Electronic Clinical Decision Tools for Improving Adherence to Colon Cancer Surveillance Guidelines: Can the Chips Finally Fall Into Place?

Shajan Peter
2018 The Journal of the National Comprehensive Cancer Network  
Colorectal cancer (CRC) remains the fourth most frequently diagnosed cancer and second leading cause of cancer death in the United States. 1 Screening of average-risk individuals reduces mortality through early detection and removal of polyps. 2 Surveillance differs from screening, and refers to the interval use of colonoscopy in patients with previously detected precancerous lesions. Surveillance accounts for 20% of the colonoscopy volume in the United States. Current, well-recognized
more » ... s on CRC screening, such as those from NCCN, 3 the US Preventive Services Task Force (USPTF), 4 and the US Multi-Society Task Force (MSTF) on CRC, 5 provide a standard protocol with risk stratification to determine the optimal interval between colonoscopies. Adherence to these recommendations forms the bedrock of patient evaluation and prudent healthcare economics. Importantly, each 1% increase in adenoma detection is associated with a 3% reduction in the subsequent detection of CRC. 6 However, despite best clinical practices and given the expanding burden of an increasing number of colonoscopies, there is an often an "over" and "under" use of these services for interval surveillance. 7 Although overuse (shorter-than-recommended intervals) promotes unnecessary cost, underuse (longer intervals) can result in unforeseen missed interval cancers. Several factors contribute to the variations regarding acceptable timing and use among current recommendations for surveillance colonoscopies. A recent analysis from the Veterans Affairs Healthcare System reported noncompliance to guidelines in individuals with high-risk adenomas but not those with low-risk adenomas. 8 In general, the screening uptake rate is 63% among the adult population, but lower for those of minority race or ethnicity and in uninsured groups. 1 However, another study showed that shorter intervals of CRC surveillance were recommended to individuals with a family history of CRC, African Americans, and Asian/Pacific Islanders. 9 Adherence to surveillance guidelines in the busy practice setting is difficult; results of one survey showed that 63.6% of gastrointestinal physicians were cognizant of the recommended surveillance interval, but a substantial proportion (28.8%) deferred from following the recommendations due to their own perception and practice preferences. 10 Interestingly, one study showed that nongastroenterologists were more likely than gastroenterologists to recommend 3-year surveillance intervals to individuals with low-risk adenomas, and physicians undergoing training were 2.5 times more likely to adhere to practice guidelines. 9 Standardizing indications and appropriate guidelines are critical for best qualityof-care outcomes. Clinical decision tools (CDTs) that are integrated into the electronic health records (EHRs) are valuable technologies that empower providers to comply with the guidelines. Such tools take into account the quality of the index colonoscopy, including adequacy of bowel preparation, withdrawal time, cecal intubation documentation, size and number of lesions removed, and histology. An electronic record of these parameters enables providers to risk stratify and determine the interval for subsequent examinations based on current recommendations. One CDT is the EHR-based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS) described by Magrath et al elsewhere in this issue. They analyzed the usefulness of this integrated digital system to determine adherence to the MSTF screening guidelines, and observed a significantly higher adherence after its implementation (84.6% vs 77.4%; P<.001), with fewer instances of overuse and underuse of surveillance recommendations. They also found that recommendations were more likely to be
doi:10.6004/jnccn.2018.7100 fatcat:jisp2hn6wrdrti6zcxctallama