Validation of Australian and Victorian guidelines for colonoscopy triage.

BACKGROUND: Managing the growing demand for colonoscopies is challenging. AIMS: To assess the diagnostic performance of National and Victorian colonoscopy triage guidelines and potential redistribution of triage categories. METHODS: This is a diagnostic validation study comparing colonoscopy triage guidelines against a reference colonoscopy dataset. Participants were a reference dataset of 2378 colonoscopies from 1 October 2014 to 30 June 2016. Comparison with triage categorisation determined using National Cancer Council Australia guidelines; Victorian triage guidelines; Optimal Cancer Care Pathways recommendations. Main outcome measures were as follows: (i) proportion of colonoscopies assigned to each triage category; (ii) detection rate (proportion of cancers assigned to triage Category 1); and (iii) conversion rate (proportion of triage Category 1 colonoscopies that diagnose a cancer). RESULTS: After adjusting for data absent in referrals, the National and Victorian guidelines reduced the proportion of Category 1 colonoscopies compared with the reference triage (National 76.3% vs 58.6%; 95% CI for difference 15.0-20.3%, P < 0.0001. Victorian 76.3% vs 66.3%; 95% CI for difference 7.4-12.6%, P < 0.0001). Victorian guidelines were associated with the highest detection rate (91.4%) and a conversion rate of 5.4% although the number of cancers limited the power to detect significant differences on these metrics. There was a higher proportion of unclassifiable colonoscopies using the National guidelines than the Victorian ones due to their focus on symptomatic indications. CONCLUSIONS: The Victorian guidelines could reduce the proportion of Category 1 colonoscopies by 10% without reducing conversion or detection rates. This would require improvements in the quality of referrals and ordering faecal occult blood tests in 6% of symptomatic patients.

Three phases of the Pacific Islands Project (1995-2010).

The Pacific Islands Project (PIP), funded by AusAid and managed by the Royal Australasian College of Surgeons (RACS), has progressed through three phases from 1995 to 2010. During this time, it has sent over 520 teams to 11 Pacific Island Countries, providing over 60,000 consultations and some 16,000 procedures. In addition to this delivery of specialist medical and surgical services that were not previously available in-country, the project has contributed as a partner in capacity building with the Fiji School of Medicine and Ministries of Health of the individual nations. By 2011, Fiji School of Medicine, which began postgraduate specialist training in 1998, had awarded 51 doctors a diploma in surgery (1 year), 20 of whom had completed their Masters in Medicine (4 years). PIP was independently evaluated on completion of every phase, including the bridging Phase III (2006-2010). The project delivered on its design, to deliver services, and also helped build capacity. The relationship established with the RACS throughout the project allowed Pacific Island graduates to access the Rowan Nicks scholarship, and the majority of MMed graduates received International Travel Grants to attend the Annual Scientific Meeting. PIP has been a highly successful partnership in delivering and building specialist medical services. Although AusAid contributed some $20 million over 16 years, the value added from pro bono contributions by Specialist Teams, Specialty Coordinators and the Project Directors amounted to an equivalent amount. With the emergence of Pacific Island-trained specialists, PIP is ready to move into a new phase where the agendas are set, monitored and managed within the Pacific, and RACS fulfils the role of a service provider. A critical mass of Pacific Island surgeons has been trained, so that sub-specialization will be an option for the general surgeons of the larger island nations.