Impact of Community Referral on Colonoscopy Quality Metrics in a Veterans Affairs Medical Center.

INTRODUCTION: The Veterans Access, Choice, and Accountability Act of 2014 expands the number of options veterans have to ensure timely access to high-quality care. There are minimal data currently available analyzing the impact and quality of colonoscopy metrics in veterans receiving procedures within the Department of Veterans' Affairs (VA) vs community settings. METHODS: All patients at our academic VA medical center who were referred to a community care colonoscopy (CCC) for positive fecal immunochemical testing, colorectal cancer screening, and adenoma surveillance from 2015 to 2018 were identified and matched for sex, age, and year of procedure to patients referred for a VA-based colonoscopy (VAC). Metrics measured included time to procedure measured in days, adenoma detection rate (ADR), advanced ADR (AADR), adenomas per colonoscopy, sessile serrated polyp detection rate, cecal intubation rate, bowel preparation quality, and compliance with guideline recommendations for surveillance. Patient comorbidities were also recorded. Variable associations with adenoma detection and compliance with surveillance guidelines were analyzed with univariate and multivariate logistic regression. RESULTS: In total, 235 veterans (mean age, 64.6 years, and 95.7% male) underwent a CCC and had an appropriately matched VAC. ADR in the community was 36.9% compared with 62.6% for the VAC group (P < 0.0001). The mean number of adenomas per procedure in the community was 0.77 compared with 1.83 per VAC (P < 0.0001). CCC AADR was 8.9% compared with 18.3% for VAC (P = 0.003). The cecal intubation rate for community colonoscopies was 90.6% compared with 95.3% for VA colonoscopies (P = 0.047). Community care compliance with surveillance guidelines was 74.9% compared with 93.3% for VA (P < 0.0001). This nonconformity was primarily due to recommending a shorter interval follow-up in the CCC group (15.3%) compared with the VAC group (5.5%) (P = 0.0012). The mean time to procedure was 58.4 days (±33.7) for CCC compared with 83.8 days (±38.6) for VAC (P < 0.0001). In multivariate regression, CCC was associated with lower ADR (odds ratio 0.39; 95% confidence interval, 0.20-0.63) and lower compliance with surveillance guidelines (odds ratio 0.21; 95% confidence interval, 0.09-0.45) (P < 0.0001 for both). DISCUSSION: Time to colonoscopy was significantly shorter for CCC compared with VAC. However, compared with VA colonoscopies, there was significantly lower ADR, AADR, and surveillance guideline compliance for services rendered by community providers. This impact on quality of care should be further studied to ensure that colonoscopy quality standards for veterans are not compromised by the process of care and site of care.

PNPLA3 polymorphism increases risk for and severity of chronic hepatitis C liver disease.

AIM: To examine the association of PNPLA3 polymorphisms in chronic hepatitis C patients and development of liver disease spectrum. METHODS: Literature was searched systematically from PubMed/MEDLINE, EMBASE, and Cochrane search engines for full-length articles written in English that examined PNPLA3 polymorphism in chronic hepatitis C (CHC) patients. Studies evaluating the association of PNPLA3 polymorphism spectrum (fatty liver, steatohepatitis, cirrhosis, and hepatocellular carcinoma) of CHC were included. Pooled data are reported as OR with 95%CI. Our study endpoint was the risk of the entire liver disease spectrum including: Steatosis/fatty liver, cirrhosis, and hepatocellular carcinoma in CHC patients with PNPLA3 polymorphisms. RESULTS: Of 380 studies identified, a total of 53 studies were included for full-text review. Nineteen on chronic hepatitis C were eligible for analysis. Pooled ORs for rs738409 GG compared to CC and CG among patients with fatty liver was 2.214 (95%CI: 1.719-2.853). ORs among advanced fibrosis/cirrhosis were 1.762 (95%CI: 1.258-2.468). Similar odds ratios among hepatocellular carcinoma patients were 2.002 (95%CI: 1.519-2.639). Pooled ORs for rs738409 GG and CG compared to CC among patients with fatty liver were 1.750 (95%CI: 1.542-1.986). Pooled ORs for advanced fibrosis/cirrhosis patients were 1.613 (95%CI: 1.211-2.147). All analyses were homogenous and without publication bias except one. The associations were maintained after adjusting for publication bias and heterogeneity. CONCLUSION: PNPLA3 polymorphisms have strong association with increased risk and severity of the liver disease spectrum in CHC patients.