State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them

Colonoscopy Training on Virtual-Reality Simulators or Physical Model Simulators: A Randomized Controlled Trial

OBJECTIVE

This study employed a randomized controlled trial to assess the efficacy of virtual-reality (VR) simulators and physical model simulators on colonoscopy training to explore the optimal and evidence-based simulation training.

DESIGN

Forty participants were divided into 2 groups and randomized as dyads: the VR simulator group and the physical model simulator group. All the participants performed a baseline test through porcine colonoscopy. After a 6 h simulation training, each participant underwent a post-test on a pig after bowel preparation, and the procedures were video-recorded. Both the baseline test and the post-test were blindly assessed by 2 experienced assistant director physicians based on the GAGES-C scoring system.

SETTING

Simulation center, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai.

PARTICIPANTS

Forty surgical residents without colonoscopy experience.

RESULTS

Both the VR simulator group and the physical model simulator group improved significantly over the baseline test. The VR simulator group performed significantly better than the physical model simulator group, p=0.042. The participants in both groups expressed a high level of simulator satisfaction.

CONCLUSIONS

Novice residents can benefit from both VR simulators and physical model simulators. The VR simulator was shown to be more effective for colonoscopy training. VR simulators were more recommended for novices conducting basic colonoscopy training.

Barriers against Implementation of European Society of Gastrointestinal Endoscopy Performance Measures for Colonoscopy in Clinical Practice

Background and Objectives: The implementation and monitoring of the European Society of Gastrointestinal Endoscopy (ESGE) performance measures for colonoscopy are suboptimal in clinical practice. Electronic reporting systems may play an important role in data retrieval. We aimed to define the possibility of systematically assessing and monitoring ESGE performance measures for colonoscopy through reporting systems. Materials and Methods: We conducted a survey during a nationwide event on the quality of colonoscopy held in Rome, Italy, in March 2023 by a self-administered questionnaire. Analyses were conducted overall and by workplace setting. Results: The attendance was 93% (M/F 67/26), with equal distribution of age groups, regions and public or private practices. Only about one-third (34%) and 21.5% of participants stated that their reporting system allows them to retrieve all the ESGE performance measures, overall and as automatic retrieval, respectively. Only 66.7% and 10.7% of respondents can systematically report the cecal intubation and the adenoma detection rate, respectively. The analysis according to hospital setting revealed no significant difference for all the items. Conclusions: We found a generalized lack of systematic tracking of performance measures for colonoscopy due to underperforming reporting systems. Our results underline the need to update reporting systems to monitor the quality of endoscopy practice in Italy.

Quality improvement of pediatric colonoscopy by application of bundle and centralization: A single-center review

BACKGROUND

To assess the quality change of our single-center pediatric colonoscopy after applying bundle for bowel preparation and general anesthesia and centralize the procedure using terminal ileum (TI) intubation rate as the main indicator.

METHODS

All elective colonoscopies performed for patients younger than 18 years old in MacKay Memorial Hospital from July 2015 through June 2020 (assigned to group 1, before bundle) and from August 2020 through July 2021 (assigned to group 2, after bundle) were retrospectively reviewed for demographic characteristics, indications, bowel preparation agent and cleansing level, diagnostic and therapeutic procedures, maximum intestinal level reached, and cecal intubation and total procedure time. Statistical analysis was done using P value < 0.05 considered to be significant.

RESULTS

Analysis included 45 and 32 colonoscopies in group 1 and 2, respectively. Bloody stool was the most frequent indication in both groups. Both TI intubation rate (42.2 % vs. 75.0 %, P = 0.004) and biopsy rate (45.0 % vs. 75.9 %, P = 0.01) increased significantly from group 1 to group 2. The narrower standard deviation of bowel preparation score (1.93 vs. 1.15) and total procedure time (37.71 vs. 22.29) in group 2 indicated a more stable quality, although the mean showed no difference. There was no statistical difference in age, gender, body weight, cecal intubation rate, or cecal intubation time.

CONCLUSION

A higher TI intubation rate and biopsy rate indicated an improved quality of pediatric colonoscopy after applying bundle including bowel preparation and general anesthesia, with additional centralization.

A survey of current practices in post-polypectomy surveillance in Korea

BACKGROUND/AIMS

We investigated the clinical practice patterns of post-polypectomy colonoscopic surveillance among Korean endoscopists.

