G. C. Edwards1,2, K. Broman4, R. L. Martin3, W. Smalley5, L. Smith5, C. L. Roumie2 1Vanderbilt University Medical Center,Department Of General Surgery,Nashville, TN, USA 2VA – Tennessee Valley Healthcare System,Geriatric Research Education And Clinical Center,Nashville, TENNESSEE, USA 3Vanderbilt University Medical Center,Department Of Medicine, Division Of Oncology,Nashville, TN, USA 4Moffitt Cancer Center And Research Institute,Division Of Surgical Oncology,Tampa, FL, USA 5VA – Tennessee Valley Healthcare System,Department Of Medicine, Division Of Gastroenterology,Nashville, TENNESSEE, USA
Introduction: Surveillance colonoscopy is recommended within one year of colorectal cancer resection to detect local recurrence and metachronous colorectal cancer. Prior work at our Veterans Affairs facility demonstrated that a low proportion of eligible patients received one-year surveillance endoscopy (34%) and this metric was impacting overall guideline adherence for colorectal cancer care.
Methods: Our interdisciplinary team standardized processes of care, assigned responsible providers, and implemented a gastroenterology-managed virtual surveillance clinic as part of an improvement initiative. In this initiative, a nurse practitioner reviews patients in the virtual clinic within 90 days of the target endoscopy date, determines eligibility for surveillance colonoscopy, and initiates referral and preparation for endoscopy. This virtual endoscopy clinic was deployed in August 2014; the process map for revised referral is demonstrated in Figure 1. Our primary outcome was the proportion of eligible patients for whom endoscopy was completed within one year of surgical resection. There were 56 weeks used as baseline and 42 weeks for post-intervention data. Secondary outcome was the proportion of endoscopy completed at any time after resection.
Results: A total of 185 patients underwent resection for Stage I – III colorectal cancer from January 2010 – February 2018. There were 113 patients in the pre-intervention group over 56 weeks and 72 patients in the post-intervention group over 42 weeks. Among this cohort, a total of 158 patients remained eligible for surveillance colonoscopy at one year: 94 (83.2%) in the pre-intervention group and 64 (88.9%) in the post-intervention group. Median time to colonoscopy decreased from 17 months pre-intervention to 12.9 months in the post-intervention group (P<0.01). Among the pre-intervention group, 29 (30.9%) of eligible patients completed surveillance colonoscopy at one year versus 32 (50%) in the post-intervention group (p=0.015). For the secondary outcome, among the pre-intervention group, 81 (86.2%) completed surveillance colonoscopy at any point after resection, versus 59 (92.2%) in the post-intervention group (P=0.24).
Conclusion: Implementation of a virtual surveillance clinic with clearly defined processes and established provider roles increased guideline-concordant endoscopic surveillance after colorectal cancer resection. This approach may serve as a model for managing the long-term needs of cancer survivors using existing resources and workflows.
