Appropriateness of colonoscopies in a Tunisian endoscopy center: factors and EPAGE-I/II criteria comparison.

Background: There is a growing demand for colonoscopy, worldwide, resulting in increased rate of inappropriate referrals. This "overuse" of colonoscopies has become a major burden for health care.

Objectives: to assess the appropriateness of colonoscopies performed at the endoscopy unit of the university hospital of Sousse and to compare these results of appropriateness according to the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) I and EPAGE II criteria.

Patients and methods: this cross-sectional study included all consecutive patients referred for a diagnostic colonoscopy, between January 2017 and December 2018. Patients referred for exclusively therapeutic indications, those with incomplete colonoscopies were not included. Patients with poor bowel preparation or missing data were also excluded. Indications were assessed using the EPAGE I and EPAGE II criteria.

Results: From 1972 consecutive patients, 1307 were included. Overall, 986 (75.4%) of all referrals were for out-patients. The majority of patients were referred by gastroenterologists (n = 1026 patients; 78.5%), followed by general surgeons (n = 85; 6.5%). The commonest indications were lower abdominal symptoms (275; 21%) followed by uncomplicated diarrhea (152; 11.6%). Relevant findings were present in 363 patients (27.7%). Neoplastic lesions were the dominant finding in 221 patients (16.9%). EPAGE I and EPAGE II criteria were applicable for 1237 (88.8%) and 1276 (97.7%) patients respectively. Hematochezia and abdominal pain recorded the highest inappropriate rates with both sets of criteria. Appropriate colonoscopies increased to 76.4% when EPAGE II criteria were applied; whereas uncertain and inappropriate procedures decreased to 10.3% and 10.9% respectively Appropriateness of indication was significantly higher in hospitalized patients. For the EPAGE II criteria, the specialty of the referring physician was also significantly associated to the appropriate use. The agreement between EPAGE I and EPAGE II criteria was slight using the weighted version of k (k = 0.153).

Conclusions: The updated and improved EPAGE II guidelines are a simple and valid tool for assessing the appropriateness of colonoscopies. They decreased the inappropriate rate and the possibility of missing potentially severe diagnoses.