Repeated faecal occult blood testing is associated with decreased advanced colorectal cancer risk: A population-based study.

OBJECTIVE: To evaluate the association between repeated faecal occult blood testing and advanced colorectal cancer risk at population level in Canada. METHODS: A retrospective cohort study of all Ontario residents aged 56-74 diagnosed with colorectal cancer from 1 April 2007 to 31 March 2010, identified using health administrative data. The primary outcome was stage IV colorectal cancer, and primary exposure was faecal occult blood testing use within five years prior to colorectal cancer diagnosis. Patients were categorized into four mutually exclusive groups based on their exposure to faecal occult blood testing in the five years prior to colorectal cancer diagnosis: none, pre-diagnostic, repeated, and sporadic. Logistic regression was utilized to adjust for confounders. RESULTS: Of 7753 patients (median age 66, interquartile range 61-70, 62% male) identified, 1694 (22%) presented with stage I, 2056 (27%) with stage II, 2428 (31%) with stage III, and 1575 (20%) with stage IV colorectal cancer. There were 4092 (53%) with no record of prior faecal occult blood testing, 1485 (19%) classified as pre-diagnostic, 1693 (22%) as sporadic, and 483 (6%) as repeated faecal occult blood testing. After adjusting for confounders, patients who had repeated faecal occult blood testing were significantly less likely to present with stage IV colorectal cancer at diagnosis (Odds ratio 0.46, 95% Confidence Interval 0.34-0.62) than those with no prior faecal occult blood testing. CONCLUSIONS: Repeated faecal occult blood testing is associated with a decreased risk of advanced colorectal cancer. Our findings support the use of organized screening programmes that employ repeated faecal occult blood testing to improve colorectal cancer outcomes at population level.

Repeat colonoscopy after a colonoscopy with a negative result in Ontario: a population-based cohort study.

BACKGROUND: Data suggest the overuse of repeat colonoscopies, especially in patients at low risk for colorectal cancer. Our objective was to evaluate the time to repeat colonoscopies in low-risk patients aged 50-79 years old and the associated patient- and endoscopist-related factors. METHODS: All patients aged 50-79 years of age who underwent a complete outpatient colonoscopy with a negative result between 2000 and 2007 were identified from the Ontario Health Insurance Plan database. A colonoscopy performed within 5.5 years of follow-up after the index colonoscopy was considered an early repeat colonoscopy. Patient, endoscopist and endoscopy setting characteristics were recorded and their association with an early repeat colonoscopy was determined using an extended Cox proportional hazards regression model. RESULTS: The cohort consisted of 546 467 patients: 55.4% of the patients were female with a mean age of 61.1 years (95% confidence interval [CI] 61.1-61.2). The cumulative percentage of early repeat colonoscopy after 5.5 years was 33.7%. The rate decreased significantly between 2000 and 2007 (hazard ratio [HR] 0.35, 95% CI 0.34-0.36). General surgeons were associated with a higher risk of early repeat colonoscopy than gastroenterologists (HR 1.27, 95% CI 1.25-1.28). Endoscopists practising in a nonhospital setting were more likely to perform an early repeat colonoscopy (HR 1.26, 95% CI 1.22-1.30) than endoscopists at a hospital. INTERPRETATION: This study showed that there was overuse of early repeat colonoscopy in more than 30% of patients who were at low risk for colorectal cancer. The risk decreased significantly between 2000 and 2007 but was still greater than 20% in 2007. Our findings can be used to develop targeted educational interventions among subgroups of endoscopists with a higher rate of early repeat colonoscopy.

Personal navigation increases colorectal cancer screening uptake.

BACKGROUND: Prior randomized, controlled trials (RCTs) indicate that patient navigation can boost colorectal cancer screening rates in primary care. The sparse literature on pragmatic trials of interventions designed to increase colorectal cancer screening adherence motivated this trial on the impact of a patient navigation intervention that included support for performance of the participants' preferred screening test (colonoscopy or stool blood testing). MATERIALS AND METHODS: Primary care patients (n = 5,240), 50 to 74 years of age, with no prior diagnosis of bowel cancer and no record of a recent colorectal cancer screening test, were identified at the Group Health Centre in northern Ontario. These patients were randomly assigned to an intervention group (n = 2,629) or a usual care control group (n = 2,611). Intervention group participants were contacted by a trained nurse navigator by telephone to discuss colorectal cancer screening. Interested patients met with the navigator, who helped them identify and arrange for performance of the preferred screening test. Control group participants received usual care. Multivariate analyses were conducted using medical records data to assess intervention impact on screening adherence within 12 months after randomization. RESULTS: Mean patient age was 59 years, and 50% of participants were women. Colorectal cancer screening adherence was higher in the intervention group (35%) than in the control group (20%), a difference that was statistically significant (OR, 2.11; confidence interval, 1.87-2.39). CONCLUSION: Preference-based patient navigation increased screening uptake in a pragmatic RCT. IMPACT: Patient navigation increased colorectal cancer screening rates in a pragmatic RCT in proportions similar to those observed in explanatory RCTs.

