Original article
Clinical endoscopy
The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria

https://doi.org/10.1016/j.gie.2011.08.039Get rights and content

Background

The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care.

Objectives

To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria.

Design

Cross-sectional study.

Setting

Endoscopy unit of a teaching hospital in Spain.

Patients

Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing.

Main Outcome Measurements

Appropriateness of colonoscopies according to the EPAGE criteria.

Results

From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer–related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted κ = 0.31) but improved to moderate (simple κ = 0.60) after grouping appropriate and uncertain levels.

Limitations

The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria.

Conclusions

Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions.

Section snippets

Design

A cross-sectional study was designed.

Setting

The study was performed at the Gastrointestinal Endoscopy Unit of a hospital. Referrals to the Endoscopy Unit are available to gastroenterologists, surgeons, oncologists, internal medicine specialists, and other specialists, but not for general practitioners. The staff of the endoscopic unit consisted of 4 senior endoscopists and several residents, and the annual volume of endoscopies exceeded 6000 explorations, with more than 2500 colonoscopies.

Patients and sample

All patients

Results

During the 4-month study period, 749 consecutive colonoscopies were performed. Of them, 619 (82.6%) were valid for analysis (Fig. 1). The mean age of the patients was 58 years (range 14-91 years), and 46% were women. Gastroenterologists referred two thirds of colonoscopies (n = 409; 66.1%), followed by surgeons (n = 120; 19.4%), general internal medicine physicians (n = 42; 6.8%), oncologists (n = 39; 6.3%), and other specialists (n = 9; 1.5%). Depending on the health care setting of the

Discussion

The results of this study show, first of all, that approximately 1 of every 4 colonoscopies in our hospital were inappropriate with the use of the EPAGE criteria. Inappropriateness decreased to 1 in 6 by using the EPAGE-II criteria, but this figure still implies more than 400 inappropriate colonoscopies each year. The 27% inappropriate use found in our study is an intermediate figure between the 31%17 and 23%18 reported in other Spanish studies with the EPAGE criteria. The 18% by using the

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    DISCLOSURE: The authors disclosed no financial relationships relevant to this publication.

    If you would like to chat with an author of this article, you may contact Dr Ponce at [email protected].

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