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Tu1737 Patient Perception of Bowel Preparation for Colonoscopy Is Associated With the Quality of Preparation
Abstracts
8.8%(14/159) of flat lesions, and 23.6% (17/72) of depressed lesions. The mean diameter (⫾SD) of the EGCs was 26.0⫾9.5mm and 28 (70%) lesions had the diameter of more than 20mm. The immediately secondary treatments with argon plasma coagulation (APC) or additional ESD (AESD) were performed in 14 (35%) and operations were done in 4 (10%) just after 1st ESD. The residual cancers were found in 2 surgical specimens of 4 patients who underwent operation. No lymph node metastasis was noted in these patients. There was no the local and distant recurrence for mean follow-up period (40.0 months ⫾ 25.2, median ⫾ SE) in 18 patients with immediately secondary treatment. Twenty-two (55%) cases without secondary treatment were followed up with endoscopic surveillance. Among 22 patients, 3 (13.6%) had the local recurrence during follow-up endoscopic surveillance (30.0 months ⫾ 19.0, median ⫾ SE). The EGCs with local recurrence were treated by Re-ESD (2 cases) and operation (1 case). Conclusions: Immediately secondary treatment was effective for the EGC patients who were regarded as laterally incomplete resection in pathologic report after ESD. The endoscopic surveillance should be performed meticulously in the patients without immediately secondary treatment. Endoscopic procedure can be firstly considered as less invasive treatment in selected patients with incompletely resected and locally recurred EGCs after ESD.
Tu1736 Temporal Changes in Colorectal Cancer Screening Practices in the Department of Veterans Affairs Between 2004 and 2010 Ashish Malhotra*, Mary Vaughan-Sarrazin, Gary Rosenthal General Internal Medicine, Iowa city VA medical Center/University of Iowa, Bettendorf, IA Background: Multiple reports have demonstrated an increase in the use of colonoscopy for colorectal cancer screening (CRC) in Medicare beneficiaries. However, there is a paucity of recent data regarding utilization trends in CRC screening procedures in Department of Veteran Affairs (VA) beneficiaries. Aim: Analyze trends in the utilization of CRC screening procedures in VA patients average and at higher risk of CRC. Methods: The VA Outpatient Care Files were used to identify patients ⬎50 years with ⬎1 primary care visits (in a given year) from 2004 to 2010. ICD-9-CM and CPT codes were used to identify veterans undergoing screening or surveillance colonoscopy, sigmoidoscopy, fecal occult blood testing (FOBT), and double-contrast barium enema (DCBE). Patients were categorized as high or average risk based on CRC risk factors and validated ICD9-CM based algorithms. Results: The total number of patients using VA primary care increased from 3,858,001 in 2004 to 4,373,358 in 2010. The proportion of patients categorized as high risk increased from 6.4%in 2004 to 8.2% in 2010. Rates of screening in high- and average-risk patients in each year are shown in Tables 1 and 2. Rates of colonoscopy increased for average-risk and decreased for high-risk patients. However, the total number of screening colonoscopies performed increased 32% between 2004 and 2010 (from 96,836 to 127,775 procedures). In contrast, the use of FOBT, sigmoidoscopy, and DCBE declined in average-risk and in high-risk patients (both with regard to numbers of procedures and proportions receiving screening). Finally, among patients who received CRC screening, the proportion screened by colonoscopy increased from 60% in 2004 to 74% in 2010 in high-risk patients and from 4% to 9.5% in average-risk category. Conclusion: In a national study of patients undergoing CRC screening in the VA healthcare system, the use of FOBT, sigmoidoscopy, and DCBE declined, while the use of colonoscopy increased. The increasing reliance on colonoscopy as a preferred CRC screening procedure in VA patients mimics findings in other populations. Table 1. Rates of screening procedures in High-risk patients from 2004-2010 Screening Procedure
2004
2005
2006
2007
2008
2009
2010
Colonoscopy (%) FOBT (%) Sigmoidoscopy or DCBE or Both (%)
25.1 19.7 6.6
23.6 17.5 5.3
22.1 15.2 3.8
21.9 12.5 3.2
21.8 11.8 2.4
21.6 10.8 1.9
22.0 10.4 1.6
Table 2. Rates of screening procedures in Average-risk patients from 2004-2010 Screening Procedure
2004
2005
2006
2007
2008
2009
2010
Colonoscopy (%) FOBT (%) Sigmoidoscopy or DCBE or Both (%)
1.0 23.4 1.2
1.0 20.9 1.0
0.9 17.5 0.7
1.0 15.3 0.6
1.1 14.2 0.4
1.2 13.0 0.3
1.2 12.0 0.2
