Calculating the adenoma detection rate in screening colonoscopies only: Is it necessary? Can it be gamed?

Background Current recommendations are to calculate the adenoma detection rate (ADR) in screening colonoscopies only. The need to confine the measure to screening has not been established. Methods We retrospectively assessed our quality database for whether calculating ADR from screening, surveillance, and diagnostic colonoscopies (overall ADR) would alter conclusions about the performance of colonoscopists, compared to using an ADR based only on screening colonoscopies. We also prospectively tested the extent to which one physician could corrupt the screening-only ADR by changing the procedure indication after reviewing the examination findings. Results For 15 physicians, screening ADRs differed from the overall ADR by a mean of 2.6 percentage points (range 0 - 6.9 percentage points). Using the overall ADR rather than screening ADR changed the ADR from just below to just above the recommended screening threshold for one physician. In the prospective assessment, a single expert colonoscopist utilized indication gaming in patients with both screening and diagnostic indications and was able to increase his apparent screening-only ADR from 48.4 % to 55.1 %. Conclusions Use of an overall ADR rather than screening-only ADR could simplify ADR measurement, increase the number of examinations available to measure ADR, seldom affect whether a doctor meets recommended ADR thresholds, and eliminate the potential for gaming the ADR by changing the colonoscopy indication.

[Methods to increase participation in cancer screening programmes]. / Metodi per aumentare la partecipazione ai programmi di screening oncologici.

OBJECTIVE: to synthesize scientific evidences about methods to increase cervical, breast and colorectal cancer screening participation. METHODS: a multidisciplinary working group has been set up to define the scope of the report and to conduct the evaluation. The scope and the final evaluation have been submitted to a stakeholder committee, including the Ministry of Health, the National Screening Observatory, regional screening program coordinators, scientific societies, and Lega Italiana Lotta ai Tumori, for comments and integrations. A systematic review of the principal biomedical and social literature databases was conducted to identify experimental and observational studies, updating the existing review by Jepson and coll. (Health Technol Assess. 2000;4(14):i-vii, 1-133). RESULTS: 5900 have been identified, 900 relevant for the topic.Among those, 148 reported quantitative information on intervention efficacy, other 90 came from the previous review. Organised screening programmes, based on invitation letter or on GP involvement,were consistently effective in increasing participation compared to spontaneous screening. Interventions are classified according to their target: individual, community, test simplification, health operators, health service organization. The report presents meta-analyses on efficacy, analyses of cost-effectiveness, impact on organisation and social inequality, and ethical and legal issues, of all the intervention reported in the literature. CONCLUSIONS: there are several interventions consistently effective in any context, some of them have minimal impact on costs and health service resources.

Responding to medical pluralism in practice: a principled ethical approach.

The popularity of complementary and alternative medicine (CAM) raises a range of ethical issues for practicing clinicians. Principles of biomedical ethics define obligations of health care professionals, but applying principles in particular cases at the interface of CAM and biomedicine may be particularly challenging. "Recognition of medical pluralism" can help clinicians' ethical deliberations related to CAM. Here we outline a 3-point practical approach to applying basic principles of biomedical ethics in light of medical pluralism: (1) inquiring about CAM use and the scientific evidence related to CAM, (2) acknowledging the health beliefs and practices of patients, and (3) accommodating diverse healing practices. Construed as such, recognition of medical pluralism encourages pragmatic willingness to examine the personal and cultural meaning associated with CAM use, the biases and assumptions of biomedicine, as well as the risk-benefit ratio of CAM practices. In this way, recognition of medical pluralism can help clinicians enhance patient care in a manner consistent with basic ethical principles.