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Colorectal Cancer Screening Quality and Efficiency

Key findings

Measure:  Perforation: number of outpatient colonoscopies followed by hospital admission for perforation within 7 days of colonoscopy per 1,000 colonoscopies

 

Desired Direction:

 

An image of an arrow pointing downwards. This indicates that desired direction for this action is downwards.

 

As of this Report:

 

An image of an arrow pointing straight in a green box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is exceeding or meeting target.

The rate of colonoscopy-related bowel perforation within 7 days of an outpatient diagnostic or therapeutic colonoscopy decreased annually from 2013 to 2016. In 2016, the rate was 0.37 per 1,000 colonoscopies, which is well below Cancer Care Ontario’s target of less than 1 perforation per 1,000 colonoscopies [1].

The rate of post-polypectomy bleeding within 14 days of an outpatient colonoscopy remained steady from 2013 to 2016. The rate in 2016 was 0.29 per 100 colonoscopies with polypectomy, which is well below Cancer Care Ontario’s target of less than 1 case of gastrointestinal bleeding per 100 colonoscopies with polypectomy [1].

In 2016, 9,254 Ontarians age 53 and older had a colonoscopy within 36 months of a previous outpatient colonoscopy that was normal and complete. These 9,254 colonoscopies represent 3.3% of the 283,382 outpatient colonoscopies performed in this age group in 2016. The percentage of colonoscopies performed within 36 months of a previous outpatient colonoscopy decreased annually from 2013 to 2016.

What is a colonoscopy?

  • A colonoscopy is an exam done by a doctor who looks at the lining of the rectum and colon using a long, flexible tube with a tiny camera on the end.
  • During a colonoscopy, the doctor can also take biopsies or perform a polypectomy to remove polyps (pre-cancerous lesions).
  • ColonCancerCheck (Ontario’s population-based colorectal cancer screening program) recommends that people at increased risk of colorectal (bowel) cancer due to family history in a first-degree relative (i.e., they have a parent, sibling or child who has been diagnosed with the disease) screen with colonoscopy beginning at age 50 or 10 years earlier than the age at which their relative was diagnosed, whichever occurs first [2]. Colonoscopy is also used as a diagnostic test for people with abnormal results on a fecal occult blood test (FOBT) (Ontario’s recommended average risk screening test) or symptoms of colorectal cancer, as well as for a number of other medical reasons.

[Efficiency to me means] optimal use of resources in order to deliver the right care in the right place at the right time.

Anonymous, Patient/Family Advisor

Figure 1. Number of outpatient colonoscopies followed by hospital admission for perforation within 7 days of procedure per 1,000 colonoscopies, 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, CIHI DAD/NACRS, RPDB

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Figure 2. Percentage of outpatient colonoscopies with polypectomy followed by hospital admission for gastrointestinal bleeding within 14 days of colonoscopy

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, CIHI DAD/NACRS, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

Figure 3. Percentage of Ontarians, 53 and older, who had a colonoscopy within 36 months of a previous normal and complete outpatient colonoscopy, by Local Health Integration Network (LHIN), 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, CIHI NACRS, OCR, RPDB, PCCF+ version 6D, OCCC

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Figure 4. Percentage of Ontarians, 53 and older, who had a colonoscopy within 36 months of a previous normal and complete outpatient colonoscopy, by age group, 2013 to 2016

More information regarding the methodology is available.

