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Gaps and Improvement Opportunities in Post-colonoscopy Communication

2023; Elsevier BV; Volume: 26; Issue: 1 Linguagem: Inglês

10.1016/j.tige.2023.10.001

2666-5107

Paolo R. Ramirez, Andrew A. Pineda, Andrew W. Schultz, Michael Mayo Smith, Audrey H. Calderwood,

Esophageal Cancer Research and Treatment

Written colonoscopy reports provide important continuity of care regarding future screening/surveillance, which is particularly important when an individualized approach is being communicated (eg, in older adults and patients with polyps).1US Preventive Services Task ForceJ Am Med Assoc. 2021; 325: 1965-1977Crossref PubMed Scopus (612) Google Scholar,2Robertson DJ et al.Am J Gastroenterol. 2002; 97: 2651-2656Crossref PubMed Google Scholar Despite gastroenterology subspecialty guidance that emphasizes the importance of standardized colonoscopy reporting systems and includes the necessary elements for a high-quality report,3Bretthauer M et al.United European Gastroenterol J. 2016; 4: 172-176Crossref PubMed Scopus (37) Google Scholar,4Lieberman D et al.Gastrointest Endosc. 2007; 65: 757-766Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar there is variation in the clarity and content of endoscopist post-colonoscopy communication.5Coburn E et al.Tech Innov Gastrointest Endosc. 2023; 25: 30-38Abstract Full Text Full Text PDF Scopus (1) Google Scholar,6Sharma RS Rossos PG Can J Gastroenterol Hepatol. 2016; 20169423142Crossref Scopus (11) Google Scholar The aim of this study was to understand how primary care providers (PCPs) perceive written post-colonoscopy communication toward a broader goal of improvement. We developed an interview guide regarding the timing and methods of receiving reports, key content, format, amount of information, and suggestions for improvement, informed by previous work.5Coburn E et al.Tech Innov Gastrointest Endosc. 2023; 25: 30-38Abstract Full Text Full Text PDF Scopus (1) Google Scholar,7Restall G et al.BMC Health Serv Res. 2018; 18: 782Crossref PubMed Scopus (7) Google Scholar Two primary investigators (P.R.R. and A.H.C.) reviewed the draft guide, which was tested during a mock interview (M.M.S.) and further modified until finalized (Appendix). Our target audience was PCPs affiliated with an academic medical system, Dartmouth Health and the Dartmouth Practice-Based Research Network in New Hampshire and Vermont, who care for adults including those >70 years old and receive colonoscopy reports. We invited them to participate in a one-time individual 30-minute virtual interview that was audio-recorded. The de-identified interviews were then transcribed. Three authors (P.R.R., A.A.P., A.W.S.) developed the codebook using an inductive (grounded theory) approach.8Corbin J Strauss A Basics of qualitative research: techniques and procedures for developing grounded theory. SAGE, Thousand Oaks, California2008Crossref Google Scholar Coding changes were tracked with discussion of disagreements that were resolved through consensus. P.R.R., A.A.P., and A.W.S. then grouped the codes into themes and discussed these with A.H.C. and M.M.S. to reach congruency. Descriptive statistics summarize the characteristics of the study participants. The study was reviewed by the Dartmouth-Hitchcock Institutional Review Board and deemed exempt. From August to November 2020, we conducted interviews with 10 PCPs: 5 (50%) were female, 6 (60%) practiced in the academic medical center and 4 (40%) in the Practice-Based Research Network, 9 (90%) were medical doctors, and 1 (10%) was an advanced associate provider. Table 1 summarizes the identified subthemes and provides illustrative quotes. A key theme was the difficulty PCPs had in receiving colonoscopy reports, especially pathology results. Communications came through many different routes, including electronic health record (EHR), mail, fax, or a mixed approach or were never received at all. Important pathology information was often missing, which led to confusion regarding what the final recommendation was.Table 1Primary Care Provider Perspectives on Receipt and Review of Written Colonoscopy ReportsDomainThemeIllustrative quoteReceipt of reportMultiple ways, not standardizedI get the results two ways – via the electronic portal, EPIC and the other by mail.I'm getting them in a variety of ways. I'm now getting the actual colonoscopy report as a communication. Not as a result. Then from there I have to look up pathology see if it's back and then I have to look under letters to see what the gastroenterologist recommended to the patients so it is cumbersome.It's not always clear to me how that documentation comes up because sometimes it's sent through letter format and CC'ed to me, sometimes it's a note or telephone call from the GI clinic, and that I have to look for the telephone call so it's just not very standardized.Too many results overallI get inundated with results. I get the mail for the same patient, like there's a lot of waste of paper.There's too many automated notifications of totally irrelevant stuff.Review of report contentSkipping informationI don't look at the procedures. I don't look at the pictures. The first part is not really important to me.I honestly skip through the peri-op note, the procedural note. And just scroll down to what is important to me which is the result of the colo.I skip through all that stuff about the anesthesia and sedation and just go to the impression and recommendations usually.Focus on impression and next intervalI honestly cut right to the chase and go right down to the impression.I will usually probably jump to impression first and then maybe scan the procedure afterwardsAll I care about is when is the repeat screening interval.So the way I approach it is one just to look at the interval and see if that's 3 years 5 years 10 years and then sometimes there's a comment about whether someone should continue surveillance given their age.Pathology report missingSometimes I don't receive the path report and maybe they just forgot to CC me.I was keeping a log of all my colonoscopy reports because I often was not getting the follow-up pathology or I had to call for it.I think the biggest problem is when the note is written before the pathology (“okay I think somebody should come back in five years pending pathology”) and then they don't go back and addend it.TerminologyIn the letter itself it's in lay language it says benign polyps and I don't know exactly what they mean by that or precancerous so I have to go looking