A European view of diagnostic yield and appropriateness of colonoscopy.

BACKGROUND/AIMS: This study's purpose was to examine the relationship between appropriateness criteria and diagnostic yield of colonoscopy. METHODOLOGY: This observational study prospectively included consecutive patients referred for colonoscopy from 21 centers in 11 countries. Patient, center, and colonoscopy characteristics were collected. Significant diagnoses included cancer, adenomatous polyps, angiodysplasia, and new diagnoses of inflammatory bowel disease. Appropriateness criteria were developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) using the RAND Appropriateness Method. Determinants associated with a significant diagnosis were examined using multiple logistic regression. RESULTS: 5,213 patients who underwent diagnostic colonoscopy were included in the study. There were 1,227 (24%) significant diagnoses made, including 218 (4%) cancers and 735 (14%) adenomatous polyps. Among patients who had a significant diagnosis, 53% had an appropriate indication, 25% had an uncertain indication and 22% had an inappropriate indication. Having an appropriate indication, increasing age, and male sex increased the odds of finding a significant diagnosis at colonoscopy. CONCLUSIONS: Appropriateness criteria enhanced the detection of significant lesions, thereby demonstrating one way to enhance quality of care. However, appropriateness criteria will never perform better than the imperfect relationship between clinical symptoms and diagnostic yield.

Variations in colonoscopy practice in Europe: a multicentre descriptive study (EPAGE).

OBJECTIVE: The volume of colonoscopies performed is increasing and differences in colonoscopy practice over time and between centres have been reported. Examination of current practice is important for bench-marking quality. The objective of this study was to examine variations in colonoscopy practice in endoscopy centres internationally. MATERIAL AND METHODS: This observational study prospectively included consecutive patients referred for colonoscopy from 21 centres in 11 countries. Patient, procedure and centre characteristics were collected through questionnaires. Descriptive statistics were performed and the variation between centres while controlling for case-mix was examined. RESULTS: A total of 6004 patients were included in the study. Most colonoscopies (93%; range between centres 70-100%) were performed for diagnostic purposes. The proportion of main indications for colonoscopy showed wide variations between centres, the two most common indications, surveillance and haematochezia, ranging between 7-24% and 5-38%, respectively. High-quality cleansing occurred in 74% (range 51-94%) of patients, and 30% (range 0-100%) of patients received deep sedation. Three-quarters (range 0-100%) of the patients were monitored during colonoscopy, and one-quarter (range 14-35%) underwent polypectomy. Colonoscopy was complete in 89% (range 69-98%) of patients and the median total duration was 20 min (range of centre medians 15-30 min). The variation between centres was not reduced when case-mix was controlled for. CONCLUSIONS: This study documented wide variations in colonoscopy practice between centres. Controlling for case-mix did not remove these variations, indicating that centre and procedure characteristics play a role. Centres generally were within the existing guidelines, although there is still some work to be done to ensure that all centres attain the goal of providing high-quality colonoscopy.

Use, appropriateness, and diagnostic yield of screening colonoscopy: an international observational study (EPAGE).