Report date: December 2017

Data source: OHIP CHDB, CIHI NACRS, OCR, RPDB, PCCF+ version 6D, OCCC

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Data Table 1. Number of outpatient colonoscopies followed by hospital admission for perforation within 7 days of procedure per 1,000 colonoscopies, 2013 to 2016

Region Rate per 1,000 in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate per 1,000 in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate per 1,000 in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate per 1,000 in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016
Ontario 0.5 221 439,497 0.44 0.57 0.42 187 446,526 0.36 0.48 0.40 187 465,485 0.34 0.46 0.37 175 470,461 0.32 0.43

Report date: December 2017

Data source: OHIP CHDB, CIHI DAD/NACRS, RPDB

Prepared by: Analytics, Cancer Screening,  P&CC

Note:

  1. Please refer to technical documentation.

Data Table 2. Percentage of outpatient colonoscopies with polypectomy followed by hospital admission for gastrointestinal bleeding within 14 days of colonoscopy

LHIN Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016
Ontario 0.4 446 128,798 0.31 0.38 0.32 447 139,232 0.29 0.35 0.31 487 154,951 0.29 0.34 0.29 485 166,565 0.27 0.32
Erie St. Clair 0.3 22 6,532 0.19 0.48 0.25 18 7,098 0.13 0.38 0.31 24 7,680 0.18 0.44 0.37 31 8,479 0.23 0.50
South West 0.6 43 7,857 0.38 0.72 0.57 50 8,721 0.41 0.74 0.43 42 9,742 0.30 0.57 0.41 43 10,458 0.28 0.54
Waterloo Wellington 0.3 20 7,177 0.15 0.41 0.28 23 8,115 0.16 0.41 0.28 24 8,717 0.16 0.39 0.15 14 9,131 0.07 0.24
Hmltn-Ngr-Hldmnd-Brnt 0.4 52 13,615 0.27 0.49 0.31 46 14,861 0.22 0.40 0.43 69 16,060 0.33 0.53 0.33 55 16,865 0.24 0.42
Central West 0.3 21 8,378 0.14 0.36 0.13 12 8,955 0.05 0.22 0.16 15 9,594 0.07 0.24 0.18 18 10,281 0.09 0.26
Mississauga Halton 0.3 30 11,292 0.17 0.37 0.30 38 12,624 0.20 0.40 0.15 21 14,186 0.08 0.21 0.26 39 15,241 0.17 0.34
Toronto Central 0.3 24 9,722 0.14 0.35 0.21 23 10,847 0.12 0.30 0.29 35 12,083 0.19 0.39 0.22 28 12,761 0.13 0.30
Central 0.3 48 17,074 0.20 0.36 0.30 54 17,920 0.22 0.38 0.33 65 19,890 0.24 0.41 0.25 56 22,438 0.18 0.32
Central East 0.3 44 14,288 0.21 0.40 0.36 56 15,642 0.26 0.45 0.38 65 16,962 0.29 0.48 0.31 54 17,684 0.22 0.39
South East 0.5 25 4,810 0.31 0.73 0.53 28 5,264 0.33 0.74 0.28 17 5,981 0.14 0.43 0.44 29 6,575 0.27 0.61
Champlain 0.3 40 12,571 0.22 0.42 0.28 37 13,280 0.19 0.37 0.28 47 16,880 0.20 0.36 0.30 56 18,492 0.22 0.38
North Simcoe Muskoka 0.3 20 6,020 0.18 0.49 0.32 20 6,192 0.17 0.47 0.29 20 6,814 0.16 0.43 0.31 21 6,829 0.17 0.45
North East 0.6 39 6,969 0.38 0.74 0.49 36 7,295 0.33 0.66 0.44 34 7,681 0.29 0.60 0.36 30 8,342 0.23 0.49
North West 0.7 18 2,493 0.37 1.07 0.25 6 2,418 0.03 0.47 0.34 9 2,681 0.10 0.57 0.37 11 2,989 0.13 0.60

Report date: December 2017

Data source: OHIP CHDB, CIHI DAD/NACRS, RPDB, PCCF+ version 6D

Prepared by: Analytics, Cancer Screening,  P&CC

    Data Table 3. Percentage of Ontarians, 53 and older, who had a colonoscopy within 36 months of a previous normal and complete outpatient colonoscopy, by Local Health Integration Network (LHIN), 2013 to 2016

