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Practice
audits in gastroenterology: Preliminay
data
By
Diana Swift
Banff,
AB—Developed
along the same lines as the Practice Audit Program in Upper GI Endoscopy
(PAGE I), PAGE II allows practitioners to track their use of colonoscopy,
confidentially compare their practice patterns online with those
of their colleagues across Canada, and earn CME credits from the
Royal College of Physicians and Surgeons of Canada.
“As colonoscopy becomes increasingly important in our practices,
it’s important to see if our individual colonoscopic practices
are appropriate,” said David Armstrong, MD, Head of Service,
Gastroenterology, and Associate Professor of Medicine, Division
of Gastroenterology, McMaster University, Hamilton, ON.
As of October 2003, 77 Canadian endoscopists completing 3,582 colonoscopies
had contributed data to PAGE II. “That amounted to 48 colonoscopies
per endoscopist over a three-week period, and that tells us that
we are now doing 25 to 30 per cent more colonoscopies than endoscopies
over the same time period,” he noted. By February 2004, 107
endoscopists had reported to PAGE II, each conducting an average
of 45 colonoscopic investigations over three weeks.
Participants
practised in communities with population bases ranging from less
than 50,000 to more than one million.
Overall, just under 60 per cent of examinations were done to investigate
abnormal symptoms or findings on other tests. A little over 25 per
cent were done for screening purposes, while roughly 20 per cent
were performed for surveillance of IBD or abnormal prior findings
such as colon polyps or cancer.
“Interestingly, the number of colon-oscopies per endoscopist
is significantly higher in smaller communities, although we must
treat these data with caution because the study was not specifically
designed to look at this distribution.”
In communities of less than 100,000 and those of 100,000 to 250,000,
the average number of colonoscopies performed by each endoscopist
ranged from 59 to 64 over three weeks.
In centres with populations of 250,000 to 500,000, the average number
per endoscopist over three weeks ranged from 33 to 36. “This
suggests there is a discrepancy among communities as to the availability
of colonoscopy.”
In the screening setting, 84 per cent of individuals were referred
for colonoscopy because of a family history of colon cancer and
44 per cent because of age. An additional 10 per cent requested
the procedure in response to TV and media advertising and three
per cent because they had a spouse or a friend with colon cancer.
In the setting of patients referred for investigation of specific
abnormalities or symptoms, the reasons for referral included:
• rectal bleeding 34 per cent,
• abdominal pain 28 per cent,
• diarrhea 24 per cent,
• anemia 18 per cent,
• prior GI abnormality 12 per cent,
• weight loss 9 per cent
• constipation 8 per cent,
• positive FOBT 6 per cent,
• anorectal pain 6 per cent, and,
• “other” 7 per cent.
Asked to record in advance of an exam the most probable expected
finding, participants listed colonic polyps (29 per cent), hemorrhoids
(28 per cent), diverticular disease (25 per cent), colon cancer
(21 per cent), IBD (15 to 20 per cent), anal fissure (four per cent)
and normal (28 per cent).
Results were grouped according to whether the patients had been
referred for abnormal findings, screening, or surveillance. Interestingly,
32 per cent (investigation of abnormal findings) to 54 per cent
(screening) of procedures yielded normal results, and, overall,
polyps were found in 26 per cent. The prevalence of polyps ranged
from 21 per cent in colonoscopies done for abnormal referrals to
29 per cent in patients sent for screening, and up to 40 per cent
in those undergoing surveillance. The usual number of polyps found
in screened patients was one, but a significant proportion had two
to five lesions.
“Overall, nearly two-thirds of colonoscopies showed abnormalities.
But at 3.1 per cent, colon cancer was less common than expected,”
Dr. Armstrong said.
“Screening colonoscopy accounted for about 25 per cent of all
exams, with a range across communities of 17 to 30 per cent. With
the polyp yields high for both screening and surveillance colonoscopy,
we need to consider these data when we plan for the development
of colonoscopic services and attendant resources in Canada over
the next few years.”
Also outlined was the pilot phase of the new PAGE III program, also
known as A Week in the Life of a Gastroenterologist. Dr. Armstrong
noted that “as colonoscopy assumes a greater proportion of
what we do, it is important to have an idea of how we spend our
time.” Thirteen participants, with practices ranging from the
community to the academic setting, reported in the pilot program.
Data suggest that practitioners are spending about one-third of
their 168-hour week in direct patient contact versus about 20 per
cent in indirect activities such as administration, paperwork, research,
and education. That leaves a scant 47 per cent per cent of the week
for personal time.
“Clearly, this is only a small sample of Canadian gastroenterologists,
but the preliminary results suggest that we need considerably more
data on the workload assumed by gastroenterologists across Canada,”
he said. “This is a tremendous opportunity for CAG to help
its members review their practice, their commitments, and their
lifestyle.”
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