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Kolber MR, Miles PJ, Shaw MD, Goosen H, Mok DCM. Evaluation of the quality of colonoscopies performed by Alberta North Zone surgeons, family physicians and internists: a quality improvement initiative. CMAJ Open 2023; 11:E654-E661. [PMID: 37527900 PMCID: PMC10400082 DOI: 10.9778/cmajo.20210237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND In Canada, endoscopy is primarily performed by gastroenterologists and surgeons, and some studies report that colonoscopies performed by nongastroenterologists have more complications and higher rates of future colorectal cancer. Our objective was to determine whether rural-based nongastroenterologist endoscopists are achieving quality benchmarks in colonoscopy. METHODS This quality improvement initiative prospectively evaluated 6 key performance indicators (KPIs) (cecal intubations, polyp detection [males and females; for first-time colonoscopies on patients aged ≥ 50 yr], bowel preparations, patient comfort and withdrawal times) on consecutive colonoscopies performed by participating Alberta North Zone endoscopists. The study period was June 2018 to March 2020. Overall and individual endoscopist's KPIs were compared with standard benchmarks. Additional performance indicators included mean number of polyps per colonoscopy and an exploration of study-defined sedation-related level of consciousness. RESULTS Data were collected on 6212 colonoscopies performed by 16 endoscopists (9 surgeons, 5 family physicians and 2 internists) in 6 hospitals. All 6 KPI benchmarks were achieved when results were pooled over all endoscopists in the study. Overall, cecal intubation occurred in 6006 of 6209 (96.7%, 95% confidence interval 94.5%-99.0%) cases. Polyp detection was 65.9% (592/898) and 49.8% (348/699) for male and female patients, respectively, aged 50 years or older. Variability in individual endoscopist results existed, especially for the mean number of polyps per 100 colonoscopies and sedation-related level of consciousness. INTERPRETATION Overall, Alberta North Zone endoscopists are performing high-quality colonoscopies, collectively achieving all 6 KPIs. To understand endoscopic performance and encourage individual and group reflection on endoscopic practices, Canadian endoscopists are encouraged to participate in similar colonoscopy quality initiative studies.
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Affiliation(s)
- Michael R Kolber
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta.
| | - Peter J Miles
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| | - Marcus D Shaw
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| | - Hilgard Goosen
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| | - Dereck C M Mok
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
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Zuniga Cisneros J, Tunon C, Adames E, Garcia C, Rivera R, Gonzalez E, Cubilla J, Lambrano L. Is There a Difference in Adenoma Detection Rates According to Indication? An Experience in a Panamanian Colorectal Cancer Screening Program. Gastroenterology Res 2023; 16:96-104. [PMID: 37187549 PMCID: PMC10181342 DOI: 10.14740/gr1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/23/2023] [Indexed: 05/17/2023] Open
Abstract
Background The benefit of colorectal cancer screening in reducing cancer risk and related death is unclear. There are quality measure indicators and multiple factors that affect the performance of a successful colonoscopy. The main objective of our study was to identify if there is a difference in polyp detection rate (PDR) and adenoma detection rate (ADR) according to colonoscopy indication and which factors might be associated. Methods We conducted a retrospective review of all colonoscopies performed between January 2018 and January 2019, in a tertiary endoscopic center. All patients ≥ 50 years old scheduled for a nonurgent colonoscopy and screening colonoscopy were included. We stratified the total number of colonoscopies into two categories according to the indication: screening vs. non-screening, and then calculated PDR, ADR and serrated polyp detection rate (SDR). We also performed logistic regression model to identify factors associated with detecting polyps and adenomatous polyps. Results A total of 1,129 and 365 colonoscopies were performed in the non-screening and screening group, respectively. In comparison with the screening group, PDR and ADR were lower for the non-screening group (33% vs. 25%; P = 0.005 and 17% vs. 13%; P = 0.005). SDR was non-significantly lower in the non-screening group when compared with the screening group (11% vs. 9%; P = 0.53 and 22% vs. 13%; P = 0.007). Conclusion In conclusion, this observational study reported differences in PDR and ADR depending on screening and non-screening indication. These differences could be related to factors related to the endoscopist, time slot allotted for colonoscopy, population background, and external factors.
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Affiliation(s)
| | - Carlos Tunon
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
| | - Enrique Adames
- School of Medicine, University of Panama, Panama City, Panama
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
| | - Carolina Garcia
- School of Medicine, University of Panama, Panama City, Panama
| | - Rene Rivera
- School of Medicine, University of Panama, Panama City, Panama
| | - Eyleen Gonzalez
- School of Medicine, University of Panama, Panama City, Panama
| | - Jan Cubilla
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
| | - Luis Lambrano
- Department of Gastroenterology, Santo Tomas Hospital, Panama City, Panama
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Kuga R, Facanali MR, Artifon ELDA. Quality indicators in colonoscopy: observational study in a supplementary health system. Acta Cir Bras 2023; 37:e371106. [PMID: 36629532 PMCID: PMC9829243 DOI: 10.1590/acb371106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/21/2022] [Indexed: 01/11/2023] Open
Abstract
PURPOSE Colorectal cancer is responsible for 9.4% of cancer deaths, and low polyp detection rate and cecal intubation rate increase the risks of interval colorectal cancer. Despite several population studies that address colonoscopy quality measures, there is still a shortage of these studies in Latin America. The aim of this study was to assess quality indicators in colonoscopy, enabling future strategies to improve colorectal cancer prevention. METHODS An observational retrospective study, in which all colonoscopies performed in 11 hospitals were evaluated through a review of medical records. Information such as procedure indication, colorectal polyp detection rate, cecal intubation rate, quality of colonic preparation, and immediate adverse events were collected and analyzed. RESULTS In 17,448 colonoscopies performed by 86 endoscopists, 57.9% were in patients aged 50 to 74 years old. Colon preparation was adequate in 94.4% procedures, with rates of cecal intubation and polyp detection of 94 and 36.6%, respectively. Acute adverse events occurred in 0.2%. In 53.9%, high-definition imaging equipment was used. The procedure location, colon preparation and high-definition equipment influenced polyp detection rates (p < 0.001). CONCLUSIONS The extraction and analysis of electronic medical records showed that there are opportunities for improvement in colonoscopy quality indicators in the participating hospitals.
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Affiliation(s)
- Rogerio Kuga
- MD, MSc. Universidade de São Paulo – Postgraduate Program in Anesthesiology, Surgical Sciences and Perioperative Medicine – School of Medicine – São Paulo (SP), Brazil; Hospital Samaritano de São Paulo , Americas Medical Services, UnitedHealth Group Brasil – São Paulo (SP), Brazil.,Corresponding author:
- (55 11) 998088119
| | - Marcio Roberto Facanali
- MD. Universidade de São Paulo – Gastroenterology Department – Hospital das Clínicas – School of Medicine – São Paulo (SP), Brazil
| | - Everson Luiz de Almeida Artifon
- MD, MSc, PhD. Universidade de São Paulo – Surgery Department – Hospital das Clínicas – School of Medicine – São Paulo (SP), Brazil
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Afify S, Tag-Adeen M, Abu-Elfatth A, Eid A, Nageh A, Alzamzamy A, El-Raey F, Basiony AN, Abdelghani M, Abdeltawab D, Ahmed RM, Nasr H, Alkady MN, Ibrahim W, Elshaarawy O, Amer H, Thoufeeq M, Alboraie M. Quality indicators for colonoscopy in Egypt: A prospective multicenter study. Arab J Gastroenterol 2022; 23:253-258. [PMID: 35934640 DOI: 10.1016/j.ajg.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/18/2021] [Accepted: 06/15/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND STUDY AIMS Despite its wide availability, we do not have sufficient data aboutthe quality of colonoscopy in Egypt. In this study, we proposed 13 indicators to assess the quality of colonoscopy procedures in the included study centers aiming to attain a representative image of the quality of CS in Egypt. PATIENTS AND METHODS A multicenter prospective study was conducted between July and December 2020, which included all patients who underwent colonoscopy in the participating centers. The following were the proposed quality indicators: indications for colonoscopy, preprocedure clinical assessment, obtaining written informed consent, adequate colon preparation, sedation, cecal intubation rate (CIR), withdrawal time, adenoma detection rate (ADR), complication rate, photographic documentation, automated sterilization, regular infection control check, and well-equipped postprocedure recovery room. RESULT A total of 1,006 colonoscopy procedures were performed during the study duration in the included centers. Our analysis showed the following four indicators that were fulfilled in all centers: appropriate indications for colonoscopy, preprocedure assessment, written informed consent, and automated sterilization. However, photographic documentation and postprocedure follow-up room were fulfilled only in 57 %. Furthermore, 71 % of the centers performed regular infection control checks. Adequate colon preparation was achieved in 61 % of the procedures, 81 % of the procedures were performed under sedation, 95.4 % CIR, 11-min mean withdrawal time, 15 % ADR, and 0.1 % overall complication rate. Statistically significant factors affecting CIR were age > 40 years, high-definition endoscope, previous colon intervention, and rectal bleeding, whereas those affecting ADR were age > 40 years, the use of image enhancement, previous colon intervention, rectal bleeding, the use of water pump, and a withdrawal time of > 9 min. CONCLUSION Our study revealed the bright aspects of colonoscopy practice in Egypt, including high CIRs and low complication rates; conversely, ADR, bowel cleansing quality, and infection control measures should be improved.
