A nurse-led model at public academic hospitals maintains high adherence to colorectal cancer surveillance guidelines.

OBJECTIVE: To examine the compliance of colorectal cancer surveillance decisions for individuals at greater risk with current evidence-based guidelines and to determine whether compliance differs between surveillance models. DESIGN: Prospective auditing of compliance of surveillance decisions with evidence-based guidelines (NHMRC) in two decision-making models: nurse coordinator-led decision making in public academic hospitals and physician-led decision making in private non-academic hospitals. SETTING: Selected South Australian hospitals participating in the Southern Co-operative Program for the Prevention of Colorectal Cancer (SCOOP). MAIN OUTCOME MEASURES: Proportions of recall recommendations that matched NHMRC guideline recommendations (March-May 2015); numbers of surveillance colonoscopies undertaken more than 6 months ahead of schedule (January-December 2015); proportions of significant neoplasia findings during the 15 years of SCOOP operation (2000-2015). RESULTS: For the nurse-led/public academic hospital model, the recall interval recommendation following 398 of 410 colonoscopies (97%) with findings covered by NHMRC guidelines corresponded to the guideline recommendations; for the physician-led/private non-academic hospital model, this applied to 257 of 310 colonoscopies (83%) (P < 0.001). During 2015, 27% of colonoscopies in public academic hospitals (mean, 27 months; SD, 13 months) and 20% of those in private non-academic hospitals (mean, 23 months; SD, 12 months) were performed more than 6 months earlier than scheduled, in most cases because of patient-related factors (symptoms, faecal occult blood test results). The ratio of the numbers of high risk adenomas to cancers increased from 6.6:1 during 2001-2005 to 16:1 during 2011-2015. CONCLUSION: The nurse-led/public academic hospital model for decisions about colorectal cancer surveillance intervals achieves a high degree of compliance with guideline recommendations, which should relieve burdening of colonoscopy resources.

Interval fecal immunochemical testing in a colonoscopic surveillance program speeds detection of colorectal neoplasia.

BACKGROUND & AIMS: Rapidly progressing or missed lesions can reduce the effectiveness of colonoscopy-based colorectal cancer surveillance programs. We investigated whether giving fecal immunochemical tests (FITs) for hemoglobin between surveillance colonoscopies resulted in earlier detection of neoplasia. METHODS: The study included 1736 patients with a family history or past neoplasia; they received at least 2 colonoscopy examinations and were followed for a total of 8863 years. Patients were excluded from the study if they had genetic syndromes, colorectal surgery, or inflammatory bowel disease. An FIT was offered yearly, in the interval between colonoscopies; if results were positive, the colonoscopy was performed earlier than scheduled. RESULTS: Among the 1071 asymptomatic subjects (61%) who received at least 1 FIT, the test detected 12 of 14 cancers (86% sensitivity) and 60 of 96 (63%) advanced adenomas. In patients with positive results from the FIT, the diagnosis of cancer was made 25 months (median) earlier and diagnosis of advanced adenoma 24 months earlier. Patients who had repeated negative results from FIT had an almost 2-fold decrease in risk for cancer and advanced adenoma compared with patients who were not tested (5.5% vs 10.1%, respectively, P = .0004). The most advanced stages of neoplasia, observed across the continuum from nonadvanced adenoma to late-stage cancer, were associated with age (increased with age), sex (increased in males), and FIT result. The probability of most advanced neoplastic stage was lowest among those with a negative result from the FIT (odds ratio, 0.68; P < .001). CONCLUSIONS: Interval examinations using the FIT detected neoplasias sooner than scheduled surveillances. Subjects with negative results from the FIT had the lowest risk for the most advanced stage of neoplasia. Interval FIT analyses can be used to detect missed or rapidly developing lesions in surveillance programs.

Accessing health information in a hospital setting: a consumer views study.

