Recall Systems for Surveillance Colonoscopy: Safe Patient Care or Unnecessary and Hazardous?
Spencer D. Dorn, MD, MPH Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill |
Surveillance colonoscopy is a cost-effective means for reducing cancer mortality, but only if it is performed at recommended intervals.1 Underuse leaves our patients at increased risk for colorectal cancer. Overly aggressive use generates unjustifiable costs and likely exposes our patients to unnecessary risk.1
Payors have begun to focus on curtailing overuse of this costly procedure. In January 2011, the National Quality Forum (NQF) endorsed measure #0659, which calculates the percentage of patients receiving a surveillance colonoscopy with a history of a prior colonic polyp who had a follow-up interval of three or more years (www.qualityforum.org). The NQF imprimatur virtually ensures that the measure will be widely adopted by pay-for-performance programs, including Medicare’s Physician Quality Reporting System. In the foreseeable future, this sort of carrot will be swapped out for a stick; payors will stop reimbursing for surveillance exams that cannot be justified.
To ensure that patients are appropriately examined based on prior colonoscopy results, most community and some academic gastroenterology practices now employ patient recall systems. In brief, after the colonoscopy is performed (and sometimes after the histopathology results are obtained), the recommended time for follow-up colonoscopy is entered into a computer-based recall system or electronic medical record (EMR). Just before this specified time elapses, an electronic recall is generated, thereby triggering a series of events designed to schedule the patient for a repeat exam. These systems effectively combat underuse. A recall system developed at Beth Israel Deaconess Medical Center increased surveillance rates from 23 to 45 percent.2 In community-based practices, these systems perform considerably higher.3
Sound great? Yes, but of course the devil is in the details. First, the patient should be recalled at the appropriate time. Gastroenterologists tend to recommend follow-up in excess of guidelines,4 especially for patients with hyperplastic polyps and single, small adenomas. Second, events that occur during the follow-up interval may affect the optimal recall time. Some patients will undergo an interval colonoscopy (e.g., for hematochezia) while others may become ill to the point that surveillance is no longer safe or recommended. Likewise, new scientific evidence may emerge and lead to revised guidelines. Third, it is not clear whether recall systems should remind patients or their physicians. Directly reminding individual patients best ensures that they get the message and, in theory, keeps patients in charge of their own health care. But this strategy may lead to overuse (e.g., by patients with poor health status) and underuse (e.g., by patients who don’t understand the recall notification or the importance of a repeat procedure). Conversely, recall reminders may target physicians, but which ones? Primary care physicians provide longitudinal care and may be best suited to determine the appropriateness of the repeat procedure and discuss the risks and benefits with their patients. Gastroenterologists who actually perform the procedures may be better able to handle procedure-related complexities, but may be unaware of other relevant patient-related details.
- Follow-up intervals should be determined immediately following the procedure and then confirmed or modified after pathology results are known. Here, standardized decision-support prompts (such as computer-generated pop-ups) can optimize decision making.6
- Recall times should be communicated back to the primary care physician so that s/he can update the patient’s file in their own EMR.
- Recall systems must be flexible enough to allow changes in recall date, for instance, due to an interval procedure or a change in surveillance guidelines. The latter would require a reason for recall (e.g., advanced adenoma) be entered into the system as structured, queryable data.
- When it is time for the repeat procedure, the patient’s primary care physician should be notified before the patient is contacted so that the reminder can be altered, if necessary.3 Likewise, patients should be instructed to discuss any questions with their primary care physician or gastroenterologist.
A properly designed and implemented recall system can help ensure that we are appropriately utilizing surveillance colonoscopy. The next step (and topic for another discussion) will be to demonstrate the value of these procedures by tracking results, perhaps using a data registry.
Dr. Dorn is a member of the AGA Clinical Practice & Quality Management Committee as well as an executive board member of the AGA Center for GI Innovation and Technology.
References
1. Saini SD, Schoenfeld P, Vijan S. Surveillance colonoscopy is cost-effective for patients with adenomas who are at high risk of colorectal cancer. Gastroenterology 2010;138:2292-9, 2299 e1.
2. Leffler DA, Neeman N, Rabb JM, Shin JY, Landon BE, Pallav K, Falchuk ZM, Aronson MD. An alerting system improves adherence to follow-up recommendations from colonoscopy examinations. Gastroenterology 2011;140:1166-1173 e1-3.
3. Allen JI. Baby-epsilon steps toward the triple aim. Gastroenterology 2011;140:1129-31.
4. Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004;141:264-71.
5. Berwick DM. A primer on leading the improvement of systems. Bmj 1996;312:619-22.
6. Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. Br Med J 1998;280:1339-46.
