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Gender Differences in Colonoscopy: Implications for Clinical Practice and Female Gastroenterologists. Dig Dis Sci 2022; 67:810-816. [PMID: 34114156 DOI: 10.1007/s10620-021-07079-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/27/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Performing colonoscopy can be technically challenging in female patients. Female patients may prefer having a female endoscopist. This preference, coupled with the fact that there are fewer female endoscopists, may result in gender differences in colonoscopy practice. We hypothesized that the duration of female colonoscopy is longer and that female endoscopists perform a higher proportion of female colonoscopy than male colleagues. We explored the potential revenue implications of gender differences in screening colonoscopy. METHODS We analyzed procedure time and gender differences in 16,573 screening colonoscopies performed by 27 male and 7 female endoscopists over a three-year period in one large academic practice. We modeled the potential revenue impacts of differences in procedure duration, proportion of female colonoscopy and the frequency of detected adenomas. RESULTS We found that screening colonoscopy takes 8.8% more time to complete in female patients compared to male patients for all endoscopists (p < 0.001), and that female endoscopists perform an average of 71.2% female exams compared to male endoscopists, who perform an average of 50.8% female exams (p < 0.001). Female patients had a lower detection adenoma rate (ADR), reducing the frequency of polypectomy and reimbursement in an RVU model. The observed gender differences could account for an estimated 9.6% revenue loss per 8-h session for a female gastroenterologist performing screening colonoscopy compared to a male counterpart. CONCLUSION Longer colonoscopy duration in females, increased proportion of female colonoscopies for female endoscopists and lower ADR in females may contribute to the gender gap in physician pay in gastroenterology.
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Brewer KC, Peacock NR, Ferrans CE, Campbell RT, Polite B, Carnahan L, Jones LA, Rauscher GH. Gender- and Race-Based Differences in Barriers and Facilitators to Early Detection of Colon Cancer. J Womens Health (Larchmt) 2020; 29:1192-1202. [PMID: 32096681 DOI: 10.1089/jwh.2019.8163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background: Early detection of colon cancer is essential to successful treatment and survival, yet most patients are diagnosed only after onset of symptoms. Previous studies suggest differences in colon cancer screening and presentation by gender and race, but reasons for this are not understood. The purpose of this study was to identify barriers and facilitators to early detection of colon cancer and to compare by gender and race. Materials and Methods: In the Colon Cancer Patterns of Care in Chicago study, non-Hispanic Black and White (NHB, NHW) patients aged 30-79 newly diagnosed with colon cancer between 2010 and 2014 (n = 249) underwent in-depth semistructured interviews regarding the pathway to colon cancer diagnosis. Mixed qualitative and quantitative methods were used to analyze patient narratives and to compare response patterns by gender and race within prespecified domains: health care access factors, provider-related factors, patient-related factors, and diagnostic workup factors. Results: Women reported more barriers than facilitators to early detection than men (barrier: facilitator ratio of 0.60 vs. 0.48). Thematic differences were seen, with women reporting more barriers related to health care access, scheduling of follow-ups, symptom recognition, and inappropriate or inconclusive diagnostic tests. Fewer women than men reported facilitators related to provider factors such as ease of scheduling follow-ups and receiving referrals for screening or a specialist. NHBs and NHWs reported similar ratios of barriers to facilitators (0.55 vs. 0.53), but more NHBs than NHWs reported barriers related to health care access, scheduling follow-ups, and clinical delays, and fewer NHBs reported facilitators related to health care accessibility (existing relationship with provider, ease of scheduling follow-ups). Conclusions: In this diverse population of patients recently diagnosed with colon cancer, we identified substantive gender- and race-based differences in the types and burden of barriers and facilitators to early detection experienced in the path to diagnosis. These differences should be explored further as they may contribute to disparities in the diagnosis and prognosis of colon cancer.
