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      Adherence to surveillance guidelines after removal of colorectal adenomas: a large, community-based study

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          Abstract

          Objective

          To determine adherence to recommended surveillance intervals in clinical practice.

          Design

          2997 successive patients with a first adenoma diagnosis (57% male, mean age 59 years) from 10 hospitals, who underwent colonoscopy between 1998 and 2002, were identified via Pathologisch Anatomisch Landelijk Geautomatiseerd Archief: Dutch Pathology Registry. Their medical records were reviewed until 1 December 2008. Time to and findings at first surveillance colonoscopy were assessed. A surveillance colonoscopy occurring within ±3 months of a 1-year recommended interval and ±6 months of a recommended interval of 2 years or longer was considered appropriate. The analysis was stratified by period per change in guideline (before 2002: 2–3 years for patients with 1 adenoma, annually otherwise; in 2002: 6 years for 1–2 adenomas, 3 years otherwise). We also assessed differences in adenoma and colorectal cancer recurrence rates by surveillance timing.

          Results

          Surveillance was inappropriate in 76% and 89% of patients diagnosed before 2002 and in 2002, respectively. Patients eligible under the pre-2002 guideline mainly received surveillance too late or were absent (57% of cases). For patients eligible under the 2002 guideline surveillance occurred mainly too early (48%). The rate of advanced neoplasia at surveillance was higher in patients with delayed surveillance compared with those with too early or appropriate timed surveillance (8% vs 4–5%, p<0.01).

          Conclusions

          There is much room for improving surveillance practice. Less than 25% of patients with adenoma receive appropriate surveillance. Such practice seriously hampers the effectiveness and efficiency of surveillance, as too early surveillance poses a considerable burden on available resources while delayed surveillance is associated with an increased rate of advanced adenoma and especially colorectal cancer.

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          Most cited references35

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          Pathology Databanking and Biobanking in The Netherlands, a Central Role for PALGA, the Nationwide Histopathology and Cytopathology Data Network and Archive

          Since 1991, a nationwide histopathology and cytopathology network and archive is in operation in The Netherlands under the name PALGA, encompassing all sixty-four pathology laboratories in The Netherlands. The overall system comprises decentralized systems at the participating laboratories, a central databank, and a dedicated communication and information exchange tool. Excerpts of all histopathology and cytopathology reports are generated automatically at the participating laboratories and transferred to the central databank. Both the decentralized systems and the central system perform checks on the quality and completeness of excerpts. Currently, about 42 million records on almost 10 million patients are stored in the central databank. Each excerpt contains patient identifiers, including demographic data and the so-called PALGA diagnosis. The latter is structured along five classification axes: topography, morphology, function, procedure, and diseases. All data transfer and communication occurs electronically with encryption of patient and laboratory identifiers. All excerpts are continuously available to all participating pathology laboratories, thus contributing to the quality of daily patient care. In addition, external parties may obtain permission to use data from the PALGA system, either on an ongoing basis or on the basis of a specific permission. Annually, 40 to 60 applications for permission to use PALGA data are submitted. Among external users are the Dutch cancer registry, population-based screening programs for cancer of the uterine cervix and breast cancer in The Netherlands, and individual investigators addressing a range of research questions. Many scientific papers and theses incorporating PALGA data have been published already. In conclusion, the PALGA system is a unique system that requires a minimal effort on the part of the participating laboratories, while providing them a powerful tool in their daily practices.
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            A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy.

            Limited data exist regarding the actual risk of developing advanced adenomas and cancer after polypectomy or the factors that determine risk. We pooled individual data from 8 prospective studies comprising 9167 men and women aged 22 to 80 with previously resected colorectal adenomas to quantify their risk of developing subsequent advanced adenoma or cancer as well as identify factors associated with the development of advanced colorectal neoplasms during surveillance. During a median follow-up period of 47.2 months, advanced colorectal neoplasia was diagnosed in 1082 (11.8%) of the patients, 58 of whom (0.6%) had invasive cancer. Risk of a metachronous advanced adenoma was higher among patients with 5 or more baseline adenomas (24.1%; standard error, 2.2) and those with an adenoma 20 mm in size or greater (19.3%; standard error, 1.5). Risk factor patterns were similar for advanced adenomas and invasive cancer. In multivariate analyses, older age (P < .0001 for trend) and male sex (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.19-1.65) were associated significantly with an increased risk for metachronous advanced neoplasia, as were the number and size of prior adenomas (P < .0001 for trend), the presence of villous features (OR, 1.28; 95% CI, 1.07-1.52), and proximal location (OR, 1.68; 95% CI, 1.43-1.98). High-grade dysplasia was not associated independently with metachronous advanced neoplasia after adjustment for other adenoma characteristics. Occurrence of advanced colorectal neoplasia is common after polypectomy. Factors that are associated most strongly with risk of advanced neoplasia are patient age and the number and size of prior adenomas.
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              Overuse of screening colonoscopy in the Medicare population.