METHODS

In a web-based survey conducted between September and November 2021, participants were asked about their preferred surveillance intervals and the patient age at which surveillance was discontinued. Adherence to the recent guidelines of the U.S. Multi-Society Task Force on Colorectal Cancer (USMSTF) was also analyzed.

RESULTS

In total, 196 endoscopists completed the survey. The most preferred first surveillance intervals were: a 5-year interval after the removal of 1-2 tubular adenomas < 10 mm; a 3-year interval after the removal of 3-10 tubular adenomas < 10 mm, adenomas ≥ 10 mm, tubulovillous or villous adenomas, ≤ 20 hyperplastic polyps < 10 mm, 1-4 sessile serrated lesions (SSLs) < 10 mm, hyperplastic polyps or SSLs ≥ 10 mm, and traditional serrated adenomas; and a 1-year interval after the removal of adenomas with highgrade dysplasia, >10 adenomas, 5-10 SSLs, and SSLs with dysplasia. In piecemeal resections of large polyps ( > 20 mm), surveillance colonoscopy was mostly preferred after 1 year for adenomas and 6 months for SSLs. The mean USMSTF guideline adherence rate was 30.7%. The largest proportion of respondents (40.8%-55.1%) discontinued the surveillance at the patient age of 80-84 years.

CONCLUSIONS

A significant discrepancy was observed between the preferred post-polypectomy surveillance intervals and recent international guidelines. Individualized measures are required to increase adherence to the guidelines.

Predictors of inadequate bowel preparation in older patients undergoing colonoscopy: A systematic review and meta-analysis

BACKGROUND

Factors that predict the quality of bowel preparation in older adults are unclear, and current guidelines do not provide specific recommendations.

OBJECTIVE

This meta-analysis aimed to identify risk factors for inadequate bowel preparation in older patients.

METHODS

PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP databases were searched from their inception to February 2023. Cohort and cross-sectional studies exploring the risk factors for inadequate bowel preparation were included in this systematic review. Odds ratio (OR) values from individual studies were pooled using fixed-effects and random-effects models. In addition, a sensitivity analysis and assessment of publication bias were performed.

RESULTS

This meta-analysis included six studies (n = 1553) on previous abdominal surgery, six studies (n = 1494) on constipation, seven studies (n = 1505) on diabetes, eight studies (n = 2093) on non-compliance with the diet regimen, seven studies (n = 1350) on incomplete intake of laxative, and nine studies (n = 2163) on inadequate exercise during preparation. The pooled analysis showed that history of abdominal surgery (OR = 2.72; 95 % confidence interval, CI: 2.07 to 3.56), constipation (OR = 3.56, 95 % CI: 2.41 to 5.25), diabetes (OR = 2.54, 95 % CI: 1.81 to 3.57), non-compliance with the diet regimen (OR = 2.51, 95 % CI: 1.96 to 3.21), incomplete intake of laxative (OR = 2.43, 95 % CI: 1.60 to 3.67), and inadequate exercise during preparation (OR = 3.13, 95 % CI: 2.39 to 4.11) were independent risk factors for inadequate bowel preparation in older patients undergoing colonoscopy.

CONCLUSIONS

Three comorbid factors and three behavioral factors were significantly associated with inadequate bowel preparation in older adults. This meta-analysis provides valuable information for developing predictive models of poor bowel preparation.

What are the priority quality indicators for colonoscopy in real-world clinical practice?

Colonoscopy is widely used as a colorectal cancer (CRC) screening tool. The effectiveness of a screening colonoscopy is associated with a decreased risk of CRC. However, colonoscopy is an operator-dependent procedure, and endoscopists' quality performance varies widely. This article reviewed the priority metrics and practices that contribute to high-quality screening colonoscopy in real-world clinical practice. With growing evidence, quality indicators have been subject to intense research and associated with reducing postcolonoscopy CRC incidence and mortality. Some quality metrics can reflect an endoscopy unit-based practice (i.e. quality of bowel preparation and withdrawal time). Other quality indicators primarily reflect individuals' skill and knowledge (i.e. cecal intubation rate, adenoma detection rate, and appropriately assigned follow-up colonoscopy interval). Measurement and improvement of priority quality indicators for colonoscopy should be made at both the endoscopist and unit levels. Substantial evidence supports the impact of high-quality colonoscopy in reducing the incidence of postcolonoscopy CRC.

