Screening Indication Associated With Lower Likelihood of Minor Adverse Events in Patients Undergoing Outpatient Colonoscopy.

We sought to determine, among outpatients at one university hospital endoscopy center, rates of self-reported minor adverse events (MAEs) at 2, 14, and 30 days postcolonoscopy and to identify predictors of MAEs at Day 2 postcolonoscopy. A single-center longitudinal cohort study with follow-ups at Days 2, 14, and 30 postcolonoscopy was conducted in Montreal, Canada. Baseline self-report data included patient age, gender, gastrointestinal discomforts and other discomforts in the preceding month, and comorbidity. Intracolonoscopy procedures and the method of insufflation were obtained from endoscopy reports. Minor adverse event data were obtained by either phone or Internet survey. Multivariate logistic regression was used to identify predictors of MAEs at Day 2. Of 705 individuals approached, 420 (mean age = 58.7 years; SD = 8.4, 45.7% female) were eligible and consented to study participation, and 378 (90%) participated in at least one follow-up. At Days 2, 14, and 30, 86 (25.1%), 46 (13.7%), and 13 (3.1%) patients, respectively, experienced at least one MAE. At the Day 30 follow-up, 2 (0.53%) patients reported having experienced a serious adverse event. The multivariable analysis results showed that screening compared with nonscreening colonoscopy was protective for MAEs at 2 days (OR = 0.5, 95% CI [0.3, 0.9]). We found that 25% of patients experienced at least one MAE at 2 days postcolonoscopy, and screening compared with nonscreening colonoscopy patients were half as likely to experience these early MAEs. Nurses may use these findings to educate and reassure patients about colonoscopy risks. Large, longitudinal multicenter studies are needed to corroborate our findings.

A Descriptive Study of Quality of Life Following Neoadjuvant Chemotherapy and Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Squamous Cell Carcinoma.

BACKGROUND: Patients with oropharyngeal squamous cell carcinoma (OPSCC) treated with radiation-based therapy suffer from short- and long-term toxicities that affect quality of life (QOL). Transoral robotic surgery (TORS) has an established role in the management of early OPSCC but adjuvant treatment is often indicated postoperatively due to the high incidence of nodal metastasis associated with advanced human papillomavirus (HPV)-related OPSCC. To overcome the need for adjuvant radiation therapy (RT), neoadjuvant chemotherapy followed by TORS and neck dissection (ND) is proposed. This study aimed to assess if QOL in HPV-associated OPSCC receiving neoadjuvant chemotherapy followed by TORS and ND returns to baseline within 12 months of completing treatment. METHODS: A 12 month longitudinal study was carried out at McGill University Health Centre in Montreal, Canada, among a convenience sample of patients with American Joint Committee on Cancer Seventh Edition stage III and IVa HPV-related OPSCC who were treated with neoadjuvant chemotherapy followed by TORS and ND. QOL data were obtained pretreatment and at 1, 3, 6, and 12 months following treatment completion using the European Organisation for Research and Treatment of Cancer Core and Head and Neck extension modules. Paired t tests and mixed models for repeated measures analysis were used to assess changes in QOL from baseline to 12 months postoperatively and over time, respectively. RESULTS: Nineteen of 23 patients (median age 58 years) who received the study treatment fulfilled the eligibility criteria. OPSCC subsites were palatine tonsil (n = 12) and base of tongue (n = 7). All 19 patients were treated per protocol and none required adjuvant RT as per pathology review and protocol requirements at a postoperative multidisciplinary team tumor board discussion. No significant differences were found when comparing 12 month QOL follow-up scores to pretreatment scores in measures that would likely be affected by RT [eg, swallowing (P = .7), social eating (P = .8), xerostomia (P = .9)]. CONCLUSION: In HPV-related OPSCC, neoadjuvant chemotherapy followed by TORS and ND as definitive treatment is associated with excellent QOL outcomes. Postoperative QOL scores returned to baseline by 3 months and were maintained for all measures, indicating a return to normal function.

