Yize R. Wang

Rate of Early/Missed Colorectal Cancers After Colonoscopy in Older Patients With or Without Inflammatory Bowel Disease in the United States

OBJECTIVES:Patients with inflammatory bowel disease (IBD) have an increased risk for colorectal cancer (CRC). Previous studies on early/missed CRCs after colonoscopy excluded IBD patients. The aim of this study was to compare the rate of early/missed CRCs after colonoscopy among IBD and non-IBD patients, and identify factors associated with early/missed CRCs.METHODS:All patients in the Surveillance, Epidemiology and End-Results Medicare-linked database who were 67 years or older at colonoscopy during 1998–2005 and those who were subsequently diagnosed with CRC within 36 months were identified. CRCs diagnosed within 6 months of colonoscopy were categorized as detected CRCs; CRCs diagnosed 6–36 months after colonoscopy were categorized as early/missed CRCs. The rate of early/missed CRCs was calculated as number of early/missed CRCs divided by number of detected and early/missed CRCs. The χ2 test and multivariate logistic regression were used in statistical analysis.RESULTS:Of 55,008 CRC patients (304 Crohns disease; 544 ulcerative colitis (UC)), the rate of early/missed CRCs was 5.8% for non-IBD patients, 15.1% for Crohns, and 15.8% for UC (P<0.001). Compared with older non-IBD patients, early/missed CRCs among older IBD patients were less likely right-sided (both P<0.05). In multivariate logistic regression, the risk of early/missed CRCs was three times as high for IBD patients (Crohns odds ratio (OR), 3.07; 95% confidence interval (CI) 2.23–4.21; UC OR, 3.05; 95% CI, 2.44–3.81). Sensitivity analyses confirmed the robustness of this finding.CONCLUSIONS:Older IBD patients had a higher rate of early/missed CRCs after colonoscopy. Our finding supports intensive surveillance colonoscopy for older IBD patients as recommended by guidelines.

Factors associated with increased bleeding post-endoscopic mucosal resection

Our aim was to identify patient and procedure characteristics that correlate with increased likelihood of bleeding during and after endoscopic mucosal resection (EMR), and thus anticipate the need for preventative therapy.

Racial/Ethnic and Regional Differences in the Prevalence of Inflammatory Bowel Disease in the United States

Background: The magnitude of racial/ethnic and regional differences in the prevalence of inflammatory bowel disease (IBD) in the United States remains largely unknown. Aims: To estimate differences in the prevalence of IBD by race/ethnicity and region. Methods: The Medical Expenditure Panel Survey, a nationally representative survey of US households and medical conditions, was used. A multivariate logistic model was used in statistical analysis. Results: Among 202,468 individuals surveyed during 1996-2007, 316 were diagnosed with IBD (26 Blacks, 21 Hispanics, and 5 Asians). The prevalence of IBD was higher in Whites [Crohns disease: 154; ulcerative colitis (UC): 89] than Blacks (Crohns disease: 68; UC: 25), Hispanics (Crohns disease: 15; UC: 35), and Asians (Crohns: 45; UC: 40) (all p < 0.05, except for UC in Asians). The differences in Crohns disease between Whites and minorities and the difference in UC between Whites and Blacks remained significant in multivariate analysis. In multivariate analysis, there was no regional difference in the prevalence of Crohns disease, but the prevalence of UC was higher in the Northeast than the South (p < 0.05). Conclusions: There were significant racial/ethnic differences in the prevalence of IBD in the USA. The underlying etiology of these differences warrants additional research.

Risk of Colorectal Cancer After Colonoscopy Compared With Flexible Sigmoidoscopy or No Lower Endoscopy Among Older Patients in the United States, 1998-2005

OBJECTIVE To determine whether the risk of colorectal cancer (CRC) decreases after colonoscopy compared with sigmoidoscopy or no lower endoscopy. PATIENTS AND METHODS Patients 67 to 80 years old in the 5% random Medicare sample of the Surveillance, Epidemiology and End Results and Medicare-linked database were grouped into those who underwent colonoscopy or flexible sigmoidoscopy from January 1, 1998, through December 31, 2002, and those who did not undergo lower endoscopy. We excluded patients with inflammatory bowel disease, history of colon polyps, or family history of CRC. All patients were followed up until the diagnosis of CRC or carcinoma in situ, death, or December 31, 2005. The risk of CRC after colonoscopy was compared with the risk after sigmoidoscopy or no lower endoscopy. The multivariate Cox proportional hazards model was used in statistical analysis. RESULTS In the colonoscopy group (n=12,266), 58 CRCs (0.5%) were diagnosed during follow-up compared with 66 CRCs (1.0%) in the sigmoidoscopy group (n=6402) and 634 (1.5%) in the control group (n=41,410) (all P<.001). In the sigmoidoscopy group, 771 patients (12.0%) underwent colonoscopy within the next 12 months. In multivariate Cox regressions, colonoscopy was associated with a decreased risk of distal CRC (hazard ratio [HR], 0.266; 95% CI, 0.161-0.437) and proximal CRC (HR, 0.451; 95% CI, 0.305-0.666); sigmoidoscopy was associated with a decreased risk of distal CRC (HR, 0.409; 95% CI, 0.207-0.809) but not proximal CRC. CONCLUSION Among older patients, the risk of distal CRC decreased after both colonoscopy and sigmoidoscopy; the risk of proximal CRC decreased after colonoscopy but not sigmoidoscopy.