Intraprocedure Artificial Intelligence Alert System for Colonoscopy Examination

Colonoscopy is a valuable tool for preventing and reducing the incidence and mortality of colorectal cancer. Although several computer-aided colorectal polyp detection and diagnosis systems have been proposed for clinical application, many remain susceptible to interference problems, including low image clarity, unevenness, and low accuracy for the analysis of dynamic images; these drawbacks affect the robustness and practicality of these systems. This study proposed an intraprocedure alert system for colonoscopy examination developed on the basis of deep learning. The proposed system features blurred image detection, foreign body detection, and polyp detection modules facilitated by convolutional neural networks. The training and validation datasets included high-quality images and low-quality images, including blurred images and those containing folds, fecal matter, and opaque water. For the detection of blurred images and images containing folds, fecal matter, and opaque water, the accuracy rate was 96.2%. Furthermore, the study results indicated a per-polyp detection accuracy of 100% when the system was applied to video images. The recall rates for high-quality image frames and polyp image frames were 95.7% and 92%, respectively. The overall alert accuracy rate and the false-positive rate of low quality for video images obtained through per-frame analysis were 95.3% and 0.18%, respectively. The proposed system can be used to alert colonoscopists to the need to slow their procedural speed or to perform flush or lumen inflation in cases where the colonoscope is being moved too rapidly, where fecal residue is present in the intestinal tract, or where the colon has been inadequately distended.

An Italian prospective multicenter study on colonoscopy practice and quality: What has changed in the last 10 years

BACKGROUND

A relevant number of adenomas can be missed during colonoscopy.

AIMS

Assess the current status of colonoscopy procedures in Italian centers.

METHODS

A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1.

RESULTS

A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold.

CONCLUSION

High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs.

Effect of Walking Exercise and Intestinal Cleansing Interval on Bowel Preparation Quality, a Single-Blind, Randomized Controlled Trial

BACKGROUND AND AIMS

High-quality intestinal preparation could promote intestinal cleanliness and lead to more accurate diagnosis, which patients will benefit from. This study aimed to explore the effectiveness of walking exercise and intestinal cleansing interval in bowel preparation before colonoscopy.

METHODS

A randomized controlled single blind study was conducted during August 2021 to February 2022. Patients requiring colonoscopy were randomly divided into three groups: 0 step, 5000 steps or 10,000 steps during the intestinal preparation. Participants took the same intestinal cleansing drugs 4-6 h prior to the procedure: 2L-dose polyethylene glycol (PEG).

RESULTS

A total of 300 patients were enrolled in the experiment (100 patients per group), and the baseline information of the three groups was close. The BBPS of right (0-step group vs 5,000-step group vs 10,000-step group: 1.78 ± 0.65 vs 1.88 ± 0.54 vs 2.36 ± 0.69, p < 0.001), transverse (0-step group vs 5,000-step group vs 10,000-step group: 2.09 ± 0.78 vs 2.18 ± 0.61 vs 2.59 ± 0.71, p < 0.001) and left (0-step group vs 5,000-step group vs 10,000-step group: 2.01 ± 0.91 vs 2.24 ± 0.59 vs 2.51 ± 0.60, p < 0.001) colon in 10,000-step group were significantly higher than others, respectively. And we also drew the same conclusion in the aspect of ADR. The adverse events and patients' satisfaction had no differences between the two groups. Moreover, intestinal cleansing interval (< 5.12 h) was only effective in BBPS of right colon (p < 0.001) and left colon (p = 0.039).

CONCLUSIONS

This study suggested that participants took 10,000-step walking exercise and took PEG 5.12 h prior to the procedure were effective in routine pre-procedure cleanout for standard colonoscopy.

NAME OF REGISTRY

Effect of starting time of bowel cleansing and walking exercise after bowel cleansing on bowel preparation: A prospective randomized controlled study.

REGISTRATION NUMBER

ChiCTR2100049214.

Efficacy, safety and tolerability of oral sulphate tablet for bowel preparation in patients with inflammatory bowel disease: A multicentre randomized controlled study

BACKGROUND AND AIMS

We evaluated the efficacy, safety and tolerability of novel oral sulphate tablets [OSTs] vs 2 L of polyethylene glycol and ascorbate [PEG/Asc] in patients with inflammatory bowel disease [IBD].