              All relevant authorities recommend an interval of 10 years between normal screening colonoscopies. We assessed the timing of repeated colonoscopies after a negative screening colonoscopy finding in a population-based sample of Medicare patients. A 5% national sample of Medicare enrollees from 2000 through 2008 was used to identify average-risk patients undergoing screening colonoscopy between 2001 and 2003. Colonoscopy was classified as a negative screening examination finding if no indication other than screening were in the claims and if no biopsy, fulguration, or polypectomy was performed. Time to repeated colonoscopy was calculated. Among 24,071 Medicare patients who had a negative screening colonoscopy finding in 2001 through 2003, 46.2% underwent a repeated examination in fewer than 7 years. In 42.5% of these patients (23.5% of the overall sample), there was no clear indication for the early repeated examination. In patients aged 75 to 79 years or 80 years or older at the time of the initial negative screening colonoscopy result, 45.6% and 32.9%, respectively, received a repeated examination within 7 years. In multivariable analyses, male sex, more comorbidities, and colonoscopy by a high-volume colonoscopist or in an office setting were associated with higher rates of early repeated colonoscopy without clear indication, while those 80 years or older had a reduced risk. There were also marked geographic variations, from less than 5% in some health referral regions to greater than 50% in others. A large proportion of Medicare patients who undergo screening colonoscopy do so more frequently than recommended. Current Medicare regulations intending to limit reimbursement for screening colonoscopy to every 10 years would not appear to be effective.
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                Author and article information

                Journal
                Gut
                Gut
                gutjnl
                gut
                Gut
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0017-5749
                1468-3288
                October 2015
                13 January 2015
                : 64
                : 10
                : 1584-1592
                Affiliations
                [1 ]Department of Public Health, Erasmus MC University Medical Centre , Rotterdam, the Netherlands
                [2 ]Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam , Amsterdam, the Netherlands
                [3 ]Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre , Rotterdam, the Netherlands
                [4 ]Department of Gastroenterology, Albert Schweitzer hospital , Dordrecht, the Netherlands
                [5 ]Department of Gastroenterology and Hepatology, Deventer Hospital , Deventer, the Netherlands
                [6 ]Department of Gastroenterology and Hepatology, Isala Clinics , Zwolle, the Netherlands
                [7 ]Department of Gastroenterology and Hepatology, Medical Centre Leeuwarden , Leeuwarden, the Netherlands
                [8 ]Department of Gastroenterology and Hepatology, Orbis Medical Centre , Sittard, the Netherlands
                [9 ]Department of Gastroenterology and Hepatology, Reinier de Graaf Hospital , Delft, the Netherlands
                [10 ]Department of Gastroenterology and Hepatology, St. Antonius Hospital , Nieuwegein, the Netherlands
                [11 ]Department of Gastroenterology, University Medical Centre Groningen , University of Groningen , Groningen, the Netherlands
                [12 ]Department of Internal Medicine, Erasmus MC University Medical Centre , Rotterdam, the Netherlands
                Author notes
                [Correspondence to ] Else-Mariette van Heijningen, Department of Public Health, Erasmus MC University Medical Centre, P.O. Box 2040, Rotterdam 3000 CA, the Netherlands; e.vanheijningen@ 123456erasmusmc.nl
                Article
                gutjnl-2013-306453
                10.1136/gutjnl-2013-306453
                4602240
                25586057
                737619bc-24d6-4f23-8e72-d9daca77177b
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

                History
                : 16 November 2013
                : 29 September 2014
                : 18 October 2014
                Categories
                1506
                Colon
                Original article
                Custom metadata
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                Gastroenterology & Hepatology
                colonoscopy,endoscopic polypectomy,surveillance,colorectal adenomas

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