous data collection and auditing, and collaboration across institutions were all key to success. “The pilot may serve to inform future implementation efforts across hospitals varied in size, location, and resource availability,” investigators led by Julia R. Berian, MD, a surgery resident at the University of Chicago, wrote in a study published online in JAMA Surgery.

[email protected]

SOURCE: Berian J et. al. JAMA Surg. 2017 Dec 20. doi: 10.1001/jamasurg.2017.4906

Enhanced recovery protocols for elective colectomy shortened length of stay (LOS) by more than a day and decreased complications without increasing readmissions, at 15 hospitals in a pilot study of the Enhanced Recovery in National Surgical Quality Improvement Program.

Guidance from experts, engaged multidisciplinary team leadership, continuous data collection and auditing, and collaboration across institutions were all key to success. “The pilot may serve to inform future implementation efforts across hospitals varied in size, location, and resource availability,” investigators led by Julia R. Berian, MD, a surgery resident at the University of Chicago, wrote in a study published online in JAMA Surgery.

[email protected]

SOURCE: Berian J et. al. JAMA Surg. 2017 Dec 20. doi: 10.1001/jamasurg.2017.4906

A 78-year-old man with a history of benign prostatic hyperplasia had double vision for 7 weeks. He also had pain in the right side of the face, altered taste, headaches that were worse when he was lying down, and lower abdominal lymphadenopathy.

His clinicians, at Brigham and Women’s Hospital in Boston, Massachusetts, say neurological examination revealed palsies of the right V, VI, VII, and XII cranial nerves. Magnetic resonance imaging revealed a clival mass and multiple lesions in the vertebrae. Radionuclide studies showed extensive tumor burden in the patient’s liver and peritoneum.

Because it is the most common cause of clival metastases, the clinicians initially suspected prostate cancer was the source of the symptoms. Moreover, the patient’s prostate-specific antigen was modestly elevated, a finding the clinicians called a red herring. The patient was instead diagnosed with a clival tumor, which is extremely rare—and made even more rare due to upper gastrointestinal (GI), the clinicians say. Only 5 cases have been reported of upper GI malignancy with clival metastasis.

Related: Cancer Prevention and Gastrointestinal Risk

The clivus is a bony structure located where the occipital and sphenoid bones meet, close to the long course of the abducens nerve. Double vision, caused by palsy at that nerve, is a prominent sign of a clival lesion, seen in > 40% of cases, the clinicians note. They suggest considering clival pathology as the cause of an abducens palsy or multiple cranial neuropathies.

The patient underwent several cycles of radiation therapy but ultimately decided on hospice care.

Source:

Lee C, Thon JM, Dhand A. BMJ Case Rep. 2017;2017: pii: bcr-2017-222725
doi: 10.1136/bcr-2017-222725.

A 78-year-old man with a history of benign prostatic hyperplasia had double vision for 7 weeks. He also had pain in the right side of the face, altered taste, headaches that were worse when he was lying down, and lower abdominal lymphadenopathy.

His clinicians, at Brigham and Women’s Hospital in Boston, Massachusetts, say neurological examination revealed palsies of the right V, VI, VII, and XII cranial nerves. Magnetic resonance imaging revealed a clival mass and multiple lesions in the vertebrae. Radionuclide studies showed extensive tumor burden in the patient’s liver and peritoneum.

Because it is the most common cause of clival metastases, the clinicians initially suspected prostate cancer was the source of the symptoms. Moreover, the patient’s prostate-specific antigen was modestly elevated, a finding the clinicians called a red herring. The patient was instead diagnosed with a clival tumor, which is extremely rare—and made even more rare due to upper gastrointestinal (GI), the clinicians say. Only 5 cases have been reported of upper GI malignancy with clival metastasis.

Related: Cancer Prevention and Gastrointestinal Risk

The clivus is a bony structure located where the occipital and sphenoid bones meet, close to the long course of the abducens nerve. Double vision, caused by palsy at that nerve, is a prominent sign of a clival lesion, seen in > 40% of cases, the clinicians note. They suggest considering clival pathology as the cause of an abducens palsy or multiple cranial neuropathies.

The patient underwent several cycles of radiation therapy but ultimately decided on hospice care.

Source:

Lee C, Thon JM, Dhand A. BMJ Case Rep. 2017;2017: pii: bcr-2017-222725
doi: 10.1136/bcr-2017-222725.

A 78-year-old man with a history of benign prostatic hyperplasia had double vision for 7 weeks. He also had pain in the right side of the face, altered taste, headaches that were worse when he was lying down, and lower abdominal lymphadenopathy.