    LHIN Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016
    Ontario 4.3 10,974 256,171 4.2 4.4 4.1 10,786 261,331 4.1 4.2 3.5 9,787 276,594 3.5 3.6 3.3 9,254 283,382 3.2 3.3
    Erie St. Clair 5.8 820 14,190 5.4 6.2 4.8 687 14,191 4.5 5.2 4.4 614 14,108 4.0 4.7 3.3 493 15,020 3.0 3.6
    South West 4.4 831 18,898 4.1 4.7 4.3 827 19,379 4.0 4.6 4.0 810 20,125 3.8 4.3 3.7 750 20,105 3.5 4.0
    Waterloo Wellington 2.8 332 11,772 2.5 3.1 2.6 316 12,387 2.3 2.8 2.1 278 13,238 1.9 2.3 1.9 261 13,579 1.7 2.2
    Hmltn-Ngr-Hldmnd-Brnt 3.8 1,121 29,119 3.6 4.1 4.4 1,334 30,142 4.2 4.7 3.7 1,146 31,308 3.5 3.9 3.7 1,207 32,251 3.5 4.0
    Central West 4.5 630 13,850 4.2 4.9 3.8 529 13,931 3.5 4.1 3.6 523 14,605 3.3 3.9 3.1 465 15,031 2.8 3.4
    Mississauga Halton 3.7 727 19,649 3.4 4.0 3.7 773 20,791 3.5 4.0 3.1 684 21,954 2.9 3.3 2.9 650 22,462 2.7 3.1
    Toronto Central 4.8 936 19,346 4.5 5.1 4.4 860 19,715 4.1 4.6 3.4 723 21,179 3.2 3.7 3.2 675 21,194 2.9 3.4
    Central 4.6 1,614 35,116 4.4 4.8 4.5 1,601 35,627 4.3 4.7 3.9 1,456 37,291 3.7 4.1 3.5 1,357 38,999 3.3 3.7
    Central East 4.3 1,321 30,496 4.1 4.6 4.1 1,271 30,867 3.9 4.3 3.7 1,185 32,185 3.5 3.9 3.4 1,109 32,923 3.2 3.6
    South East 4.3 444 10,285 3.9 4.7 4.7 502 10,602 4.3 5.1 3.9 437 11,233 3.5 4.3 3.7 436 11,889 3.3 4.0
    Champlain 3.7 864 23,085 3.5 4.0 3.4 825 23,929 3.2 3.7 2.9 792 27,713 2.7 3.1 2.8 773 27,816 2.6 3.0
    North Simcoe Muskoka 3.8 437 11,410 3.5 4.2 3.9 436 11,249 3.5 4.2 3.2 380 11,924 2.9 3.5 3.2 375 11,664 2.9 3.5
    North East 5.1 736 14,540 4.7 5.4 4.7 662 14,210 4.3 5.0 4.2 633 15,053 3.9 4.5 3.6 567 15,671 3.3 3.9
    North West 3.6 161 4,415 3.1 4.2 3.8 163 4,311 3.2 4.4 2.7 126 4,678 2.2 3.2 2.8 136 4,778 2.4 3.3

    Report date: December 2017

    Data source: OHIP CHDB, CIHI NACRS, OCR, RPDB, PCCF+ version 6D, OCCC

    Prepared by: Analytics, Cancer Screening,  P&CC

    Note:

    1. Please refer to technical documentation.

    Data Table 4. Percentage of Ontarians, 53 and older, who had a colonoscopy within 36 months of a previous normal and complete outpatient colonoscopy, by age group, 2013 to 2016