PATIENTS AND METHODS

A total of 110 patients with clinically inactive IBD were enrolled in this single-blind multicentre non-inferiority study. Patients were randomly assigned to the OST or 2 L PEG/Asc group and we applied a split-dose regimen. The primary efficacy endpoint was bowel cleansing success rate defined as Harefield Cleansing Scale Grade A or B. The secondary endpoints were perfect preparation rate, the presence of air bubbles, safety as assessed by laboratory abnormalities and self-reported adverse events, or IBD symptom flare-ups. Tolerability was assessed by a pre-procedural visual analog scale [VAS] interview.

RESULTS

Both groups showed high cleansing success rates [98.1%] and there was no significant difference in perfect preparation rate. The proportion of a bubble score 0 was significantly higher in the OST group [94.5% vs 50.0%, p < 0.001]. There was no significant intergroup difference in vomiting or bloating. Symptom flare-ups occurred in two OST group patients. No clinically significant blood test abnormalities were noted in either group. Ease of ingestion and taste scores were significantly higher in the OST group. More patients in the OST group [94.5%] wanted to take the same preparation agent for their next colonoscopy.

CONCLUSIONS

Both OST and 2 L PEG/Asc demonstrated high successful cleansing and safety in patients with inactive IBD. OST achieved higher satisfaction than 2 L PEG/Asc. Our results suggest that the OST split-dose regimen is effective and safe for patients with inactive IBD.

Minimal water exchange by the air-water valve versus left colon water exchange in unsedated colonoscopy: a randomized controlled trial

BACKGROUND

Water exchange colonoscopy is the least painful method for unsedated colonoscopies. Simplified left colon water exchange (LWE) reduces the cecal intubation time but it is difficult to avoid the use of an additional pump. Minimal water exchange (MWE) is an improved novel method that eliminates the need for pumps, but it is not clear whether MWE has the same efficiency as LWE.

METHODS

This was a prospective, randomized, controlled, noninferiority trial conducted in a tertiary hospital. Enrolled patients were randomized 1:1 to the LWE group or MWE group. The primary outcome was recalled insertion pain measured by a 4-point verbal rating scale. Secondary outcomes included adenoma detection rate (ADR), cecal intubation time, volume of water used, and patient willingness to repeat unsedated colonoscopy.

RESULTS

226 patients were included (LWE n = 113, MWE n = 113). The MWE method showed noninferior moderate/severe pain rates compared with the LWE method (10.6 % vs. 9.7 %), with a difference of 0.9 percentage points (99 % confidence interval [CI] -9.5 to 11.3; threshold, 15 %). ADR, cecal intubation time, and willingness to repeat unsedated colonoscopy were not significantly different between the two groups, but the mean volume of water used was significantly less with MWE than with LWE (163.7 mL vs. 407.2 mL; 99 %CI -298.28 to -188.69).

CONCLUSION

Compared with LWE, MWE demonstrated a noninferior outcome for insertion pain, and comparable cecal intubation time and ADR, but reduced the volume of water used and eliminated the need for a water pump.

Do Gastroenterologists Have a "Weak" Day? Impact of Day of the Week on the Quality of Outpatient Screening Colonoscopies

GOAL

The goal of this study is to determine the significance of day of the work week and its contribution to endoscopist performance using adenoma detection rate (ADR) and proposed surrogate quality measures.

BACKGROUND

Nearly a quarter of adenomas are missed on routine screening colonoscopy which contributes to between 50% and 60% of interval colorectal cancer.

MATERIALS AND METHODS

Adult patients who underwent outpatient screening colonoscopy between January 2015 and April 2020 were included. Measurement of ADR and proposed quality metrics were analyzed for each day of the work week. Secondary outcomes included rates of good or excellent bowel preparation, trainee fellow participation, performance quartile of individual endoscopists, and patient demographic data. A generalized linear mixed model was used to analyze predictors of ADR.