Surgical residents' perceptions on learning gastrointestinal endoscopy: more hours and more standardization wanted.

OBJECTIVE: Gastrointestinal endoscopy is a complex task that involves an interaction of cognitive and manual skills. There is no consensus on the optimal way to teach endoscopy. We sought to evaluate our formal endoscopy curriculum for general surgery trainees to improve the effectiveness and quality of the endoscopy teaching in this program. DESIGN: We conducted focus group sessions over a 2-year period. Participants were general surgery residents, who are at the end of their endoscopy training rotation. The goal was to obtain the opinions and perceptions of trainees actively involved in learning endoscopy. SETTING: University-based general surgery residency. PARTICIPANTS: Second-year general surgery residents. RESULTS: A total of 24 residents participated in 7 focus group sessions over 2 years. Four central themes emerged that included training structure and expectations, development of endoscopy competence, teaching approaches and teaching tools, and recommendations for improvement of the training experience. CONCLUSIONS: An assessment of the themes led to the following concrete suggestions for improvement: the development of an algorithmic approach to endoscopy for the novice learner, consideration to introduce additional experience in endoscopy later in the 5-year surgery program, and consideration to incorporate a train-the-trainer curriculum for faculty that teach endoscopy.

Ontario's ColonCancerCheck: results from canada's first province-wide colorectal cancer screening program.

BACKGROUND: ColonCancerCheck (CCC), Canada's first province-wide colorectal cancer screening program, was publicly launched in Ontario in April 2008. The objective of this article is to report on key indicators of CCC Program performance since its inception. METHODS: The CCC Program recommends biennial guaiac-based fecal occult blood test (gFOBT) for persons 50 to 74 years of age at average risk for colorectal cancer and colonoscopy for those at increased risk (having one or more first-degree relatives with a diagnosis of colorectal cancer). Opportunistic screening with colonoscopy is available in Ontario. Five data sources were used to compute indicators of program performance during 2008 to 2011. The indicators computed were FOBT participation, overdue for screening, FOBT positivity, positive predictive value (PPV) of FOBT for colorectal cancer, diagnostic follow-up, and colorectal cancer detection rate. RESULTS: In 2011, FOBT participation was 29.8% and 46.8% of the target population was overdue for screening. FOBT positivity was higher among men (5.1%) than women (3.5%), and the PPV of FOBT for cancer was 4.3% in 2011. Follow-up colonoscopy within 6 months of a positive FOBT was completed by 74.6% of Program participants in 2011. The cancer detection rates for FOBT and for colonoscopy in those with a family history were 1.3 per 1,000 and 4.0 per 1,000, respectively, in 2011. CONCLUSION: These results provide an early indication of Program performance and provide findings relevant to other organized colorectal cancer screening programs. IMPACT: The greater cancer detection rate in those at increased risk due to family history who undergo colonoscopy screening suggests that a strategy of risk stratification will enhance the impact of FOBT-based screening programs.

Postoperative health-care utilization in Crohn's disease: the impact of specialist care.

OBJECTIVES: Crohn's disease (CD) patients frequently require surgery. We sought to characterize postoperative health-care utilization and its impact on outcomes. METHODS: We assembled a population-based cohort of CD patients who underwent first surgery in Ontario, Canada, between 1996 and 2009. We compared intra-individual preoperative and postoperative health-care utilization and characterized utilization of early postoperative gastrointestinal care (EPGIC) and its impact on health outcomes. RESULTS: For the 2,943 CD patients who underwent surgery, the 5-year risk of recurrent surgery was 26%. In the 5th postoperative year, the average annual number of inflammatory bowel disease (IBD)-related clinic visits, emergency department visits, endoscopy procedures, radiological procedures, and hospitalizations decreased by 62, 62, 82, 78, and 89% compared with prior to surgery. Regional utilization of EPGIC varied between 18 and 62% and correlated with the number of gastroenterologists within a regional local health integration network (ρ=0.71; P=0.006). EPGIC was associated with reduced risk of late postoperative CD-related hospitalizations (at least 1 year after surgery; adjusted incidence ratio (IRR), 0.82; 95% confidence interval (CI): 0.72-0.94). Other predictors of late hospitalizations included having an emergency department visit within 6 months (adjusted IRR, 2.60; 95% CI: 2.21-3.05), lower income, and higher comorbidity. Individuals residing in regions with high aggregate EPGIC utilization experienced lower rates of hospitalization compared with those in regions with low utilization (adjusted IRR, 0.83; 95% CI: 0.70-0.95). CONCLUSIONS: IBD-related health-care utilization decreased significantly up to 5 years following surgery. EPGIC may reduce late CD-related hospitalizations following surgery.

Women's sexual orientation and health: results from a Canadian population-based survey.

