Quality and Case Yield of Screening Colonoscopies Performed by Primary Care Physicians

Objective:

To evaluate the quality and patient safety of screening colonoscopies performed by primary care physicians PCPs) in terms of cecal intubation rate, cecal intubation time, endoscope withdrawal time, complication rate (perforation, hemorrhage, and non-specific symptoms), polyp and cancer yield rate, as related to procedure volume of the performing physician

Study Design:

Retrospective data analysis on 13,366 screening colonoscopies performed by PCPs in South Carolina trained by a colonoscopy-credentialed physician, with an expert available on call. Quality and patient safety indicators will be compared with documented gastroenterologists' statistics. Quality and safety impacts of PCPs' procedure experience will be examined, classifying colonoscopies into three categories based on their physician's procedure volume: 1-50 colonoscopies (e.g the 20th colonoscopy of Physician A or B or C belonged in this category), 51-100 colonoscopies, and 100-plus. To test for procedure volume effect, mixed-effect logistic/linear regression model using Proc GLIMMIX/Proc Mixed in SAS for the dependent variables cecal intubation achievement, case yield, complication, cecal intubation time and withdrawal time will be fitted, (experience as fixed effect and PCP as random effect). We will control for patient demographics (age, gender and race), and number of polyps. A 2% chart review showed high accuracy of the database. Cleaned data are currently under analysis.

Policy Implications:

Colonoscopy screening can prevent 90% of approximately 145,000 annual incidence cases of colorectal cancer (CRCA) and 95% of 47,000 annual deaths in the US, by detecting and removing polyps, the precursors of CRCA. The former CRCA screening tool, sigmoidoscopy, which was widely performed by primary care physicians is now widely abandoned because of missing about 50% of cases due to its limited reach up the colon. The need for 23 million colonoscopies is nearly double the present performance of about 12 million with currently available expert capacity. African Americans (AA) have disproportionately higher case incidence, deaths, and aggressive cancers relative to whites, have twice the incidence of CRCA in the below-50 years age group, and have far higher incidence of right (ascending) colon polyps and cancers, the sites missed by sigmoidoscopy. For all these reasons, it is urgently necessary to increase colonoscopy screening capacity to reduce CRCA disparities. To advance towards this goal, this project was funded by the National Cancer Institute under the South Carolina Cancer Disparities and Control Network Program to examine the safety and efficacy of trained primary care physicians' performance of this procedure (NCI/CRCHD Grant #: 3 U01CA114601-03S5).