BACKGROUND: Screening for colorectal cancer (CRC) has been shown to decrease mortality. OBJECTIVE: To examine determinants associated with having (1) a screening colonoscopy, (2) an appropriate indication for screening, and (3) a significant diagnosis at screening. DESIGN: Prospective observational study. SETTING: Twenty-one endoscopy centers from 11 countries. PATIENTS: Asymptomatic patients who underwent a colonoscopy for the purpose of detecting CRC and who did not have a history of polyps or CRC, a lesion observed at a recent barium enema or sigmoidoscopy, or a recent positive fecal occult blood test. INTERVENTION: Screening colonoscopy. MAIN OUTCOME MEASUREMENTS: Appropriateness according to the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria and significant diagnoses (cancer, adenomatous polyps, new diagnoses of inflammatory bowel disease, angiodysplasia). RESULTS: Of 5069 colonoscopies, 561 (11%) were performed for screening purposes. Patients were more likely to have a screening colonoscopy if they were aged 45 to 54 years (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.60-3.99). Screening colonoscopies were appropriate, uncertain, and inappropriate in 26%, 60%, and 14% of cases, respectively. Eighty-one significant diagnoses were made, including 4 cancers. Significant diagnoses were more often made for uncertain/appropriate indications (OR 3.20, 95% CI 1.12-9.17) than for inappropriate indications. LIMITATIONS: Although data completeness was asked of all centers, it is possible that not all consecutive patients were included. Participating centers were a convenience sample and thus may not be representative. CONCLUSIONS: About 1 of 10 colonoscopies were performed for screening, preferentially in middle-aged individuals. A higher diagnostic yield in uncertain/appropriate indications suggests that the use of appropriateness criteria may enhance the efficient use of colonoscopy for screening.

Case verification of children with asthma in Ontario.

Asthma is an important chronic childhood illness. A population-based surveillance program could measure the burden of illness, but first, the validity of an administrative diagnosis of asthma must be confirmed. The objective was to evaluate the accuracy of population-based outpatient administrative data in identifying children with asthma for the purpose of on-going asthma surveillance and research. Twenty-one primary care physician (PCP) clinics in Ontario participated. Patients under 18 yr old were categorized into three diagnosis categories according to administrative data diagnosis codes: asthma, asthma-related, and non-asthma. In each PCP clinic, for each diagnosis category, 10 charts were randomly selected for abstraction. A panel of experts (blind to the code) reviewed the abstracted charts and identified them as asthma or non-asthma. The reviewers' diagnosis was considered the gold standard. The accuracy of the administrative data diagnosis coding was analyzed using the concepts of diagnostic test evaluation. Six hundred and thirty patient charts were abstracted and reviewed. Overall agreement between the diagnosis provided by expert chart review and the administrative data diagnosis code was 84.8% (p < 0.001), and was 60.2%, 94.8% and 99.5% for the asthma, asthma-related, and non-asthma categories, respectively. Additionally, the sensitivity and specificity were 91.4% and 82.9%, respectively. Agreement between the administrative data diagnosis code and the PCP chart diagnosis was 99.4% (p < 0.001). An administrative data diagnosis code of asthma is sensitive and specific for identifying asthma. By using the results of this study as a starting point, future research will create a cohort of children with asthma to be used for population-based surveillance and research.

The EPAGE internet guideline as a decision support tool for determining the appropriateness of colonoscopy.

BACKGROUND: Few studies have examined how physicians perceive guidelines, much less their perceptions of an Internet presentation of such guidelines. This study assessed physicians' acceptance ofan Internet-based guideline on the appropriateness of colonoscopy. METHODS: Gastroenterologists participating in an international observational study consulted an Internet-based guideline for consecutive patients referred for colonoscopy. The guideline was produced by the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE), using a validated method (RAND). Through the use of questionnaires, physicians were asked their opinions and perspectives of the guideline and website. RESULTS: There were 289 patients included in the study. The mean time for consulting the website was 1.8 min, and it was considered easy to use by 86% of physicians. The recommendations were easily located for 82% of patients and physicians agreed with the appropriateness in 86% of cases. According to the EPAGE criteria, colonoscopy was appropriate, uncertain, and inappropriate in 59, 28, and 13% of patients, respectively. CONCLUSIONS: The EPAGE guideline was considered acceptable and user-friendly and the use, usefulness and relevance of the website were considered acceptable. However, its actual use will depend on the removal of certain organizational and cultural obstacles.

What factors are associated with poor developmental attainment in young Canadian children?