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Affiliation(s)
- Shimaa Afify
- Department of Gastroenterology, National Hepatology and Tropical Medicine Research Institute, Cairo, Postal Code: 11796 Cairo, Egypt
| | - Mohammed Tag-Adeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Qena Faculty of Medicine, South Valley University, Qena, Postal Code: 83523 Qena, Egypt.
| | - Ahmed Abu-Elfatth
- Department of Tropical Medicine and Gastroenterology, Assuit University, Assiut, Postal Code: 71515 Assiut, Egypt
| | - Alshaimaa Eid
- Department of Hepatogastroenterology and Infectious Disease, Al-Azhar University, Cairo, Postal Code: 11615 Cairo, Egypt
| | - Ahmed Nageh
- Department of Gastroenterology and Endoscopy, Alexandria Hepatology, GIT and Fever Hospital, Alexandria, Postal Code: 21544 Alexandria, Egypt
| | - Ahmed Alzamzamy
- Department of Gastroenterology and Hepatology, Maadi Armed Forces Medical Complex, Military Medical Academy, Cairo, Postal Code: 11711 Cairo, Egypt
| | - Fathiya El-Raey
- Department of Hepatogastroenterology and Infectious diseases, Al-Azhar University, Damietta, Postal Code: 34711 Damietta, Egypt
| | - Ahmed N Basiony
- Department of Tropical Medicine, Ain Shams University, Cairo, Postal Code: 11566 Cairo, Egypt
| | - Mohamed Abdelghani
- Department of Tropical Medicine and Gastroenterology, Assuit University, Assiut, Postal Code: 71515 Assiut, Egypt
| | - Doaa Abdeltawab
- Department of Tropical Medicine and Gastroenterology, Assuit University, Assiut, Postal Code: 71515 Assiut, Egypt
| | - Rasha M Ahmed
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Assuit University, Assiut, Postal Code: 71515 Assiut, Egypt
| | - Hayam Nasr
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Assuit University, Assiut, Postal Code: 71515 Assiut, Egypt
| | - Mohamed N Alkady
- Division of Gastro-intestinal Endoscopy, Department of Internal Medicine, Kasr Alaini Faculty of Medicine, Cairo University, Giza, Postal Code: 12613 Giza, Egypt
| | - Wael Ibrahim
- Department of Gastroenterology and Hepatology, Nasser Institute for Research and Treatment, Cairo, Postal Code: 11796 Cairo, Egypt
| | - Omar Elshaarawy
- Department of Hepatology and Gastroenterology, National Liver Institute, Menoufia University, Menoufia, Postal Code: 13829 Menoufia, Egypt
| | - Hossam Amer
- Department of General Medicine, Suad Kafafy University Hospital, Misr University for Science and Technology, Cairo, Postal Code: 12566 Cairo, Egypt
| | - Mo Thoufeeq
- Department of Endoscopy, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, Postal Code: S5 7AU Sheffield, United Kingdom
| | - Mohamed Alboraie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine , Al-Azhar University, Cairo, Postal Code: 11615 Cairo, Egypt
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Azizian J, Dalai C, Adams MA, Murcia A, Tabibian JH. Medical professional liability in gastroenterology: definitions, trends, risk factors, provider behaviors, and implications. Expert Rev Gastroenterol Hepatol 2021; 15:909-918. [PMID: 34112036 DOI: 10.1080/17474124.2021.1940957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Medical professional liability (MPL) is a notable concern for many clinicians, especially in procedure-intensive specialties such as gastroenterology (GI). Comprehensive understanding of the basis for MPL claims can improve gastroenterologists' practice, lower MPL risk, and improve the overall patient care experience. This is particularly relevant in the setting of the increasing average compensation per paid GI-related MPL claim, and evolving healthcare delivery patterns and regulations.Areas Covered: MPL claims are generally grounded in the concept of negligence, a broad term that may apply to situations involving medical errors, ameliorable adverse events, inadequate informed consent and/or refusal, and numerous others. Though often not directly discussed in GI training or thereafter, there are various mechanisms and behaviors that can alter (decrease or increase) MPL risk. Additional dimensions of MPL include telemedicine, social media, and vicarious liability. We discuss these topics as well as takeaways to mitigate risk, thus reducing unnecessary clinician anxiety, promoting professional development, and optimizing healthcare outcomes.Expert Opinion: MPL risk is modifiable. Strong provider-patient relationships, through effective communication, patient reassurance, and enhanced informed consent, decrease risk, as does thorough documentation. Conversely, provider 'defensive' mechanisms intended to decrease MPL risk, including assurance and avoidance behaviors, may paradoxically increase it.
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Affiliation(s)
- John Azizian
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Camellia Dalai
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Megan A Adams
- Center for Clinical Management Research, Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Division of Gastroenterology, University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Andrew Murcia
- California Lawyers Association, Sacramento, CA, USA.,LLM Program, NYU School of Law, New York, NY, USA
| | - James H Tabibian
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Gastroenterology, Olive View-UCLA Medical Center, Sylmar, CA, USA.,GI Expert Opinion, Los Angeles, CA, USA
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Vojtechova G, Ngo O, Grega T, Kmochova K, Voska M, Buckova B, Majek O, Zavoral M, Suchanek S. The conversion factor for predicting adenoma detection rate from polyp detection rate varies according to colonoscopy indication and patient sex. Eur J Cancer Prev 2021; 29:294-302. [PMID: 32543806 DOI: 10.1097/cej.0000000000000558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The adenoma detection rate (ADR) is the primary quality indicator for colonoscopies. The polyp detection rate (PDR) is available from administrative data and does not depend on histology verification. The correlation between PDR and ADR and the ADR/PDR conversion factor in preventive colonoscopies were evaluated. In the prospective study, asymptomatic individuals aged 45-75 years with preventive colonoscopy in 2012-2016 were included. Spearman's correlation coefficient was used to assess PDR/ADR for each endoscopist. Conversion factor predicting ADR from PDR was obtained by linear regression and subsequently compared with adenoma to polyp detection rate quotient. One thousand six hundred fourteen preventive colonoscopies performed by 16 endoscopists in 8 screening colonoscopy centres in the Czech Republic were analysed. Correlation between PDR and ADR in all preventive colonoscopies was high and statistically significant (Rs 0.82; P < 0.001). There was a strong correlation between PDR and ADR in men (Rs 0.74; P = 0.002) and in screening colonoscopies (Rs 0.85; P < 0.001). The conversion factor to convert ADR from PDR was 0.72 in all preventive colonoscopies, 0.76 in FOBT+ colonoscopies and 0.67 in screening colonoscopies. ADR may be replaced by PDR in the assessment of colonoscopy quality. The value of the conversion factor varies according to colonoscopy indication and gender of examined individuals; in this Czech study, it was 0.72 in all preventive colonoscopies. The minimum requested ADR of 25 % corresponds to a PDR of 35 %, when converted with the appropriate conversion factor.
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Affiliation(s)
- Gabriela Vojtechova
- Department of Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, Prague
| | - Ondrej Ngo
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Grega
- Department of Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, Prague
| | - Klara Kmochova
- Department of Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, Prague
| | - Michal Voska
- Department of Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, Prague
| | - Barbora Buckova
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondrej Majek
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslav Zavoral
- Department of Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, Prague
| | - Stepan Suchanek
- Department of Medicine, 1st Faculty of Medicine, Charles University, Military University Hospital, Prague
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The potential of deep learning for gastrointestinal endoscopy—a disruptive new technology. Artif Intell Med 2021. [DOI: 10.1016/b978-0-12-821259-2.00012-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Abstract
BACKGROUND Colonoscopy performance by gastroenterologists has been shown to be associated with lower rates of developing interval colorectal cancer. However, it is unclear if this difference among specialists stems from a difference in meeting colonoscopy quality indicators. OBJECTIVE The purpose of this study is to determine and compare the rates of colonoscopy quality indicators between different specialties. DESIGN This is a cohort study of patients undergoing screening colonoscopy investigating quality metrics as compared by the proceduralist specialty. SETTING All screening colonoscopies performed at the Cleveland Clinic between 2012 and 2014 were followed by manual chart review. PATIENTS Average-risk patients, ≥50 years of age, who had a complete screening colonoscopy were included. MAIN OUTCOME MEASURES Adenoma detection rate, cecal intubation rate, withdrawal time, and other nonestablished overall and segment-specific rates were calculated and compared using t tests. RESULTS A total of 4151 patients were included in the analysis. Colonoscopies were performed by 54 (64.3%) gastroenterologists, 21 (25%) colorectal surgeons, and 9 (10.7%) general surgeons. Gastroenterologists had the highest overall adenoma detection rate (28.6 ± 1.2; p < 0.001), followed by colorectal surgeons (24.3 ± 1.5) and general surgeons (18.4 ± 2.3), as well as the highest adenoma detection rate in men (34.7 ± 1.3; p < 0.001), followed by colorectal surgeons (28.2 ± 1.6) and general surgeons (23.7 ± 2.6). Similarly, gastroenterologists had the highest adenoma detection rate in women (24.3 ± 1.1; p < 0.001), followed by colorectal surgeons (21.6 ± 1.4) and general surgeons (12.9 ± 2.0). Withdrawal time was the longest among general surgeons (11.1 ± 5.5; p = 0.041), followed by colorectal surgeons (10.94 ± 5.2) and gastroenterologists (10.16 ± 1.26). LIMITATIONS We could not adjust for some procedure-related details such as retroflexion in the right colon and the use of end-of-scope devices. CONCLUSIONS In this study, only gastroenterologists met the currently accepted overall and sex-specific adenoma detection rate benchmarks. They also outperformed nongastroenterologists in many other nonestablished quality metrics. See Video Abstract at http://links.lww.com/DCR/B232. CALIDAD DE LA COLONOSCOPIA UNA COMPARACIÓN ENTRE GASTROENTERÓLOGOS Y NO GASTROENTERÓLOGOS: Se ha demostrado que el rendimiento de la colonoscopia por parte de los gastroenterólogos, se asocia con tasas más bajas de cáncer colorrectal en intervalos de desarrollo. Sin embargo, no está claro si esta diferencia entre especialistas, se deriva de una diferencia en el cumplimiento de los indicadores de calidad de la colonoscopia.El propósito del estudio, es determinar y comparar las tasas de indicadores de calidad de colonoscopia entre diferentes especialidades.Este es un estudio de cohorte de pacientes sometidos a una colonoscopia de detección, que investiga métricas de calidad en comparación con la especialidad de procesos.Todas las colonoscopias de detección realizadas en la Clínica Cleveland entre 2012 y 2014, fueron seguidas por una revisión manual del expediente.Pacientes de riesgo promedio, ≥50 años de edad que se sometieron a una colonoscopia de detección completa.La tasa de detección de adenomas, tasa de intubación cecal, tiempo de retirada y otras tasas generales y específicas de segmento no establecidas, se calcularon y compararon usando pruebas t.Un total de 4,151 pacientes fueron incluidos en el análisis. Las colonoscopias fueron realizadas por 54 (64.3%) gastroenterólogos, 21 (25%) cirujanos colorrectales y 9 (10.7%) cirujanos generales. Los gastroenterólogos tuvieron la tasa de detección más alta de adenomas en general (28.6 ± 1.2; p < 0.001), seguidos por los cirujanos colorrectales (24.3 ± 1.5) y los cirujanos generales (18.4 ± 2.3), así como la tasa de detección más alta de adenoma en hombres (34.7 ± 1.3; p < 0.001) seguido por cirujanos colorrectales (28.2 ± 1.6) y cirujanos generales (23.7 ± 2.6). Del mismo modo, los gastroenterólogos tuvieron la tasa más alta de detección de adenoma en mujeres (24.3 ± 1.1; p < 0.001), seguidos por los cirujanos colorrectales (21.6 ± 1.4) y los cirujanos generales (12.9 ± 2.0). El tiempo de extracción fue el más largo entre los cirujanos generales (11.1 ± 5.5; p = 0.041) seguido por los cirujanos colorrectales (10.94 ± 5.2) y los gastroenterólogos (10.16 ± 1.26).No pudimos ajustar algunos detalles relacionados con el procedimiento, tales como la retroflexión en el colon derecho y el uso de accesorios endoscópicos.En este estudio, solo los gastroenterólogos cumplieron con los índices de referencia actualmente aceptados, de detección de adenomas en general y específicas de género. También superaron a los no gastroenterólogos en muchas otras métricas no establecidas de calidad. Consulte Video Resumen en http://links.lww.com/DCR/B232. (Traducción-Dr. Fidel Ruiz Healy).