Quality in colonoscopy reporting: An assessment of compliance and performance improvement

BACKGROUND An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined. AIMS To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention. METHODS 300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance. RESULTS Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16). CONCLUSION This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.

Use of surveillance colonoscopy in medicare patients with inflammatory bowel disease prior to colorectal cancer diagnosis.

Background: Patients with longstanding inflammatory bowel disease (IBD) involving large intestine proximal to rectum are considered to be at increased risk for colorectal cancer (CRC). One prior study showed low utilization of surveillance colonoscopy in patients with ≥8 years of ulcerative colitis (UC) in the USA. Aims: To study use of surveillance colonoscopy among Medicare beneficiaries with IBD in the 2-year period prior to CRC diagnosis. Data and Methods: Our study sample included Medicare beneficiaries in the SEER-Medicare-linked database who were diagnosed with CRC during 2001-2005 and had ≥3 physician visits with ICD-9 diagnosis code for IBD prior to CRC diagnosis. Medicare beneficiaries aged >85 years without Part B coverage or enrolled in HMOs were excluded. Colonoscopy performed within 6-30 months prior to CRC diagnosis was defined as surveillance colonoscopy. The χ2 test and multivariate logistic regression were used in statistical analysis. Results: Of 241 Medicare beneficiaries with IBD and diagnosed with CRC, 92 (38%) patients underwent ≥1 surveillance colonoscopy in the 2 years prior to cancer diagnosis. The use of surveillance colonoscopy was similar between Crohns disease (28/86, 33%) and UC (64/155, 41%). In multivariate logistic regression, older age (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.94-0.99) was negative associated with surveillance colonoscopy use and personal history of colon polyp (OR 2.73, 95% CI 1.09-6.87) was positively associated with surveillance colonoscopy use. Conclusions: Use of surveillance colonoscopy was low among Medicare beneficiaries with IBD in the 2 years prior to CRC diagnosis.

Increased Odds of Interval Left-Sided Colorectal Cancer After Flexible Sigmoidoscopy Compared With Colonoscopy in Older Patients in the United States: A Population-Based Analysis of the SEER-Medicare Linked Database, 2001-2005

OBJECTIVES To compare the proportion of interval left-sided colorectal cancers (CRCs) after flexible sigmoidoscopy vs colonoscopy in older patients and to identify factors associated with interval CRC. PATIENTS AND METHODS Using the Surveillance, Epidemiology, and End Results-Medicare-linked database, we studied patients 67 years or older with left-sided CRC who had at least one lower endoscopy performed within the previous 36 months between July 1, 2001, and December 31, 2005. The CRCs diagnosed within 6 months of lower endoscopy were defined as detected CRCs; CRCs diagnosed 6 to 36 months after lower endoscopy were defined as interval CRCs. The proportion of interval CRCs was calculated as number of interval CRCs divided by number of detected and interval CRCs. The χ(2) test and a multivariate logistic regression model were used in the statistical analysis. RESULTS Of 15,484 older patients with left-sided CRC, the proportion of interval CRCs after flexible sigmoidoscopy was 8.8% compared with 2.5% after colonoscopy (P<.001). This difference was similar across left colon locations and largest in the descending colon (17.1% vs 3.5%; P<.001). In multivariate logistic regression, the odds of interval CRC after flexible sigmoidoscopy was 3 times as high as that after colonoscopy (odds ratio, 3.52; 95% CI, 2.66-4.65). CONCLUSION In older patients with left-sided CRC, the odds of interval CRC after flexible sigmoidoscopy was 3 times as high as that after colonoscopy. Whether this finding reflects differences in bowel preparation quality, sedation use, or depth of insertion warrants future research.

Decreased Risk of Colorectal Cancer after Colonoscopy in Patients 76-85 Years Old in the United States