RESULTS

A total of 1884 screening procedures were included in our analysis. ADR on Friday (35.6%) was significantly lower than all other days of the work week ( P <0.001). When compared with Friday, all days were found to be independent predictors of increased ADR. Male gender [95% confidence interval (CI): 1.12-1.65, P =0.002], good rather than excellent bowel preparation (95% CI: 1.22-2.28, P =0.001) and colonoscopy withdrawal time (CWT) (95% CI: 1.02-1.03, P <0.001) were all found to be predictors of increased ADR. Proposed quality indicators were all well correlated with ADR ( r >0.811, P ≤0.001) apart from CWT ( r =0.28, P =0.379).

CONCLUSIONS

The data suggests there is a decline in endoscopist performance on Friday when compared with all other days of the work week. ADR correlates well with many proposed quality parameters, however, CWT may be of additional value as a quality metric.

Artificial intelligence-based assessments of colonoscopic withdrawal technique: a new method for measuring and enhancing the quality of fold examination

BACKGROUND

This study aimed to develop an artificial intelligence (AI)-based system for measuring fold examination quality (FEQ) of colonoscopic withdrawal technique. We also examined the relationship between the system's evaluation of FEQ and FEQ scores from experts, and adenoma detection rate (ADR) and withdrawal time of colonoscopists, and evaluated the system's ability to improve FEQ during colonoscopy.

METHODS

First, we developed an AI-based system for measuring FEQ. Next, 103 consecutive colonoscopies performed by 11 colonoscopists were collected for evaluation. Three experts graded FEQ of each colonoscopy, after which the recorded colonoscopies were evaluated by the system. We further assessed the system by correlating its evaluation of FEQ against expert scoring, historical ADR, and withdrawal time of each colonoscopist. We also conducted a prospective observational study to evaluate the system's performance in enhancing fold examination.

RESULTS

The system's evaluations of FEQ of each endoscopist were significantly correlated with experts' scores (r = 0.871, P < 0.001), historical ADR (r = 0.852, P = 0.001), and withdrawal time (r = 0.727, P = 0.01). For colonoscopies performed by colonoscopists with previously low ADRs (< 25 %), AI assistance significantly improved the FEQ, evaluated by both the AI system (0.29 [interquartile range (IQR) 0.27-0.30] vs. 0.23 [0.17-0.26]) and experts (14.00 [14.00-15.00] vs. 11.67 [10.00-13.33]) (both P < 0.001).

CONCLUSION

The system's evaluation of FEQ was strongly correlated with FEQ scores from experts, historical ADR, and withdrawal time of each colonoscopist. The system has the potential to enhance FEQ.

Medical malpractice and gastrointestinal endoscopy

PURPOSE OF REVIEW

Medical liability is a perennial issue that most physicians will face at some point in their careers. Gastroenterologists routinely perform endoscopic procedures to aid in the diagnosis and treatment of their patients. Advances in endoscopic techniques and technology have accelerated movement of the field into a more surgical realm. These developments warrant consideration of pitfalls that may expose gastroenterologists to liability. This review will explore trends in malpractice facing gastroenterologists and offer strategies to deliver high quality and safe patient care.

RECENT FINDINGS

Despite being a procedure-oriented subspeciality, only a minority of malpractice claims against gastroenterologists are related to procedures. Diagnostic error is among the most prevalent reason for lawsuits. The consequences of malpractice are costly due litigation and indemnity as well as the increase in defensive medical practice. Improving diagnostic quality, optimizing informed consent, and enhancing patient-physician communication are important elements of risk mitigation.

SUMMARY

Understanding the important role that diagnosis plays in medical liability allows physicians to better evaluate risk and apply deliberate decision-making in order to practice confidently.

Development and validation of a deep learning-based algorithm for colonoscopy quality assessment

BACKGROUND

Quality indicators should be assessed and monitored to improve colonoscopy quality in clinical practice. Endoscopists must enter relevant information in the endoscopy reporting system to facilitate data collection, which may be inaccurate. The current study aimed to develop a full deep learning-based algorithm to identify and analyze intra-procedural colonoscopy quality indicators based on endoscopy images obtained during the procedure.

METHODS

A deep learning system for classifying colonoscopy images for quality assurance purposes was developed and its performance was assessed with an independent dataset. The system was utilized to analyze captured images and results were compared with those of real-world reports.

