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. 2018 Feb 27;18(1):229.
doi: 10.1186/s12885-018-4140-0.

Development and evaluation of a risk assessment tool to improve clinical triage accuracy for colonoscopic investigations

Anton R Lord  1 , Lisa A Simms  2 , Allison Brown  2   3 , Katherine Hanigan  2 , Krupa Krishnaprasad  2 , Belinda Schouten  2 , Anthony R Croft  2 , Mark N Appleyard  3 , Graham L Radford-Smith  2   3   4
Affiliations

Development and evaluation of a risk assessment tool to improve clinical triage accuracy for colonoscopic investigations

Anton R Lord et al. BMC Cancer. .

Abstract

Background: Gastroenterology Departments at hospitals within Australia receive thousands of General Practitioner (GP)-referral letters for gastrointestinal investigations every month. Many of these requests are for colonoscopy. This study aims to evaluate the performance of the current symptoms-based triage system compared to a novel risk score using objective markers.

Methods: Patients with lower abdominal symptoms referred by their GPs and triaged by a Gastroenterology consultant to a colonoscopy consent clinic were recruited into the study. A risk assessment tool (RAT) was developed using objective data (clinical, demographic, pathology (stool test, FIT), standard blood tests and colonoscopy outcome). Colonoscopy and histology results were scored and then stratified as either significant bowel disease (SBD) or non-significant bowel disease (non-SBD).

Results: Of the 467 patients in our study, 45.1% were male, the mean age was 54.3 ± 13.8 years and mean BMI was 27.8 ± 6.2. Overall, 26% had SBD compared to 74% with non-SBD (42% of the cohort had a normal colonoscopy). Increasing severity of referral symptoms was related to a higher triage category, (rectal bleeding, P = 2.86*10-9; diarrhoea, P = 0.026; abdominal pain, P = 5.67*10-4). However, there was no significant difference in the prevalence of rectal bleeding (P = 0.991) or diarrhoea (P = 0.843) for SBD. Abdominal pain significantly reduced the risk of SBD (P = 0.0344, OR = 0.52, CI = 0.27-0.95). Conversely, the RAT had a very high specificity of 98% with PPV and NPV of SBD prediction, 74% and 77%, respectively. The RAT provided an odds ratio (OR) of 9.0, 95%CI 4.29-18.75, p = 2.32*10-11), higher than the FIT test (OR = 5.3, 95%CI 2.44-11.69, p = 4.88*10-6), blood score (OR = 2.8, 95%CI 1.72- 4.38, p = 1.47*10-5) or age (OR = 2.5, 95%CI 1.61-4.00, 5.12*10-5) independently. Notably, the ORs of these individual objective measures were higher than the current practice of symptoms-based triaging (OR = 1.4, 95%CI 0.88-2.11, p = 0.153).

Conclusions: It is critical that individuals with high risk of having SBD are triaged to the appropriate category with the shortest wait time. Here we provide evidence that a combination of blood markers, demographic markers and the FIT test have a higher diagnostic accuracy for SBD than FIT alone.

Keywords: Bowel disease; Colonoscopy; Colorectal cancer; Faecal immunochemical test; Risk assessment tool.

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Conflict of interest statement

Ethics approval and consent to participate

The Human Research Ethics Committee of The Prince Charles Hospital approved the study (protocol: HREC/13/QPCH/47). All participants gave written informed consent before enrolment in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Algorithm for calculating the risk of SBD prior to colonoscopy
Fig. 2
Fig. 2
STARD showing study population inclusion and available data
Fig. 3
Fig. 3
Time between referral and colonoscopy for high-, medium- and low-risk patients (category 1, 2 and 3, respectively)
Fig. 4
Fig. 4
Flowchart detailing leave one out cross validation from the RAT
See this image and copyright information in PMC

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