Educational interventions are associated with improvements in colonoscopy quality indicators: a systematic review and meta-analysis

Relative Efficacies of Interventions to Improve the Quality of Screening-Related Colonoscopy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND & AIMS

Significant variability exists in colonoscopy quality indicators, including adenoma detection rate (ADR). We synthesized evidence from randomized trials in a network meta-analysis on interventions to improve colonoscopy quality.

METHODS

We included trials from database inceptions to September 25, 2023, of patients undergoing screening-related colonoscopy and presented efficacies of interventions within domains (periprocedural parameters, endoscopist-directed interventions, intraprocedural techniques, endoscopic technologies, distal attachment devices, and additive substances) compared to standard colonoscopy. The primary outcome was ADR. We used a Bayesian random-effects model using Markov-chain Monte Carlo simulation, with 10,000 burn-ins and 100,000 iterations. We calculated odds ratios with 95% credible intervals and present surface under the cumulative ranking (SUCRA) curves.

RESULTS

We included 124 trials evaluating 37 interventions for the primary outcome. Nine interventions resulted in statistically significant improvements in ADR compared to standard colonoscopy (9-minute withdrawal time, dual observation, water exchange, i-SCAN [Pentax Ltd], linked color imaging, computer-aided detection, Endocuff [Olympus Corp], Endocuff Vision [Olympus Corp], and oral methylene blue). Dual observation (SUCRA, 0.84) and water exchange (SUCRA, 0.78) ranked highest among intraprocedural techniques; i-SCAN (SUCRA, 0.95), linked color imaging (SUCRA, 0.85), and computer-aided detection (SUCRA, 0.78) among endoscopic technologies; WingCap (A&A Medical Supply LLC) (SUCRA, 0.87) and Endocuff (SUCRA, 0.85) among distal attachment devices and oral methylene blue (SUCRA, 0.94) among additive substances. No interventions improved detection of advanced adenomas, and only narrow-band imaging improved detection of serrated lesions (odds ratio, 2.94; 95% credible interval, 1.46-6.25).

CONCLUSIONS

Several interventions are effective in improving adenoma detection and overall colonoscopy quality, many of which are cost-free. These results can inform endoscopists, unit managers, and endoscopy societies on relative efficacies.

Effectiveness and safety of thin vs. thick cold snare polypectomy of small colorectal polyps: Systematic review and meta-analysis

Background and study aims Cold-snare polypectomy (CSP) is considered the standard of care for resection of colorectal polyps ≤10 mm. Data on the efficacy of CSP performed with thin-wire snares compared0 with thick-wire snares are conflicting. We performed a meta-analysis comparing complete resection (CR) and adverse event rates of CSP using thin-wire and thick-wire snares. Patients and methods Comparative studies of adult patients with ≧1 colorectal polyp(s) ≦10 mm who underwent CSP with thin-wire or thick-wire snares were included. We collected data on study, patient, polyp, and snare characteristics. The primary outcome was CR rate. Secondary outcomes were polyp retrieval rate, intraprocedural bleeding, delayed post-polypectomy bleeding, deep mural injury or perforation, patient discomfort, total sedation, and procedure time. We used random-effects models to calculate risk ratios for outcomes. We performed risk of bias assessments, rated the certainty of evidence, and assessed publication bias for all studies. Results We included four randomized controlled trials (RCTs) and two observational studies including 1316 patients with 1679 polyps (826 thin-wire CSPs and 853 thick-wire CSPs). There was no significant difference between thin-wire CSP (92.1%) and thick-wire CSP (87.7%) for RCTs (risk ratio [RR] 1.05, 95% confidence interval [CI] 0.94-1.16) or observational studies (78.1% versus 79.6%, RR 1.03, 95% CI 0.99-1.08). There were no significant differences in polyp retrieval rate or intraprocedural bleeding. There were no cases of delayed bleeding or perforation. Conclusions We found no differences in CR rates for CSP between thin-wire and thick-wire snares. CSP, regardless of snare type, is safe and effective for resection of small colorectal polyps.

Pediatric endoscopy: how can we improve patient outcomes and ensure best practices?

