Adherence to Post-polypectomy Guidelines: Just One Piece of an Important Puzzle

Adherence to post-polypectomy surveillance guidelines not only is an essential element of high-quality colorectal cancer (CRC) prevention programs, but also offers novel and important areas for further investigation. The growing emergence of accountable care organizations (ACOs), which care for individuals using finite resources, further emphasizes the importance of adherence to surveillance guidelines, which aim to prevent the development of advanced adenomas and CRC, while limiting unnecessary risk from exposure to too frequent procedures. Furthermore, overuse of surveillance colonoscopy services adversely impacts the capacity to perform colonoscopies, increasing the opportunity cost for those who require initial screening colonoscopy. The importance of appropriate use of surveillance colonoscopy is highlighted by the development, endorsement, and inclusion of Quality Measure #185 (Endoscopy/ Polyp Surveillance: Colonoscopy Interval for Patients with History of Adenomatous Polyps—Avoidance of Inappropriate Use) in Medicare’s Physician Quality Reporting System [1], a ‘‘pay-for-reporting’’ program that provides incentives and payment adjustments for satisfactorily reporting quality measures. Under this program, physicians who do not satisfactorily report surveillance colonoscopy data during the 2015 performance year will receive a financial penalty of -2.0 % in 2017 [1]. The existing literature has robustly documented the underuse and overuse of surveillance colonoscopy among different populations within and outside the USA [2, 3]. Several studies have identified predictors of physicians’ non-adherence to guideline recommendations. With regard to the timing of subsequent surveillance colonoscopy, Saini et al. [4] reported that the lack of knowledge of specific surveillance intervals stated in the guidelines and disagreement with the guidelines was associated with guideline-discordant recommendations. Iskandar et al. [5] identified that physicians who were trained before 1990, were currently in training, performed a low volume of colonoscopies, or practiced at a non-academic center were more likely to make guideline-discordant recommendations. Both studies surveyed guideline knowledge eliciting recommendations based on hypothetical scenarios, but did explore the relationship between survey responses and actual clinical practice. In this issue of Digestive Diseases and Sciences, Patel et al. [6] used a combination of methods to address reasons for physicians’ deviation from post-polypectomy surveillance colonoscopy guidelines. The study included an online survey of gastroenterologists and trainees within a single university system. They also analyzed a chart review of 600 patients under the supervision of the surveyed gastroenterologists, seeking to delineate the predictors of guideline concordance and guideline discordance. Among the analyzed patients, the overall rate of guideline-appropriate recommendations was 85 %; 13 % of patients were recommended a shorter surveillance interval than indicated by guidelines, and only 3 % of the patients were recommended a longer surveillance interval than indicated by guidelines. Guideline knowledge and trainee status were associated with superior guideline adherence, with trainees 2.5-fold more likely to adhere with guidelines, in contrast to the findings of Iskandar et al. [5]. Conversely, uncertainty among physicians regarding the aggressiveness of & Audrey H. Calderwood audrey.calderwood@bmc.org