Background/Aims: The benefits of colonoscopy in reducing colorectal cancer (CRC) risk for patients over 75 years are controversial. We aimed to determine whether colonoscopy use is associated with a decreased risk of CRC in patients 76-85 years old in the United States (US). Patients and Methods: All patients in the Medicare 5% random sample of the Surveillance, Epidemiology and End Results-Medicare linked database 76-85 years old at outpatient colonoscopy between January 1, 1998 and December 31, 2002 were identified. Using the Kaplan-Meier method, we estimated the cumulative incidence of CRC in the above-mentioned colonoscopy group and compared with the control group of patients without colonoscopy. All patients were followed until diagnosis of CRC or carcinoma in situ, death or December 31, 2005. The multivariate Cox proportional hazards model was used in statistical analysis. CRC was separated by location into distal vs. proximal CRC in subgroup analysis. Results: Of 5,701 patients in the colonoscopy group, 37 (0.65%) patients were diagnosed with CRC, compared to 379 (1.55%) out of 24,437 patients in the control group (p < 0.001). The cumulative incidences of distal and proximal CRC were lower in the colonoscopy group compared to those in the control group (5-year distal CRC: 0.26 vs. 0.77%; 5-year proximal CRC: 0.43 vs. 0.79%, both p < 0.05). In multivariate Cox regression, colonoscopy was associated with decreased risk of all CRC (hazard ratio ((HR) 0.42, 95% CI 0.28-0.65), distal CRC (HR 0.36, 95% CI 0.18-0.70), and proximal CRC (HR 0.53, 95% CI 0.30-0.92)). Conclusion: Among patients 76-85 years old in the United States, colonoscopy use was associated with decreased risks of both distal and proximal CRC, with a smaller risk reduction in distal colon. Due to inherent limitations associated with our retrospective design, future prospective studies are needed to validate these findings.

Rate and Predictors of Interval Esophageal and Gastric Cancers after Esophagogastroduodenoscopy in the United States

Background and Aims: In the United States, little is known about the rates of interval upper gastrointestinal (GI) cancer (possibly missed out) after an esophagogastroduodenoscopy (EGD) is performed. Data from non-US studies reported interval cancer rates of 7-26%. We aimed to study the rate and predictors of interval upper GI cancers in the United States. Methods: Using the random 5% sample of Medicare beneficiaries in the Surveillance, Epidemiology, and End Results-Medicare linked database, we identified patients diagnosed with esophageal or gastric cancer during 2000-2007. EGD performed within 36 months prior to cancer diagnosis was identified using CPT codes. Cancers diagnosed 6-36 months after EGD were defined as interval (vs. detected) cancers. The chi-square test and the multivariate logistic model were used in statistical analysis. Results: Of 751 patients diagnosed with upper GI cancer, 52 patients (6.9%) were diagnosed with interval cancers 6-36 months after EGD. The rate of interval cancers was 5.5% (31/568) for gastroenterologists and 11.5% (21/183) for non-gastroenterologists (p < 0.01). In multivariate logistic regression, EGDs performed by gastroenterologists (vs. non-gastroenterologists: OR 0.46, 95% CI 0.25-0.83) and those in inpatient setting (vs. outpatient: OR 0.53, 95% CI 0.28-0.997) were associated with a lower likelihood of interval cancers. Sensitivity analyses limited to outpatient EGDs or interval cancers 6-30 months after EGDs led to similar results. Conclusions: The rate of interval cancers after EGD is the same as the rate of colonoscopy among Medicare patients in the United States. EGDs performed by gastroenterologists and in in-patient settings were associated with a lesser likelihood of interval cancers.

Su1060 Racial/Ethnic Differences in Inflammatory Bowel Disease Phenotypes At a Tertiary Care Academic Medical Center

Background: Inflammatory bowel disease (IBD) including Crohns disease and ulcerative colitis (UC) is increasingly recognized in minority patients. Prior studies suggest that African American and Hispanic patients with IBD tend to have more aggressive disease phenotypes compared to non-Hispanic white patients. Aims: To compare the differences in Crohns disease and UC phenotypes among African American, Hispanic and non-Hispanic white IBD patients at a tertiary care academic medical center. Data and Methods: A list of all inpatient and outpatient visits with attending gastroenterologists and an ICD-9 diagnosis code for IBD (Crohns disease 555.x; UC 556.x) between 01/2011 and 10/2012 were provided by the Health Information Management Department. Chart review was performed to verify IBD diagnosis and to obtain patient demographics including race/ethnicity, Crohns disease location and behavior (non-stricturing and non-penetrating vs. stricturing or penetrating), and extent of UC. The chi-square test or Fishers exact test was used in statistical analysis. Results: There were a total of 502 IBD patients in our study sample, including 86 African Americans (47 Crohns; 39 UC), 43 Hispanics (23 Crohns; 20 UC), and 373 non-Hispanic whites (154 Crohns; 219 UC). For Crohns disease, there were no significant racial/ethnic difference in disease location (small bowel: African American 64.4%, Hispanic 66.7%, White 70.1%; colon: African American 66.7%, Hispanic 66.7%, White 53.7%), involvement of upper digestive tract (African American 6.7%, Hispanic 9.5%, White 6.1%), disease behavior (stricturing or penetrating: African American 41.3%, Hispanic 52.2%, White 41.7%), or presence of perianal disease (African American 13.3%, Hispanic 23.8%, White 15.0%). For UC, the proportion with extensive colitis was significantly higher among Hispanics (63.2%) and non-Hispanic whites (51.7%) compared to African Americans (29.0%) (both p,0.05). Conclusions: At our tertiary care academic medical center, there was no significant racial/ ethnic difference in Crohns disease phenotype, but more Hispanic and non-Hispanic white UC patients had extensive colitis compared to African American UC patients. Whether these findings reflect potential referral bias to our IBD center is an important question for future research.