Quality of Colonoscopy Performed in Rural Practice: Experience From the Clinical Outcomes Research Initiative and the Oregon Rural Practice-Based Research Network.

PURPOSE: Colon cancer screening is effective. To complete screening in 80% of individuals over age 50 years by 2018 will require adequate colonoscopy capacity throughout the country, including rural areas, where colonoscopy providers may have less specialized training. Our aim was to study the quality of colonoscopy in rural settings. METHODS: The Clinical Outcomes Research Initiative (CORI) and the Oregon Rural Practice-based Research Network (ORPRN) collaborated to recruit Oregon rural practices to submit colonoscopy reports to CORI's National Endoscopic Database (NED). Ten ORPRN sites were compared to non-ORPRN rural (n = 11) and nonrural (n = 43) sites between January 2009 and October 2011. Established colonoscopy quality measures were calculated for all sites. RESULTS: No ORPRN physicians were gastroenterologists compared with 82% of nonrural physicians. ORPRN practices reached the cecum in 87.4% of exams compared with 89.3% of rural sites (P = .0002) and 90.9% of nonrural sites (P < .0001). Resected polyps were less likely to be retrieved (84.7% vs 91.6%; P < .0001) and sent to pathology (77.1% vs 91.3%; P < .0001) at ORPRN practices compared to nonrural sites. The overall polyp detection (39.0% vs 40.3%) was similar (P = .217) between ORPRN and nonrural practices. Of exams with polyps, the rate for largest polyp on exam 6-9 mm was 20.8% at ORPRN sites, compared to 26.8% at nonrural sites (P < .0001), and for polyps >9mm 16.6% vs 18.7% (P = .106). CONCLUSION: ORPRN sites performed well on most colonoscopy quality measures, suggesting that high-quality colonoscopy can be performed in rural settings.

Race, ethnicity, and sex affect risk for polyps >9 mm in average-risk individuals.

BACKGROUND & AIMS: Colorectal cancer risk differs based on patient demographics. We aimed to measure the prevalence of significant colorectal polyps in average-risk individuals and to determine differences based on age, sex, race, or ethnicity. METHODS: In a prospective study, colonoscopy data were collected, using an endoscopic report generator, from 327,785 average-risk adults who underwent colorectal cancer screening at 84 gastrointestinal practice sites from 2000 to 2011. Demographic characteristics included age, sex, race, and ethnicity. The primary outcome was the presence of suspected malignancy or large polyp(s) >9 mm. The benchmark risk for age to initiate screening was based on white men, 50-54 years old. RESULTS: Risk of large polyps and tumors increased progressively in men and women with age. Women had lower risks than men in every age group, regardless of race. Blacks had higher risk than whites from ages 50 through 65 years and Hispanics had lower risk than whites from ages 50 through 80 years. The prevalence of large polyps was 6.2% in white men 50-54 years old. The risk was similar among the groups of white women 65-69 years old, black women 55-59 years old, black men 50-54 years old, Hispanic women 70-74 years old, and Hispanic men 55-59 years old. The risk of proximal large polyps increased with age, female sex, and black race. CONCLUSIONS: There are differences in the prevalence and location of large polyps and tumors in average-risk individuals based on age, sex, race, and ethnicity. These findings could be used to select ages at which specific groups should begin colorectal cancer screening.

Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness.

BACKGROUND: Establishing a threshold of bowel cleanliness below which colonoscopies should be repeated at accelerated intervals is important, yet there are no standardized definitions for an adequate preparation. OBJECTIVE: To determine whether Boston Bowel Preparation Scale (BBPS) scores could serve as a standard definition of adequacy. DESIGN: Cross-sectional observational analysis of colonoscopy data from 36 adult GI endoscopy practices and prospective survey showing 4 standardized colonoscopy videos with varying degrees of bowel cleanliness. SETTING: The Clinical Outcomes Research Initiative. PATIENTS: Average-risk patients attending screening colonoscopy. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Recommended follow-up intervals among average-risk, screening colonoscopies without polyps stratified by BBPS scores. RESULTS: We evaluated 2516 negative screening colonoscopies performed by 74 endoscopists. If the BBPS score was ≥2 in all 3 segments (N = 2295), follow-up was recommended in 10 years in 90% of cases. Examinations with total BBPS scores of 3 to 5 (N = 167) had variable recommendations. Follow-up within 1 year was recommended for 96% of examinations with total BBPS scores of 0 to 2 (N = 26). Similar results were noted among 167 participants in a video survey with pre-established BBPS scores. LIMITATIONS: Retrospective study. CONCLUSION: BBPS scores correlate with endoscopist behavior regarding follow-up intervals for colonoscopy. A total BBPS score ≥6 and/or all segment scores ≥2 provides a standardized definition of adequate for 10-year follow-up, whereas total scores ≤2 indicate that a procedure should be repeated within 1 year. Future work should focus on finding consensus for management of examinations with total scores of 3 to 5.