Tu1737 Patient Perception of Bowel Preparation for Colonoscopy Is Associated With the Quality of Preparation Edward W. Holt*, Kidist Yimam, Hanley Ma, Richard E. Shaw, Richard Sundberg, Michael S. Verhille California Pacific Medical Center, San Francisco, CA Background: Colorectal cancer (CRC) is preventable by colonoscopic polypectomy. Prior studies have shown an association between the quality of bowel preparation and polyp detection rate (PDR). Identification of modifiable factors that influence PDR, including patient factors, may increase the yield of colonoscopy. Purpose: To determine the association between patient perception of and attitude toward bowel preparation and both the quality of bowel preparation and the yield of colonoscopy Methods: Between March and July 2011 we prospectively enrolled 430 patients presenting for colonoscopy. Prior to the procedure, patients answered questions about how much of the bowel preparation they completed (95%, 75%, 50% or ⬍50%), how clear their bowel movements were after the preparation (clear, yellow, brown, semi-solid or solid) and the tolerability of bowel preparation (good, tolerable, unpleasant, intolerable). The quality of bowel preparation was assessed using the validated Ottawa scale. PDR and ADR (adenoma detection rate) were calculated using procedure and pathology reports. Kendall’s tau-b test was used to identify factors associated with detection of polyps and adenomas. Results: The mean age was 60.4 (range 24-84), and 211 (49.1%) participants were male. The majority of participants (93.8%) reported competing 95% of the preparation, while 31.2% reported completely clear bowel movements after the prep and 21.0% rated their experience with the preparation “good”. At colonoscopy, 87.3% of the bowel preps were excellent (total Ottawa score 4 or less). In a univariate analysis, there were significant associations between the quality of bowel preparation and the self-reported percent completed (p⬍0.001), the self-reported clarity of bowel movements (p⬍0.001) and the self-reported tolerability of bowel preparation (p⫽0.006). These associations remained significant when considering the quality of bowel preparation in the right colon only (p⬍0.001, p⫽0.010 and p⫽0.013, respectively). Patient self-reported tolerability of bowel preparation - but not selfassessment of completion or clarity - was significantly associated with the detection of both polyps and adenomas (Table 1). Conclusion: In this singlecenter prospective study, patient perception of and attitude toward bowel preparation was significantly associated with differences in the quality of bowel preparation. Furthermore, patients who self-reported a better experience with bowel preparation had significantly greater rates of both adenoma and polyp detection. Efforts to make bowel preparation more tolerable for patients may lead to improvements in the quality of bowel preparation and in adenoma yield. Table 1. Associations between patient self-reported tolerability of bowel preparation and yield of polyps and adenomas during colonoscopy
Polyp in entire colon Adenoma in entire colon Polyp in right colon Adenoma in right colon
Good (nⴝ88)
Tolerable (nⴝ229)
Unpleasant (nⴝ85)
Intolerable (nⴝ16)
p-value
65.9% 50.0%
57.6% 44.5%
44.7% 37.6%
50.0% 18.8%
0.005 0.021
34.1% 27.3%
27.1% 23.1%
17.6% 17.6%
25.0% 12.5%
0.019 0.072
Tu1738 Time of Day: A Predictor of ERCP Outcomes? Eric M. Nelsen*1, James H. Tabibian2, Felicity Enders2, Todd H. Baron2 1 Internal Medicine, Mayo Clinic, Rochester, MN; 2Gastroenterology, Mayo Clinic, Rochester, MN Introduction: Emerging data suggest that time of day of endoscopic procedures may be associated with differences in outcome, including rates of colonoscopy completion and polyp detection. Such differences have been attributed to progressive endoscopist fatigue and decreased concentration. We hypothesized that afternoon endoscopic retrograde cholangiopancreatography (ERCP) would have worse outcomes including procedural success rates, averse event (AE) rates, and procedure duration. Methods: 423 consecutive outpatient ERCPs performed at Mayo Clinic, Rochester between November 2010 and April 2011 were identified and medical records reviewed for pertinent data. Patients with surgically altered anatomy were excluded. AEs including bleeding, perforation, pancreatitis, cholangitis, pain, and post-ERCP hospital admission were identified from the medical record as well as an existing institutional AE infrastructure. ERCP complexity was graded using published consensus guidelines. Multivariate analysis was performed to assess for differences between morning and afternoon ERCP adjusting for variables that were significantly different between groups in univariate analysis. Results: Of the 423 ERCPs, 260 (61.5%) were performed in the morning and 163 (38.5 %) were afternoon. Mean patient age was 58.2, and 237 patients were male (56%). Procedural success was lower for afternoon ERCPs, 92% compared to 97.2% (p⫽0.014; odds ratio [OR] 3.13; 95% confidence