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Detection Measures for Colonoscopy: Considerations On the Adenoma Detection Rate, Recommended Detection Thresholds, Withdrawal Times, and Potential Updates to Measures. J Clin Gastroenterol 2020; 54:130-135. [PMID: 31851104 DOI: 10.1097/mcg.0000000000001301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The adenoma detection rate (ADR) was first proposed by the US Multi-Society Task Force on Colorectal Cancer in 2002 and, subsequently, has been validated as a strong predictor of colorectal cancer risk after colonoscopy. ADR is now widely considered the most important quality measure in colonoscopy. ADR is a surrogate for missed lesions and for cancer incidence after colonoscopy. ADR has weaknesses, and multiple other detection targets have been evaluated as alternatives. This review discusses the history of ADR, the strength and weaknesses of ADR, and proposed alternatives to ADR. Of the alternatives, adenomas per colonoscopy has the most advantages with limited disadvantages relative to ADR and has some potential to eventually replace ADR.
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10
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Baker FA, Mari A, Hosadurg D, Suki M, Ovadia B, Gal O, Kopelamn Y. The impact of colonoscopy indication on polyp detection rate. Ann Gastroenterol 2019; 32:278-282. [PMID: 31040625 PMCID: PMC6479646 DOI: 10.20524/aog.2019.0374] [Citation(s) in RCA: 5] [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: 01/22/2019] [Accepted: 03/11/2019] [Indexed: 12/30/2022] Open
Abstract
Background Adenoma/polyp detection rates are considered to be among the most important quality indicators of colonoscopy and are key measures of a quality procedure. However, they are designed for use in the screening setting and are not amenable to other colonoscopy indications. Little is known about their significance in other colonoscopy indications. We aimed to evaluate the impact of the various indications on polyp detection rate (PDR). Methods This was a retrospective, single-center study. Electronic reports of index colonoscopy procedures with adequate bowel preparation over a 10-year period were reviewed. Patients were divided into 7 groups based on the study indication. PDR was determined for each group and was compared to that of a control group, the screening indication group. Adjustment was made for potential confounders such as age, sex, and procedural setting. Results A total of 13,054 patients were considered suitable for the study. PDR was greatest in the positive fecal occult blood test group, with a value of 33.1% (P<0.01). Overall, the remaining groups showed similar PDRs compared with screening (22.1% vs. 20.4%; P=0.15). This trend persisted in a multivariate analysis, which showed the odds ratio in the positive fecal occult blood test group to be significantly higher, with a value of 1.955 (1.759-2.172, P<0.001) compared with the screening group. Conclusion PDR was highest for the positive fecal occult blood test indication, but was not affected significantly by most indications. Further randomized studies are warranted to confirm these findings and help calculate recommended thresholds for "overall" PDR.
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Affiliation(s)
- Fadi Abu Baker
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel; Affiliated to the Technion Faculty of Medicine, Haifa, Israel (Fadi Abu Baker, Muhammed Suki, Baruch Ovadia, Oren Gal, Yael Kopelamn)
| | - Amir Mari
- Department of Gastroenterology, Nazareth EMMS Hospital; Affiliated with the Faculty of Medicine, Bar Illan University (Amir Mari)
| | | | - Muhammed Suki
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel; Affiliated to the Technion Faculty of Medicine, Haifa, Israel (Fadi Abu Baker, Muhammed Suki, Baruch Ovadia, Oren Gal, Yael Kopelamn)
| | - Baruch Ovadia
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel; Affiliated to the Technion Faculty of Medicine, Haifa, Israel (Fadi Abu Baker, Muhammed Suki, Baruch Ovadia, Oren Gal, Yael Kopelamn)
| | - Oren Gal
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel; Affiliated to the Technion Faculty of Medicine, Haifa, Israel (Fadi Abu Baker, Muhammed Suki, Baruch Ovadia, Oren Gal, Yael Kopelamn)
| | - Yael Kopelamn
- Department of Gastroenterology and Hepatology, Hillel Yaffe Medical Center, Hadera, Israel; Affiliated to the Technion Faculty of Medicine, Haifa, Israel (Fadi Abu Baker, Muhammed Suki, Baruch Ovadia, Oren Gal, Yael Kopelamn)
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Segal JP, Kanagasundaram C, Mills P, Bassett P, Greenfield SM. Polyp detection rate: does length matter? Frontline Gastroenterol 2019; 10:107-112. [PMID: 31205648 PMCID: PMC6540303 DOI: 10.1136/flgastro-2017-100945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 06/20/2018] [Accepted: 07/09/2018] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Polyp detection rate is a surrogate marker for adenoma detection rate and therefore a surrogate marker of quality colonoscopy. To our knowledge, this is the first study that compares distance from the monitor to the endoscopist on polyp detection rate. METHODS This was a retrospective study comparing polyp detection rate across two different endoscopy room set-ups. All colonoscopies performed between December 2013 and November 2014 were retrieved. The difference in the room set-up was the distance from the endoscopist to the endoscopy monitor. Room A had a distance of 219 cm and Room B had 147 cm. We used two identical rooms, C and D, as a control arm with a distance of 190 cm between the endoscopist and the monitor. RESULTS There were significant differences in polyp detection rates between Room A and Room B in the bowel cancer screening lists. For these lists, the room with the closest distance from the endoscopist to the monitor (147 cm) had a statistically significant higher polyp detection rate than the room that had a further monitor to endoscopist distance of 219 cm (p<0.0006) and a trend towards a higher polyp detection rate compared with the room where the distance between the monitor and the endoscopist was 190 cm (p=0.08). This effect was not noticed across the service lists. CONCLUSIONS This study has suggested that the distance from the endoscopist to the monitor can affect polyp detection rate. It appears that for bowel cancer screening lists, the further the endoscopist from the monitor the lower their polyp detection rate.
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Affiliation(s)
- Jonathan P Segal
- Department of Gastroenterology, St Mark’s Hospital, Harrow, UK,Department of Surgery and Cancer, Imperial College, London, UK
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12
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Gessl I, Waldmann E, Penz D, Majcher B, Dokladanska A, Hinterberger A, Szymanska A, Ferlitsch A, Trauner M, Ferlitsch M. Evaluation of adenomas per colonoscopy and adenomas per positive participant as new quality parameters in screening colonoscopy. Gastrointest Endosc 2019; 89:496-502. [PMID: 30138613 DOI: 10.1016/j.gie.2018.08.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 08/04/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The primary aim of this study was to evaluate adenomas per positive participant (APP) and adenomas per colonoscopy (APC) as new quality parameters in screening colonoscopy. Furthermore, we wanted to assess whether these parameters differ depending on the setting or profession. METHODS Colonoscopy records were obtained from the database of the Austrian certificate of quality for screening colonoscopy. The Spearman correlation was calculated to compare the adenoma detection rate (ADR), APC, APP, and advanced ADR. The parameters were compared between surgeons and internists and between private practices and hospitals by using the t test. RESULTS A total of 44,142 colonoscopies performed by 202 endoscopists were included. APC showed a strong correlation with ADR (r = 0.94; P < .01), and both showed a similar correlation with the advanced ADR (ADR: r = 0.47; P < 0.01, APC: r = 0.46; P < .01). APP showed weaker correlations compared with all other parameters (ADR: r = 0.36; P < .01; advanced ADR: r = 0.19; P < .01). Private practices did not differ in ADR, APP or APC from hospitals. Among endoscopists with ADRs of ≥25%, 7 (10.3%) had an APP in the lowest quartile, whereas no endoscopists had an APC in the lowest quartile. CONCLUSIONS APC did not reveal additional information to ADR, and thus there is no need to use it instead of or additionally to ADR. Although the APP identifies endoscopists who find few adenomas per procedure despite acceptable ADRs, this additional information might not be important in regard to sufficient colorectal cancer prevention, because these endoscopists still had high advanced ADRs.
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Affiliation(s)
- Irina Gessl
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Elisabeth Waldmann
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Daniela Penz
- Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Barbara Majcher
- Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Angelika Dokladanska
- Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Anna Hinterberger
- Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Aleksandra Szymanska
- Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Arnulf Ferlitsch
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
| | - Monika Ferlitsch
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Austria Society of Gastroenterology and Hepatology: quality assurance working group, Vienna, Austria
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Maida M, Morreale G, Sinagra E, Ianiro G, Margherita V, Cirrone Cipolla A, Camilleri S. Quality measures improving endoscopic screening of colorectal cancer: a review of the literature. Expert Rev Anticancer Ther 2019; 19:223-235. [PMID: 30614284 DOI: 10.1080/14737140.2019.1565999] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is a major health-care problem all over the world and CRC screening is effective in reducing mortality and increasing the 5-year survival. Colonoscopy has a central role in CRC screening. It can be performed as a primary test, as a recall policy after a positive result of another screening test, and for surveillance. Since effectiveness of endoscopic screening depends on adequate detection and removal of colonic polyps, consistent quality measures, which are useful in enhancing the diagnostic yield of examination, are essential. Areas covered: The aim of this review is to analyze current evidence from literature supporting quality measures able to refine endoscopic screening of colorectal cancer. Expert commentary: Quality measures namely a) time slot allotted to colonoscopy, b) assessment of indication, c) bowel preparation, d) Cecal intubation, e) withdrawal time, f) adenoma detection rate, g) proper management of lesions (polypectomy technique, polyps retrieval rate and tattooing of resection sites), and h) adequate follow-up intervals play a key role in identifying malignant and at-risk lesions and improving the outcome of screening. Adherence to these quality measures is critical to maximize the effectiveness of CRC screening, as well as, a proper technique of colonoscopy and a quality report of the procedure. Among all recommended measures, adenoma detection rate is the most important and must be kept above the recommended quality threshold by all physicians practicing in the setting of screening.
