The appropriateness of colonoscopies at a teaching hospital: magnitude, associated factors, and comparison of EPAGE and EPAGE-II criteria

Background: The growing demand for colonoscopies and inappropriate colonoscopies have become a significant problem for health care. Objectives: To assess the appropriateness of colonoscopies and to analyze the association with some clinical and organizational factors. To compare the results of the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) and the EPAGE-II criteria. Design: Cross-sectional study. Setting: Endoscopy unit of a teaching hospital in Spain. Patients: Patients referred for colonoscopy, excluding urgent, therapeutic indications, and poor cleansing. Main Outcome Measurements: Appropriateness of colonoscopies according to the EPAGE criteria. Results: From 749 colonoscopies, 619 were included. Most patients were referred by gastroenterologists (66.1%) in an outpatient setting (80.6%). Hematochezia was the most frequent indication (31.5%) followed by colorectal cancer-related indications (27.3%); a clinically relevant diagnosis was established in 41%. Inappropriate use was higher with EPAGE (27.0%) than EPAGE-II (17.4%) criteria. Surveillance after colonic polypectomy and uncomplicated lower abdominal pain were the indications exhibiting higher inadequacy. Inappropriate use was less with older age, in hospitalized patients, with referrals from internal medicine, and in colonoscopies with clinically relevant diagnoses. Agreement between EPAGE and EPAGE-II was fair (weighted kappa = 0.31) but improved to moderate (simple kappa = 0.60) after grouping appropriate and uncertain levels. Limitations: The appropriateness criteria are based on panel opinions. Some patients (12%) could not be evaluated with the EPAGE criteria. Conclusions: Our study identifies substantial colonoscopy overuse, especially in tumor disease surveillance. The EPAGE-II criteria decrease the inappropriate rate and the possibility of overlooking potentially severe lesions. (Gastrointest Endosc 2012;75:138-45.)