Endoscopist specialty is associated with colonoscopy quality.

BACKGROUND: Some studies have shown that endoscopist specialty is associated with colorectal cancers missed by colonoscopy. We sought to examine the relationship between endoscopist specialty and polypectomy rate, a colonoscopy quality indicator. Polypectomy rate is defined as the proportion of colonoscopies that result in the removal of one or more polyps. METHODS: A cross-sectional study was conducted of endoscopists and their patients from 7 Montreal and 2 Calgary endoscopy clinics. Eligible patients were aged 50-75 and covered by provincial health insurance. A patient questionnaire assessed family history of colorectal cancer, history of large bowel conditions and symptoms, and previous colonoscopy. The outcome, polypectomy status, was obtained from provincial health administrative databases. For each city, Bayesian hierarchical logistic regression was used to estimate the odds ratio for polypectomy comparing surgeons to gastroenterologists. Model covariates included patient age, sex, family history of colorectal cancer, colonoscopy indication, and previous colonoscopy. RESULTS: In total, 2,113 and 538 colonoscopies were included from Montreal and Calgary, respectively. Colonoscopies were performed by 38 gastroenterologists and 6 surgeons in Montreal, and by 31 gastroenterologists and 5 surgeons in Calgary. The adjusted odds ratios comparing surgeons to gastroenterologists were 0.48 (95% CI: 0.32-0.71) in Montreal and 0.73 (95% CI: 0.43-1.21) in Calgary. CONCLUSIONS: An association between endoscopist specialty and polypectomy was observed in both cities after adjusting for patient-level covariates. Results from Montreal suggest that surgeons are half as likely as gastroenterologists to remove polyps, while those from Calgary were associated with a wide, non-significant Bayesian credible interval. However, residual confounding from patient-level variables is possible, and further investigation is required.

Effectiveness of an organized colorectal cancer screening program on increasing adherence in asymptomatic average-risk Canadians.

BACKGROUND: Colorectal cancer (CRC) is the third most commonly diagnosed cancer and second highest cause of cancer-related mortality in Canada. Despite the availability of screening services and establishment of guidelines, utilization of colorectal cancer screening in Canada remains low. In 2008, the province of Ontario launched ColonCancerCheck, an organized colorectal cancer screening program aimed at increasing CRC screening adherence. In this study, we adopt a quasi-experimental approach to estimate and describe the impact of ColonCancerCheck on screening behavior in the asymptomatic average risk population. METHODS: Annual screening rates from the target population were estimated using five cycles of the Canadian Community Health Survey, a cross-sectional nationally representative survey of health status, healthcare use, and determinants of health in the Canadian population. We used a difference-in-differences design to measure the overall impact of ColonCancerCheck on past-year fecal occult blood testing (FOBT) and endoscopy in Ontario relative to the rest of Canada. Several verification tests validated the suitability of our model specification. RESULTS: The difference-in-differences analysis shows that ColonCancerCheck increased FOBT screening in the average risk population by 5.2 percentage points (95% CI [3.2, 7.2]), an increase of 33% relative to pre-program screening rates. The program had no observed effect on endoscopy screening and we found no evidence that ColonCancerCheck differentially altered the screening practices of population sub-groups. CONCLUSIONS: Our findings suggest ColonCancerCheck has been successful at increasing use of FOBT in the asymptomatic average risk population.

Developing model-based algorithms to identify screening colonoscopies using administrative health databases.