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Affiliation(s)
- Marcello Maida
- a Section of Gastroenterology , S.Elia - Raimondi Hospital , Caltanissetta , Italy
| | - Gaetano Morreale
- a Section of Gastroenterology , S.Elia - Raimondi Hospital , Caltanissetta , Italy
| | - Emanuele Sinagra
- b Gastroenterology and Endoscopy Unit , Fondazione Istituto San Raffaele Giglio , Cefalù , Italy
| | - Gianluca Ianiro
- c Internal Medicine, Gastroenterology & Liver Unit , Università Cattolica Sacro Cuore , Rome , Italy
| | - Vito Margherita
- d Section of Public Health Epidemiology and Preventive Medicine , S.Elia-Raimondi Hospital , Caltanissetta , Italy
| | - Alfonso Cirrone Cipolla
- d Section of Public Health Epidemiology and Preventive Medicine , S.Elia-Raimondi Hospital , Caltanissetta , Italy
| | - Salvatore Camilleri
- a Section of Gastroenterology , S.Elia - Raimondi Hospital , Caltanissetta , Italy
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Popa P, Gheonea DI, Săftoiu A, Calița M. No Interval Cancers in Endoscopic Practice. CURRENT HEALTH SCIENCES JOURNAL 2019; 45:5-18. [PMID: 31297257 PMCID: PMC6592672 DOI: 10.12865/chsj.45.01.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 03/12/2019] [Indexed: 11/18/2022]
Abstract
Colonoscopy is long time the most preferred method for CRC screening along with diagnosis and treatment for a range of colon diseases. Based on its difficulty in visualizing precursor CRC lesions, mostly those located on the right colon, this method can be subject of improvement. The colonoscopy quality can be influenced by many factors such as colon preparation, retraction time, the colonoscopists medical training and knowledges as well as the performance of endoscopy equipment. The bad quality of colonoscopy will result in the emergence of interval cancers defined, based on the author, as cancers that appear at 3-5 years up to 10 years from the colonoscopy procedure. Interval cancers have predominantly incriminated both the colonoscopy quality and the clinician competences and less the tumor biology. Subsequently there were set quality indicators of colonoscopy in order to raise the quality of the exploration. Among the important indicators, proving their utility in studies, the ADR (adenoma detection rate) is most commonly used along with PDR (polyp detection rate) and APC (adenoma per colonoscopy). Following the purpose of obtaining a higher colonoscopy quality the medical units should keep in check all indicators. Furthermore, there should be an active involvement in an additional training of non-conforming medical personnel or even restrain of practice, given the medical legal actions that have interval cancers as a main cause.
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Affiliation(s)
- P Popa
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - D I Gheonea
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - A Săftoiu
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - M Calița
- Department of Gastroenterology, Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
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15
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Abu Baker F, Mari A, Feldman D, Suki M, Gal O, Kopelman Y. Melanosis Coli: A Helpful Contrast Effect or a Harmful Pigmentation? CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2018; 11:1179552218817321. [PMID: 30574001 PMCID: PMC6299301 DOI: 10.1177/1179552218817321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 11/09/2018] [Indexed: 01/17/2023]
Abstract
Background Melanosis coli, a brown discoloration of colonic mucosa, is considered as a benign condition mainly observed in patients under chronic anthranoid laxatives. Recent data link this condition with an increased adenoma detection rate. Moreover, its tumorigenic potential and possible association with the development of colorectal cancer remains uncertain. We conducted this study to compare the polyp detection rate and colorectal cancer diagnosis in patients with melanosis against matched control group without melanosis. Patients and methods A retrospective single-center study. Patients diagnosed with melanosis coli on colonoscopy over a 15-year period were included. Each melanosis coli patient was matched with three controls by age, gender, setting (inpatient/outpatient), and procedure's indication. Polyp detection rate and diagnosis of colorectal cancer were recorded and compared between the groups before and after adjustment for bowel preparation. Results A cohort of 718 patients with melanosis and 2154 controls were included. The polyp detection rates were 33.4% and 21.8% of melanosis and control groups, respectively (P < .001). Melanosis coli, however, was associated with less diagnosis of colorectal cancer than controls (0.3% vs 3.9%; P < .001). In multivariate analysis, melanosis diagnosis on endoscopy was significantly associated with higher polyp detection rate (odds ratio [OR] = 1.986, 95% confidence interval [CI]: 1.626-2.425; P value < .01). Conclusions Melanosis coli is not associated with increased diagnosis of colorectal cancer. It is associated, however, with enhanced polyp detection likely due to chromo-endoscopy-like effect.
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Affiliation(s)
- Fadi Abu Baker
- Fadi Abu Baker, Department of Gastroenterology and Hepatology, Hillel Yaffe Medical center, Technion Faculty of Medicine, Hashalom st., Hadera 38100, Israel.
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16
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Carbon Dioxide Insufflation Increases Colonoscopic Adenoma Detection Rate Compared With Air Insufflation. J Clin Gastroenterol 2018. [PMID: 29521725 DOI: 10.1097/mcg.0000000000001003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
GOALS To determine the effect of carbon dioxide insufflation on the most important outcome measure of colonoscopic quality: adenoma detection rate (ADR). BACKGROUND Bowel cancer is the second most common cause of cancer deaths in males and females in Australia. Carbon dioxide has in recent times become the insufflation methodology of choice for screening colonoscopy for bowel cancer, as this has been shown to have significant advantages when compared with traditional air insufflation. STUDY Endoscopies performed over a period of 9 months immediately before and after the implementation of carbon dioxide insufflation at endoscopy centers were eligible for inclusion. RESULTS The difference in ADR between the carbon dioxide and air insufflation methods was statistically significant, with an increased ADR in the carbon dioxide group. The superiority of carbon dioxide insufflation was sustained with a logistic regression model, which showed ADR was significantly impacted by insufflation method. CONCLUSIONS Carbon dioxide insufflation is known to reduce abdominal pain, postprocedural duration of abdominal pain, abdominal distension, and analgesic requirements. This study represents for the first time the beneficial effect of carbon dioxide insufflation upon the key quality colonoscopy indicator of ADR.
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Kane SV, Chandrasekhara V, Sedlack RE, Buttar NS. Credentialing for Endoscopic Practice: The Mayo Clinic Model. Clin Gastroenterol Hepatol 2018; 16:1370-1373.e1. [PMID: 29913274 DOI: 10.1016/j.cgh.2018.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Sunanda V Kane
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota.
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Robert E Sedlack
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Navtej S Buttar
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
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18
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Zago RDR, Popoutchi P, Santana Nova da Costa L, Averbach M. Post-polypectomy surveillance interval based on flexible spectral color imaging enhancement (FICE) with magnifying zoom imaging for optical biopsy. Endosc Int Open 2018; 6:E1051-E1058. [PMID: 30105293 PMCID: PMC6086687 DOI: 10.1055/a-0629-8985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 03/19/2018] [Indexed: 10/27/2022] Open
Abstract
Abstract
Background and study aims Post-polypectomy surveillance interval (SI) is determined based on the number, size, and histology of colorectal polyps. Electronic chromoendoscopy in association with magnifying imaging colonoscopy allows “in vivo” polyp histology prediction. Colorectal polyps ≤ 5 mm can be resected and discarded without pathologic assessment if the endoscopic technology when used with high confidence provides ≥ 90 % agreement between the post-polypectomy SI and the SI based on pathological assessment. The aim of this study was to evaluate the agreement between the post-polypectomy SI based on flexible spectral color imaging enhancement (FICE) chromoendoscopy in association with magnified imaging and the pathology-based SI.
Patients and methods Each diagnosed colorectal polyp received a histology prediction (neoplastic or non-neoplastic) based on the FICE capillary-vessel pattern classification. Each prediction was classified as high or low confidence. SI based on the FICE prediction was compared to the pathology-based SI recommendation according to the US Multi-Society Task Force on Colorectal Cancer guideline. Sensitivity, specificity and accuracy of FICE in diagnosing neoplastic lesions were compared with the pathology assessment. Interobserver and intraobserver agreement for FICE-based SI predictions was evaluated using the kappa coefficient.
Results A total of 267 polyps had histology prediction assessed with high confidence in 136 patients. Sensitivity of FICE was 98.7 % (95 % CI: 93.5 – 99.3) and specificity was 62.5 % (95 % CI: 43.6 – 78.9). Prediction accuracy was 94.4 % (95 % CI: 88.6 – 96 – 1) in differentiating between neoplastic and non-neoplastic lesions. Therefore, magnifying FICE colonoscopy-based SI recommendation was consistent with pathological assessment in 88.3 % of general cases (95 % CI: 82.1 – 92.6) and in 89.7 % (95 % CI: 83 – 94.5) of the high-confidence evaluation cases. The intraobserver agreement value for FICE-based SI predictions was 0.87 (high-confidence evaluations), and the interobserver agreement values were 0.78 (high- and low-confidence evaluations) and 0.82 (high-confidence evaluations) (95 % CI: 0.79 – 0.95).
Conclusions FICE-based SI demonstrated 89.7 % concordance with the pathology-based SI.
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Affiliation(s)
- Rodrigo de Rezende Zago
- Hospital Sírio-Libanês, São Paulo, Brazil,Corresponding author Rodrigo de Rezende Zago Hospital Sírio-LibanêsEndoscopy CenterRua D. Adma Jafet, 115Bela Vista, São Paulo – SP, Brazil 01307-000+55 11 3231-0800
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Pathirana IN, Albert DM, Young PE, Womeldorph CM. Colorectal Cancer Screening: a North American Point of View. CURRENT COLORECTAL CANCER REPORTS 2016; 12:241-250. [DOI: 10.1007/s11888-016-0330-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Yoon JY, Cha JM. Can We Measure the Learning Curve of Colonoscopy Using Polyp Detection Rate? Clin Endosc 2016; 49:6-7. [PMID: 26855916 PMCID: PMC4743721 DOI: 10.5946/ce.2016.49.1.6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 12/27/2015] [Indexed: 12/03/2022] Open
Affiliation(s)
- Jin Young Yoon
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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22
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Abstract
Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.