RESULTS

In total, 10,417 images from the hospital endoscopy database and 3157 from Hyper-Kvasir open dataset were utilized to develop the quality assurance algorithm. The overall accuracy of the algorithm was 96.72% and that of the independent test dataset was 94.71%. Moreover, 761 real-world reports and colonoscopy images were analyzed. The accuracy of electronic reports about cecal intubation rate was 99.34% and that of the algorithm was 98.95%. The agreement rate for the assessment of polypectomy rates using the electronic reports and the algorithm was 0.87 (95% confidence interval 0.83-0.90). A good correlation was found between the withdrawal time calculated using the algorithm and that entered by the physician (correlation coefficient r = 0.959, p < 0.0001).

CONCLUSION

We proposed a novel deep learning-based algorithm that used colonoscopy images for quality assurance purposes. This model can be used to automatically assess intra-procedural colonoscopy quality indicators in clinical practice.

Risk factors for underestimation of patient pain in outpatient colonoscopy

BACKGROUND

Adequate management of patient pain and discomfort during colonoscopy is crucial to obtaining a high-quality examination. We aimed to investigate the ability of endoscopists and endoscopy assistants to accurately assess patient pain in colonoscopy.

METHODS

This was a single-center, cross-sectional study including patients scheduled for an outpatient colonoscopy. Procedure-related pain, as experienced by the patient, was scored on a verbal rating scale (VRS). Endoscopists and endoscopy assistants rated patient pain likewise. Cohen's kappa was used to measure the agreement between ratings and logistic regression applied to test for potential predictors associated with underestimation of moderate-severe pain.

RESULTS

In total, 785 patients [median age: 54 years; females: n = 413] were included. Mild, moderate, and severe pain was reported in 378/785 (48%), 168/785 (22%), and 111/785 (14%) procedures respectively. Inter-rater reliability of patient pain comparing patients with endoscopists was κ = 0.29, p < .001 and for patients with endoscopy assistants κ = 0.37, p < .001. In the 279 patients reporting moderate/severe pain, multivariable analysis showed that male gender (OR = 1.79), normal BMI (OR = 1.71), no history of abdominal surgery (OR = 1.81), and index-colonoscopy (OR = 1.81) were factors significantly associated with a risk for underestimation of moderate/severe pain by endoscopists. Young age (OR = 2.05) was the only corresponding factor valid for endoscopy assistants.

CONCLUSIONS

In a colonoscopy, estimation of patient pain by endoscopists and endoscopy assistants is often inaccurate. Endoscopists need to pay specific attention to subgroups of patients, such as male gender, and normal BMI, among whom there seems to be an important risk of underestimation of moderate-severe pain.

Quality indicators of colonoscopy care: a qualitative study from the perspectives of colonoscopy participants and nurses

Background

Quality of care in colonoscopy is closely related to colonoscopy participants and the nursing workforce in endoscopy-related settings. However, limited data are available on the evaluations and recommendations regarding quality indicators for nursing care by these two groups. Therefore, the aim of this study was to explore the standards and requirements of quality of care in colonoscopy from the perspectives of patients and nurses.

Method

With a descriptive qualitative study, semi-structured interviews were conducted between November 2021 and January 2022 with colonoscopy participants (P = 11) and nursing workforce (N = 7) in the endoscopy unit in a tertiary hospital. The interviews were analyzed using a thematic analysis.

Results

Nine major themes emerged according to the structure, process, and outcome care quality model: workforce structure, quality requirements, unit facilities, nursing tools, nursing quality control systems, dynamic assessment and intervention, pre-examination care, strengthening education, and colonoscopy outcomes.

Conclusion

The indicator of quality of colonoscopy care should be used to assess and improve current practices to ensure a more direct and sustained impact of colonoscopy care. This study highlights the importance of nurse managers valuing the opinions and reflections of people involved in colonoscopy to improve the quality of colonoscopy care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08466-5.

CC-CLEAR (Colon Capsule Cleansing Assessment and Report): the novel scale to evaluate the clinical impact of bowel preparation in capsule colonoscopy - a multicentric validation study

BACKGROUND

Colon Capsule Cleansing Assessment and Report (CC-CLEAR) is a novel quantitative bowel preparation scale for colon capsule.

AIM

The aim of this study is to validate the association between CC-CLEAR's classification and major CC outcomes: lesion detection rate, surveillance recommendations and post-CC endoscopic treatment.

METHODS

Multicentric cohort of consecutive CCs. An expert's panel decided post-CC recommendations. Data included CC-CLEAR and Leighton-REX scales. Major CC outcomes were associated with the different cleansing grades.