BACKGROUND: Algorithms to identify screening colonoscopies in administrative databases would be useful for monitoring colorectal cancer (CRC) screening uptake, tracking health resource utilization, and quality assurance. Previously developed algorithms based on expert opinion were insufficiently accurate. The purpose of this study was to develop and evaluate the accuracy of model-based algorithms to identify screening colonoscopies in health administrative databases. METHODS: Patients aged 50-75 were recruited from endoscopy units in Montreal, Quebec, and Calgary, Alberta. Physician billing records and hospitalization data were obtained for each patient from the provincial administrative health databases. Indication for colonoscopy was derived using Bayesian latent class analysis informed by endoscopist and patient questionnaire responses. Two modeling methods were used to fit the data, multivariate logistic regression and recursive partitioning. The accuracies of these models were assessed. RESULTS: 689 patients from Montreal and 541 from Calgary participated (January to March 2007). The latent class model identified 554 screening exams. Multivariate logistic regression predictions yielded an area under the curve of 0.786. Recursive partitioning using the latent outcome had sensitivity and specificity of 84.5% (95% CI: 81.5-87.5) and 63.3% (95% CI: 59.7-67.0), respectively. CONCLUSIONS: Model-based algorithms using administrative data failed to identify screening colonoscopies with sufficient accuracy. Nevertheless, the approach of constructing a latent reference standard against which model-based algorithms were evaluated may be useful for validating administrative data in other contexts where there lacks a gold standard.

Feasibility of a call-in centre to deliver colorectal cancer screening in primary care.

OBJECTIVE: To evaluate the feasibility of a call-in centre to deliver colorectal cancer (CRC) screening in primary care through self-administered fecal occult blood testing (FOBT). DESIGN: Four-month intervention study (September 2010 to January 2011) with randomly selected follow-up interviews. SETTING: The family medicine clinics of 3 hospitals in Montreal, Que. PARTICIPANTS: Letters from doctors invited their patients to contact the call-in centre (N = 761). Eligible patients agreeing to FOBT were sent testing kits that could be returned by mail (N = 100). Randomly selected patients (N = 36) were interviewed to explore the reasons why they did not contact the call-in centre, or why they did or did not adhere to FOBT. MAIN OUTCOME MEASURES: Feasibility was assessed by the proportions of patients who contacted the call-in centre, who were eligible for FOBT, and who adhered to FOBT; and by the time between invitation mail-out and contact with the call-in centre, initial telephone contact and receipt of the signed consent form, and FOBT kit mail-out and receipt of the kit by the laboratory. Hierarchical logistic regression evaluated the effect of patient characteristics on feasibility indicators, adjusting for clustering by physician and centre. RESULTS: Of 761 patients (61.6% female, mean age 61.0 years), 250 (32.9%) contacted the call-in centre, of whom 100 (40.0%) were eligible for and consented to FOBT; 62 (62.0%) of these patients adhered to FOBT. Median (interquartile range) time from invitation mail-out to call-in centre contact was 21 (7 to 29) days, from initial telephone contact to receipt of the signed consent form was 24 (10 to 38) days, and from FOBT kit mail-out to receipt at the laboratory was 23 (18 to 32) days. With the exception of previous cancer diagnosis, patient characteristics were not associated with feasibility indicators. Of the 115 (46.0%) patients determined to be ineligible for FOBT screening, 111 (96.5%) were up to date with or already scheduled for screening. CONCLUSION: Feasibility of the call-in centre was demonstrated. Targeting screening-eligible individuals or coupling a call-in service with another evidence-based CRC screening improvement strategy might further improve uptake of fecal testing.

Different screening definitions have little impact on polypectomy rate estimates.

BACKGROUND: Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate. OBJECTIVE: To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications. METHODS: A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer. RESULTS: A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94. DISCUSSION: Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar. CONCLUSION: The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.

Qualitative study of physician perspectives on classifying screening and nonscreening colonoscopy using administrative health data: adding practice does not make perfect.