BACKGROUND: This study was undertaken to determine the association between poor developmental attainment (PDA) and biological, home environment and socio-demographic factors in a population-based sample of Canadian children. METHODS: Cross-sectional data from two cycles (1994/95 and 1996/97) of the National Longitudinal Survey of Children and Youth were used. Children aged 1-5 years were included. PDA was defined as < or = 15th percentile for motor and social developmental skills (1-3 year olds) or Peabody Picture Vocabulary Test (4-5 year olds). Multiple logistic regression was used. RESULTS: The proportion of children with PDA varies across Canada, between males and females, and by age. Among 1 year olds in Cycle I, having a low birthweight (OR=3.3; 95% CI: 2.1-5.2), being male (OR=1.6; 95% CI: 1.2-2.2) and having a mother who is an immigrant (OR=1.6; 95% CI: 1.1-2.2) increased the odds of PDA. Similar results were observed in Cycle II. Among children aged 4-5 years in Cycle II, having a mother who is an immigrant (OR=5.3; 95% CI: 4.1-6.9) and a mother with low educational attainment (OR=2.8; 95% CI: 2.1-3.9) increased the odds of PDA. Low income was a significant predictor of PDA across all age groups. INTERPRETATION: The strong and consistent associations with living in a low-income household, having a mother with low educational attainment or a mother who is an immigrant highlight the need for targeting developmental assessments and services to this population.

Risk markers for poor developmental attainment in young children: results from a longitudinal national survey.

OBJECTIVE: To evaluate social and environmental determinants of poor developmental attainment among preschool children by means of longitudinal data from a population-based sample of Canadian children. DESIGN: Secondary analysis of data from cycles 1 (1994-1995) and 2 (1996-1997) of the National Longitudinal Survey of Children and Youth using a cohort design with 2-year follow-up. PARTICIPANTS: A total of 4987 children aged 1 to 5 years at baseline, whose biological mother completed risk factor information and who were included in both cycles. MAIN OUTCOME MEASURES: Poor developmental attainment (developing unusually slowly) was defined as scores more than 1 SD below the age-standardized mean for the Motor and Social Development Scale, revised Peabody Picture Vocabulary Test, or Canadian Achievement Tests in mathematics and reading/comprehension, depending on the child's age. RESULTS: The prevalence of sustained poor developmental attainment after 2 years of follow-up was 4.6%. Factors found to be associated with poor developmental attainment included male sex (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.10-1.70), maternal depression (OR, 1.64; 95% CI, 1.25-2.15), low maternal education (OR, 1.57; 95% CI, 1.19-2.08), maternal immigrant status (OR, 1.93; 95% CI, 1.38-2.71), and household low income adequacy (OR, 1.43; 95% CI, 1.11-1.83). CONCLUSIONS: Having a mother who has symptoms of depression, has low education, or is an immigrant, and living in a household with low income adequacy increase the risk of poor developmental attainment in children aged 1 to 5 years. The notable risks associated with these factors indicate them as possible targets for screening and interventions to prevent poor developmental attainment.

Is obesity associated with asthma in young children?

OBJECTIVE: The aim of this study was to evaluate the association between obesity and asthma in a population-based sample of Canadian children. STUDY DESIGN: Baseline data from the National Longitudinal Survey of Children and Youth were used in this cross-sectional study. We included 11199 children age 4 to 11 years whose biological mother reported data on asthma, height, and weight. Body mass index was categorized, and obesity was defined as body mass index >or=85th percentile. Children with asthma had parents who reported the diagnosis, and they took prescribed inhalants, had wheezing or an attack in the previous year, or had their activities limited by asthma. Multiple logistic regression was used. RESULTS: The prevalence of asthma was 9.9%. Maternal history of asthma was a risk factor for asthma among all children. Single child status and maternal depression were risk factors for girls. The odds ratio for asthma, comparing highest and lowest body mass index categories, was 1.02 (99% confidence interval, 0.70-1.46) for boys and 1.06 (99% confidence interval, 0.67-1.69) for girls. CONCLUSION: This study suggests that there is no statistical association between obesity and asthma among Canadian children age 4 to 11 years.