    Age group Rate (%) in 2013 Numerator in 2013 Denominator in 2013 Lower confidence interval in 2013 Upper confidence interval in 2013 Rate (%) in 2014 Numerator in 2014 Denominator in 2014 Lower confidence interval in 2014 Upper confidence interval in 2014 Rate (%) in 2015 Numerator in 2015 Denominator in 2015 Lower confidence interval in 2015 Upper confidence interval in 2015 Rate (%) in 2016 Numerator in 2016 Denominator in 2016 Lower confidence interval in 2016 Upper confidence interval in 2016 p-value
    Total 53+ 4.3 10,974 256,171 4.2 4.4 4.1 10,786 261,331 4.1 4.2 3.5 9,787 276,594 3.5 3.6 3.3 9,254 283,382 3.2 3.3
    53 to 54 3.4 840 24,534 3.2 3.7 3.6 875 24,272 3.4 3.8 3.1 817 26,296 2.9 3.3 3.0 759 25,390 2.8 3.2 Ref.
    55 to 59 3.6 2,163 59,339 3.5 3.8 3.5 2,150 60,821 3.4 3.7 3.0 1,951 64,062 2.9 3.2 2.8 1,825 64,804 2.7 2.9 0.161
    60 to 64 4.1 2,236 54,955 3.9 4.2 3.7 2,026 55,134 3.5 3.8 3.2 1,892 58,295 3.1 3.4 3.1 1,858 60,753 2.9 3.2 0.591
    65 to 69 4.3 2,113 48,650 4.2 4.5 4.3 2,190 50,843 4.1 4.5 3.6 1,938 54,137 3.4 3.7 3.3 1,840 55,999 3.1 3.4 0.026
    70 to 74 5.0 1,704 33,876 4.8 5.3 4.7 1,638 35,179 4.4 4.9 4.0 1,492 37,270 3.8 4.2 3.5 1,401 39,470 3.4 3.7 <0.001
    75+ 5.5 1,918 34,817 5.3 5.7 5.4 1,907 35,082 5.2 5.7 4.6 1,697 36,534 4.4 4.9 4.2 1,571 36,966 4.0 4.5 <0.001

    Report date: December 2017

    Data source: OHIP CHDB, CIHI NACRS, OCR, RPDB, PCCF+ version 6D, OCCC

    Prepared by: Analytics, Cancer Screening,  P&CC

    Note:

    1. Please refer to technical documentation.

    What do the results show?

    The number of colonoscopy-related bowel perforations in Ontario has decreased (Figure 1).

    Measure:  Post-polypectomy bleeding: percentage of outpatient colonoscopies with polypectomy followed by hospital admission for gastrointestinal bleeding within 14 days of colonoscopy

     

    Desired Direction:

     

    An image of an arrow pointing downwards. This indicates that desired direction for this action is downwards.

     

    As of this Report:

     

    An image of an arrow pointing straight in a grey box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action does not have identified targets.

    • The rate of people admitted to hospital with a perforation within 7 days of outpatient colonoscopy decreased annually from 2013 (0.50 per 1,000 colonoscopies) to 2016 (0.37 per 1,000 colonoscopies). This represents an overall improvement in performance for this indicator.
    • Ontario’s perforation rate was well under the target of less than 1 perforation per 1,000 colonoscopies.

    Hospital admissions for gastrointestinal bleeding within 14 days of outpatient colonoscopy with polypectomy have been steady in Ontario (Figure 2).

    • The Ontario rate of post-polypectomy bleeding remained steady from 2013 to 2016 at around 0.30%.
    • Ontario’s post-polypectomy bleeding rate was well under the target of less than 1 case of gastrointestinal bleeding per 100 colonoscopies with polypectomy.
    • The Waterloo Wellington Local Health Integration Network (LHIN) has the lowest rate of post-polypectomy bleeding (0.15%), while the South East LHIN had the highest (0.44%).

    A minority of Ontarians have a second colonoscopy within 36 months of a normal and complete outpatient colonoscopy, although there is notable regional variation (Figure 3).