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Affiliation(s)
- Crispin J Corte
- Department of Gastroenterology, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Rupert W Leong
- Department of Gastroenterology, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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Marcondes FO, Dean KM, Schoen RE, Leffler DA, Rose S, Morris M, Mehrotra A. The impact of exclusion criteria on a physician's adenoma detection rate. Gastrointest Endosc 2015; 82:668-75. [PMID: 26385275 PMCID: PMC4575765 DOI: 10.1016/j.gie.2014.12.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/21/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The adenoma detection rate (ADR) is a validated and widely used measure of colonoscopy quality. There is uncertainty in the published literature as to which colonoscopy examinations should be excluded when measuring a physician's ADR. OBJECTIVE To examine the impact of varying the colonoscopy exclusion criteria on physician ADR. DESIGN We applied different exclusion criteria used in 30 previous studies to a dataset of endoscopy and pathology reports. Under each exclusion criterion, we calculated physician ADR. SETTING A private practice colonoscopy center affiliated with the University of Illinois College of Medicine. PATIENTS Data on 20,040 colonoscopy examinations performed by 11 gastroenterologists from July 2009 to May 2013 and associated pathology notes. MAIN OUTCOME MEASUREMENTS ADRs across all colonoscopy examinations, each physician's ADR, and ADR ranking. RESULTS There were 28 different exclusion criteria used when measuring the ADR. Each study used a different combination of these exclusion criteria. The proportion of all colonoscopy examinations in the dataset excluded under these combinations of exclusion criteria ranged from 0% to 92.2%. The mean ADR across all colonoscopy examinations was 39.1%. The change in mean ADR after applying the 28 exclusion criteria ranged from -5.5 to +3.0 percentage points. However, the exclusion criteria affected each physician's ADR relatively equally, and therefore physicians' rankings via the ADR were stable. LIMITATIONS ADR assessment was limited to a single private endoscopy center. CONCLUSION There is wide variation in the exclusion criteria used when measuring the ADR. Although these exclusion criteria can affect overall ADRs, the relative rankings of physicians by ADR were stable. A consensus definition of which exclusion criteria are applied when measuring ADR is needed.
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Affiliation(s)
| | | | | | | | - Sherri Rose
- Harvard Medical School, Boston, Massachusetts
| | | | - Ateev Mehrotra
- Harvard Medical School, Boston, Massachusetts,Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Robertson DJ, Kaminski MF, Bretthauer M. Effectiveness, training and quality assurance of colonoscopy screening for colorectal cancer. Gut 2015; 64:982-90. [PMID: 25804631 DOI: 10.1136/gutjnl-2014-308076] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/07/2015] [Indexed: 12/14/2022]
Abstract
Screening for colorectal cancer has been proven to be effective in reducing colorectal cancer incidence and mortality. While the precise benefit of screening exclusively by colonoscopy is not yet known, unarguably, the exam is central to the success of any screening programme. The test affords the opportunity to detect and resect neoplasia across the entire large bowel and is the definitive examination when other screening tests are positive. However, colonoscopy is invasive and often requires sedation as well as extensive bowel preparation, all of which puts the patient at risk. Furthermore, the test can technically be demanding and, unarguably, there is variation in how it is performed. This variation in performance has now been definitively linked to important outcome measures. For example, interval cancers are more common in low adenoma detectors as compared with high adenoma detectors. This review outlines the most current thinking regarding the effectiveness of colonoscopy as a screening tool. It also outlines key concepts to optimise its performance through robust quality assurance programmes and high-quality training.
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Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, USA Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michal F Kaminski
- Department of Gastroenterology and Hepatology, Medical Center for Postgraduate Education, Warsaw, Poland Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Institute of Health and Society, University of Oslo, Oslo, Norway Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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Rozeboom ED, Broeders IAMJ, Fockens P. Feasibility of joystick guided colonoscopy. J Robot Surg 2015; 9:173-8. [PMID: 26531196 PMCID: PMC4540779 DOI: 10.1007/s11701-015-0511-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 04/28/2015] [Indexed: 12/11/2022]
Abstract
The flexible endoscope is increasingly used to perform minimal invasive interventions. A novel add-on platform allows single-person control of both endoscope and instrument at the site of intervention. The setup changes the current routine of handling the endoscope. This study aims to determine if the platform allows effective and efficient manipulation to position the endoscope at potential intervention sites throughout the bowel. Five experts in flexible endoscopy first performed three colonoscopies on a computer simulator using the conventional angulation wheels. Next they trained with the joystick interface to achieve their personal level of intubation time with low pain score. 14 PhD students (novices) without hands-on experience performed the same colonoscopy case using either the conventional angulation wheels or joystick interface. Both novice groups trained to gain the average expert level. The cecal intubation time, pain score and visualization performance (% of bowel wall) were recorded. All experts reached their personal intubation time in 6 ± 6 sessions. Three experts completed their learning curve with low pain score in 8 ± 6 sessions. The novices required 11 ± 6 sessions using conventional angulation wheels, and 12 ± 6 sessions using the joystick interface. There was no difference in the visualization performance between the novice and between the expert groups. This study shows that the add-on platform enables endoscope manipulation required to perform colonoscopy. Experts need only a relatively short training period. Novices are as effective and as efficient in endoscope manipulation when comparing the add-on platform with conventional endoscope control.
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Affiliation(s)
- Esther D Rozeboom
- Department of Robotics and Mechatronics, Faculty of Electrical Engineering, University of Twente, P.O. Box 217, 7500 AE, Enschede, The Netherlands.
| | - Ivo A M J Broeders
- Department of Robotics and Mechatronics, University of Twente, Enschede, The Netherlands. .,Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands.
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Atia MA, Ramirez FC, Gurudu SR. Quality monitoring in colonoscopy: Time to act. World J Gastrointest Endosc 2015; 7:328-335. [PMID: 25901211 PMCID: PMC4400621 DOI: 10.4253/wjge.v7.i4.328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 01/03/2015] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Colonoscopy is the gold standard test for colorectal cancer screening. The primary advantage of colonoscopy as opposed to other screening modalities is the ability to provide therapy by removal of precancerous lesions at the time of detection. However, colonoscopy may miss clinically important neoplastic polyps. The value of colonoscopy in reducing incidence of colorectal cancer is dependent on many factors including, the patient, provider, and facility level. A high quality examination includes adequate bowel preparation, optimal colonoscopy technique, meticulous inspection during withdrawal, identification of subtle flat lesions, and complete polypectomy. Considerable variation among institutions and endoscopists has been reported in the literature. In attempt to diminish this disparity, various approaches have been advocated to improve the quality of colonoscopy. The overall impact of these interventions is not yet well defined. Implementing optimal education and training and subsequently analyzing the impact of these endeavors in improvement of quality will be essential to augment the utility of colonoscopy for the prevention of colorectal cancer.
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Abstract
Colonoscopy is the cornerstone of colorectal cancer screening programs. There is significant variability in the quality of colonoscopy between endoscopists. Colonoscopy quality assessment tracks various metrics to improve the effectiveness of colonoscopy, aiming at reducing the incidence and mortality from colorectal cancer. Adenoma detection rate is the prime metric, because it is associated with the risk of interval cancer. Implementing processes to measure and improve the adenoma detection rate is essential to improve the quality of colonoscopy.
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Affiliation(s)
- Nabil F Fayad
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, suite 225, Indianapolis, IN 46202, USA; Section of Gastroenterology and Hepatology, Medicine Department, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Room 111G, Indianapolis, IN 46202, USA.
| | - Charles J Kahi
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 702 Rotary Circle, suite 225, Indianapolis, IN 46202, USA; Section of Gastroenterology and Hepatology, Medicine Department, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Room 111G, Indianapolis, IN 46202, USA
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Abstract
Adenoma detection rate (ADR) has emerged as a key quality metric for colonoscopy. Despite limitations, its major strength is based on its proven correlation with interval colorectal cancer. This has prompted extensive efforts to identify factors and interventions that improve ADR. Potentially modifiable factors that may influence ADR can be patient related (eg, bowel preparation), endoscopist related (eg, withdrawal time, quality of mucosal inspection, additional observers), or procedure related (eg, water infusion, additional examination of right colon, change in position, antispasmodics, colonoscopic equipment, and accessories). Providing endoscopists with educational material and/or feedback also seems to improve ADR.
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Sung JJY, Ng SC, Chan FKL, Chiu HM, Kim HS, Matsuda T, Ng SSM, Lau JYW, Zheng S, Adler S, Reddy N, Yeoh KG, Tsoi KKF, Ching JYL, Kuipers EJ, Rabeneck L, Young GP, Steele RJ, Lieberman D, Goh KL. An updated Asia Pacific Consensus Recommendations on colorectal cancer screening. Gut 2015; 64:121-32. [PMID: 24647008 DOI: 10.1136/gutjnl-2013-306503] [Citation(s) in RCA: 302] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Since the publication of the first Asia Pacific Consensus on Colorectal Cancer (CRC) in 2008, there are substantial advancements in the science and experience of implementing CRC screening. The Asia Pacific Working Group aimed to provide an updated set of consensus recommendations. DESIGN Members from 14 Asian regions gathered to seek consensus using other national and international guidelines, and recent relevant literature published from 2008 to 2013. A modified Delphi process was adopted to develop the statements. RESULTS Age range for CRC screening is defined as 50-75 years. Advancing age, male, family history of CRC, smoking and obesity are confirmed risk factors for CRC and advanced neoplasia. A risk-stratified scoring system is recommended for selecting high-risk patients for colonoscopy. Quantitative faecal immunochemical test (FIT) instead of guaiac-based faecal occult blood test (gFOBT) is preferred for average-risk subjects. Ancillary methods in colonoscopy, with the exception of chromoendoscopy, have not proven to be superior to high-definition white light endoscopy in identifying adenoma. Quality of colonoscopy should be upheld and quality assurance programme should be in place to audit every aspects of CRC screening. Serrated adenoma is recognised as a risk for interval cancer. There is no consensus on the recruitment of trained endoscopy nurses for CRC screening. CONCLUSIONS Based on recent data on CRC screening, an updated list of recommendations on CRC screening is prepared. These consensus statements will further enhance the implementation of CRC screening in the Asia Pacific region.
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Affiliation(s)
- J J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - S C Ng
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, NT, Hong Kong Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - F K L Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, NT, Hong Kong Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - H M Chiu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - H S Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - T Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - S S M Ng
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - J Y W Lau
- Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - S Zheng
- Cancer Institute, Zhejiang University, Hanggzhou, Zhejiang, China
| | - S Adler
- Division of Gastroenterology, Bikur Holim Hospital, Jerusalem, Israel
| | - N Reddy
- Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, Andhra Pradesh, India
| | - K G Yeoh
- Department of Medicine, Asian Healthcare Foundation, National University of Singapore and Senior Consultant Gastroenterologist, Singapore
| | - K K F Tsoi
- School of Public Health & Primary Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - J Y L Ching
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - E J Kuipers
- Department of Medicine & Therapeutics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - L Rabeneck
- Institute of Clinical Evaluative Sciences, University of Toronto, Ontario, Canada
| | - G P Young
- Department of Gastroenterology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - R J Steele
- Department of Surgery and Molecular Oncology, University of Dundee, Dundee, UK
| | - D Lieberman
- Portland VA Medical Centre, Portland, Oregon, USA
| | - K L Goh
- Department of Gastroenterology and Hepatology, University of Malaya, Kuala Lumpur, Malaysia
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Rex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, Lieb JG, Park WG, Rizk MK, Sawhney MS, Shaheen NJ, Wani S, Weinberg DS. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81:31-53. [PMID: 25480100 DOI: 10.1016/j.gie.2014.07.058] [Citation(s) in RCA: 752] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 07/24/2014] [Indexed: 02/07/2023]
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Fayad NF, Kahi CJ. Quality measures for colonoscopy: a critical evaluation. Clin Gastroenterol Hepatol 2014; 12:1973-80. [PMID: 24095973 DOI: 10.1016/j.cgh.2013.09.052] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 09/25/2013] [Accepted: 09/25/2013] [Indexed: 02/07/2023]
Abstract
In a recent article in The New York Times, "The $2.7 Trillion Medical Bill,"(1) colonoscopy was singled out for its cost. In their response, the leading gastroenterology professional societies highlighted colonoscopy's effectiveness and cost-effectiveness for the prevention of colorectal cancer (CRC). Affirming colonoscopy's central role in CRC prevention, both as a frontline test and as the final common pathway for other CRC screening modalities, requires strategies to measure and improve colonoscopy quality, particularly by controlling operator-dependent factors. Although colonoscopy is a powerful CRC screening test,(2-6) several recent studies have highlighted decreased protection, mainly against right-sided CRC,(5,7-16) an observation that has been linked to performance quality.
