Prospective Study of the Quality of Colonoscopies Performed by Primary Care Physicians: The Alberta Primary Care Endoscopy (APC-Endo) Study

Abstract

BackgroundThe quality of colonoscopies performed by primary care physicians (PCPs) is unknown.ObjectiveTo determine whether PCP colonoscopists achieve colonoscopy quality benchmarks, and patient satisfaction with having their colonoscopy performed by a primary care physician.DesignProspective multi-center, multi-physician observational study. Colonoscopic quality data collection occurred via completion of case report forms and pathological confirmation of lesions. Patient satisfaction was captured by a telephone survey.SettingThirteen rural and suburban hospitals in Alberta, Canada.MeasurementsProportion of successful cecal intubations, average number of adenomas detected per colonoscopy, proportion of patients with at least one adenoma, and serious adverse event rates; patient satisfaction with their wait time and procedure, as well as willingness to have a repeat colonoscopy performed by their primary care endoscopist.ResultsIn the two-month study period, 10 study physicians performed 577 colonoscopies. The overall adjusted proportion of successful cecal intubations was 96.5% (95% CI 94.6–97.8), and all physicians achieved the adjusted cecal intubation target of ≥90%. The average number of ademonas detected per colonoscopy was 0.62 (95% CI 0.5–0.74). 46.4% (95% CI 38.5–54.3) of males and 30.2% (95% CI 22.3–38.2) of females ≥50 years of age having their first colonoscopy, had at least one adenoma. Four serious adverse events occurred (three post polypectomy bleeds and one perforation) and 99.3% of patients were willing to have a repeat colonoscopy performed by their primary care colonoscopist.LimitationsTwo-month study length and non-universal participation by Alberta primary care endoscopists.ConclusionsPrimary care physician colonoscopists can achieve quality benchmarks in colonoscopy. Training additional primary care physicians in endoscopy may improve patient access and decrease endoscopic wait times, especially in rural settings.

Expanding Access to Colorectal Cancer Screening: Benchmarking Quality Indicators in a Primary Care Colonoscopy Program

“…Our results are consistent with those of previous studies in reporting that quality indicators from colonoscopies conducted by primary care physicians are comparable to those performed by specialists 28,[31][32][33][34] with respect to meeting the recommendations of the ASGE for safe and effective endoscopic surveillance for CRC. 2,35 It is estimated that approximately 50% of colon cancers are located in the ascending or proximal part of the transverse colon and therefore cannot be detected by flexible sigmoidoscopy.…”

“…Delays in scheduling have been found to hinder the receipt of colonoscopy following positive FOBT. 26,31 Patients 39 and physicians 26 also identify delays as contributory to nonadherence to colonoscopy referral. Incorporating colonoscopy into primary care practices may have the added benefit of ensuring continuity of care, decreasing costs to patients, and decreasing transportation barriers (including travel time).…”

“…2,31 Photographic documentation of landmarks was performed for all procedures. Cecal intubation rate was calculated by dividing the number of procedures in which the cecum was attained by the total number of procedures performed.…”

Screening for colorectal cancer: the role of the primary care physician

“…Other data from different settings in many countries show that adequately trained PCPs can provide safe and technically competent colonoscopies. Their results compare favorably with the currently reported comparative data from specialist endoscopists 29,30.…”

Skills, Practice Patterns, and Knowledge of Canadian Family Physician Endoscopists

“…1 A few family physicians (FPs) perform endoscopy, primarily in rural communities. 2 While some studies demonstrate that Canadian FPs perform high quality endoscopies, 3,4 others claim future colorectal cancer rates are higher when colonoscopies are performed by non-gastroenterologists. [5][6][7] As no formal training program in gastrointestinal (GI) medicine for Canadian FPs exists, current FP endoscopists likely have differing skill sets, a fact which may partially explain the discrepancy in quality findings.…”