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Affiliation(s)
- Katherine C Brewer
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Nadine R Peacock
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Carol E Ferrans
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA.,Center of Excellence in Eliminating Disparities, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Richard T Campbell
- Center of Excellence in Eliminating Disparities, University of Illinois at Chicago, Chicago, Illinois, USA.,Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Blase Polite
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medicine & Biological Sciences, Chicago, Illinois, USA
| | - Leslie Carnahan
- Division of Community Health Sciences, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA.,Center for Research on Women and Gender, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Lindsey A Jones
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Garth H Rauscher
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Illinois, USA.,Center of Excellence in Eliminating Disparities, University of Illinois at Chicago, Chicago, Illinois, USA
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Abstract
PURPOSE Cecal intubation time (CIT) is an indicator for difficult colonoscopy which is associated with patients' unpleasant experience as well as increased risk of complications. Several studies have attempted to identify predictors for prolonged CIT but those studies tended to be small which gave rise to inconsistent and underpowered results. This systematic review and meta-analysis was conducted to summarize all available data. METHODS MEDLINE and EMBASE databases were searched through November 2017 for studies that investigated the factors for prolonged CIT. Only factors that were reported by at least three studies were included in the meta-analyses. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated using random effects model. The between-study heterogeneity of effect size was quantified using the Q statistic and I2. RESULTS A total of nine studies involving 7131 patients were included. A total of six factors were analyzed. Patients with older age (≥ 65 versus < 65), female sex (versus male), low body mass index (BMI) (< 25 versus ≥ 25 kg/m2), and poor bowel preparation (versus fair to good) had significantly longer CIT. The presence of diverticulosis and prior abdominal surgery were not significantly associated with prolonged CIT. CONCLUSIONS The current meta-analyses have demonstrated that old age, female sex, low BMI, and poor bowel preparation were the predictors for prolonged CIT.
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Robertson AR, Kennedy NA, Robertson JA, Church NI, Noble CL. Colonoscopy quality with Entonox ®vs intravenous conscious sedation: 18608 colonoscopy retrospective study. World J Gastrointest Endosc 2017; 9:471-479. [PMID: 28979712 PMCID: PMC5605347 DOI: 10.4253/wjge.v9.i9.471] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 07/10/2017] [Accepted: 08/15/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To compare colonoscopy quality with nitrous oxide gas (Entonox®) against intravenous conscious sedation using midazolam plus opioid. METHODS A retrospective analysis was performed on a prospectively held database of 18608 colonoscopies carried out in Lothian health board hospitals between July 2013 and January 2016. The quality of colonoscopies performed with Entonox was compared to intravenous conscious sedation (abbreviated in this article as IVM). Furthermore, the quality of colonoscopies performed with an unmedicated group was compared to IVM. The study used the following key markers of colonoscopy quality: (1) patient comfort scores; (2) caecal intubation rates (CIRs); and (3) polyp detection rates (PDRs). We used binary logistic regression to model the data. RESULTS There was no difference in the rate of moderate-to-extreme discomfort between the Entonox and IVM groups (17.9% vs 18.8%; OR = 1.06, 95%CI: 0.95-1.18, P = 0.27). Patients in the unmedicated group were less likely to experience moderate-to-extreme discomfort than those in the IVM group (11.4% vs 18.8%; OR = 0.71, 95%CI: 0.60-0.83, P < 0.001). There was no difference in caecal intubation between the Entonox and IVM groups (94.4% vs 93.7%; OR = 1.08, 95%CI: 0.92-1.28, P = 0.34). There was no difference in caecal intubation between the unmedicated and IVM groups (94.2% vs 93.7%; OR = 0.98, 95%CI: 0.79-1.22, P = 0.87). Polyp detection in the Entonox group was not different from IVM group (35.0% vs 33.1%; OR = 1.01, 95%CI: 0.93-1.10, P = 0.79). Polyp detection in the unmedicated group was not significantly different from the IVM group (37.4% vs 33.1%; OR = 0.97, 95%CI: 0.87-1.08, P = 0.60). CONCLUSION The use of Entonox was not associated with lower colonoscopy quality when compared to intravenous conscious sedation using midazolam plus opioid.
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Affiliation(s)
- Alexander R Robertson
- Department of Gastroenterology, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
| | - Nicholas A Kennedy
- Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh EH4 2XU, United Kingdom
- Department of Gastroenterology, University of Exeter, Exeter EX4 4QJ, United Kingdom
| | - James A Robertson
- School of Life Sciences, University of Nottingham, Nottingham NJ7 2UH, United Kingdom
| | | | - Colin L Noble
- Department of Gastroenterology, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
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Singh S, Dhawan M, Chowdhry M, Babich M, Aoun E. Differences between morning and afternoon colonoscopies for adenoma detection in female and male patients. Ann Gastroenterol 2016; 29:497-501. [PMID: 27708517 PMCID: PMC5049558 DOI: 10.20524/aog.2016.0079] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/27/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Colonoscopies performed in the afternoon (PM) have been shown to have lower adenoma detection rates (ADR) compared to those in the morning (AM). Endoscopist fatigue has been suggested as a possible reason. Colonoscopies tend to be technically more challenging in female patients. Furthermore, women have a lower incidence of adenomas then men. The impact of the timing of colonoscopy based on sex has not been studied. We hypothesized that any decrease in ADR in PM colonoscopies would be more pronounced in female patients when compared to male patients. METHODS We retrospectively reviewed colonoscopies performed for screening or surveillance in our outpatient endoscopy center from January 2008 to December 2011. Complete colonoscopies with a documented cecal intubation were included. All patients with a history of colorectal cancer or colonic resection, inadequate bowel preparation, or incomplete data were excluded. RESULTS A total of 2305 patients (1207 female) were included. Overall, ADR was significantly higher in AM than in PM procedures. Multivariate analysis demonstrated that ADR for females was lower in PM than in AM colonoscopies (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.44-0.91, P=0.015). There was a non-significant trend towards a lower ADR for males in PM (OR 0.84, 95% CI 0.62-1.15, P=0.28). Females had a prolonged intubation time and a longer procedure time. CONCLUSION The difference in ADR between AM and PM procedures seems to apply mainly to female patients. No significant change in ADR was noted in male patients in the afternoon.