BACKGROUND: Previously developed screening colonoscopy algorithms based on diagnostic and endoscopy procedural variables have not been sufficiently accurate for use in epidemiological and health services research. OBJECTIVE: To increase understanding of the administrative health database variables that could help to discern screening and nonscreening colonoscopy. METHODS: A qualitative study using physician focus groups was conducted in Montreal (Quebec), Calgary (Alberta) and Toronto (Ontario). Specialty-specific focus group sessions were held among family physicians and gastroenterologists - the physicians responsible for referring patients to and performing screening colonoscopy, respectively. Interview guides were developed to better understand physician clinical and billing practices. Discussions were audiotaped, transcribed verbatim and analyzed using the constant comparative approach. RESULTS: Forty family physicians and seven gastroenterologists participated in five focus group sessions. Patient variables included demographics (age) and medical history (colorectal cancer risk factors/symptoms, medication for colorectal cancer risk factors/symptoms, gastrointestinal disorders, severe disease). Clinical practice variables included timing of the colonoscopy (evenings, weekends, holidays, during hospitalization; same-day endoscopist consultation and colonoscopy), use of services (hospitalization, annual examination, transfer from other facility) and procedure use patterns (large bowel or other medical/surgical procedure before and subsequent to colonoscopy). However, wide variability in clinical and billing practices will likely preclude the development of a reasonably accurate screening colonoscopy algorithm. Physicians suggested adding a screening colonoscopy code to the administrative health data. CONCLUSIONS: Failure to acknowledge the limitations of the provincial administrative health databases to identify screening colonoscopy may lead to incorrect conclusions and the establishment of inappropriate health care policies.

Rate of serious complications of colonoscopy in Quebec.

BACKGROUND: The rate of serious complications is one marker of the quality of colonoscopy services. OBJECTIVE: To estimate the rate of serious complications of colonoscopy according to colonoscopy indication and polypectomy status. METHODS: A prospective cohort study of patients scheduled for colonoscopy who were recruited from seven endoscopy facilities across Montreal (Quebec) was conducted. Before colonoscopy, patients completed a brief questionnaire and provided their health insurance numbers. Colonoscopy indication was based on patient-reported medical history. Polypectomy status was obtained from provincial physician billing records (Régie de l'assurance maladie du Québec). Diagnoses and procedures associated with hospitalization in the 30 days following colonoscopy were obtained from the provincial hospitalization database (MedEcho). RESULTS: Of the 2134 patients enrolled (mean age 60.9 years, 50.1% male), 33 (1.55% [95% CI 1.06% to 2.16%]) were hospitalized within 30 days. One patient experienced bleeding following a colonoscopy that involved polypectomy and was diagnosed with carcinoma in situ of the rectum. Based on self-reported rectal bleeding in the previous six months, the colonoscopy was nonscreening. The provincial hospitalization data showed no occurrences of perforation, diverticulitis, myocardial infarction/stroke or death; thus, the rate of serious colonoscopy complications was 0.05% (95% CI 0.00% to 0.26%). DISCUSSION: The rate of serious colonoscopy complications requiring hospitalization was low and comparable with what is reported in the literature. The serious complication occurred subsequent to polypectomy and in a nonscreening colonoscopy. CONCLUSION: The findings support the relative safety of screening colonoscopy in persons without large bowel diseases and symptoms. However, future research to determine the rate of serious complications not requiring hospitalization is warranted to reassure decision makers of the safety of colonoscopy for colorectal cancer screening.

Report on the expert forum on using information technology to facilitate uptake and impact of colorectal cancer screening guidelines.

The present report summarizes the proceedings of the pan-Canadian Expert Forum on Using Information Technology to Facilitate Uptake and Impact of Colorectal Cancer Screening Guidelines, which was held in Montreal, Quebec, November 18 to 19, 2011. The meeting assembled a multidisciplinary group of family physicians, gastroenterologists, nurses, patients, foundation representatives, screening program administrators and researchers to discuss the development of a mechanism or strategy that would permit the collection of comparable data by all colorectal cancer (CRC) screening programs, which would not only support the needs of each program but also provide a national perspective. The overarching theme of the meeting was 'designing a national approach to computerized electronic data collection and dissemination for CRC screening that would improve knowledge transfer across the continuum of preventive health care'. The forum encouraged presentations on clinical, research and technical topics. The meeting fostered valuable cross-disciplinary communication and delivered the message that it is essential to develop a national health informatics approach for CRC screening data collection and dissemination to support provincial CRC screening programs.