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Affiliation(s)
- Nabil F Fayad
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana
| | - Charles J Kahi
- Indiana University School of Medicine, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.
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Sewitch MJ, Jiang M, Fon Sing M, Barkun A, Joseph L. Screening polypectomy rates below quality benchmarks: A prospective study. World J Gastroenterol 2014; 20:16300-16305. [PMID: 25473187 PMCID: PMC4239521 DOI: 10.3748/wjg.v20.i43.16300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 05/05/2014] [Accepted: 06/13/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To estimate and compare sex-specific screening polypectomy rates to quality benchmarks of 40% in men and 30% in women.
METHODS: A prospective cohort study was undertaken of patients aged 50-75, scheduled for colonoscopy, and covered by the Québec universal health insurance plan. Endoscopist and patient questionnaires were used to obtain screening and non-screening colonoscopy indications. Patient self-report was used to obtain history of gastrointestinal conditions/symptoms and prior colonoscopy. Sex-specific polypectomy rates (PRs) and 95%CI were calculated using Bayesian hierarchical logistic regression.
RESULTS: In total, 45 endoscopists and 2134 (mean age = 61, 50% female) of their patients participated. According to patients, screening PRs in males and females were 32.4% (95%CI: 23.8-41.8) and 19.4% (95%CI: 13.1-25.4), respectively. According to endoscopists, screening PRs in males and females were 30.2% (95%CI: 27.0-41.9) and 16.6% (95%CI: 16.3-28.6), respectively. Sex-specific PRs did not meet quality benchmarks at all ages except for: males aged 65-69 (patient screening indication), and males aged 70-74 (endoscopist screening indication). For all patients aged 50-54, none of the CI included the quality benchmarks.
CONCLUSION: Most sex-specific screening PRs in Québec were below quality benchmarks; PRs were especially low for all 50-54 year olds.
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Abstract
BACKGROUND Diverticulosis, a prevalent condition at screening colonoscopy, has been associated with colorectal cancers that develop after a clearing colonoscopy, or interval cancers. AIMS To quantify the overall risk of diverticulosis in the development of interval cancers and examine this association in relevant subgroups. METHODS Using a linked database containing SEER tumor registry data and Medicare claims, we identified patients aged ≥69 years with colorectal cancer who underwent colonoscopy within 6 months of diagnosis. Patients with an additional colonoscopy from 36 to 6 months prior to cancer diagnosis were characterized as having interval cancers. We compared characteristics of patients with interval cancers and detected cancers according to a diagnosis of diverticulosis not associated with a colonoscopy procedure from 1991 through the date of the most recent colonoscopy in both univariate and multivariate models. RESULTS A previous diagnosis of diverticulosis was documented in 14,452 (26.9 %) patients with detected cancers compared to 2,905 (69.3 %) patients with interval cancers (p < 0.001); these results were consistent in multivariable analysis. Moreover, the association was found as well in the proximal colon (OR 2.88, 95 % CI 2.66, 3.12), distal colon (OR 3.56, 95 % CI 3.09, 4.11), and rectum (OR 4.07, 95 % CI 3.34, 4.95). The vast majority of diverticulosis diagnoses were without complications such as hemorrhage or diverticulitis. CONCLUSIONS Diverticulosis was strongly associated with interval colorectal cancers in all segments of the colon. Given its known predominance in the left colon, the findings argue against impaired visualization of lesions at colonoscopy as the only pathogenic factor.
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Gohel TD, Burke CA, Lankaala P, Podugu A, Kiran RP, Thota PN, Lopez R, Sanaka MR. Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist. Clin Gastroenterol Hepatol 2014; 12:1137-42. [PMID: 24315881 DOI: 10.1016/j.cgh.2013.11.023] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 10/29/2013] [Accepted: 11/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The adenoma detection rate (ADR) is an important measure of the quality of colonoscopy; it is associated with interval colorectal cancer and varies among sexes and locations. Recommended indicators of competence for colonoscopy include minimal ADRs >25% for average-risk men and >15% for women. These ADRs are rigorous, so polypectomy detection rate (PR) has been suggested as a surrogate. Colonoscopy is less effective in the proximal colon, where interval cancers are more likely to occur. We compared ADRs and PRs in different segments of colon and between sexes. METHODS We performed a cross-sectional review of findings from 2167 screening colonoscopies performed by 65 endoscopists on average-risk outpatients at the Cleveland Clinic, 2008-2009. We reviewed colonoscopy and pathology reports of randomly selected procedures (mean, 33 ± 16 procedures per endoscopist). We calculated PRs, ADRs, and correlation between PR and ADR for each colon segment and sex. RESULTS The mean overall PR was 42% ± 16.7%, and ADR was 25% ± 3.3%. The correlation between overall ADR and PR was strong (r = 0.80). PR of 40% in men and 30% in women correlated with the established minimum benchmark ADRs of 25% and 15% for men and women, respectively. PR was more strongly correlated with ADR in the proximal colon (r = 0.92) than the distal colon (r = 0.58). The correlation was stronger in men than in women, as well as in the entire colon (r = 0.88 vs 0.75), the proximal colon (r = 0.91 vs 0.87), and the distal colon (r = 0.75 vs 0.55). The advanced ADR was 4% and did not correlate with PR (r = 0.32). CONCLUSIONS On the basis of a review of findings from screening colonoscopies, overall PR correlates with ADR for the entire colon, but PR and ADR correlate most strongly for the proximal colon, where many adenomas can be missed and interval cancers develop. The correlation between PR and ADR is weaker for women than men and for distal colon. If PR is used as a surrogate for ADR, colon location and patient sex should be considered.
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Affiliation(s)
- Tushar D Gohel
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Pavan Lankaala
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Amareshwar Podugu
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ravi Pokala Kiran
- Department of Colorectal Surgery, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Prashanthi N Thota
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Rocio Lopez
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio.
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Tinmouth J, Kennedy EB, Baron D, Burke M, Feinberg S, Gould M, Baxter N, Lewis N. Colonoscopy quality assurance in Ontario: Systematic review and clinical practice guideline. Can J Gastroenterol Hepatol 2014; 28:251-74. [PMID: 24839621 PMCID: PMC4049257 DOI: 10.1155/2014/262816] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 02/07/2014] [Indexed: 12/21/2022] Open
Abstract
Colonoscopy is fundamental to the diagnosis and management of digestive diseases and plays a key role in colorectal cancer (CRC) screening and diagnosis. Therefore, it is important to ensure that colonoscopy is of high quality. The present guidance document updates the evidence and recommendations in Cancer Care Ontario's 2007 Colonoscopy Standards, and was conducted under the aegis of the Program in Evidence-Based Care. It is intended to support quality improvement for colonoscopies for all indications, including follow-up to a positive fecal occult blood test, screening for individuals who have a family history of CRC and those at average risk, investigation for symptomatic patients, and surveillance of those with a history of adenomatous polyps or CRC. A systematic review was performed to evaluate the existing evidence concerning the following three key aspects of colonoscopy: physician endoscopist training and maintenance of competency; institutional quality assurance parameters; and colonoscopy quality indicators and auditable outcomes. Where appropriate, indicators were designated quality indicators (where there was sufficient evidence to recommend a specific target) and auditable outcomes (insufficient evidence to recommend a specific target, but which should be monitored for quality assurance purposes). The guidance document may be used to support colonoscopy quality assurance programs to improve the quality of colonoscopy regardless of indication. Improvements in colonoscopy quality are anticipated to improve important outcomes in digestive diseases, such as reduction of the incidence of and mortality from CRC.
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Affiliation(s)
| | - Erin B Kennedy
- Program in Evidence-based Care, McMaster University/Cancer Care Ontario, Hamilton
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Butterly L, Robinson CM, Anderson J, Weiss JE, Goodrich M, Onega TL, Amos CI, Beach ML. Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry. Am J Gastroenterol 2014; 109:417-26. [PMID: 24394752 PMCID: PMC4082336 DOI: 10.1038/ajg.2013.442] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 11/04/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopist's withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection. METHODS We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection. RESULTS Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8-9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase. CONCLUSIONS A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.
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Affiliation(s)
- Lynn Butterly
- Geisel School of Medicine at Dartmouth, Section of Gastroenterology, 46 Centerra Parkway, Evergreen Center, Suite 105, Lebanon, NH 03766, , Phone: 603-653-3427, Fax: 603-650-3415
| | | | - Joseph Anderson
- Geisel School of Medicine at Dartmouth, Department of Medicine and the Dartmouth Institute, VA Medical Center, White River Junction
| | - Julia E. Weiss
- Geisel School of Medicine at Dartmouth, Department of Community & Family Medicine
| | - Martha Goodrich
- Geisel School of Medicine at Dartmouth, Department of Community & Family Medicine
| | - Tracy L. Onega
- Geisel School of Medicine at Dartmouth, Department of Community & Family Medicine and the Dartmouth Institute
| | - Christopher I. Amos
- Geisel School of Medicine at Dartmouth, Department of Community and Family Medicine
| | - Michael L. Beach
- Geisel School of Medicine at Dartmouth, Departments of Anesthesiology and Community & Family Medicine
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Denis B, Sauleau EA, Gendre I, Exbrayat C, Piette C, Dancourt V, Foll Y, Ait Hadad H, Bailly L, Perrin P. The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: a population-based cohort study. Dig Liver Dis 2014; 46:176-81. [PMID: 24054769 DOI: 10.1016/j.dld.2013.08.129] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/05/2013] [Accepted: 08/07/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Measuring adenoma detection is a priority in the quality improvement process for colonoscopy. Our aim was (1) to determine the most appropriate quality indicators to assess the neoplasia yield of colonoscopy and (2) to establish benchmark rates for the French colorectal cancer screening programme. METHODS Retrospective study of all colonoscopies performed in average-risk asymptomatic people aged 50-74 years after a positive guaiac faecal occult blood test in eight administrative areas of the French population-based programme. RESULTS We analysed 42,817 colonoscopies performed by 316 gastroenterologists. Endoscopists who had an adenoma detection rate around the benchmark of 35% had a mean number of adenomas per colonoscopy varying between 0.36 and 0.98. 13.9% of endoscopists had a mean number of adenomas above the benchmark of 0.6 and an adenoma detection rate below the benchmark of 35%, or inversely. Correlation was excellent between mean numbers of adenomas and polyps per colonoscopy (Pearson coefficient r=0.90, p<0.0001), better than correlation between mean number of adenomas and adenoma detection rate (r=0.84, p=0.01). CONCLUSION The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy. Benchmark could be established at 0.6 in the French programme.