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Affiliation(s)
- Shailendra Singh
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Manish Dhawan
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Monica Chowdhry
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Michael Babich
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Elie Aoun
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
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Jain D, Goyal A, Zavala S. Predicting Colonoscopy Time: A Quality Improvement Initiative. Clin Endosc 2016; 49:555-559. [PMID: 26996219 PMCID: PMC5152781 DOI: 10.5946/ce.2015.110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 11/08/2015] [Accepted: 01/03/2016] [Indexed: 12/14/2022] Open
Abstract
Background/Aims There is lack of consensus on the optimal time allotted for colonoscopy, which increases patient wait times. Our aim was to identify and quantify the individual pre-procedural factors that determine the total procedure time (TPT) of colonoscopy. Methods This retrospective study involved 4,494 subjects, undergoing outpatient colonoscopy. Effects of age, sex, body mass index, abdominal surgery history, procedure indication (screening, surveillance, or diagnostic), procedure session (morning or afternoon), and endoscopist’s experience (fellow or attending) on TPT were evaluated using multiple regression analysis. A p<0.05 was considered significant. Results A total of 1,239 subjects satisfied the inclusion/exclusion criteria. Women, older individuals, and those with a history of abdominal surgery were found to have a shorter TPT (p>0.05) as did afternoon session colonoscopies (p=0.004). Less experienced endoscopists had longer TPTs (p>0.05). Screening (p=0.01) and surveillance (p=0.008) colonoscopies had a longer TPT than diagnostic procedures. Overall, the F-value of the regression model was 0.0009. Conclusions The indication for colonoscopy and the time of day have statistically significant associations with TPT. These results will help in streamlining workflow, reduce wait time, and improve patient satisfaction.
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Affiliation(s)
- Deepanshu Jain
- Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Abhinav Goyal
- Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Stacey Zavala
- Division of Gastroenterology, Department of Internal Medicine, Albert Einstein Medical Center, Philadelphia, PA, USA
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Abstract
BACKGROUND AND AIMS Polyp size ≥ 1 cm triggers more frequent colonoscopic surveillance, yet size is typically based on subjective endoscopic estimates. We sought to compare contemporary assessments of polyp size by endoscopic estimation and pathology measurement. METHODS Colonoscopy and pathology reports were reviewed from the 2012 medical records at a large institution. Only polyps resected in toto with both endoscopic estimates and pathology measurements were included. Pathology measurements were considered the criterion standard. Factors affecting endoscopic miscall rates were assessed by multivariate analyses. RESULTS From 6067 polyps resected, both endoscopic and pathology sizes were available on 1528. Distribution of polyp size appraised by endoscopy but not by pathology revealed modal clustering, particularly around 1 cm. Among 99 polyps endoscopically called 1 cm, 72% were <1 cm on pathology. Of all 222 polyps estimated as ≥ 1 cm on endoscopy, 46% were <1 cm on pathology; of 1306 polyps estimated as <1 cm, 3.9% were ≥ 1 cm on pathology. By histology, 39% of adenomatous, 59% of sessile serrated, and 73% of hyperplastic polyps were overcalled; P = .008. By configuration, 34% of pedunculated, 49% of sessile, and 61% of flat polyps were overcalled; P = .014. Endoscopic overestimation was more common in women (54%) than in men (40%) (P = .03) and with proximal (56%) than distal (40%) sites; P = .02. Miscall rates were unaffected by endoscopist covariates. CONCLUSIONS Substantial discordance exists between endoscopic and pathology-based assessments of polyp size. Almost half of polyps called advanced on endoscopic estimates of size ≥ 1 cm fell below this threshold on actual pathology measurements.