Health Care Perspectives of Adult Patients with Lower Educational Attainment in Inflammatory Bowel Disease: A Qualitative Study.

Patients with lower educational attainment are underrepresented in inflammatory bowel disease (IBD) research. To increase our understanding of the health care perspectives of patients with less than a university degree, semi-structured interviews were conducted among 23 outpatients at the McGill University Health Centre IBD Centre (Montreal, Canada). Thematic analysis was used to analyze the qualitative data. Perspectives focused on communication with health care professionals, access to care, symptoms and treatment, and outside support. Access to an IBD specialist was the most important aspect of care. Good care, kind and receptive staff, and a lengthy delay to diagnosis were frequently reported experiences. IBD specialists, nurses, and family and friends were most helpful in managing disease. Physical and emotional symptoms, reduced social engagement, and medications were difficult aspects of living with IBD. An ideal IBD clinic would provide access to traditional and non-traditional services and assist with obtaining support to help patients engage in social activities, increase affordability of care, and maintain employment. Study findings may be helpful in designing equitable models of health care delivery.

Patient Experiences in the Management of Inflammatory Bowel Disease: A Qualitative Study.

Background: Inflammatory bowel disease (IBD) can lead to substantial impairments of quality-of-life. Clinical guidelines and quality indicators aid physicians in practice but may not reflect the perspectives and experiences of patients with IBD. To address this, the objectives of this study were to understand patient experiences with IBD care and to explore priorities. Methods: Based on a convenience sample of 36 participants, five focus groups were completed at four sites across Canada. Data were analyzed using a deductive thematic analysis approach to assess emergent themes and variability in participants' experiences. Results: Our results are organized by themes of structure, process and outcomes to illustrate common issues with respect to how care is organized in the healthcare system, how patients receive and experience care and how patients perceive the outcomes of their care. Our results frame a health systems quality approach that signal needed improvements in access to care, the need for innovation with respect to virtual medicine, the potential expansion of multidisciplinary team-based care and the importance of addressing the psychosocial dimensions for patients with IBD and their caregivers in order to better deliver patient-centred care. Conclusions: The issues identified have the potential to impact priority areas in the system, IBD care delivery, and how outcomes can be improved by focusing on 'lived experience' and patient-centred care. The differing values and perspectives of all those involved in caring for patients with IBD underscore the importance of good communication with patients, caregivers and family members, as well as staying responsive to evolving needs.

Accuracy of administrative claims data for polypectomy.

BACKGROUND: The frequency of polypectomy is an important indicator of quality assurance for population-based colorectal cancer screening programs. Although administrative databases of physician claims provide population-level data on the performance of polypectomy, the accuracy of the procedure codes has not been examined. We determined the level of agreement between physician claims for polypectomy and documentation of the procedure in endoscopy reports. METHODS: We conducted a retrospective cohort study involving patients aged 50-80 years who underwent colonoscopy at seven study sites in Montréal, Que., between January and March 2007. We obtained data on physician claims for polypectomy from the Régie de l'Assurance Maladie du Québec (RAMQ) database. We evaluated the accuracy of the RAMQ data against information in the endoscopy reports. RESULTS: We collected data on 689 patients who underwent colonoscopy during the study period. The sensitivity of physician claims for polypectomy in the administrative database was 84.7% (95% confidence interval [CI] 78.6%-89.4%), the specificity was 99.0% (95% CI 97.5%-99.6%), concordance was 95.1% (95% CI 93.1%-96.5%), and the kappa value was 0.87 (95% CI 0.83-0.91). INTERPRETATION: Despite providing a reasonably accurate estimate of the frequency of polypectomy, physician claims underestimated the number of procedures performed by more than 15%. Such differences could affect conclusions regarding quality assurance if used to evaluate population-based screening programs for colorectal cancer. Even when a high level of accuracy is anticipated, validating physician claims data from administrative databases is recommended.