AB506 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
8.8%(14/159) of flat lesions, and 23.6% (17/72) of depressed lesions. The mean diameter (⫾SD) of the EGCs was 26.0⫾9.5mm and 28 (70%) lesions had the diameter of more than 20mm. The immediately secondary treatments with argon plasma coagulation (APC) or additional ESD (AESD) were performed in 14 (35%) and operations were done in 4 (10%) just after 1st ESD. The residual cancers were found in 2 surgical specimens of 4 patients who underwent operation. No lymph node metastasis was noted in these patients. There was no the local and distant recurrence for mean follow-up period (40.0 months ⫾ 25.2, median ⫾ SE) in 18 patients with immediately secondary treatment. Twenty-two (55%) cases without secondary treatment were followed up with endoscopic surveillance. Among 22 patients, 3 (13.6%) had the local recurrence during follow-up endoscopic surveillance (30.0 months ⫾ 19.0, median ⫾ SE). The EGCs with local recurrence were treated by Re-ESD (2 cases) and operation (1 case). Conclusions: Immediately secondary treatment was effective for the EGC patients who were regarded as laterally incomplete resection in pathologic report after ESD. The endoscopic surveillance should be performed meticulously in the patients without immediately secondary treatment. Endoscopic procedure can be firstly considered as less invasive treatment in selected patients with incompletely resected and locally recurred EGCs after ESD.
Tu1736 Temporal Changes in Colorectal Cancer Screening Practices in the Department of Veterans Affairs Between 2004 and 2010 Ashish Malhotra*, Mary Vaughan-Sarrazin, Gary Rosenthal General Internal Medicine, Iowa city VA medical Center/University of Iowa, Bettendorf, IA Background: Multiple reports have demonstrated an increase in the use of colonoscopy for colorectal cancer screening (CRC) in Medicare beneficiaries. However, there is a paucity of recent data regarding utilization trends in CRC screening procedures in Department of Veteran Affairs (VA) beneficiaries. Aim: Analyze trends in the utilization of CRC screening procedures in VA patients average and at higher risk of CRC. Methods: The VA Outpatient Care Files were used to identify patients ⬎50 years with ⬎1 primary care visits (in a given year) from 2004 to 2010. ICD-9-CM and CPT codes were used to identify veterans undergoing screening or surveillance colonoscopy, sigmoidoscopy, fecal occult blood testing (FOBT), and double-contrast barium enema (DCBE). Patients were categorized as high or average risk based on CRC risk factors and validated ICD9-CM based algorithms. Results: The total number of patients using VA primary care increased from 3,858,001 in 2004 to 4,373,358 in 2010. The proportion of patients categorized as high risk increased from 6.4%in 2004 to 8.2% in 2010. Rates of screening in high- and average-risk patients in each year are shown in Tables 1 and 2. Rates of colonoscopy increased for average-risk and decreased for high-risk patients. However, the total number of screening colonoscopies performed increased 32% between 2004 and 2010 (from 96,836 to 127,775 procedures). In contrast, the use of FOBT, sigmoidoscopy, and DCBE declined in average-risk and in high-risk patients (both with regard to numbers of procedures and proportions receiving screening). Finally, among patients who received CRC screening, the proportion screened by colonoscopy increased from 60% in 2004 to 74% in 2010 in high-risk patients and from 4% to 9.5% in average-risk category. Conclusion: In a national study of patients undergoing CRC screening in the VA healthcare system, the use of FOBT, sigmoidoscopy, and DCBE declined, while the use of colonoscopy increased. The increasing reliance on colonoscopy as a preferred CRC screening procedure in VA patients mimics findings in other populations. Table 1. Rates of screening procedures in High-risk patients from 2004-2010 Screening Procedure
2004
2005
2006
2007
2008
2009
2010
Colonoscopy (%) FOBT (%) Sigmoidoscopy or DCBE or Both (%)
25.1 19.7 6.6
23.6 17.5 5.3
22.1 15.2 3.8
21.9 12.5 3.2
21.8 11.8 2.4
21.6 10.8 1.9
22.0 10.4 1.6
Table 2. Rates of screening procedures in Average-risk patients from 2004-2010 Screening Procedure
2004
2005
2006
2007
2008
2009
2010
Colonoscopy (%) FOBT (%) Sigmoidoscopy or DCBE or Both (%)
1.0 23.4 1.2
1.0 20.9 1.0
0.9 17.5 0.7
1.0 15.3 0.6
1.1 14.2 0.4
1.2 13.0 0.3
1.2 12.0 0.2
