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Spiegel BM (VA Greater Los Angeles Healthcare System; Sepulveda HSR&D COE), Chan M
(VA Greater LA HCS), Shekelle P
(VA Greater LA HCS), Aberbrook M
(VA Greater LA HCS), Cohen H
(VA Greater LA HCS)
Objectives:
The primary purpose of screening colonoscopy is to find and remove pre-malignant polyps – a maneuver proven to reduce subsequent colorectal cancer (CRC). The VA has committed extensive resources to ensuring use of screening colonoscopy in eligible veterans. Yet it remains untested whether the VA is adhering to published quality indicators (QIs) for the technical performance of colonoscopy and, if not, whether non-adherence negatively impacts polyp detection rates.
Methods:
We prospectively measured the technical characteristics of colonoscopies performed in consecutive veterans undergoing CRC screening between 2005-2007 in the VA Greater Los Angeles Healthcare System, including (1) bowel preparation quality (“good”/“excellent” vs. other), (2) cecal intubation achievement, and (3) withdrawal time. We measured adherence with the following published QIs: (1) achieve high quality preparation in all patients, (2) achieve cecal intubation in > 90%, and (3) slow withdrawal to > =6 minutes per patient. For QIs with sub-optimal adherence, we first performed a t-test to compare mean polyps detected with vs. without the QI achieved. We then performed Poisson regression to measure the effect of QI achievement on polyp detection while adjusting for a range of patient-level (age, gender, race, polyp history, BMI), provider-level (provider ID and years of training), and procedural-level (prep type, sedation dose, time of day) variables.
Results:
There were 932 patients (97% men; age 64+/-10). 92% had a > =6 minute withdrawal. Cecal intubation was achieved in 91%. Only 70% had a high quality bowel preparation. Patients with high quality preps had more polyps detected than patients with low quality preps (1.6 vs. 1.1 polyps; p=0.0006). In Poisson regression, preparation quality remained an independent predictor of polyp detection after adjusting for pre-specified variables (beta=0.23; p=0.001).
Implications:
In a large regional VA system, adherence with withdrawal time and cecal intubation QIs is acceptable. However, 30% of veterans present with a low quality bowel preparation. Moreover, low quality preparation predicts low polyp detection.
Impacts:
Polyps cannot be removed if they are not seen. These data indicate that poor bowel preparation is common and associated with low polyp detection. Future research must aim to improve bowel preparation quality among veterans undergoing screening colonoscopy.