A literature review of quality in lower gastrointestinal endoscopy from the patient perspective.

BACKGROUND: Given the limited state of health care resources, increased demand for colorectal cancer (CRC) screening raises concerns about the quality of endoscopy services. Little is known about quality in colonoscopy and endoscopy from the patient perspective. OBJECTIVE: To systematically review the literature on quality that is relevant to patients who require colonoscopy or endoscopy services. METHODS: A systematic PubMed search was performed on articles that were published between January 2000 and February 2011. Keywords included "colonoscopy" or "sigmoidoscopy" or "endoscopy" AND "quality"; "colonoscopy" or "sigmoidoscopy" or "endoscopy" AND "patient satisfaction" or "willingness to return". The included articles were qualitative and quantitative English language studies regarding aspects of colonoscopy and/or endoscopy services that were evaluated by patients in which data were collected within one year of the colonoscopy/endoscopy procedure. RESULTS: In total, 28 quantitative studies were identified, of which eight (28.6%) met the inclusion criteria (four cross-sectional, three prospective cohort and one single-blinded controlled study). Aspects of quality included comfort, management of pain and anxiety, endoscopy unit staff manner, skills and specialty, procedure and results discussion with the doctor, physical environment, wait times for the appointment and procedure, and discharge. Qualitative studies eliciting the patient perspective on what constituted quality in colonoscopy/endoscopy were not found. CONCLUSIONS: Factors related to comfort, staff, communication and the service environment were evaluated from the patient perspective using closed-ended questions that were designed by clinicians and researchers. Future research using qualitative methodology to elicit the patient perspective on quality in colonoscopy and/or endoscopy services is needed.

Mobile health technologies supporting colonoscopy preparation: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Mobile health (mHealth) technologies are innovative solutions for delivering instructions to patients preparing for colonoscopy. OBJECTIVE: To systematically review the literature evaluating the effectiveness of mHealth technologies supporting colonoscopy preparation on patient and clinical outcomes. METHODS: MEDLINE, EMBASE, CINAHL and CENTRAL were searched for randomized controlled trials (RCTs) that evaluated the effectiveness of mHealth technologies for colonoscopy preparation on patient and clinical outcomes. Two reviewers independently assessed study eligibility, extracted data, and appraised methodological quality using the Cochrane Risk-of-Bias tool. Data were pooled using random effects models and when heterogeneity, assessed using I2, was statistically significant, a qualitative synthesis of the data was performed. Publication bias was assessed using a funnel plot. RESULTS: Ten RCTs (3,383 participants) met inclusion criteria. MHealth interventions included smartphone apps, SMS text messages, videos, camera apps, and a social media app. Outcomes were bowel cleanliness quality, user satisfaction, colonoscopy quality indicators (cecal intubation time, withdrawal time, adenoma detection rate), adherence to diet, and cancellation/no-show rates. MHealth interventions were associated with better bowel cleanliness scores on the Boston Bowel Preparation Scale [standardized mean difference (SMD) 0.57, 95%CI 0.37-0.77, I2 = 60%, p = 0.08] and the Ottawa Bowel Preparation Scale [SMD -0.39, 95%CI -0.59-0.19, I2 = 45%, p = 0.16], but they were not associated with rates of willingness to repeat the colonoscopy using the same regimen [odds ratio (OR) 1.88, 95%CI 0.85-4.15, I2 = 48%, p = 0.12] or cancellations/no-shows [OR 0.96, 95%CI 0.68-1.35, I2 = 0%]. Most studies showed that adequate bowel preparation, user satisfaction and adherence to diet were better in the intervention groups compared to the control groups, while inconsistent findings were observed for the colonoscopy quality indicators. All trials were at high risk of bias for lack of participant blinding. Visual inspection of a funnel plot revealed publication bias. CONCLUSIONS: MHealth technologies show promise as a way to improve bowel cleanliness, but trials to date were of low methodological quality. High-quality research is required to understand the effectiveness of mHealth technologies on colonoscopy outcomes.