RESULTS

From 168 CC's included, findings were reported in 123 (73.2%), 67 (54.4%) of those being colorectal polyps. CC-CLEAR influenced CC's lesion detection (OR 1.25 95% IC [1.07-1.46], p-value .004) and polyp detection rate (OR 1.22 95% IC [1.04-1.43], p-value.014). Thirty-two (19%) post-CC colonoscopies were recommended, including 22 (68.75%) with at least one polypectomy. CC-CLEAR was associated with post-CC colonoscopy treatment (OR 1.40 95% IC [1.07-1.84], p-value .015). Regarding surveillance, CC-CLEAR influenced the decision for immediate CC repetition (OR 0.21 95% IC [0.12-0.36], p-value < .001) and the recommendation for CC in 3-5 years' time (OR 1.47 95% IC [1.50-1.86], p-value < .002). The Leighton-Rex scale was not correlated with major CC outcomes.

CONCLUSION

CC-CLEAR impacts major CC outcomes: lesion detection, surveillance recommendations and post-CC endoscopic treatment.

Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

Optimal Strategies for Colorectal Cancer Screening

OPINION STATEMENT

Colorectal cancer (CRC) imposes significant morbidity and mortality, yet it is also largely preventable with evidence-based screening strategies. In May 2021, the US Preventive Services Task Force updated guidance, recommending screening begin at age 45 for average-risk individuals to reduce CRC incidence and mortality in the United States (US). The Task Force recommends screening with one of several screening strategies: high-sensitivity guaiac fecal occult blood test (HSgFOBT), fecal immunochemical test (FIT), multi-target stool DNA (mt-sDNA) test, computed tomographic (CT) colonography (virtual colonoscopy), flexible sigmoidoscopy, flexible sigmoidoscopy with FIT, or traditional colonoscopy. In addition to these recommended options, there are several emerging and novel CRC screening modalities that are not yet approved for first-line screening in average-risk individuals. These include blood-based screening or "liquid biopsy," colon capsule endoscopy, urinary metabolomics, and stool-based microbiome testing for the detection of colorectal polyps and/or CRC. In order to maximize CRC screening uptake in the US, patients and providers should engage in informed decision-making about the benefits and limitations of recommended screening options to determine the most appropriate screening test. Factors to consider include the invasiveness of the test, test performance, screening interval, accessibility, and cost. In addition, health systems should have a programmatic approach to CRC screening, which may include evidence-based strategies such as patient education, provider education, mailed screening outreach, and/or patient navigation, to maximize screening participation.

Measuring and Improving Quality of Colonoscopy for Colorectal Cancer Screening

Colorectal cancer (CRC) is largely preventable, yet it remains a major public health issue as it is the third most common and deadly malignancy in the United States. While there are many ways to screen for CRC, colonoscopy remains the gold standard as it is the only test that is both cancer-detecting and cancer-preventing through removal of precancerous polyps. Through identifying and removing neoplastic lesions, colonoscopy reduces CRC incidence by 31%-91% and CRC mortality by 65%-88%. However, colonoscopy is not an infallible test-there is a chance for missed lesions during the exam and there is substantial variation in outcomes among endoscopists. To enhance the quality of colonoscopic exams, and ultimately to improve CRC outcomes, quality indicators have been developed for measuring endoscopists' performance. In this review, we describe the colonoscopic quality indicators and benchmarks recommended by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy for screening colonoscopies in average-risk individuals. Measuring and monitoring endoscopists' performance on these measures are critical first steps in striving toward conducting high quality exams. We also review the evidence for interventions that aim to improve critical measures including adenoma detection rate, withdrawal time, cecal intubation, and bowel preparation quality. Finally, we provide a preview of the forthcoming Advancing Care for Appropriate Colon Health Merit-Based Incentive Payment System Value Pathway by the Centers for Medicare & Medicaid Services and its potential impact on clinical practice.

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.

The challenge of quantifying screening colonoscopy quality: Development and psychometric properties of the Colonoscopy Quality Score instrument

INTRODUCTION AND AIMS

Colonoscopy quality is measured by the degree in which the examination increases the likelihood of obtaining adequate results on health. Our aim was to develop an instrument for evaluating the quality of screening colonoscopies, taking into account the performance of endoscopists and endoscopy units.

