title: Open access colonoscopy: Critical appraisal of indications, quality metrics and outcomes.
abstract: BACKGROUND
  In an era of cost containment and measurement of value, screening for colon cancer represents a clear target for better accountability. Bundling payment is a real possibility and will likely have to rely on open-access colonoscopy (OAC). OAC is a method to allow patients to undergo endoscopy without prior evaluation by a gastroenterologist. We conducted a cross-sectional study to evaluate the indications and outcomes among patients scheduled for OAC or traditional colonoscopy at a tertiary medical center. We hypothesized that outcomes in OAC patients would be similar to those from traditional referral modes.
  
  
  METHODS
  Using a standardized data abstraction form, we documented indications for colonoscopy, clinical outcomes (complications, emergency room visits, phone calls), and compliance with quality indicators (QI) in a random sample of 1000 patients who underwent an outpatient colonoscopy at an academic medical center in 2013. We compared baseline characteristics and outcomes between two cohorts: OAC vs. patients who were scheduled after previous evaluation by a gastroenterologist or physician assistant or non-open access colonoscopy (NOAC).
  
  
  RESULTS
  Patients in the OAC group were more likely to be male, non-Hispanic, to be privately insured, and to have screening (vs. diagnostic) indication. However they were significantly less likely than those in the NOAC group to have a procedure performed once scheduled, (45.5% vs. 66.9%, p<0.001), due to no-show (24/178 or 13.5% vs. 60/822 or 7.3%), cancellation (56/178 or 31.5 vs. 156/822 or 19.0%), and non-compliance (9/178 or 5.1% vs. 20/822 or 2.4%). There were no clinically meaningful differences between groups with respect to outcomes such as polyp detection (35.6% OE vs. 39.5% NOE, p=0.54), postoperative call to GI practice (5.5% vs. 2.5%, p=0.41), or QI metrics such as documentation of prep quality (99.8% vs. 98.8%, p=0.24).
  
  
  CONCLUSIONS
  Patients undergoing OAC are more likely to have a screening colonoscopy but with overall similar clinical outcomes and compliance with QI to patients scheduled as NOAC. OAC remains handicapped by high cancellation and no-show rates.
authors.affiliation: Division of Gastroenterology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, United States. Electronic address: rony.ghaoui@baystatehealth.org.
authors.forename: Rony
authors.initials: R
authors.lastname: Ghaoui
authors.affiliation: Division of General Internal Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, United States.
authors.forename: Sheryl
authors.initials: S
authors.lastname: Ramdass
authors.affiliation: Epidemiology/Biostatistics Research Core, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, United States.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Friderici
authors.affiliation: Division of Gastroenterology, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, United States.
authors.forename: David J
authors.initials: DJ
authors.lastname: Desilets
mesh_terms: D000328:Adult; D000368:Aged; D003113:Colonoscopy / Q000379:methods*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D003430:Cross-Sectional Studies; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000379:methods; D008404:Massachusetts; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D019984:Quality Indicators, Health Care; D062606:Tertiary Care Centers
keywords: Access to care; Outcome research; Screening for colorectal cancer