Meeting consumers' needs for health information is an important role for all health professionals. A Consumer Views Study was conducted at Flinders Medical Centre (FMC) to ensure strategies for improving access to health information for staff and consumers were congruent with consumers' views. Semi-structured questionnaires were completed by 100 consumers of FMC services. A key finding was the strong preference consumers have for accessing health information through staff members, which confirms the important part that education plays in information provision. A concern was that less than half of the participants were provided with written information. This could be indicative of the difficulties staff have in accessing health information to provide to consumers. Results also showed the important role General Practitioners (GPs) have in providing health information to consumers. Findings have helped shape strategies that focus on coordinated electronic access to quality health information, which will support staff in accessing and providing health information to consumers, and improve direct access to health information for consumers.

Improving management of oesophageal varices in patients with cirrhosis.

PROBLEM: A retrospective audit of management of oesophageal varices in patients with cirrhosis identified the need to improve adherence to guidelines. DESIGN: Prospective audit of the effect of disseminating guidelines in 2004; prospective audit of the effect of a nurse coordinator for oesophageal variceal screening and surveillance from 2005 to 2008. SETTING: A major public hospital in Australia 2001-2008. Patients with cirrhosis of the liver and those who had experienced a variceal bleed were studied. KEY MEASURES FOR IMPROVEMENT: (1) Adherence with primary prevention protocols for prevention of primary variceal bleeding in patients with cirrhosis of the liver. (2) Adherence with protocols for acute management of variceal bleeding and secondary prevention of bleeding. STRATEGIES FOR CHANGE: Local protocols were developed and disseminated. A nurse coordinator was introduced to manage the primary prevention process according to a clinical protocol. EFFECTS OF CHANGE: The introduction of a nurse coordinator to manage the primary prevention process resulted in dramatic and rapid improvements in primary prevention. This has been maintained with our target of 90% adherence being achieved for the last 3 years. LESSONS LEARNT: Disseminating guidelines had little effect on primary prevention practice. Less than 1 year after a nurse coordinator was introduced to manage primary prevention, adherence to primary prevention guidelines increased from 13% to 79%. However, significant improvements in the management of acute variceal bleeding where medical staff have a clear responsibility for patient care were achieved through the development and dissemination of clear clinical protocols and the introduction of auditing and feedback mechanisms.

Applying evidence-based guidelines improves use of colonoscopy resources in patients with a moderate risk of colorectal neoplasia.

OBJECTIVES: To determine whether applying National Health and Medical Research Council (NHMRC) guidelines for colorectal cancer prevention would reduce the number of follow-up colonoscopies. DESIGN: A prospective audit of colonoscopic surveillance decisions before and after the intervention. SETTING: The endoscopy suite at a metropolitan tertiary hospital three months before and after January 2000. INTERVENTION: Dissemination of NHMRC guidelines, and supervision of application of the guidelines by a nurse coordinator. SUBJECTS: We compared colonoscopic surveillance decisions before and after the intervention in two groups of 100 consecutive patients after polypectomy and in two groups of 50 consecutive patients with a family history of colorectal cancer after a normal colonoscopy. MAIN OUTCOME MEASURES: Change in concordance of decisions with NHMRC guidelines; and effect on number of follow-up colonoscopies. RESULTS: After the intervention, the proportion of postpolypectomy surveillance decisions matching the guidelines increased from 37% to 96% (P < 0.05). The mean time to repeat colonoscopy after polypectomy increased from 2.7 to 3.5 years (P < 0.005) (ie, a 23% reduction in the number of postpolypectomy surveillance colonoscopies performed per year). Likewise, the proportion of family-history surveillance decisions matching the guidelines increased from 63% to 96%. Adhering to the guidelines resulted in a 17% reduction in colonoscopies performed on the basis of a family history of colorectal cancer. CONCLUSIONS: Supervised application of evidence-based guidelines to a colorectal cancer surveillance program significantly reduces the number of surveillance colonoscopies performed.