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Affiliation(s)
- Bernard Denis
- Department of Gastroenterology, Pasteur Hospital, 39 avenue de la Liberté, Colmar, France; Association for Colorectal Cancer Screening in Alsace (ADECA Alsace), 122 rue de Logelbach, Colmar, France.
| | | | - Isabelle Gendre
- Association for Colorectal Cancer Screening in Alsace (ADECA Alsace), 122 rue de Logelbach, Colmar, France
| | - Catherine Exbrayat
- Association for Cancer Screening in Isère (ODLC 38), 19 chemin de la Dhuy - Maupertuis, Meylan, France
| | - Christine Piette
- Association for Cancer Screening in Ille-et-Vilaine (ADECI 35), 7 rue Armand Herpin Lacroix, Rennes, France
| | - Vincent Dancourt
- Association for Cancer Screening in Côte d'Or (ADECA 21), 16 rue Nodot, Dijon, France
| | - Yvon Foll
- Association for Cancer Screening in Finistère (ADEC 29), 1 avenue du Baron Lacrosse, Brest, France
| | - Hamou Ait Hadad
- Association for Cancer Screening in Essonne (ADMC 91), centre médical de Bligny, Courtaboeuf, France
| | - Laurent Bailly
- Association for Cancer Screening in Alpes-Maritimes (APREMAS), 227 avenue de la lanterne, Nice, France
| | - Philippe Perrin
- Association for Colorectal Cancer Screening in Alsace (ADECA Alsace), 122 rue de Logelbach, Colmar, France
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Ravindran NC, Vasilevska-Ristovska J, Coburn NG, Mahar A, Zhang Y, Gunraj N, Sutradhar R, Law CH, Tinmouth J. Location, size, and distance: criteria for quality in esophagogastroduodenos copy reporting for pre-operative gastric cancer evaluation. Surg Endosc 2014; 28:1660-7. [PMID: 24452290 DOI: 10.1007/s00464-013-3367-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 12/01/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is a lack of existing literature regarding the quality of esophagogastroduodenoscopy (EGD) reporting for gastric cancer evaluation. This study aims to determine criteria for quality endoscopic evaluation of gastric cancer in North America by identifying important features of the EGD report for pre-operative evaluation of gastric cancer and assessing inclusion of these features in existing reports. METHODS Semi-structured interviews were conducted with experienced endoscopists from community and academic hospitals affiliated with the University of Toronto to identify essential elements for an EGD report. Then, 225 EGD reports from 2005 to 2008 were evaluated by two trained reviewers for inclusion of recommended EGD report elements and global assessment of report quality and adequacy for surgical planning. RESULTS Essential elements recommended by interviewed endoscopists include tumor size, location, and distance from gastroesophageal junction (GEJ). Approximately 95 % of all reports documented the location of lesions, <5 % documented distance from the GEJ, and <15 % documented tumor size. Overall report quality was rated as excellent for 4-5 % of reports; 20-42 % of all reports were deemed to be adequate for surgical planning. All surgeons interviewed as part of the endoscopist panel indicated that they would repeat the EGD before consulting with patients regarding surgical planning. CONCLUSIONS For pre-operative evaluation of gastric cancer, tumor size, location, and distance from key anatomical landmarks were proposed as essential elements of a quality EGD report. Most of the reviewed reports did not document these elements. Report quality is perceived to be poor and may lead to repeat endoscopy. Developing a standardized EGD reporting format based on inclusion of individual parameters can improve the quality of gastric cancer management.
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Affiliation(s)
- Nikila C Ravindran
- Division of Gastroenterology, St. Michael's Hospital, Toronto, ON, Canada
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Bourikas LA, Tsiamoulos ZP, Haycock A, Thomas-Gibson S, Saunders BP. How we can measure quality in colonoscopy? World J Gastrointest Endosc 2013; 5:468-475. [PMID: 24147190 PMCID: PMC3797899 DOI: 10.4253/wjge.v5.i10.468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/10/2013] [Accepted: 08/17/2013] [Indexed: 02/05/2023] Open
Abstract
Measuring quality is a current need of medical services either to assess their cost-effectiveness or to identify discrepancies requiring refinement. With the advent of bowel cancer screening and increasing patient awareness of bowel symptoms, there has been an unprecedented increase in demand for colonoscopy. Consequently, there is an expanding open-discussion on missed rates of cancer or precancerous polyps during diagnostic/screening colonoscopy and on the rate of adverse events related to therapeutic colonoscopy. Delivering a quality colonoscopy service is therefore a healthcare priority. Colonoscopy is a multi-step process and therefore assessment of all aspects of the procedure must be addressed. Quality in colonoscopy refers to a combination of many patient-centered technical and non-technical skills and knowledge aiming to patient’s safety and satisfaction through a continuous effort for improvement. The benefits of this endless process are hiding behind small details which can eventually make the difference in colonoscopy. Identifying specific quality metrics help to define and shape an optimal service and forms a secure basis of improvement. Τhis paper does not aim to give technical details on how to perform colonoscopy but to summarize what to measure and when, in accordance with the current identified quality indicators and standards for colonoscopy.
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Differences in detection rates of adenomas and serrated polyps in screening versus surveillance colonoscopies, based on the new hampshire colonoscopy registry. Clin Gastroenterol Hepatol 2013; 11:1308-12. [PMID: 23660415 PMCID: PMC3841980 DOI: 10.1016/j.cgh.2013.04.042] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 04/09/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The adenoma detection rate (ADR) is an important quality indicator originally developed for screening colonoscopies. However, it is unclear whether the ADR should be calculated using data from screening and surveillance examinations. The recommended benchmark ADR for screening examinations is 20% (15% for women and 25% for men ≥50 y). There are few data available to compare ADRs from surveillance vs screening colonoscopies. We used a population-based registry to compare ADRs from screening vs surveillance colonoscopies. The serrated polyp detection rate (SDR), a potential new quality indicator, also was examined. METHODS By using data from the statewide New Hampshire Colonoscopy Registry, we excluded incomplete and diagnostic colonoscopies, and those performed in patients with inflammatory bowel disease, familial syndromes, or poor bowel preparation. We calculated the ADR and SDR (number of colonoscopies with at least 1 adenoma or serrated polyp detected, respectively, divided by the number of colonoscopies) from 9100 colonoscopies. The ADR and SDR were compared by colonoscopy indication (screening, surveillance), age at colonoscopy (50-64 y, ≥65 y), and sex. RESULTS The ADR was significantly higher in surveillance colonoscopies (37%) than screening colonoscopies (25%; P < .001). This difference was observed for both sexes and age groups. There was a smaller difference in the SDR of screening (8%) vs surveillance colonoscopies (10%; P < .001). CONCLUSIONS In a population-based study, we found that addition of data from surveillance colonoscopies increased the ADR but had a smaller effect on the SDR. These findings indicate that when calculating ADR as a quality measure, endoscopists should use screening, rather than surveillance colonoscopy, data.
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Abstract
Colonoscopy is an excellent area for quality improvement because it is high volume, has significant associated risk and expense, and there is evidence that variability in its performance affects outcomes. The best end point for validation of quality metrics in colonoscopy is colorectal cancer incidence and mortality, but a more readily accessible metric is the adenoma detection rate. Fourteen quality metrics were proposed in 2006, and these are described in this article. Implementation of quality improvement initiatives involves rapid assessments and changes on an iterative basis, and can be done at the individual, group, or facility level.
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Lee CK, Kim YW, Shim JJ, Jang JY. Prevalence of proximal serrated polyps and conventional adenomas in an asymptomatic average-risk screening population. Gut Liver 2013; 7:524-31. [PMID: 24073309 PMCID: PMC3782666 DOI: 10.5009/gnl.2013.7.5.524] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 11/13/2012] [Accepted: 12/01/2012] [Indexed: 12/22/2022] Open
Abstract
Background/Aims Detection of proximal serrated polyps (PSPs) is increasingly recognized as a new qualitative target for colonoscopy. The aims of this study were to assess the detected prevalence of PSPs and synchronous adenomas in an asymptomatic average-risk screening cohort and to evaluate potential factors associated with detection of PSPs. Methods The study included 1,375 asymptomatic average-risk Korean patients (aged 50 years or older) who underwent screening colonoscopy. In total, 1,710 polyps were evaluated pathologically. Results The overall PSP detection rate (PSPDR) was low at 3.1%, despite high polyp (54.0%) and adenoma detection rates (ADRs, 43.5%). ADR did not correlate with PSPDR, but it was strongly correlated with PDR (r=0.810; p<0.001). Patients with PSPs were more likely to have longer withdrawal time and more proximal colon adenomas than patients without PSPs (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.09 to 1.31; p<0.001) (adjusted OR, 2.03; 95% CI, 1.06 to 3.88; p=0.031, respectively). Conclusions The detected prevalence of PSPs was low (<5%) in an asymptomatic average-risk screening Korean population, despite the high prevalence of conventional adenomas. A longer mucosal inspection of the proximal colon may serve as a practical method to enhance detection of PSPs.