    • The percentage of colonoscopies within 3 years of a normal and complete outpatient colonoscopy is an indicator that measures the appropriateness of colonoscopy and its potential overuse.
    • Ontario has improved relative to this indicator, with fewer Ontarians in 2016 having a second colonoscopy within 36 months of a normal and complete outpatient colonoscopy than they did in 2013 (3.3% vs 4.3%).
    • Almost all LHINs have improved against this indicator since 2015. The LHINs with the highest percentage of colonoscopies within 36 months of a normal and complete outpatient colonoscopy in 2016 were South West, Hamilton Niagara Haldimand Brant and South East (all at 3.7%).
    • The LHIN with the lowest percentage of colonoscopies within 36 months of a normal and complete outpatient colonoscopy was Waterloo Wellington (1.9%). 

    Measure:  Subsequent colonoscopy: percentage of Ontario men and women, age 53 and older, who had a colonoscopy within 36 months of a normal and complete outpatient colonoscopy

     

    Desired Direction:

     

    An image of an arrow pointing downwards. This indicates that desired direction for this action is downwards.

     

    As of this Report:

     

    An image of an arrow pointing downwards in a green box. This indicates that there has been an increase in performance over the previous years identified and this action is exceeding or meeting target.

    Colonoscopy within 36 months of a normal and complete outpatient colonoscopy varies by demographic factor (Figure 4).

    • The percentage of repeat colonoscopies within 36 months of a normal and complete outpatient colonoscopy has improved across all ages, but it remained the highest in the oldest age groups in 2016. It was 3.3% for people age 65 to 69, 3.5% for people age 70 to 74, and 4.2% for people over age 75.
    • Repeat colonoscopy within 3 years of a normal and complete colonoscopy may be necessary in older adults because the development of new symptoms is common in this population.
    • In 2016, a greater percentage of women than men had a colonoscopy within 36 months of a normal and complete outpatient colonoscopy (3.4% vs. 3.1%).

    Why is this important to Ontarians?

    • Ontario is performing well with respect to perforations (target of less than 1 perforation for 1,000 colonoscopies) and post-polypectomy gastrointestinal bleeding (target of less than 1 incident of bleeding per 100 colonoscopies) [1]. Close monitoring is warranted, however, given the potential serious risks associated with colonoscopy (perforations can lead to death in rare cases) [3].
    • The percentage of colonoscopies within 3 years of a normal and complete outpatient colonoscopy is an indicator that measures the appropriateness of colonoscopy and potential overuse, which may expose patients to needless risks. It is also an inappropriate use of healthcare resources. One potential reason for the overuse of colonoscopy is poor continuity of care.
    • A repeat colonoscopy within 3 years of a normal and complete colonoscopy may be necessary in specific circumstances (e.g., due to the development of a new symptom, such as weight loss or diarrhea). While these circumstances are more common in older adults, the population of interest for this analysis, it is anticipated that repeat colonoscopy should only occur in a minority of cases [4].

    Next steps

    • Minimizing harms to patients is an essential component of an organized screening program. Cancer Care Ontario will continue to monitor colonoscopy indicators, including rates of perforation, bleeding and repeat colonoscopies.
    • Since 2017, these indicators have been monitored annually at the facility and physician levels through the Quality Management Partnership to support quality improvement. The Quality Management Partnership is a partnership between Cancer Care Ontario and the College of Physicians and Surgeons of Ontario.
    • Cancer Care Ontario is also updating its post-polypectomy colonoscopy surveillance recommendations and educating physicians about appropriate colonoscopy intervals in patients who have previously had polyps removed.

    Notes

    1. Tinmouth J, Kennedy E, Baron D, Burke M, Feinberg S, Gould M, et al. Guideline for colonoscopy quality assurance in Ontario. Toronto: Cancer Care Ontario; 2013.
    2. Cancer Care Ontario [Internet]. Toronto: Cancer Care Ontario. ColonCancerCheck: Colorectal Screening Program; 2015 July 16 [cited 2018 Mar 26]. Available from: here.
    3. Rabeneck L, Paszat LF, Hilsden RJ, Saskin R, Leddin D, Grunfeld E, et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology. 2008;135:1899–1906.
    4. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology [Internet]. 2012 Sep;143(3):844–857.