Colonoscopy utilization and outcomes 2000 to 2011.

BACKGROUND: Understanding colonoscopy utilization and outcomes can help determine when the procedure is most effective. OBJECTIVE: To study trends in utilization and outcomes of colonoscopy in the United States from 2000 to 2011. DESIGN: Prospective collection of colonoscopy data. SETTING: A total of 84 adult diverse GI practices. PATIENTS: All adult patients receiving colonoscopy for any reason. INTERVENTION: Colonoscopy. MAIN OUTCOME MEASUREMENTS: Polyps >9 mm or suspected malignant tumor. RESULTS: We analyzed 1,372,838 reports. The most common reason for colonoscopy in patients aged <50 years is evaluation of symptoms such as irritable bowel syndrome (IBS) (28.7%) and bleeding or anemia (35.3%). In patients aged 50 to 74 years, colorectal cancer screening accounts for 42.9% of examinations. In patients aged >74 years, surveillance for cancer or polyps is the most common indication. The use of colonoscopy for average-risk screening increased nearly 3-fold during the study period. The prevalence of large polyps increases with age and is higher in men for every procedure indication. The prevalence of large polyps in patients with symptoms of IBS was lower than in those undergoing average-risk screening (odds ratio [OR] 0.85; 95% confidence interval [CI], 0.83-0.87). With increasing age, there was a shift from distal to proximal large polyps. The rate of proximal large polyps is higher in the black population compared with the white population (OR 1.19; 95% CI, 1.13-1.25). LIMITATIONS: In the absence of pathology data, use of surrogate as the main outcome. CONCLUSION: Colonoscopy utilization changed from 2000 to 2011, with an increase in primary screening. The proximal location of large polyps in the black population and with advancing age has implications for screening and surveillance.

Validity of a Web-based educational program to disseminate a standardized bowel preparation rating scale.

GOALS: Our goal was to assess the validity of a Web-based educational program on the Boston Bowel Preparation Scale (BBPS). BACKGROUND: Data on Web-based education for improving the practice and quality of colonoscopy are limited. STUDY: Endoscopists worldwide participated in the BBPS Educational Program. We assessed program completion rates, satisfaction, short-term (0 to 90 d) and long-term (91 to 180 d) uptake of the BBPS, and the validity of the program by measuring the reliability of the BBPS among participants. RESULTS: A total of 207 endoscopists completed the program. Overall, 93% found the content relevant, 89% felt confident in using the BBPS, and 97% thought the quality was good or excellent. Uptake of the BBPS into clinical practice was robust with 91% and 98% of colonoscopy reports containing the BBPS at short-term and long-term follow-up, respectively. The interobserver and test-retest reliability of BBPS segment and total scores were both substantial. CONCLUSIONS: A BBPS Web-based educational program facilitates adoption into clinical practice and teaches the BBPS to be used reliably by a diverse group of endoscopists worldwide.

Evaluating the accuracy of electronic pediatric drug dosing rules.

OBJECTIVE: To determine the accuracy of vendor-supplied dosing eRules for pediatric medication orders. Inaccurate or absent dosing rules can lead to high numbers of false alerts or undetected prescribing errors and may potentially compromise safety in this already vulnerable population. MATERIALS AND METHODS: 7 months of medication orders and alerts from a large pediatric hospital were analyzed. 30 medications were selected for study across 5 age ranges and 5 dosing parameters. The resulting 750 dosing rules from a commercial system formed the study corpus and were examined for accuracy against a gold standard created from traditional clinical resources. RESULTS: Overall accuracy of the rules in the study corpus was 55.1% when the rules were transformed to fit a priori age ranges. Over a pediatric lifetime, the dosing rules were accurate an average of 57.6% of the days. Dosing rules pertaining to the newborn age range were as accurate as other age ranges on average, but exhibited more variability. Daily frequency dosing parameters showed more accuracy than total daily dose, single dose minimum, or single dose maximum. DISCUSSION: The accuracy of a vendor-supplied set of dosing eRules is suboptimal when compared with traditional dosing sources, exposing a gap between dosing rules in commercial products and actual prescribing practices by pediatric care providers. More research on vendor-supplied eRules is warranted in order to understand the effects of these products on safe prescribing in children.

