1. Complications after Colonoscopy and Risk Factors Xinliang “Albert” Liu, PhD Latarsha Chisholm, PhD Department of Health Management and Informatics University of Central Florida

2. 2 What is colonoscopy Colonoscopy is a procedure in which a physician examines the inner lining of the large intestine (rectum and colon). Colonoscopy is used to diagnose causes of some lower gastrointestinal symptoms. It can also be used to detect and remove precancerous polyps or cancer. It is recommended to start colorectal screening at age 50 for people at average risk.

3. 3 Colonoscopy procedures examined in the study CPT code Short DescriptorDescription 45378 Diagnostic colonoscopy Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) 45380 Colonoscopy and biopsy Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 45383 Lesion removal colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 45384 Lesion removal colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 45385 Lesion removal colonoscopy Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

4. 4 Each year half a million colonoscopies were performed on patients age 50 or above in Florida 4537845380453834538445385Total 2005223,71599,96913,47074,75895,801467,314 2006239,254109,52513,83978,253100,270496,984 2007241,431123,05813,34283,632108,395521,733 Total704,400332,55240,651236,643304,4661,486,031

5. 5 Colonoscopy was done for a variety of reasons Principal diagnosis DescriptionFrequencyPercent 211.3 Benign neoplasm of colon 429,77528.92 V76.51 Special screening for malignant neoplasms of colon 186,29012.54 V12.72 Personal history of colonic polyps 79,6725.36 562.10 Diverticulosis Of Colon (Without Mention Of Hemorrhage) 72,5394.88 787.99 Other symptoms involving digestive system 70,0824.72 569.3Hemorrhage of rectum and anus 67,4074.54

6. 6 Patient age distribution (50 and above)

7. 7 Physician volume distribution

8. 8 Who paid for colonoscopy Primary expected payer (uniform) PayerFrequencyPercentCumulative FrequencyPercent Medicare 638,37142.97638,37142.97 Medicaid 19,5351.31657,90644.29 Private insurance 766,77151.611,424,67795.90 Self-pay 16,5891.121,441,26697.02 No charge 4,8660.331,446,13297.35 Other 39,4402.651,485,572100

9. 9 Charges of colonoscopy CPT code Short Descriptor Medicaid fee schedule (2006) Medicaid fee schedule (2014) 45378 Diagnostic colonoscopy202.83216.11 45380 Colonoscopy and biopsy239.60257.47 45383 Lesion removal colonoscopy285.36310.82 45384 Lesion remove colonoscopy237.60256.03 45385 Lesion removal colonoscopy270.57289.69

10. 10 Complications within 30 days after colonoscopy Same day emergency department (ED) visit and/or hospitalization Serious gastrointestinal events  colonic perforation and lower gastrointestinal bleeding Other gastrointestinal events  intestinal obstruction, abdominal pain, diverticulitis, ulcerative colitis, nausea and vomiting, and disorders of fluid Other non-gastrointestinal events  Anemia, sedation-related cardiopulmonary complications (e.g., aspiration pneumonia), infection (fever, bacteremia, and endocarditis following the procedure), and complications of procedure (e.g., failure of sterile precautions during procedure)

11. 11 Identify and measure complications The discharge records of colonoscopy patients were linked to emergency department and hospital discharge records. Potential complications were detected when a patient visited the emergency department or got hospitalized after receiving colonoscopy A follow up period of 30 days was used

12. 12 Rates of complications after colonoscopy Events, nRisk per 1000 patients Same day transfer35412.3 Patient fall35412.3 Serious GI events12590.8 Colonic perforation5940.4 Lower GI bleeding6780.4 Other GI event62574.0 Intestinal obstruction19621.3 Diverticulitis12240.8 Disorders of fluid36152.3 Other non-GI events1726911.1 Anemia NOS52353.4 Aspiration pneumonia2900.2 Pneumonia, organism unspecified12100.8 MI/Angina66764.3 Arrhythmias53793.5 Heart failure24901.6 Syncope/dizziness19151.2 Hypotension10870.7 Respiratory/cardiac arrest14090.9 infection8810.6 Complications of procedure9250.6

13. 13 Risk factors All Adverse EventsSerious GI Events Odds Ratio 95% Confidence IntervalP-value Odds Ratio 95% Confidence IntervalP-value Age groups (reference 80 or above) 40-640.3150.2970.334<.0001 0.3670.2820.478<.0001 65-690.3890.3670.411<.0001 0.5050.3910.652<.0001 70-790.5620.5350.59<.0001 0.6590.5260.8260.0003 FEMALE1.0451.0131.0780.0055 0.7330.6410.839<.0001 Race (reference=other) White0.9620.9280.9980.0378 0.8830.7611.0240.0996 Black1.431.3131.558<.0001 0.9740.6491.460.8972 Charlson index (reference=3 or higher) 00.2010.1830.22<.0001 0.2720.1730.427<.0001 10.3310.2990.367<.0001 0.3460.210.571<.0001 20.6460.5720.73<.0001 0.8180.4621.4490.4913 Primary payer (reference=self-pay) Medicare1.281.1791.389<.0001 1.1810.8271.6880.3603 Medicaid1.9681.7892.164<.0001 2.0951.3993.1360.0003 Private insurance0.7950.7350.86<.0001 1.0460.7471.4640.7933 Invasiveness (reference=Diagnostic procedure) Colonoscopy and biopsy1.2191.1751.264<.0001 1.4771.2641.726<.0001 Lesion removal colonoscopy1.231.1831.278<.0001 1.4541.2391.707<.0001

14. 14 Conclusions Colonoscopy is a commonly performed procedure in Florida Complications after colonoscopy are rare. Female gender, advanced age, comorbidities, and more invasive procedures are associated with elevated risks. Colorectal cancer is preventable. Get screened is the key. Be mindful of your body.  blood in the stool, abdominal pain, diarrhea, a change in bowel habit, and weight loss

15. 15 Thank you!