Reducing cancer disparities: Incident cancer after colonoscopies by primary care

描述(由申请者提供)：该项目在南卡罗来纳州培训和利用初级保健医生(PCP)进行结肠镜筛查的创新计划下，探索了关于初级保健医生(PCP)进行结肠镜检查的质量和结直肠癌(CRC)保护效果的关键知识缺口。该计划使用独特的临床方案，具有内置的质量保障措施，以弥补PCP缺乏正式的胃肠病学培训。先前NCI资助的一项研究记录了PCP结肠镜检查的高质量和患者安全性，为在结构化环境下进行PCP结肠镜检查的临床有效性提供了证据基础。同一项研究还发现，与未受过培训的PCP相比，接受过培训的AA PCP患者的结肠镜检查率显著更高，这是由于AA患者，尤其是AA男性患者的急剧增加所致。尽管前景看好，但在这一创新计划扩大到扩大AAS的结肠镜检查途径之前，仍有一些问题需要解决。问题是：a)PCP的腺瘤/癌症产率和手术性能指标是否与在相同临床环境下进行结肠镜检查并筛查来自相同人群的患者的专科医生相匹配？这项研究的目的将阐明PCP结肠镜检查的表现质量，说明由于未观察到的人群相关变量而可能造成的混杂。B)初级保健医生是否与为相同人群服务的专科医生提供类似的CRC保护率，以及PCP队列保护率是否与随机临床试验中发现的CRC保护率相比较好？这项研究将使用54名初级保健医生对13,688例结肠镜检查的数据和5名专家对5031例结肠镜检查的数据来调查这些问题。为了检测性能质量和病例产出率的差异，我们将比较PCP手术和专家手术在以下指标上的差异：a)息肉检测率和每个患者平均检测到的息肉，b)每个患者的腺瘤检测率和平均腺瘤，c)先进的腺瘤检测率和每个患者的平均腺瘤，d)癌症检测率，e)检测到的腺瘤的位置-右侧、左侧和盲肠腺瘤，f)当没有发现息肉和当发现息肉(S)时，结肠镜插入和退出时间，g)盲肠插管率，h)不完全结肠镜检查的原因(没有达到盲肠插管)，I)由于操作不满意而再次进行结肠镜检查，以及j)上述所有指标均按PCP的培训状态和操作量进行分类。为了达到研究目标2，我们将评估PCP和专家服务的队列中发生癌症的数量和类型(13,688名PCP结肠镜检查的65,685人年(PYO)和5031名专科结肠镜检查的34,255人年PYO)。我们将从南卡罗来纳州中央癌症登记处(SCCCR)获得癌症数据，并从SC生命统计登记处获得死亡数据。我们将根据文献记载的算法(Pabby等人)将发生的癌症按可能原因分类为4类：漏诊癌、新癌、不完全切除、活检检测失败和不完全结肠镜检查。 公共卫生相关性：该项目探索了南卡罗来纳州初级保健医生(PCP)根据一项创新计划(具有内置的质量保证机制以弥补初级保健医生缺乏正规胃肠病培训)进行结肠镜检查的性能、质量和结直肠癌(CRC)保护效果方面的关键知识差距。这项研究将探索：a)癌前病变腺瘤和癌症的PCP结肠镜检查队列比率和其他质量指标是否与在相同临床环境和人群中进行的专家队列检查的比率相当，以及b)PCP结肠镜检查是否为专科医生的患者提供类似的CRC保护，并与随机临床试验中记录的比率相同。它将使用结肠镜检查和癌症登记数据，这些数据与13,688次PCP结肠镜检查后65,685人年(PYO)和5031名专家进行结肠镜检查后34,255人年(PYO)的随访有关。

DESCRIPTION (provided by applicant): This project explores a key knowledge gap regarding the quality and colorectal cancer (CRC) protection effect of primary care physician (PCP)-performed colonoscopies under a innovative program in South Carolina that trains and utilizes primary care physicians (PCP) for colonoscopy screening. The program uses a unique clinical protocol, with inbuilt quality safeguards to compensate for PCPs' lack of formal gastroenterology training. A previous NCI-funded study documented the high quality and patient safety of PCP-performed colonoscopies, providing the evidence base for the clinical effectiveness of PCP-colonoscopies performed in a structured setting. The same study also found significantly higher colonoscopy rates among patients of trained AA PCPs relative to untrained PCPs, an increase that was led by drastic increases among AAs, particularly AA men. Though promising, questions remain to be addressed before this innovative program can be scaled up to expand colonoscopy access for AAs. The questions are: a) Do PCPs' adenoma/cancer yield rates and procedure performance indicators match those of specialists performing colonoscopies in the same clinical setting and screening patients drawn from the same population? This study aim will clarify the performance quality of PCP-colonoscopies accounting for potential confounding due to unobserved population-related variables. b) Do PCPs confer similar CRC protection rates as specialists serving the same population, and do PCP-cohort protection rates compare well with the CRC protection rates found in randomized clinical trials? This study will investigate these questions using data on 13,688 screening colonoscopies by 54 PCPs and on 5031 colonoscopies by 5 specialists. To detect differences in performance quality and case yield rates we will compare PCP-performed procedures with specialist-performed procedures on the following metrics: a) polyp detection rate and mean polyps detected per patient, b) adenoma detection rate and mean adenomas per patient, c) advanced adenoma detection rate and mean per patient, d) cancer detection rate, e) location of detected adenomas - right-sided, left-sided and cecal adenomas, f) colonoscope insertion and withdrawal times when no polyp was found and when polyp(s) were found, g) cecal intubation rate, h) reasons for incomplete colonoscopies (not achieving cecal intubation), i) repeat colonoscopy due to unsatisfactory procedure, and j) all of the above indicators classified by PCPs' training status and procedure volume. To satisfy study aim 2 we will assess the number and type of incident cancers among PCP- vs. specialist-served cohorts (65,685 person years (PYO) from 13,688 PCP colonoscopies, and 34,255 PYOs from the 5031 specialist-performed colonoscopies). We will source cancer data from the South Carolina Central Cancer Registry (SCCCR) and death data from the SC Vital Statistics registry. We will classify incident cancers by probable cause as per the documented algorithm (Pabby et al) into 4 categories: missed cancer, new cancer, incomplete removal, failed biopsy detection, and incomplete colonoscopy. PUBLIC HEALTH RELEVANCE: This project explores a key knowledge gap regarding the performance quality and colorectal cancer (CRC) protection effect of colonoscopies performed by primary care physicians (PCP) under a innovative program (with inbuilt quality assurance mechanisms to compensate for PCPs' lack of formal gastroenterology training) in South Carolina. The study will explore: a) whether the PCP-colonoscopy cohort rates of precancerous adenomas and cancer, and other quality measures are comparable to those of the specialist cohort performed in the same clinical setting and population, and b) whether PCP-performed colonoscopies confer similar CRC protection on patients as specialists, and as per the documented rates in randomized clinical trials. It will use colonoscopy and cancer registry data pertaining to 65,685 person years (PYO) of follow-up following 13,688 PCP colonoscopies, and 34,255 PYOs following 5031 specialist-performed colonoscopies.