His clinicians, at Brigham and Women’s Hospital in Boston, Massachusetts, say neurological examination revealed palsies of the right V, VI, VII, and XII cranial nerves. Magnetic resonance imaging revealed a clival mass and multiple lesions in the vertebrae. Radionuclide studies showed extensive tumor burden in the patient’s liver and peritoneum.

Because it is the most common cause of clival metastases, the clinicians initially suspected prostate cancer was the source of the symptoms. Moreover, the patient’s prostate-specific antigen was modestly elevated, a finding the clinicians called a red herring. The patient was instead diagnosed with a clival tumor, which is extremely rare—and made even more rare due to upper gastrointestinal (GI), the clinicians say. Only 5 cases have been reported of upper GI malignancy with clival metastasis.

Related: Cancer Prevention and Gastrointestinal Risk

The clivus is a bony structure located where the occipital and sphenoid bones meet, close to the long course of the abducens nerve. Double vision, caused by palsy at that nerve, is a prominent sign of a clival lesion, seen in > 40% of cases, the clinicians note. They suggest considering clival pathology as the cause of an abducens palsy or multiple cranial neuropathies.

The patient underwent several cycles of radiation therapy but ultimately decided on hospice care.

Source:

Lee C, Thon JM, Dhand A. BMJ Case Rep. 2017;2017: pii: bcr-2017-222725
doi: 10.1136/bcr-2017-222725.

SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.

There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.

Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.

“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.

The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.

His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.

The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).

In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).

The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.

There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.

Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.

“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.

The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.

His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.

The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).

In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).

The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.

SCOTTSDALE, ARIZ. – In colorectal surgery, transversus abdominis plane (TAP) block was associated with shorter hospital stays than epidural, according to a study that was conducted in patients undergoing both open and laparoscopic surgeries. TAP fared well in both groups.

There were higher rates of nausea/vomiting in the TAP group, suggesting the need for preoperative management in patients preparing to undergo TAP block. Urine retention was higher in the epidural group.

Physicians used liposomal bupivacaine, which is more costly than alternatives, and that fact met some resistance in the audience when the study was presented at the annual meeting of the Western Surgical Association. But patients receiving TAP had a 0.5-day shorter length of stay, which should reduce costs overall, and the drug component cost of TAP was less than $100 more than for the epidural.

“The biggest conclusion we drew from this study was that in patients where you would always consider an epidural historically, like an open procedure or a laparoscopic procedure where the conversion risk to open was higher, [favoring epidural] is now being called into question. We really believe that TAP block affords the length of stay benefit with no change in the pain control regimen after surgery,” Shawn Obi, DO, chief of surgery at Henry Ford Allegiance Health, Jackson, Mich., said in an interview.

The findings dovetail with an overall trend of improved protocols in colon surgery. “I think we’re working toward colorectal surgery as an outpatient operation, similar to what has happened in the joint arena,” said Dr. Obi.

His colleague, Matt Torgeson, DO, who is a surgical resident at Henry Ford Allegiance Health, noted that the hospital stay following colorectal surgery was once 6-8 days, and it has been shortened to 3-3.5 days. Enhanced recovery protocols made the biggest impact, shaving about 3 days. “Now we’re going to be seeing small, incremental changes,” said Dr. Torgeson.

The researchers randomized patients undergoing open or laparoscopic colorectal surgery to receive either an epidural (n = 37) or TAP block (n = 41). All patients entered an enhanced recovery pathway following surgery, with standardized discharge criteria. The two groups had similar times to return to normal bowel function (TAP, 1.7 days; epidural, 1.9 days) but the length of hospital stay was lower in the TAP group (2.8 days vs. 3.3 days; P = .023; 74.9 hours vs. 86.3 hours; P = .045). Subjects in the epidural group had a higher frequency of urinary retention (29.7% vs. 14.6%), though this did not reach statistical significance (P = .11). Postoperative nausea occurred at a higher rate in the TAP group (31.7% vs. 13.5%; odds ratio, 2.97), though this result just missed significance (P = .06).

In patients who had open surgery or laparoscopic surgery that converted to open, the length of stay was 2.9 days in the TAP group (n = 9) and 4.4 days in the epidural group (n = 5). Those numbers are small, but they suggest that TAP is effective even in open surgery. The cost of TAP was about $80 more than epidural medication ($406.16 vs. $322.73).

The study received no outside funding. Dr. Torgeson and Dr. Obi reported having no financial disclosures.