Developing a survey to assess factors that contribute to physician involvement in clinical research.

BACKGROUND: Investment in research, including clinical research, has positive effects both on health of a population and economic growth of a country. Several factors have been suggested as being related to the performance of clinical research. The goal of this work was to develop and perform initial validation of a survey that measures both current research involvement of physicians, as well as previously noted factors and additional informatics factors affecting this involvement. The survey was developed in both English and Spanish with the goal of its use in Latin America. METHODS: The initial survey was developed primarily from experience with other validated surveys developed for similar purposes. It was validated in three stages with modification or elimination of questions as indicated by this testing. RESULTS: The final survey contains 33 questions in the categories of research experience, education in research, environmental factors, computer experience, and collaboration.

Caveats for the use of operational electronic health record data in comparative effectiveness research.

The growing amount of data in operational electronic health record systems provides unprecedented opportunity for its reuse for many tasks, including comparative effectiveness research. However, there are many caveats to the use of such data. Electronic health record data from clinical settings may be inaccurate, incomplete, transformed in ways that undermine their meaning, unrecoverable for research, of unknown provenance, of insufficient granularity, and incompatible with research protocols. However, the quantity and real-world nature of these data provide impetus for their use, and we develop a list of caveats to inform would-be users of such data as well as provide an informatics roadmap that aims to insure this opportunity to augment comparative effectiveness research can be best leveraged.

The use of databases and registries to enhance colonoscopy quality.

Administrative databases, registries, and clinical databases are designed for different purposes and therefore have different advantages and disadvantages in providing data for enhancing quality. Administrative databases provide the advantages of size, availability, and generalizability, but are subject to constraints inherent in the coding systems used and from data collection methods optimized for billing. Registries are designed for research and quality reporting but require significant investment from participants for secondary data collection and quality control. Electronic health records contain all of the data needed for quality research and measurement, but that data is too often locked in narrative text and unavailable for analysis. National mandates for electronic health record implementation and functionality will likely change this landscape in the near future.

Representing multi-database study schemas for reusability.

The need for easy, non-technical interfaces to clinical databases for research preceded translational research activities but is made more important because of them. The utility of such interfaces can be improved by the presence of a persistent, reusable and modifiable structure that holds the decisions made in extraction of data from one or more datasources for a study, including the filtering of records, selection of the fields within those records, renaming of fields, and classification of data. This paper demonstrates use of the Web Ontology Language (OWL) as a data representation of these decisions which define a study schema.

Improving quality in cancer screening: the excellence report for colonoscopy.

The goal of this project was to create and evaluate a quality measures program for colonoscopy procedures using measures recently defined by multi-specialty groups and using resources of the Clinical Outcomes Research Initiative (CORI), a gastrointestinal endoscopy research consortium. Participants collect procedure data through an endoscopic reporting system developed by CORI. Endoscopists practicing at 35 sites in 21 communities and 16 states were included in the study. Individual quality reports with 15 measures were made available monthly to endoscopists in 2/3 of the communities. Compliance with the quality measures was captured for each endoscopist prior to and at the end of the one-year intervention period. Changes in measure compliance were small and limited by lack of pathology data and documentation as well as modifications to the computing system during the study period. This study points out the difficulties of utilizing quality report cards with data captured during clinical care.

Assessment of the quality of colonoscopy reports: results from a multicenter consortium.