INTRODUCTION

Strategies to promote high-quality endoscopy in children require consensus around pediatric-specific quality standards and indicators. Using a rigorous guideline development process, the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) was developed to support continuous quality improvement efforts within and across pediatric endoscopy services.

AREAS COVERED

This review presents a framework, informed by the PEnQuIN guidelines, for assessing endoscopist competence, granting procedural privileges, audit and feedback, and for skill remediation, when required. As is critical for promoting quality, PEnQuIN indicators can be benchmarked at the individual endoscopist, endoscopy facility, and endoscopy community levels. Furthermore, efforts to incorporate technologies, including electronic medical records and artificial intelligence, into endoscopic quality improvement processes can aid in creation of large-scale networks to facilitate comparison and standardization of quality indicator reporting across sites.

EXPERT OPINION

PEnQuIN quality standards and indicators provide a framework for continuous quality improvement in pediatric endoscopy, benefiting individual endoscopists, endoscopy facilities, and the broader endoscopy community. Routine and reliable measurement of data, facilitated by technology, is required to identify and drive improvements in care. Engaging all stakeholders in endoscopy quality improvement processes is crucial to enhancing patient outcomes and establishing best practices for safe, efficient, and effective pediatric endoscopic care.

Long-Term Follow-Up of Colonoscopy Quality Monitoring

INTRODUCTION

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear.

METHODS

We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly.

RESULTS

Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%.

DISCUSSION

Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Video-based interventions to improve self-assessment accuracy among physicians: A systematic review

PURPOSE

Self-assessment of a physician's performance in both procedure and non-procedural activities can be used to identify their deficiencies to allow for appropriate corrective measures. Physicians are inaccurate in their self-assessments, which may compromise opportunities for self- development. To improve this accuracy, video-based interventions of physicians watching their own performance, an experts' performance or both, have been proposed to inform their self-assessment. We conducted a systematic review of the effectiveness of video-based interventions targeting improved self-assessment accuracy among physicians.

MATERIALS AND METHODS

The authors performed a systematic search of MEDLINE, Embase, EBM reviews, and Scopus databases from inception to August 23, 2022, using combinations of terms for "self-assessment", "video-recording", and "physician". Eligible studies were empirical investigations assessing the effect of video-based interventions on physicians' self-assessment accuracy with a comparison of self-assessment accuracy pre- and post- video intervention. We defined self-assessment accuracy as a "direct comparison between an external evaluator and self-assessment that was quantified using formal statistical analysis". Two reviewers independently screened records, extracted data, assessed risk of bias, and evaluated quality of evidence. A narrative synthesis was conducted, as variable outcomes precluded a meta-analysis.

RESULTS

A total of 2,376 papers were initially retrieved. Of these, 22 papers were selected for full-text review; a final 9 studies met inclusion criteria for data extraction. Across studies, 240 participants from 5 specialties were represented. Video-based interventions included self-video review (8/9), benchmark video review (3/9), and/or a combination of both types (1/9). Five out of nine studies reported that participants had inaccurate self-assessment at baseline. After the intervention, 5 of 9 studies found a statistically significant improvement in self-assessment accuracy.

CONCLUSIONS

Overall, current data suggests video-based interventions can improve self-assessment accuracy. Benchmark video review may enable physicians to improve self-assessment accuracy, especially for those with limited experience performing a particular clinical skill. In contrast, self-video review may be able to provide improvement in self-assessment accuracy for more experience physicians. Future research should use standardized methods of comparison for self-assessment accuracy, such as the Bland-Altman analysis, to facilitate meta-analytic summation.

Evaluation of the quality of colonoscopies performed by Alberta North Zone surgeons, family physicians and internists: a quality improvement initiative

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.

Optimizing adenoma detection in screening-related colonoscopy

INTRODUCTION

Screening-related colonoscopy is a vital component of screening initiatives to both diagnose and prevent colorectal cancer (CRC), with prevention being reliant upon early and accurate detection of pre-malignant lesions. Several strategies, techniques, and interventions exist to optimize endoscopists' adenoma detection rates (ADR).

