The effects of inadequate preparation quality for colonoscopy
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The effects of inadequate preparation quality for colonoscopy. Eric Sherer and Michael Catlin August 20 th , 2010 HSR&D Work-in-Progress. Outline. Background Lengthy Adenoma detection rates Appendix… or stand alone???. Outcomes Methods Random questions Compliance Costs Mortality
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The effects of inadequate preparation quality for colonoscopy Eric Sherer and Michael Catlin August 20th, 2010 HSR&D Work-in-Progress Outline Background Lengthy Adenoma detection rates Appendix… or stand alone??? Outcomes Methods Random questions Compliance Costs Mortality Preliminary results ORANGE TEXT => INPUT FROM AUDIENCE Background Detection rates - Literature Harewood et al. 2003 93,004 colonoscopies Adequate vs. Inadequate POLYPS <10 MM Froechlich et al. 2005 5,832 colonoscopies Low vs. Intermediate quality Low vs. High quality POLYPS <10 MM Unanswered questions What about adenomas? Diminutive (<=5mm) vs. small (<10mm) adenomas? “cannot exclude adenomas <=5mm” Adjust for individual colonoscopist Want sensitivity NOT detection rates Adenoma detection rates Padequate vs. fair = 0.17 Padequate vs. poor < 0.01 Adenoma detection rates Padequate vs. fair = 0.28 Padequate vs. poor < 0.01 Padequate vs. fair = 0.62 Padequate vs. poor = 0.80 Adenoma detection rates Padequate vs. fair = 0.25 Padequate vs. poor < 0.01 Adenoma detection rates Medium adenomas (6-9mm) Adequate vs. poor prep qualities 22% relative difference; 3.2% absolute difference Adequate vs. fair prep qualities 13% relative difference; 1.9% absolute difference Padequate vs. fair = 0.16 Padequate vs. poor = 0.21 Adenoma detection rates Medium adenomas (6-9mm) Adequate vs. poor prep qualities 22% relative difference; 3.2% absolute difference Adequate vs. fair prep qualities 13% relative difference; 1.9% absolute difference Surveillance colonoscopy findings Outcomes Effects of inadequate preparation quality Missed adenomas => Δcancer Recommendations after 1st colonoscopy 2003-2010 colonoscopy prep qualities 1,675 (64.1%) adequate 750 (28.7%) fair 187 (7.1%) poor Effect of inadequate preparation Rex et al. 2002 400 patients 200 public hospital 200 private hospital Authors assumed… Perfect inadequacy Perfect compliance Procedure invariance Outcomes Effects of inadequate preparation quality Missed adenomas => Δcancer Earlier recalls => Δnumber of tests Outcomes Primary Patient Δ E[Quality adjusted life-year (QALY)] Δ E[colon costs] Δ lifetime CRC risk Clinic Δ E[colonoscopies / patient / life-year] (How many more colonoscopies are done per patient each year) Secondary Prep quality intervention Methods Calculations Monte Carlo trials Implementation All adequate prep scenario “Normal” prep scenario Range of compliances Independent & greedy assumptions To-do: Sensitivity analysis Costs Select patient Colon disease free & 50<=age<=80 r1 Select random prep quality f (gender, BMI, prev prep quality) r2 Random colonoscopy findings History dependent r3 Select compliance 40% - 80% reported in literature Independent events vs. All-or-nothing r4 Determine follow-up interval Expected vs. distributed behavior r5 Age > 80? Age > 100? Functions Measuring patient outcomes Quality-Adjusted Life Years (QALYs) 40 years Perfect health (utility 1.0) 40 QALYs Measuring patient outcomes Quality-Adjusted Life Years (QALYs) 40 years Perfect health (utility 1.0) 40 QALYs 80 years Poor health (utility 0.5) 40 QALYs Measuring patient outcomes Quality-Adjusted Life Years (QALYs) 40 years Perfect health (utility 1.0) 40 QALYs Utility of model states (Ness et al. 2000) 80 years Poor health (utility 0.5) 40 QALYs Measuringclinic costs CRC treatment Initial costs Continuing costs (Ness et al. 2000) Colonoscopies Colonoscopy Polypectomy Pathology Complications Perforation Measuringclinic costs CRC treatment Initial costs Continuing costs (Ness et al. 2000) Terminal care costs not included Colonoscopies Colonoscopy Polypectomy Pathology Complications Perforation Measuringclinic costs CRC treatment Initial costs Continuing costs Colonoscopies Colonoscopy ($614 per procedure) Polypectomy ($131 for removal of polyps) Pathology ($67 per polyp examined) (Tafazzoli et al. 2009) Complications Perforation Measuringclinic costs CRC treatment Initial costs Continuing costs Colonoscopies Colonoscopy Polypectomy Pathology Complications Perforation (0.2% incidence, 0.01% mortality) (Tafazzoli et al. 2009) Measuring mortality Discount each event by the probability of prior mortality. Measuring mortality Discount each event by the probability of prior mortality. Probability of surviving from age 50 Patient viability with age Ai = age at first colonoscopy Af = current age Patient age Preliminary Results Clinic outcomes E[colonoscopies / patient / life-year] E[N] of surveillance colonoscopies:Independent event assumption w/ ghosts 26.8% of surveillance colonoscopies due to inadequate prep Patient outcomes E[QALY / patient] E[colon costs / patient]E[CRC / patient] E[QALY / patient] E[colon costs / patient] E[CRC / patient] Secondary Outcome Effect of prep quality intervention E[N] surveillance colonoscopies100% compliance Big Picture Overall project Objective: “Best” time for a patient to receive colon tests Tools needed Longitudinal predictions Test parameters Cost-utility Decision analysis Thank you Limitations Discussed in Rex et al. 2002 Additional Likelihood of CRC Intermediate preps, detection & recs Longitudinal adenoma prevalence Study interval bias Correlation in prep qualities Additional surveillance colonoscopies
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