Primary care physicians have a responsibility to choose the best possible colonoscopy services when referring patients to a subspecialist, according to a consensus statement(www.springerlink.com) from the National Colorectal Cancer Roundtable.
The consensus statement, which recently was published in the Journal of General Internal Medicine, was drafted by the roundtable's Quality Assurance Task Force. Family physicians John Pope, M.D., of Shreveport, La., and Michael Potter, M.D., of San Francisco, are members of the task force.
"The idea is that if you're a primary care doctor and you want a patient to get a colonoscopy, you need to send them to someone who will do a good job," said Potter, who is a professor in the department of family and community medicine at the University of California, San Francisco, School of Medicine. "It's an attempt to acquaint primary care doctors with the key elements of high-quality colonoscopy and what key information should be documented on the colonoscopy report."
The consensus statement says that quality is not measured by training, specialty or experience alone. Instead, referrals should be based on actual performance, and the document outlines quality measures for the endoscopist's report, technical competence and the need for a safe setting for the procedure.
In 2007, the Quality Assurance Task Force published a standardized reporting system(www.giejournal.org) that specifies the elements that should be included in colonoscopy reports, as well as a standard method for reporting those elements. The new consensus statement reiterates the importance of the endoscopist reporting back to the primary care physician and covering the following key elements:
- depth of insertion;
- quality of bowel preparation;
- patient tolerance of procedure;
- description of polyps -- including number, size, location, morphology and histology of adenomas -- and whether they were removed or biopsied;
- pathology results from biopsies; and
- clear recommendations for follow-up and/or surveillance, including an explanation if the recommended time interval for repeated colonoscopy differs from national guidelines.
The consensus statement also says that reports should include recommendations for colorectal cancer screening in family members when appropriate. For example, for patients who are diagnosed with cancer or advanced adenoma at a young age, guideline-appropriate recommendations for follow-up of family members should be included in the report. Both endoscopists and primary care physicians should encourage patients to notify family members if they are at increased risk.
"Primary care doctors need to start holding the colonoscopist accountable for reporting procedure results and follow-up plans based on final pathology results and evidence-based guidelines," Potter told AAFP News Now. "We want to close the communication loop to be sure that patients receive maximal benefit from having had the procedure. Both patients and their referring clinicians need to have this information."
The consensus statement acknowledges that many primary care physicians perform colonoscopies, and Potter said they also should follow these standards for reporting.
"Documentation of procedure quality and follow-up will be needed to plan future care whether or not the person performing the endoscopy is also the patient's primary care physician," he said. "Therefore, primary care endoscopists should follow the same procedure reporting standards as anyone else."
The statement also outlines quality measures for cecal intubation rate (90 percent or higher is the recommended target) and adenoma detection rate. Based on known prevalence of adenomas by age and gender, among adults ages 50 and older, initial screening examinations should detect adenomas in 15 percent of women and 25 percent of men.
Finally, the document outlines characteristics of a safe setting, including adequate cleaning and disinfection of equipment, well-maintained equipment, well-trained endoscopist and staff, and the ability to react to emergencies during a procedure.
"With a better understanding of quality standards for colonoscopy," the consensus statement says, "primary care clinicians can be better advocates for their patients."