AREAS COVERED

This narrative review provides an overview of the importance of ADR and other colonoscopy quality indicators. It then summarizes the available evidence regarding the effectiveness of the following domains in terms of improving ADR: endoscopist factors, pre-procedural parameters, peri-procedural parameters, intra-procedural strategies and techniques, antispasmodics, distal attachment devices, enhanced colonoscopy technologies, enhanced optics, and artificial intelligence. These summaries are based on an electronic search of the databases Embase, Pubmed, and Cochrane performed on December 12, 2022.

EXPERT OPINION

Given the prevalence and associated morbidity and mortality of CRC, the quality of screening-related colonoscopy quality is appropriately prioritized by patients, endoscopists, units, and payers alike. Endoscopists performing colonoscopy should be up to date regarding available strategies, techniques, and interventions to optimize their performance.

Interventions to improve the quality of screening-related colonoscopy: protocol for a systematic review and network meta-analysis of randomised controlled trials

INTRODUCTION

Colonoscopy quality can vary depending on endoscopist-related factors. Quality indicators, such as adenoma detection rate (ADR), have been adopted to reduce variations in care. Several interventions aim to improve ADR, but these fall into several domains that have traditionally been difficult to compare. We will conduct a systematic review and network meta-analysis of randomised controlled trials evaluating the efficacies of interventions to improve colonoscopy quality and report our findings according to clinically relevant interventional domains.

METHODS AND ANALYSIS

We will search MEDLINE (Ovid), PubMed, EMBASE, CINAHL, Web of Science, Scopus and Evidence-Based Medicine from inception to September 2022. Four reviewers will screen for eligibility and abstract data in parallel, with two accordant entries establishing agreement and with any discrepancies resolved by consensus. The primary outcome will be ADR. Two authors will independently conduct risk of bias assessments. The analyses of the network will be conducted under a Bayesian random-effects model using Markov-chain Monte-Carlo simulation, with 10 000 burn-ins and 100 000 iterations. We will calculate the ORs and corresponding 95% credible intervals of network estimates with a consistency model. We will report the impact of specific interventions within each domain against standard colonoscopy. We will perform a Bayesian random-effects pairwise meta-analysis to assess heterogeneity based on the I² statistic. We will assess the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework for network meta-analyses.

ETHICS AND DISSEMINATION

Our study does not require research ethics approval given the lack of patient-specific data being collected. The results will be disseminated at national and international gastroenterology conferences and peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42021291814.

Causes and Outcomes of Medicolegal Proceedings Following Gastrointestinal Endoscopy in Canada

Background and Aims

Endoscopic procedures are frequently performed in Canada but can be associated with potential complications and medicolegal implications. This study aimed to identify potential medicolegal cases in Canada relating to upper and lower endoscopies as well as advanced endoscopic procedures.

Methods

Westlaw Canada was searched for any cases regarding upper and lower endoscopies and advanced endoscopic procedures from inception to December 31, 2020. Cases were classified by type of case, procedure performed, patient and defendant demographics, outcome, and alleged reason for litigation/complaint.

Results

Twenty-nine civil cases and 9 board and tribunal decisions for upper and lower endoscopies and 3 advanced endoscopic procedure cases were analyzed. The most frequent defendant specialties were family physician, general surgery, and gastroenterology. The plaintiff was successful in 12 cases involving upper or lower endoscopy with an average award of $243,934 (2021 CDN). The most alleged reasons for litigation were procedural error or negligence (n = 19). The plaintiff was successful in 1 advanced endoscopic procedure case with an award of $153,032.

Conclusion

Medicolegal cases regarding gastrointestinal endoscopy in Canada occur infrequently. Endoscopy should be performed by skilled providers with appropriate informed consent from the patient, and careful consideration of whether procedures are indicated are key for endoscopic providers.

Association Between Endoscopist Specialty and Colonoscopy Quality: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Colonoscopy quality indicators provide measurable assessments of performance, but significant provider-level variations exist. We performed a systematic review and meta-analysis to assess whether endoscopist specialty is associated with adenoma detection rate (ADR) - the primary outcome - or cecal intubation rate, adverse event rates, and post-colonoscopy colorectal cancer rates.