The current study sought to determine whether health status and health risk behaviors of Canadian women varied based on sexual identity. This was a cross-sectional analysis of data from the Canadian Community Health Survey: cycle 2.1, a national population-based survey designed to gather health data on a representative sample of over 135,000 Canadians including 354 lesbian respondents, 424 bisexual women respondents, and 60,937 heterosexual women respondents. Sexual orientation was associated with disparities in health status and health risk behaviors for lesbian and bisexual women in Canada. Bisexual women were more likely than lesbians or heterosexual women to report poor or fair mental and physical health, mood or anxiety disorders, lifetime STD diagnosis, and, most markedly, life-time suicidality. Lesbians and bisexual women were also more likely to report daily smoking and risky drinking than heterosexual women. In sum, sexual orientation was associated with health status in Canada. Bisexual women, in particular, reported poorer health outcomes than lesbian or heterosexual women, indicating this group may be an appropriate target for specific health promotion interventions.

Hospitalizations for inflammatory bowel disease: profile of the uninsured in the United States.

BACKGROUND: Inflammatory bowel disease (IBD) patients may be at increased risk for having no health insurance. Our objectives were to assess the prevalence of hospitalized IBD patients without insurance in the US and to characterize predictive factors. METHODS: We identified IBD admissions in the Nationwide Inpatient Sample (1999-2005) and a 1% sample of general medical patients. We used population estimates from the US Census Bureau to calculate hospitalization rates, and logistic regression to determine predictors of being uninsured. RESULTS: Although uninsured IBD patients were less likely to be hospitalized than those privately insured (incidence rate ratio [IRR] 0.41; 95% confidence interval [CI]: 0.38-0.45), their hospitalization rate increased from 8.3/100,000 to 12.5/100,000 (P < 0.001) over 7 years, outpacing private admissions. The proportion of uninsured IBD inpatients increased from 4.6% to 6.5% (P < 0.001), and IBD patients were more likely than general medical patients to be uninsured (5.1% vs. 4.1%, P < 0.0001). Predictors of being uninsured were being 21 to 40 years (odds ratio [OR] 1.95; 95% CI: 1.64-2.31), African American (OR 1.51; 95% CI: 1.29-0.76) or Hispanic (OR 2.21; 95% CI: 1.79-2.74), or residing in the southern US (OR 1.63; 95% CI: 1.27-2.11). Being female (OR 0.65; 95% CI: 0.61-0.70), residing in higher income neighborhoods (OR 0.69; 95% CI: 0.62-0.77), and higher comorbidity were protective factors. CONCLUSIONS: The rate of uninsured IBD admissions has risen disproportionately relative to the privately insured and general medical populations. We need measures to alleviate the burden of being uninsured among young and otherwise healthy adults with IBD who are most vulnerable.

Regular health care use by lesbians: a path analysis of predictive factors.

BACKGROUND: Lesbians have more health risks than other women but access preventive medical care less frequently. OBJECTIVE: To test the influence of (i) provider inquiry about sexual orientation, (ii) perceived provider gay-positivity and (iii) patient disclosure of sexual orientation on regular health care use in a sample of Canadian lesbians. METHODS: A path analysis using community survey data from 489 lesbian respondents. RESULTS: 78.5% [95% confidence interval (CI): 74.7-82.0] of women reported regular health service use; 75.8% (95% CI: 72.2-79.8) of women had disclosed their sexual orientation to their provider; and 24.4% (95% CI: 20.6-28.2) of women had been asked about their sexual orientation by their provider. Of those women whose physicians had inquired about their sexual orientation, 100% (95% CI: 97.5-100.0) had disclosed. In the final path analysis, perceived provider gay-positivity and level of patient outness predicted disclosure, which, along with health status predicted regular health care use. All paths were significant at P < 0.05. CONCLUSIONS: Provider-related factors including perceived gay-positivity and inquiry about sexual orientation are strongly associated with disclosure of sexual orientation. Disclosure is associated with regular health care use. Minor changes to practice could improve access to health services for lesbians.

Are claims of equivalency in digestive diseases trials supported by the evidence?

BACKGROUND & AIMS: Traditionally, randomized controlled trials (RCTs) have attempted to show the superiority of one intervention over another. However, when effective treatment already exists, it is sometimes more useful to prove that an intervention is equivalent, or at least not inferior, to the standard of care. Our aim was to determine whether claims of equivalency in digestive diseases trials are supported by the evidence. METHODS: Medline was searched for RCTs published between 1989 and 2002 using the MeSH headings "exp therapeutic equivalency" and "exp digestive diseases" and the text words "equivalence," "equal," "equals," or "equivalent," yielding 902 articles. Of these, 73 articles met the inclusion criteria. These articles were evaluated using previously published criteria for equivalency. RESULTS: Of the included articles, 33% stated an a priori research aim of equivalency, 92% reported differences of <20% between "equal" interventions, 34% set an equivalency boundary and tested it appropriately, and 19% performed a sample size calculation for equivalency. Overall, 12% of the reviewed articles met all 5 criteria. Fifty-two percent of our sample inappropriately used a failed superiority test (i.e., a P value > 0.05) as statistical "proof" of equivalency. Nonsurgical trials and those published between 1996 and 2002 were more likely to meet criteria than were surgical trials (P = 0.07) or trials published before 1996 (P = 0.003). CONCLUSIONS: Claims of equivalency between interventions in digestive diseases trials tend to be poorly supported by the evidence. Erroneous claims of equivalency are potentially dangerous and may lead to substandard patient care.