Variation in gastroscopy rate in English general practice and outcome for oesophagogastric cancer: retrospective analysis of Hospital Episode Statistics.

OBJECTIVE: To determine whether variation in gastroscopy rates in English general practice populations is associated with inequality in oesophagogastric (OG) cancer outcome. DESIGN: Retrospective observational study of the Hospital Episode Statistics (HES) dataset for England (2006-2008) linked to death registration. METHODS: were validated using independent local and national data. General practices with new cases of OG cancer were included. Practices were grouped into tertiles according to standardised elective gastroscopy rate per capita (low, medium or high). Outcome measures for cancer cases were: emergency admission during diagnostic pathway, major surgical resection and mortality at 1 year. Covariates were: age group, gender, comorbidity, general practice average deprivation and patient deprivation. RESULTS: 22 488 incident cases of OG cancer from 6513 general practices were identified. Patients registered with the low tertile group of practices had the lowest rate of major surgery, highest rate of emergency admission and highest mortality. The inequality was widest for the most socioeconomically deprived cases. After adjustment for covariates in logistic regression, the gastroscopy rate (low, medium or high) at the patient's general practice was an independent predictor of emergency admission, major surgery and mortality. CONCLUSIONS: There is wide variation in the rate of gastroscopy among general practice populations in England. On average, OG cancer patients belonging to practices with the lowest rates of gastroscopy are at greater risk of poor outcome. These findings suggest that initiatives or current guidelines aimed at limiting the use of gastroscopy may adversely affect cancer outcomes.

Metal stents: a bridge to surgery in hilar cholangiocarcinoma.

BACKGROUND: Obstructive jaundice in patients with hilar cholangiocarcinoma is a known risk factor for hepatic failure after liver resection. Plastic stents are most widely used for preoperative drainage. However, plastic stents are known to have limited patency time and therefore, in palliative settings, the self-expanding metal stent (SEMS) is used. This type of stent has been shown to be superior because it allows for rapid biliary decompression and a reduced complication rate after insertion. This study explores the use of the SEMS for biliary decompression in patients with operable hilar cholangiocarcinoma. METHODS: A retrospective evaluation of a prospectively maintained database at a tertiary hepatobiliary referral centre was carried out. All patients with resectable cholangiocarcinoma were recorded. RESULTS: Of 260 patients referred to this unit with cholangiocarcinoma between January 2008 and April 2012, 50 patients presented with operable cholangiocarcinoma and 27 of these had obstructive jaundice requiring stenting. Ten patients were initially treated with SEMSs; no stent failure occurred in these patients. Seventeen patients initially received plastic stents, seven of which failed in the interval between stent placement and laparotomy. These stents were replaced by SEMSs in four patients and by plastic stents in three patients. Median time to laparotomy was 45 days and 68 days in patients with SEMSs and plastic stents, respectively. CONCLUSIONS: Self-expanding metal stents provide adequate and rapid biliary drainage in patients with obstruction caused by hilar cholangiocarcinoma. No re-interventions were required. This probably reflects the relatively short interval between stent placement and laparotomy.

The effect of high quality assurance measures in bowel cancer screening on patient satisfaction of colonoscopy.

BACKGROUND: To ensure patient safety, rigorous quality assurance (QA) measures for colonoscopy were introduced for the Bowel Cancer Screening Programme (BCSP) in England. The impact of these high QA measures on patient experience and satisfaction is unknown. AIMS: To determine the impact of this high-level QA of colonoscopy on patient satisfaction. METHODS: A case controlled study using a retrospective audit & telephone interview patient survey was performed between 1/1/07-01/10/08 on patients that underwent colonoscopy. Data were analyzed by comparing quantitative and qualitative performance colonoscopy indicators in patients within the BCSP with those outside the programme (NON-BCSP). PARTICIPANTS: 720 patients that had undergone day case colonoscopy. SETTING: Accredited BCSP centre: University Hospitals Aintree, UK. INTERVENTION: Comparing patient satisfaction between BCSP to NON-BCSP populations. RESULTS: Uptake was 68% (n=488). Caecal intubation rate (CIR) was higher (99 v 91%; p=0.001), and sedation doses lower in BCSP compared to NON-BCSP (Midazolam dose Median [IQR] (1 [0, 2] v 2 [1, 3] mg; respectively p=0.0001). For patient satisfaction and experience, scores were high and pain scores were low in both groups; with no statistically significant difference between groups. However, willingness to have a repeat procedure was higher in BCSP (p=0.001). CONCLUSIONS: Whilst superior CIR with less sedation within BCSP, overall scores were similar for patient satisfaction, both in and outside the programme. With the higher 'willingness for repeat' within BCSP, a positive impact of higher level of QA is suggested and that good patient experience can be achieved with minimal conscious sedation in expert hands.