Tu1737 Patient Perception of Bowel Preparation for Colonoscopy Is Associated With the Quality of Preparation Edward W. Holt*, Kidist Yimam, Hanley Ma, Richard E. Shaw, Richard Sundberg, Michael S. Verhille California Pacific Medical Center, San Francisco, CA Background: Colorectal cancer (CRC) is preventable by colonoscopic polypectomy. Prior studies have shown an association between the quality of bowel preparation and polyp detection rate (PDR). Identification of modifiable factors that influence PDR, including patient factors, may increase the yield of colonoscopy. Purpose: To determine the association between patient perception of and attitude toward bowel preparation and both the quality of bowel preparation and the yield of colonoscopy Methods: Between March and July 2011 we prospectively enrolled 430 patients presenting for colonoscopy. Prior to the procedure, patients answered questions about how much of the bowel preparation they completed (95%, 75%, 50% or ⬍50%), how clear their bowel movements were after the preparation (clear, yellow, brown, semi-solid or solid) and the tolerability of bowel preparation (good, tolerable, unpleasant, intolerable). The quality of bowel preparation was assessed using the validated Ottawa scale. PDR and ADR (adenoma detection rate) were calculated using procedure and pathology reports. Kendall’s tau-b test was used to identify factors associated with detection of polyps and adenomas. Results: The mean age was 60.4 (range 24-84), and 211 (49.1%) participants were male. The majority of participants (93.8%) reported competing 95% of the preparation, while 31.2% reported completely clear bowel movements after the prep and 21.0% rated their experience with the preparation “good”. At colonoscopy, 87.3% of the bowel preps were excellent (total Ottawa score 4 or less). In a univariate analysis, there were significant associations between the quality of bowel preparation and the self-reported percent completed (p⬍0.001), the self-reported clarity of bowel movements (p⬍0.001) and the self-reported tolerability of bowel preparation (p⫽0.006). These associations remained significant when considering the quality of bowel preparation in the right colon only (p⬍0.001, p⫽0.010 and p⫽0.013, respectively). Patient self-reported tolerability of bowel preparation - but not selfassessment of completion or clarity - was significantly associated with the detection of both polyps and adenomas (Table 1). Conclusion: In this singlecenter prospective study, patient perception of and attitude toward bowel preparation was significantly associated with differences in the quality of bowel preparation. Furthermore, patients who self-reported a better experience with bowel preparation had significantly greater rates of both adenoma and polyp detection. Efforts to make bowel preparation more tolerable for patients may lead to improvements in the quality of bowel preparation and in adenoma yield. Table 1. Associations between patient self-reported tolerability of bowel preparation and yield of polyps and adenomas during colonoscopy
Polyp in entire colon Adenoma in entire colon Polyp in right colon Adenoma in right colon
Good (nⴝ88)
Tolerable (nⴝ229)
Unpleasant (nⴝ85)
Intolerable (nⴝ16)
p-value
65.9% 50.0%
57.6% 44.5%
44.7% 37.6%
50.0% 18.8%
0.005 0.021
34.1% 27.3%
27.1% 23.1%
17.6% 17.6%
25.0% 12.5%
0.019 0.072
Tu1738 Time of Day: A Predictor of ERCP Outcomes? Eric M. Nelsen*1, James H. Tabibian2, Felicity Enders2, Todd H. Baron2 1 Internal Medicine, Mayo Clinic, Rochester, MN; 2Gastroenterology, Mayo Clinic, Rochester, MN Introduction: Emerging data suggest that time of day of endoscopic procedures may be associated with differences in outcome, including rates of colonoscopy completion and polyp detection. Such differences have been attributed to progressive endoscopist fatigue and decreased concentration. We hypothesized that afternoon endoscopic retrograde cholangiopancreatography (ERCP) would have worse outcomes including procedural success rates, averse event (AE) rates, and procedure duration. Methods: 423 consecutive outpatient ERCPs performed at Mayo Clinic, Rochester between November 2010 and April 2011 were identified and medical records reviewed for pertinent data. Patients with surgically altered anatomy were excluded. AEs including bleeding, perforation, pancreatitis, cholangitis, pain, and post-ERCP hospital admission were identified from the medical record as well as an existing institutional AE infrastructure. ERCP complexity was graded using published consensus guidelines. Multivariate analysis was performed to assess for differences between morning and afternoon ERCP adjusting for variables that were significantly different between groups in univariate analysis. Results: Of the 423 ERCPs, 260 (61.5%) were performed in the morning and 163 (38.5 %) were afternoon. Mean patient age was 58.2, and 237 patients were male (56%). Procedural success was lower for afternoon ERCPs, 92% compared to 97.2% (p⫽0.014; odds ratio [OR] 3.13; 95% confidence
AB506 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org