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Affiliation(s)
- Chang Kyun Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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Abstract
OBJECTIVES Little is known about the correlation between the polyp detection rate (PDR) and the adenoma detection rate (ADR) in individual colonic segments. The adenoma-to-polyp detection rate quotient (APDRQ) has been utilized in retrospective study as a constant to estimate ADR from PDR. It has been previously stated that diminutive polyps in the rectum are more likely to be non-adenomatous, compared with more proximal segments, yet the APDRQ uses data from the entire colon. We sought to characterize and compare ADR and PDR in each colonic segment, estimate ADR using the conversion factor, APDRQ, and assess the correlation between estimated and actual ADR for each colonic segment. METHODS As part of a quality improvement program, a retrospective chart review was conducted of all outpatient colonoscopies performed by 20 gastroenterologists between 1 October 2010 and 31 March 2011 at a single academic tertiary-care referral center. PDR, ADR, and the APDRQ were calculated for each gastroenterologist, using data from the entire colon and then for each colonic segment separately. Actual ADR was compared with estimated ADR based on the measured APDRQ. RESULTS During 1,921 colonoscopies, 2,285 polyps were removed; 1,122 (49%) were adenomas. The mean (s.d.) PDR for the group was 49% (12.4%) (range, 16-64%). The mean (s.d.) ADR was 31% (7.4%) (range, 13-42%). PDR and ADR correlated well in segments proximal to the splenic flexure, but diverged in distal segments. ADR was significantly higher in the right colon (17.1%) than in the left (13.5%) (P=0.001). The correlation between estimated and actual ADR using the APDRQ was significantly higher in the right colon (r=0.95 (95% confidence interval (CI), 0.87-0.98)) than in the left (r=0.59 (95% CI, 0.17-0.83)) (P<0.05). CONCLUSIONS Although PDR and ADR correlate well in segments proximal to the splenic flexure, they do not correlate well in the left colon. Caution should be exercised when using PDR as a surrogate for ADR if data from the rectum and sigmoid are included.
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Jiang M, Sewitch MJ, Barkun AN, Joseph L, Hilsden RJ. Endoscopist specialty is associated with colonoscopy quality. BMC Gastroenterol 2013; 13:78. [PMID: 23638769 PMCID: PMC3646699 DOI: 10.1186/1471-230x-13-78] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 04/22/2013] [Indexed: 12/12/2022] Open
Abstract
Background Some studies have shown that endoscopist specialty is associated with colorectal cancers missed by colonoscopy. We sought to examine the relationship between endoscopist specialty and polypectomy rate, a colonoscopy quality indicator. Polypectomy rate is defined as the proportion of colonoscopies that result in the removal of one or more polyps. Methods A cross-sectional study was conducted of endoscopists and their patients from 7 Montreal and 2 Calgary endoscopy clinics. Eligible patients were aged 50–75 and covered by provincial health insurance. A patient questionnaire assessed family history of colorectal cancer, history of large bowel conditions and symptoms, and previous colonoscopy. The outcome, polypectomy status, was obtained from provincial health administrative databases. For each city, Bayesian hierarchical logistic regression was used to estimate the odds ratio for polypectomy comparing surgeons to gastroenterologists. Model covariates included patient age, sex, family history of colorectal cancer, colonoscopy indication, and previous colonoscopy. Results In total, 2,113 and 538 colonoscopies were included from Montreal and Calgary, respectively. Colonoscopies were performed by 38 gastroenterologists and 6 surgeons in Montreal, and by 31 gastroenterologists and 5 surgeons in Calgary. The adjusted odds ratios comparing surgeons to gastroenterologists were 0.48 (95% CI: 0.32–0.71) in Montreal and 0.73 (95% CI: 0.43–1.21) in Calgary. Conclusions An association between endoscopist specialty and polypectomy was observed in both cities after adjusting for patient-level covariates. Results from Montreal suggest that surgeons are half as likely as gastroenterologists to remove polyps, while those from Calgary were associated with a wide, non-significant Bayesian credible interval. However, residual confounding from patient-level variables is possible, and further investigation is required.
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Affiliation(s)
- Mengzhu Jiang
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, 687 Pine Avenue West, V Building, Room V2.15, Montreal, QC H3A 1A1, Canada
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Ekkelenkamp VE, Dowler K, Valori RM, Dunckley P. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013; 19:2355-61. [PMID: 23613629 PMCID: PMC3631987 DOI: 10.3748/wjg.v19.i15.2355] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 12/19/2012] [Accepted: 01/17/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To explore the relationship of patient comfort and experience to commonly used performance indicators for colonoscopy. METHODS All colonoscopies performed in our four endoscopy centres are recorded in two reporting systems that log key performance indicators. From 2008 to 2011, all procedures performed by qualified endoscopists were evaluated; procedures performed by trainees were excluded. The following variables were measured: Caecal intubation rate (CIR), nurse-reported comfort levels (NRCL) on a scale from 1 to 5, polyp detection rate (PDR), patient experience of the procedure (worse than expected, as expected, better than expected), and use of sedation and analgesia. Pearson's correlation coefficient was used to identify relationships between performance indicators. RESULTS A total of 17027 colonoscopies were performed by 23 independent endoscopists between 2008 and 2011. Caecal intubation rate varied from 79.0% to 97.8%, with 18 out of 23 endoscopists achieving a CIR of > 90%. The percentage of patients experiencing significant discomfort during their procedure (defined as NRCL of 4 or 5) ranged from 3.9% to 19.2% with an average of 7.7%. CIR was negatively correlated with NRCL-45 (r = -0.61, P < 0.005), and with poor patient experience (r = -0.54, P < 0.01). The average dose of midazolam (mean 1.9 mg, with a range of 1.1 to 3.5 mg) given by the endoscopist was negatively correlated with CIR (r = -0.59, P < 0.01). CIR was positively correlated with PDR (r = 0.44, P < 0.05), and with the numbers of procedures performed by the endoscopists (r = 0.64, P < 0.01). CONCLUSION The best colonoscopists have a higher CIR, use less sedation, cause less discomfort and find more polyps. Measuring patient comfort is valuable in monitoring performance.
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Schoenfeld PS, Cohen J. Quality indicators for colorectal cancer screening for colonoscopy .. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013; 15:59-68. [PMID: 24098071 DOI: 10.1016/j.tgie.2013.02.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The growing importance of colonoscopy in the prevention of colorectal cancer has stimulated an effort to identify and track quality indicators for this procedure. Several factors have been identified so far which are readily measurable and in many cases have been associated with improved patient outcomes. There is also ample evidence of variations in performance of this procedure. As a result, gathering data about quality indicators may play a vital role in the process of continuous quality improvement. Quality indicators for colonoscopy in colorectal cancer prevention are described along with the evidence that supports their use in benchmarking, quality reporting, and continuous quality improvement.
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Affiliation(s)
- Philip S Schoenfeld
- Division of Gastroenterology, University of Michigan School of Medicine, 2215 Fuller Road, Room 111D, Ann Arbor, Michigan 48105
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Lee RH. Quality colonoscopy: A matter of time, technique or technology? World J Gastroenterol 2013; 19:1517-1522. [PMID: 23539562 PMCID: PMC3602468 DOI: 10.3748/wjg.v19.i10.1517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 01/24/2013] [Indexed: 02/06/2023] Open
Abstract
Quality colonoscopy is defined by the detection of adenomatous polyps at least 25% of the time in men and 15% of the time in women. Recent studies highlight the importance of key aspects of high quality colonoscopy. These include the amount of time spent examining the mucosa or withdrawal time, the quality of withdrawal technique and new technologies which seek to maximize the detection of colonic neoplasia. This review summarizes the latest evidence regarding the role of time, technique and technology in shaping the quality of colonoscopy.
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Do A, Weinberg J, Kakkar A, Jacobson BC. Reliability of adenoma detection rate is based on procedural volume. Gastrointest Endosc 2013; 77:376-80. [PMID: 23211748 DOI: 10.1016/j.gie.2012.10.023] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/17/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Adenoma detection rate (ADR) is a widely touted quality measure for colonoscopy. However, there are no guidelines for minimum numbers of procedures to include to ensure reliable ADR estimates. OBJECTIVE We sought to illustrate how a confidence interval (CI)-based approach can suggest minimum numbers for ADR calculations and provide a reasonable method for comparing ADRs and the mean number of adenomas per procedure (MAP) when relying on limited numbers of procedures. DESIGN Mathematical modeling and use of real world clinical inputs. SETTING Academic medical center. PATIENTS Adults presenting for screening colonoscopy. METHODS AND MAIN OUTCOME MEASUREMENTS: We calculated 95% CIs for theoretical ADRs of 15% to 40%, with varying sample sizes, using the formula p ± 1.96√[p(1 - p)/n], where p is the ADR point estimate and n is the number of procedures. We then compared the ADRs and 95% CIs among 17 endoscopists to determine whether CIs offered important additional information. We also calculated MAPs with 95% CIs using the formula x ± 1.96(sd/√n), where x is the MAP point estimate and sd is the standard deviation of the number of adenomas detected per procedure. RESULTS Large numbers of procedures (eg, 500) are needed to provide narrow CIs for typical ADR estimates. Although 10 of the 17 endoscopists had an ADR below the group's combined mean ADR of 34%, only 3 endoscopists had CIs failing to contain 34%. Likewise, whereas 9 endoscopists had MAPs below the group's combined mean MAP of 0.66, only 4 had CIs failing to contain 0.66. LIMITATIONS Clinical examples come from small numbers of physicians and patients. CONCLUSIONS Large sample sizes are required for a reliable assessment of an endoscopist's ADR. When calculating ADRs and MAPs, 95% CIs account for uncertainty and better reflect endoscopist performance.
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Affiliation(s)
- Albert Do
- Boston University Medical Center, Boston, MA, USA
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Measurement of polypectomy rate by using administrative claims data with validation against the adenoma detection rate. Gastrointest Endosc 2013. [PMID: 23199647 DOI: 10.1016/j.gie.2012.09.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The adenoma detection rate (ADR) is a main quality indicator in colonoscopy but has many challenges for calculating. The polypectomy rate (PR) may be calculable from administrative claims data, but this has not been validated against the ADR. OBJECTIVE To determine whether a PR calculated from United States billing claims data is an accurate surrogate for the ADR. DESIGN A PR was calculated by using billing claims data from Current Procedural Terminology codes. The ADR was calculated for each endoscopist by using an endoscopy report database to which the pathology report data had been added. The relationship between PR and ADR was evaluated with the Pearson correlation coefficient. The ADR was plotted against the PR by individual endoscopist, and a least-squares regression line was created. A t test was used to analyze the differences in lesion detection between endoscopists with a PR above and below the benchmark PR. SETTING Tertiary-care, outpatient endoscopy center. PATIENTS All ages undergoing colonoscopy. MAIN OUTCOME MEASUREMENTS PR and ADR. RESULTS A total of 5382 colonoscopies were reviewed. A significant relationship between endoscopists' calculated PRs and ADRs was seen (r = 0.85; P < .001). Endoscopists needed a PR of 35% to achieve the recommended benchmark ADR of 20%. Endoscopists with PRs of 35% or greater had an ADR of 27% (6.2 standard deviation [SD]) as compared with 19% (1.9 SD) for those with PRs less than 35% (P = .0029). LIMITATIONS Study population. CONCLUSION Calculated PR from billing claims data is an accurate surrogate for ADR and may become an important quality measure for external and internal use.
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