BACKGROUND: To improve colonoscopy quality, reports must include key quality indicators that can be monitored. OBJECTIVE: To determine the quality of colonoscopy reports in diverse practice settings. SETTING: The consortium of the Clinical Outcomes Research Initiative, which includes 73 U.S. gastroenterology practice sites that use a structured computerized endoscopy report generator, which includes fields for specific quality indicators. DESIGN: Prospective data collection from 2004 to 2006. MAIN OUTCOMES MEASUREMENTS: Reports were queried to determine if specific quality indicators were recorded. Specific end points, including quality of bowel preparation, cecal intubation rate, and detection of polyp(s) >9 mm in screening examinations were compared for 53 practices with more than 100 colonoscopy procedures per year. RESULTS: Of the 438,521 reports received during the study period, 13.9% did not include bowel-preparation quality and 10.1% did not include comorbidity classification. The overall cecal intubation rate was 96.3%, but cecal landmarks were not recorded in 14% of the reports. Missing polyp descriptors included polyp size (4.9%) and morphology (14.7%). Reporting interventions for adverse events during the procedure varied from 0% to 6.5%. Among average-risk patients who received screening examinations, the detection rate of polyps >9 mm, adjusted for age, sex, and race, was between 4% and 10% in 81% of practices. LIMITATION: Bias toward high rates of reporting because of the standard use of a computerized report generator. CONCLUSIONS: There is significant variation in the quality of colonoscopy reports across diverse practices, despite the use of a computerized report generator. Measurement of quality indicators in clinical practice can identify areas for quality improvement.

Identifying challenges and opportunities in clinical research informatics: analysis of a facilitated discussion at the 2006 AMIA Annual Symposium.

Clinical Research Informatics (CRI) is a rapidly developing sub-domain of Biomedical Informatics that has seen considerable growth in recent years. While there are numerous activities and initiatives ongoing in this domain, systematic consideration and analysis of the challenges and opportunities that exist in this area are lacking. To begin to address this gap in knowledge and inform next steps in advancing this developing domain, we conducted a facilitated discussion among a diverse group of interested participants attending a meeting of the Clinical Research Informatics Working Group at the AMIA 2006 annual symposium. Findings from our analysis of these data are presented here and indicate a broad array of challenges and opportunities facing this developing area. These findings add new information to the limited literature regarding CRI and should provide direction for those working to set the CRI research and development agenda.

Evaluation of reliability in the use of endoscopic terminology.

Variability in the reporting of gastrointestinal endoscopic findings may affect the validity of analyses of data collected from clinical reports of those findings. In this project, images of 10 endoscopic findings were collected from the data repository of the Clinical Outcomes Research Initiative (CORI), all of which had been described by the reporting endoscopist. These images were presented to 52 experienced endoscopists recruited from the clinical affiliates of CORI who were asked to assign each a term from the Minimum Standard Terminology for Digestive Endoscopy. Proportion of agreement with the endoscopist varied by finding from 84.3% to 51.0% (overall 67.6% with 95% CI 63.4-71.8%). Proportion of agreement among the subjects varied by finding from 76.3% to 38.5%.(overall 55.6% with 95% CI 52.4-58.8%). Possible reasons for this lack of agreement are discussed.

Developing an interaction-centered evaluation tool for distance education.

Web-based distance instruction is growing in popularity. As more courses and programs go online, instructional methods and technologies are changing to meet new demands. These courses and instructional methods need be evaluated to determine their quality and to aid in their development. An instrument that measures the quality of student interaction within courses could play a useful role in this evaluation. The objective of this project was to produce an interaction-centered evaluation tool for distance education. We developed items for the evaluation tool based on a review of the literature and interviews with distance education faculty. We then conducted a measurement study to determine the instrument's validity and reliability. Fifty-five students in seven medical informatics courses participated in this study. Questionnaire items were included or rejected based on their fit with underlying theoretical constructs. In conclusion, the Web-based evaluation tool developed in this project measures student perception of quality of course interactions with demonstrated validity and reliability.

Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians.

OBJECTIVE: Computerized physician documentation (CPD) has been implemented throughout the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC. DESIGN: A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital. MEASUREMENTS: Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing. RESULTS: Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care. CONCLUSION: CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them.

Computer science education for medical informaticians.

The core curriculum in the education of medical informaticians remains a topic of concern and discussion. This paper reports on a survey of medical informaticians with Master's level credentials that asked about computer science (CS) topics or skills that they need in their employment. All subjects were graduates or "near-graduates" of a single medical informatics Master's program that they entered with widely varying educational backgrounds. The survey instrument was validated for face and content validity prior to use. All survey items were rated as having some degree of importance in the work of these professionals, with retrieval and analysis of data from databases, database design and web technologies deemed most important. Least important were networking skills and object-oriented design and concepts. These results are consistent with other work done in the field and suggest that strong emphasis on technical skills, particularly databases, data analysis, web technologies, computer programming and general computer science are part of the core curriculum for medical informatics.