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If there is one take-home message from the new study on diagnostic colonoscopy by the Accreditation Association of Ambulatory Health Care’s Institute for Quality Improvement (IQI), the institute’s director, Naomi Kuznets, PhD, says it is to improve comfort levels for patients or risk losing them as patients in the future.
The danger isn’t that an organization loses the money associated with that patient, she says, but that the patient never returns for another colonoscopy and ends up with more advanced, less treatable, and more expensive cancers.
In August, Kuznets said it was a potential public health nightmare. Now that she’s seen the data in the report, she isn’t inclined to change her opinion.
Colonoscopy is the second most frequently performed procedure in ambulatory settings. It is designed to detect colorectal cancer, the third leading cancer in this country. The IQI collected real time data from 33 organizations covering 776 cases. Of those cases, 340 patients recalled their procedures. While more than three-quarters of them had no or minimal discomfort, 12% rated their discomfort at 3 (on a scale of 1-5 with 1 being no pain), 5% at 4, and 5% at 5 during the procedure.
Of those with severe discomfort, 28% of them had no preoperative medication. Of the 760 respondents, 3% said they would never have another colonoscopy even if recommended, and a third of those — eight patients — said they had discomfort that rated a four or five.
Fourteen patients, or 1.8%, were not satisfied with their level of comfort when they left, and one said he wouldn’t have a colonoscopy if recommended.
"If you don’t do a colonoscopy, you miss about a quarter of cancers," says Kuznets. "If that’s true, and the discomfort will keep people from having the procedure, then we need to address this. Why should this be a traumatic experience?"
Among the other findings:
• There is no relationship between volume of cases and supply costs or procedure time. That means the size of an organization doesn’t impact its ability to be efficient. The annual volume of respondents ranged from 267 to 5,280 with most in the 2,000 to 3,000 range.
• Median pre-procedure time was 37 minutes and ranged from a low of 13.2 to a high of more than 80 minutes. The report notes that pre-procedure time is influenced by early and late patient arrival, and that patients who are very early can make that time longer, while those who arrive close to procedure time can decrease the average.
The best performer in the group keeps pre-procedure time short by making calls to patients in advance to answer patients’ questions. Another better-performing organization, whose time before the procedure is less than 16 minutes, attributes its success to keeping track of how on time physicians are running and letting patients know in advance if their procedure will be delayed. Patients are also sent their paperwork ahead of time and are told not to arrive too early.
• Median procedure time was 16.6 minutes, with a low of less than 10 minutes and a high of more than 50. This figure is impacted by the complexity of the case, the number of polyps and other abnormalities identified, and their biopsy and removal.
The lowest procedure time was 8.4 minutes, but that organization found fewer polyps or other lesions and performed a smaller number of biopsies and removals on average. That organization says its speed is related to its bowel preparation with Colyte, preoperative patient education, starting IVs in the holding area, and the length of experience clinical personnel have — a minimum of three to four years. Other quick procedure artists also cite experienced nurses and technicians as factors in their speed.
• Median discharge time was 43.5 minutes with a range from just over 30 minutes to nearly 80 minutes. The best performing groups believe they are fast because they start recovery in the OR; they take vital signs at the end of the procedure and check them again after five minutes; and because they use Fentanyl instead of Demerol, which patients recover from more quickly. Organizations that used Fentanyl and Versed, or Versed and Demerol had faster discharges that those who used morphine, Diprivan, Reglan, or Zantac.
• Total facility time, from when the patient enters the facility to the time the patient is ready for discharge had a median of 125.7 minutes. The low was under 90 minutes, and the high was nearly 200 minutes.
• Procedure preparation includes a median of 10 hours of nil by mouth for the patients, although recent guidelines suggest that patients can have clear liquid up to two hours prior to surgery. The range for respondents was 3.3 hours to 18.7 hours. Other preparations include polyethylene glycol (PEG) solutions such as Co-Lav, Colavage, Colyte, Go-Evac, GoLYTELY, NuLYTELY, and OCL (41%), or Fleets Phosphosoda preparation (39%). Magnesium citrate and other laxative medications were used by 20% of the respondents.
• In the 776 uncomplicated procedures studies, 650 polyps were discovered, 554 were removed and 277 biopsied. Of the 166 other abnormalities found, 148 were biopsied and 21 were removed. The report states that this suggests the utility of colonoscopy, assuming that a significant number of the biopsies resulted in malignant or pre-malignant findings. Other techniques, the report states, don’t allow biopsies to be performed.
• Although there were 32 cases in which complications were reported, none of them involved perforations or hospital transfers. They included arrhythmia, bleeding, extended recovery time, hypotension, and hypoxia.
Kuznets says the real message is that even for patients getting a colonoscopy as part of a primary prevention program, there are polyps and abnormalities that are found, which would have been missed if they had a barium enema or sigmoidoscopy. "If you add in secondary prevention patients — those who have some symptom that is being looked into — almost 50% have polyps and other abnormalities that were observed in the upper part of the tract that wouldn’t otherwise have been found."
Next for the IQI is another cataract study (see Healthcare Benchmarks, August 2000) and a tumescent liposuction study. There is also a study planned for liposuction with sedation, regional and/or general anesthesia, and a knee arthroscopy study is due to be printed later this fall. Organizations interested in signing up for the first three studies mentioned can get more information through the institute web site at www.aaahciqi.org.
[For more information on the studies or to order them, visit the AAAHC web site at www.aaahc.org, or contact:
• Naomi Kuznets, PhD, Director of the Accreditation Association for Ambulatory Health Care, Institute for Quality Improvement, 3201 Old Glenview Road, #300, Wilmette, IL 60091. Telephone: (847) 853-6079.]