European panel on the appropriateness of gastrointestinal endoscopy II guidelines help in selecting and prioritizing patients referred to colonoscopy – a quality control study

Abstract

Objective. To use information from the referral letters to assess the appropriateness of colonoscopies in a primary open-access referral center, according to the criteria from the European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) II, and to compare with the first EPAGE guidelines. Second, to evaluate how the appropriateness and other patient- or doctor-related factors affected the diagnostic yield (DY). Material and methods. A set of variables; symptoms, referring physician and final diagnosis, for 323 referrals accepted for colonoscopy were recorded prospectively and later on assessed using the EPAGE and EPAGE II criteria, respectively. Patients with incomplete visualization of the entire colon or colonoscopic findings as indication were excluded. Results. EPAGE and EPAGE II criteria were applicable in 287 (95.3%) and 295 (98.0%) referrals, respectively. A total of 166 (57.8%) patients were considered appropriate by EPAGE and 240 (81.4%) patients were considered appropriate by EPAGE II. DY for appropriate versus uncertain/inappropriate referrals was 34.9% versus 17.4% for EPAGE (odds ratio [OR] = 2.5, 95% confidence interval [CI]: 1.8–4.4, p = 0.003) and 31.3% versus 10.9% for EPAGE II (OR = 3.5, 95% CI: 1.4–8.9, p = 0.007). Sensitivity was higher for EPAGE II (92.6% vs. 73.4%). According to EPAGE II, 68 (23.1%) patients were referred due to lesions identified on other diagnostic procedures, producing a DY of 39.7%. In this group, 70% presented symptoms appropriate for a primary referral to colonoscopy. Conclusions. The majority of colonoscopies were found appropriate by EPAGE II. There was a clear association between high appropriateness of the indication and a high DY. EPAGE II is a guideline-improvement that may be useful for both referring physicians and gastroenterologists when considering referrals.

Key Words::

• appropriateness
• colonoscopy
• diagnostic yield
• European Panel on the Appropriateness of Gastrointestinal Endoscopy
• European Panel on the Appropriateness of Gastrointestinal Endoscopy II

Declaration of interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work. Funding: E Dalén og S L Eskeland have received research grants from South-Eastern Norway Regional Health Authority.

Data sharing: Full dataset and statistical code are available from the corresponding author. All authors have approved the final version of the article and take full responsibility for the integrity of the data and the accuracy of the data analysis.