Online Program

Colorectal cancer prevention efficacy of primary care physician-performed vs. specialist-performed colonoscopies at one endoscopy center

Monday, November 4, 2013 : 12:50 p.m. - 1:10 p.m.

Sudha Xirasagar, MBBS, PhD, Dept of Health Services Policy and Management, University of South Carolina, Arnold School of Public Health, Columbia, SC
Yi-Jhen Li, PhD, Dept of Health Services Policy and Management, University of South Carolina, Arnold School of Public Health, Columbia, SC
Thomas G. Hurley, MS, Cancer Prevention & Control Program, University of South Carolina, Columbia, SC
James W. Hardin, PhD, Department of Biostatistics, University of South Carolina, Arnold School of Public Health, Columbia, SC
Deborah M Hurley, MSPH, South Carolina Central Cancer Registry, South Carolina Department of Health and Environmental Control, Columbia, SC
James R. Hebert, ScD, Arnold School of Public Health, University of South Carolina, Columbia, SC
Piet C de Groen, MD, Department of Internal Medicine and Consultant, Division of Gastroenterology, Mayo Clinic College of Medicine, Rochester, MN
Background: Lifetime risk of colorectal cancer (CRC) in the US is 5-6%. Well-performed colonoscopy screening and surveillance to clear the colon of precancerous polyps in theory can greatly reduce CRC incidence. A major hurdle for screening and surveillance is the shortage of endoscopists. A potential solution, training primary care physicians (PCPs) in colonoscopy, was called into question by a Canadian study that reported poor CRC protection among PCP-served patients. Aim: To examine the CRC prevention impact of PCPs performing screening colonoscopies under a standardized, polyp yield-maximizing clinical protocol implemented across all providers at a single endoscopy center in South Carolina. Methods: Since 2001, an innovative colonoscopy protocol along with systematic data documentation was implemented. Fifty-four PCPs were trained in colonoscopy using training processes similar to those of gastroenterology fellowship programs (hands-on expert involvement transitioning into supervised, independent performance over the first 140 procedures, the credentialing benchmark for gastroenterology fellows). Following training, PCPs were provided hands-on assistance by an endoscopy technician, with an onsite expert always available for rescue assistance. A previous study documented high rates of adenoma detection and patient safety. Post-colonoscopy CRC incidence rates for PCP vs. specialist cases, merging the center's 2001-2008 colonoscopy cohort data with 1996-2010 CRC data from the South Carolina Central Cancer Registry (SCCCR), were compared. The SCCCR is a NAACR-accredited gold-rated registry that captures all CRC cases diagnosed in South Carolina or in any of 20 surrounding states via reciprocal data exchange agreements. Age-, sex- and race-adjusted standardized incidence ratios (SIR) relative to South Carolina and SEER-17 incidence rates were calculated. Results: Of 16,364 study-eligible persons (4 excluded due to missing SSN) with screening colonoscopy 12,383 (76%) were performed by PCPs and 3,981 by specialists, with total 75,318 person-years (mean 4.5, median 4.9) of observation (PYO). Nineteen persons developed CRC (14 and 5 among PCP and specialist cases, respectively). Overall SIR was 17%. Cancer prevention efficacy was 83% for PCPs and 80% for specialists. Analyses limiting the cohort to 2001-2004 (to ensure >5-year follow-up) resulted in 7,921 patients with 49,356 PYOs (mean 6.7, median 6.6) and showed an 87% cancer prevention efficacy for PCPs and 83% for specialists. Conclusions: Colonoscopy by PCPs conferred high CRC protection similar to the highest ever documented protection rate of 76-90% reported in the 1993 National Polyp Study. PCP-performed colonoscopies with technical support under a standardized, high-performance colonoscopy protocol may be a solution to the shortage of endoscopists.

Learning Areas:

Chronic disease management and prevention
Conduct evaluation related to programs, research, and other areas of practice

Learning Objectives:
Describe the colorectal cancer prevention efficacy of primary care physicians performing screening colonoscopy under a quality-maximizing protocol, with technical support and onsite specialist rescue assistance when needed, compared to specialsits Describe the colonoscopy protocol and support conditions under which the cancer prevention efficacy was achieved. Describe the cancer profile of those who developed cancer despite colonoscopy to evaluate the context of post-screening cancer development Evaluate whether the center's model of PCP utilization may be part of hte solution to the endoscopist shortage.

Keyword(s): Cancer Prevention, Quality

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the PI of the grant that supported this study and primary researcher responsible for the planning and conduct of the study. I have an MBBS (doctor of medicine)and PhD degree in health services research and my research expertise is in the areas of colorectal cancer screening and in health services research on quality of care.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.