for the pathology myself.Improving communicationConsolidationGet everything in one piece, the colonoscopy results the path and the recommendation so they're not three different places and that I would have it in a medical language not lay language.If there could be a single communication to the PCP or CC note to the PCP about the biopsy results, the surveillance interval, that would be better than 2 separate notes.I wish that you know the pathology, you know there would be some way to link the report to the Pathology.Updating health maintenance tabI'm going into care gaps to say like okay now we're going to change the surveillance to like 5 years or 7 years or whatever it is and so if I mean what would be easiest is if I knew that the GI clinic was adjusting those. Open table in a new tab Another key theme was reports having excessive, unnecessary information and lack of a standard format, making locating key recommendations difficult. PCPs mentioned skipping unnecessary information (eg, technical aspects, images), focusing solely on the impression and follow-up recommendation. Many reported missing results as well as too much information and occasional irrelevant information. Suggestions for changes to improve communication addressed both the colonoscopy report content and process of communication delivery. PCPs suggested standardization and consolidation of results before they are sent to them, with prioritization of the impression and recommendations at the top of the report. They also suggested sending the report by a consistent and established route. PCPs also wanted endoscopists working within their shared EHR to update the EHR health maintenance recommendation to reflect the next interval or whether the patient could stop exams. All of the themes and suggestions for improvements applied to colonoscopy reports in general and were not limited to those for older adults. Guidance on colonoscopy reports has focused mostly on comprehensive documentation as a quality measure4Lieberman D et al.Gastrointest Endosc. 2007; 65: 757-766Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar and has not addressed prioritization of information presentation, practical integration of pathology results, or method of communicating to referring providers. This guidance, developed by endoscopy societies3Bretthauer M et al.United European Gastroenterol J. 2016; 4: 172-176Crossref PubMed Scopus (37) Google Scholar,4Lieberman D et al.Gastrointest Endosc. 2007; 65: 757-766Abstract Full Text Full Text PDF PubMed Scopus (253) Google Scholar did not account for other relevant stakeholders, such as PCPs or patients.6Sharma RS Rossos PG Can J Gastroenterol Hepatol. 2016; 20169423142Crossref Scopus (11) Google Scholar Our finding regarding PCPs not receiving all or parts of reports is validated by a previous study that included surveys of 16 PCPs from a Canadian province and concluded that a centralized intake system could improve communication.7Restall G et al.BMC Health Serv Res. 2018; 18: 782Crossref PubMed Scopus (7) Google Scholar Although this may be applicable in countries with single or integrated health systems or centralized colorectal cancer screening programs,3Bretthauer M et al.United European Gastroenterol J. 2016; 4: 172-176Crossref PubMed Scopus (37) Google Scholar it would not be readily feasible in the current US health care system. What can endoscopists do to improve post-colonoscopy communication? They can work with their referring PCPs as a team to advocate for system-level changes and leveraging of existing information technology to develop better communication pathways. Artificial intelligence may have an important role in integrating pathology results with colonoscopy reports and generating patient follow-up letters in a more efficient and complete way. Until EHR health maintenance intervals can be automatically populated on the basis of the colonoscopy and pathology results,9Ahmad NA Mehta SJ Clin Gastroenterol Hepatol. 2022; 20 (e1): 252-255Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar endoscopy practices should set clear expectations for who is responsible for updating that field and could leverage their administrative staff for these tasks. Presenting the colonoscopy impression and recommendations at the top of the report would be in line with some current outpatient clinics that prioritize the assessment and plan at the top of their notes and could be automated on transfer from the endoscopy reporting system to the EHR. Reducing the time and effort PCPs spend finding required information and recommendations and also their understanding of next steps for patients would decrease their administrative burdens, a major concern in primary care.10Dymek C et al.J Am Med Inform Assoc. 2021; 28: 1057-1061Crossref PubMed Scopus (24) Google Scholar Of note, PCPs have reported changing their referral patterns to exclusively send patients needing colonoscopy to endoscopists whose reports they receive in a timely way.7Restall G et al.BMC Health Serv Res. 2018; 18: 782Crossref PubMed Scopus (7) Google Scholar To our knowledge, this is the first study to focus on post-colonoscopy communication with PCPs in the United States. Our findings could also be relevant to the broader field of endoscopy, including areas such as upper endoscopy for Barrett's esophagus surveillance, for example. Limitations include the small sample of PCPs who practice in one US geographic region, limiting generalizability; however, the issues they identified are likely relevant to different systems and may be further amplified among endoscopy practices serving many different referring providers in separate systems or potentially diminished in integrated care systems such as Kaiser Permanente or the Veterans Administration. We focused this study on PCP perspectives but recognize that there are other important stakeholders, including patients and families. In summary, our interviews of PCPs identified multiple difficulties with current processes for communicating results and recommendations from screening colonoscopies. It behooves endoscopists to work with their PCP partners to think about ways to consolidate colonoscopy information and include the pathology in one summary and deliver in a consistent, streamlined reliable manner. This could reduce the risk for missed or delayed care. Future work should include development of consolidated reports with integrated pathology to test if this improves inter-specialty post-colonoscopy communication. Download .docx (.02 MB) Help with docx files