Comparing patient and endoscopist perceptions of the colonoscopy indication.

BACKGROUND: determining whether a colonoscopy is performed for screening or nonscreening purposes can facilitate clinical practice and research. However, there is no simple method to determine the colonoscopy indication using patient medical files or health administrative databases. OBJECTIVE: to determine patient-endoscopist agreement on the colonoscopy indication. METHODS: a cross-sectional study was conducted among staff endoscopists and their patients at seven university-affiliated hospitals in Montreal, Quebec. The study participants were 50 to 75 years of age, they were able to understand English or French, and were about to undergo colonoscopy. Self- (endoscopist) and interviewer-administered (patient) questionnaires ascertained information that permitted classification of the colonoscopy indication. Patient colonoscopy indication was defined as the following: perceived screening (routine screening, family history, age); perceived nonscreening (follow-up); medical history that implied nonscreening; and a combination of the three preceding indications. Agreement between patient and endoscopist indications was measured using concordance and Kappa statistic. RESULTS: in total, 702 patients and 38 endoscopists participated. The three most common reasons for undergoing colonoscopy were routine screening/regular check-up (33.8%), follow-up to a previous problem (30.2%) and other problem (24.6%). Concordance (range 0.79 to 0.85) and Kappa (range 0.58 to 0.70) were highest for perceived nonscreening colonoscopy. Recent large bowel symptoms accounted for 120 occurrences of disagreement in which the patient perceived a nonscreening colonoscopy while the endoscopist perceived a screening colonoscopy. CONCLUSIONS: patient self-report may be an acceptable means for rapidly assessing whether a colonoscopy is performed for screening or nonscreening purposes. Delivery of patient-centred care may help patients and endoscopists reach a shared understanding of the reason for colonoscopy.

Association between Smoking and 30-Day Outcomes in Otologic Surgery.

OBJECTIVE: To determine the effect of current smoking status on 30-day postoperative adverse events in patients undergoing otologic surgery. STUDY DESIGN: Retrospective cohort study. SETTING: Database of the American College of Surgeons National Surgical Quality Improvement Program from 2006 to 2016. SUBJECTS AND METHODS: Adult patients undergoing middle ear and mastoid surgery were included. Preoperative smoking status was determined, and adverse events within 30 days of surgery were recorded. Descriptive statistics were used to characterize the study sample. Multivariable logistic regression was performed to identify the association between sociodemographic and clinical variables and postoperative adverse events. Population-attributable fractions were then calculated. RESULTS: A total of 10,684 patients who underwent otologic surgery were included, of whom 2036 (19.1%) were smokers. The most commonly performed surgery was tympanoplasty with and without ossicular chain reconstruction, followed by canal wall up tympanomastoidectomy. Adverse events occurred in 221 (2.1%) patients; the most common was superficial wound infections (n = 99, 0.9%). In smokers, the odds ratio for any adverse event was 1.97 (95% CI, 1.42-2.71). The odds ratios (95% CIs) for superficial wound infections, wound dehiscence, and 30-day readmission among smokers were 1.89 (1.32-2.86), 3.92 (1.26-11.60), and 1.84 (1.15-2.87), respectively. The population-attributable fraction for any adverse event in smokers was 15.5%. CONCLUSIONS: In patients undergoing otologic surgery, smokers are more likely than nonsmokers to have postoperative adverse events-in particular, wound infections, wound dehiscence, and readmission to hospital.