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Wu XR, Church JM, Jarrar A, Liang J, Kalady MF. Risk factors for delayed postpolypectomy bleeding: how to minimize your patients' risk. Int J Colorectal Dis 2013; 28:1127-34. [PMID: 23440363 DOI: 10.1007/s00384-013-1661-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE Secondary bleeding after colonoscopic polypectomy is a serious complication. Most studies show polyp size, location, and shape to be important risk factors but other factors may allow refinement of risk. The aim of this study is to look for other factors associated with delayed postpolypectomy bleeding. METHODS This case-matched study compares patients who developed postpolypectomy bleeding with those who underwent uncomplicated polypectomy. Matching was performed for known risk factors: polyp size, location and shape, with a ratio of three controls to one subject. RESULTS Postpolypectomy bleeding occurred in 19/494 patients with polyps >2.0 cm diameter (3.8%) and 11/4161 patients with polyps <2.0 cm (0.3%). There was a median interval of 3 days (range 0-9 days) from polypectomy to hemorrhage. Twenty-five patients were readmitted to this institution. Ten (40.0%) were transfused and 19 (76.0%) were re-colonoscoped, with 13 needing either cautery (n = 7) or adrenaline injection (n = 6). Ninety patients were selected as controls, matched for polyp size, location, and shape. Mean age at polypectomy was 69.9 ± 9.2 years for patients and 64.9 ± 12.2 for controls (p = 0.042); 63.3% subjects were male, compared to 47.8% of controls (p = 0.140). Univariate analysis showed that older age, piecemeal polypectomy, need for additional sedation, concurrent diverticulosis and intraprocedural bleeding were significantly associated with increased risk of delayed bleeding. The associations between delayed bleeding and additional sedation, concurrent diverticulosis and intraprocedural bleeding were confirmed by multivariate logistic regression analysis. CONCLUSION Difficult colonoscopy and intraprocedural bleeding identify patients with a particularly high risk of secondary postpolypectomy bleeding. Preventive measures should be considered in such cases.
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Affiliation(s)
- Xian-rui Wu
- Department of Colorectal Surgery, Digestive Disease Institute, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195, USA
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Jang HW, Cheon JH, Nam CM, Moon CM, Lee JH, Jeon SM, Park JJ, Kim TI, Kim WH. Factors affecting insertion time for colonoscopy performed under intramuscular analgesia in patients with history of colorectal resection. Surg Endosc 2011; 25:2316-22. [PMID: 21298530 DOI: 10.1007/s00464-010-1555-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 12/13/2010] [Indexed: 01/28/2023]
Abstract
BACKGROUND Colonoscopy can detect both early intraluminal recurrence and metachronous neoplasia after colorectal cancer resection. Because colon length and location change after colorectal resection, factors affecting insertion time during colonoscopy also might be altered. The goal of this study was to examine whether colonoscope insertion time differs between left-sided resection and right-sided resection and to identify factors that impact the performance of colonoscopy after colorectal resection. METHODS We included consecutive patients who underwent colonoscopy between November 2005 and November 2009 after colorectal resection for colorectal cancer. We classified surgical methods into left-sided resection (left hemicolectomy, low anterior resection, anterior resection, Hartman, and Mile's operation) or right-sided resection (right hemicolectomy) and retrospectively evaluated the colonoscope insertion time. Moreover, we analyzed factors that might affect the insertion time. RESULTS A total of 1,260 patients underwent colonoscopy after colorectal resection during the study period. Of these, 1,248 patients (771 men) who underwent complete colonoscopy were evaluated in this study. The colonoscopy completion rate was 99%, and the mean insertion time was 6.5±5.1 min (median, 5 min; range, 0.3-61 min). Right-sided resection, female gender, poor quality of bowel preparation, lower endoscopist case volume, open laparotomy, and colonoscopy performed more than 1 year after colorectal resection were found to be independent factors associated with prolonged insertion time. CONCLUSIONS This large study identified six factors that affect colonoscope insertion time after colorectal resection. These findings have implications for the practice and teaching of colonoscopy after colorectal resection.
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Affiliation(s)
- Hui Won Jang
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 134, Shinchon-dong, Seodaemun-gu, Seoul, 120-752, Korea
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Witte TN, Enns R. The difficult colonoscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:487-90. [PMID: 17703247 PMCID: PMC2657972 DOI: 10.1155/2007/520431] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Todd N Witte
- St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
- George Washington University Hospital, Washington, DC
| | - Robert Enns
- St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia
- Correspondence: Dr Robert Enns, St Paul’s Hospital, UBC, Suite #770-1190 Hornby Street, Vancouver, British Columbia. Telephone 604-688-6332, fax 604-689-2004, e-mail
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