EGD: Indications 20002001

1
Tracking Colon Cancer Screening in Office
Practice C5 Summit New York June 5, 2008
David Lieberman MD Chief, Division of
Gastroenterology Oregon Health Sciences
University Portland VAMC
2
Colonoscopy
3
Colonoscopy
Rex et al Am J Gastroenterol 2002 97
1296-1308 Rex, Faigel, Pike ASGE/ACG Task Force
GIE 200663 S16-S28Lieberman et al
Gastrointest Endosc 2007 65 757-66
Depends on

• Appropriate utilization
• High-quality exam to cecum
• Low rate of missed lesions
• Low rate of incompletely removed lesions
• Low rate of adverse events

4
Colonoscopy Quality Concerns

• Interval cancers
• Missed Lesions
• Incompletely removed lesions
• Over-utilization
• Under utilization
• Complications

5
Brave New World

• Pay for performance
• Health savings accounts
• Payers who demand quality data

6
Challenges for GI Specialists

• Document and monitor quality
• Document appropriateutilization
• Document qualityimprovement efforts

7
Standardized Colonoscopy Reporting and Data
System CORADS
Rex et al Am J Gastroenterol 2002 97
1296-1308 Rex, Faigel, Pike ASGE/ACG Task Force
GIE 200663 S16-S28Lieberman et al
Gastrointest Endosc 2007 65 757-66

• Appropriate indication
• Bowel Prep quality
• Cecal Intubation rate
• Withdrawal time from cecum
• Polyp descriptors and retrieval
• Adenoma detection rate
• Appropriate surveillance intervals
• Adverse events/Unplanned events

8
National Endoscopic Database
www.cori.org
9
CORI

• CONCEPT
• Collect endoscopic practice data from diverse
  clinical practice settings throughout the United
  States
• GOAL
• Measure outcomes related to endoscopy
• FUNDING
• NIDDK since 1999

10
Endoscopy
Shining the light on
Endoscopy
- Who receives endoscopy? - Why do we do it ? -
Do patients benefit? - What is the impact on
management?
To understand what works in real life practice we
need to collect practice-based data
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Data Collection/Transmission
Patient Privacy
Central Databank

• - 72 adult practices
• 25 states
• 260,000 reports/yr
• - 70 from private practice

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Central Data Bank
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Colonoscopy (2007)

• Represents 59 of outpatient procedures
• Male 45
• Age
• lt50 16
• 50-59 35
• 60-69 27
• 70-79 16
• gt79 5
• Race
• White 88
• Black 5
• Hispanic 6

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Colonoscopy Indications (2007)

• Average-risk screening 29
• FHx CRC or polyps 12
• () FOBT 5
• Polyp/CRC surveillance 19
• Bleeding 23
• IBS cluster 16

15
Colonoscopy Quality
How are doing? n 438,521 2004-2006
16
Bowel Prep not reported 13.9
17
(No Transcript)
18
100
96.3
Cecal Landmarks not reported 14
90
19
Quality Indicators Polyp Descriptors258,601
polyps

• Polyp size reported
• NO 11.9
• Morphology reported (flat, sessile,
  pedunculated)
• NO 14.7
• Retreival Reported
• NO 4.5

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Mean 6.3
21
Colonoscopy
Rex et al Am J Gastroenterol 2002 97
1296-1308 Rex, Faigel, Pike ASGE/ACG Task Force
GIE 200663 S16-S28Lieberman et al
Gastrointest Endosc 2007 65 757-66
Depends on

• Appropriate utilization
• High-quality exam to cecum
• Low rate of missed lesions
• Low rate of incompletely removed lesions
• Low rate of adverse events

22
Tracking Utilization

• Screening intervals
• Average-risk 10-year interval after negative
  exam
• Family history of colon cancer 5-year interval
  if relative lt60 yrs.
• Surveillance intervals after polyps or cancer
• Too much exposes patients to unnecessary cost
  and risk
• Too little patients at risk may develop interval
  cancer

23
Colonoscopy
Rex et al Am J Gastroenterol 2002 97
1296-1308 Rex, Faigel, Pike ASGE/ACG Task Force
GIE 200663 S16-S28Lieberman et al
Gastrointest Endosc 2007 65 757-66
Depends on

• Appropriate utilization
• High-quality exam to cecum
• Low rate of missed lesions
• Low rate of incompletely removed lesions
• Low rate of adverse events

24
Challenges for GI Specialists

• Document and monitor quality
• Document appropriateutilization
• Document qualityimprovement efforts