METHODS

We searched EMBASE, Google Scholar, MEDLINE, and the Cochrane Central Registry of Controlled Trials from inception to December 14, 2020. Two reviewers independently screened titles and abstracts. Citations underwent duplicate full-text review, with disagreements resolved by a third reviewer. Data were abstracted in duplicate. The DerSimonian and Laird random effects model was used to calculate pooled odds ratios (ORs) with respective 95% confidence intervals (CIs). Risk of bias was assessed using Risk of Bias in Non-randomised Studies of Interventions.

RESULTS

Of 11,314 citations, 36 studies representing 3,500,832 colonoscopies were included. Compared with colonoscopies performed by gastroenterologists, those by surgeons were associated with lower ADRs (OR, 0.81; 95% CI, 0.74-0.88) and lower cecal intubation rates (OR, 0.76; 95% CI, 0.63-0.92). Compared with colonoscopies performed by gastroenterologists, those by other (non-gastroenterologist, non-surgeon) endoscopists were associated with lower ADRs (OR, 0.91; 95% CI, 0.87-0.96), higher perforation rates (OR, 3.02; 95% CI, 1.65-5.51), and higher post-colonoscopy colorectal cancer rates (OR, 1.23; 95% CI, 1.14-1.33). Substantial to considerable heterogeneity existed for most analyses, and overall certainty in the evidence was low according to the Grading of Recommendations, Assessment, Development, and Evaluations framework.

CONCLUSION

Colonoscopies performed by surgeons or other endoscopists were associated with poorer quality metrics and outcomes compared with those performed by gastroenterologists. Targeted quality improvement efforts may be warranted.

Progress in understanding of factors related to colonoscopic adenoma detection rate

Adenoma detection rate (ADR) is the proportion of average-risk patients undergoing screening colonoscopy in whom an adenoma is found, and it is an important quality indicator of colonoscopy. ADR is closely related to the risk of interval colorectal cancer. A deeply study of ADR is essential for endoscopists. In this paper, we review the progress in the understanding of factors related to ADR before, during, and after colonoscopy, as well as several issues worthy of attention.

Endocuff Vision improves adenoma detection rate in a large screening-related cohort

Background and study aims  Endocuff Vision (ECV) increases adenoma detection rate (ADR) in randomized clinical trials; however, observational effectiveness data are lacking. We evaluated the effectiveness, safety, and practical aspects of ECV use in a large screening-related real-world cohort. Patients and methods  In this observational study, patients undergoing screening-related colonoscopy from November 2018 to April 2019 comprised the baseline period, and those undergoing it from June to November 2019 comprised the ECV period, where ECV use was discretionary. The primary outcome was ADR, compared: 1) between ECV use and standard colonoscopy across both periods; and 2) between time periods. Secondary outcomes included indication-specific ADR, sessile serrated ADR (SSADR), cecal intubation rate (CIR), procedure times, patient comfort scores, and sedation use. Multilevel logistic regression was performed, yielding adjusted odds ratios (AOR) with 95 % confidence intervals (CIs). Results  In 15,814 colonoscopies across both time periods, ADR was 46.7 % with standard colonoscopy and 54.6 % when ECV was used ( P  < 0.001). Endoscopists used ECV in 77.6 % of procedures in the ECV period, during which overall ADR rose to 53.2 % compared to 46.3 % in the baseline period ( P  < 0.001). ECV use was significantly associated with higher ADR (AOR 1.24, 95 % CI 1.10 to 1.40) after adjusting for relevant covariates including time period. ECV use did not result in lower CIR, longer procedure time, increased sedation use, or poorer comfort scores. Conclusions  ECV use is associated with improved ADR without negatively impacting other key procedure and patient-related factors. Future studies should evaluate the cost-effectiveness of incorporating ECV into routine screening-related practice.

Thoughts on factors related to colonoscopy quality

With the increase in health consciousness and the prevalence of early gastrointestinal cancer screening, the number of diagnosed cases of colorectal polyps and adenomas in the Chinese general population has substantially increased. However, the overall adenoma detection rate (ADR) in China remains lower than the global standard of 30%. High quality colonoscopy is pivotal for increasing the ADR and reducing the risk of interval colon cancer. A few factors are related to the quality of colonoscopy, including preoperative evaluation of examinees, bowel preparation, techniques for intubation, use of image enhancement endoscopy, withdraw time, and prevention of adverse events.