MATERIALS AND METHODS

Mixed methodology was employed. The first stage (qualitative) consisted of a Medline search, from which a group of experts developed the quality score items. The second stage (quantitative) utilized a modified Delphi technique to reach consensus (3 rounds). We evaluated the psychometric properties of the instrument (reliability and construct validity) in elective screening colonoscopies (in patients ≥ 50 years of age), performed within the January-April 2017 time frame.

RESULTS

A final instrument with 8 items was produced: (1) the Boston Bowel Preparation Scale score; (2) cecal intubation rate; (3) colonoscopy withdrawal time; (4) image documentation; (5) adenoma detection rate; (6) endoscopic surveillance planning; (7) perforation rate, and (8) continuous improvement programs. The instrument was evaluated in 323 colonoscopies performed by 31 endoscopists and found to be one-dimensional and reliable (Cronbach's alpha 0.76). Performance was compared between endoscopists (center 1) and an expert endoscopist from another center (center 2): Boston Bowel Preparation Scale score 8.3 vs. 7.36 (P < .001), cecal intubation rate 93.5 vs. 96%, colonoscopy withdrawal time 14.8 vs. 8.4 min (P < .001), and adenoma detection rate 34 vs. 52.2% (P < .001), respectively.

CONCLUSION

The Colonoscopy Quality Score is a reliable and valid instrument for evaluating screening colonoscopy quality. Its results could be adapted to the usual endoscopic report to adjust monitorization frequency post-colonoscopy.

Clinical practice standards for colonoscopy

Colonoscopy is considered as the most effective tool for preventing, screening, and diagnosing colorectal lesions. Effectiveness of colonoscopy was identified as a major priority, and it strictly depends on quality measures. Therefore, international guidelines were formulated on quality indicators for colonoscopy, aiming to reduce the rate of interval cancers related to missed lesions during colonoscopy. Quality indicators are divided into 3 time periods: preprocedure, intraprocedure, and postprocedure.  The main pre-procedural indicators are the assessment of the appropriateness of indication of colonoscopy and the prescription of adequate bowel preparation during a consultation prior to colonoscopy. Per-procedural criteria include all technical aspects of the procedure, which are "endoscopist-dependent" factors, particularly cecal intubation, detection of adenomas and withdrawal time. The main post-procedure indicators are the rate of complications, patient experience and optimal surveillance intervals following removal of colorectal polyps. The implementation of key performance measures in endoscopy practice is increasingly important as it can help improving our care of patients and optimize outcomes. In this review, the "Club d'endoscopie digestive" (CED) presented a summary of the main colonoscopy quality indicators, and suggested recommendations that took into account the particularities of our local conditions.

The Prediction of Inadequate Colon Capsule Cleansing: A Cohort Selection Guided by CC-CLEAR

Introduction

In order to optimize the rate of adequate cleansing in colon capsule, it may be important to identify risk factors that can predict a suboptimal colon preparation.

Aim

To define predictive factors for inadequate bowel preparation in colon capsule, according to CC-CLEAR (Colon Capsule CLEansing Assessment and Report).

Methods

Retrospective, single center, cohort study. Patients' demographics, data, and quality of bowel preparation, according to CC-CLEAR, were collected retrospectively. A univariate analysis tested the association between covariables and the outcome, inadequate cleansing. The statistically significant variables were included in multivariable logistic binary regression, and a receiver operating characteristic curve (ROC) assessment was performed.

Results

We included 167 consecutive colon capsules. Sixty-eight percent (n = 114) of patients were female, with a mean age of 64 years. The main indication for colon capsule was previous incomplete colonoscopy, in 158 patients (94.6%). The colon capsules cleansing was graded as good or excellent in 96 patients (57.5%) and as inadequate in 71 (42.5%), according to CC-CLEAR. The variables inadequate previous colon cleansing (OR adjusted 41.72 [95% CI 12.57–138.57], p value < 0.001); chronic laxative (OR adjusted 4.86 [95% CI 1.08–21.79], p value = 0.039); antidepressant (OR adjusted 5.00 [95% CI 1.65–15.16], p value = 0.004), and impaired mobility (OR adjusted 5.54 [95% CI 1.17–26.31], p value = 0.031) were independently associated with the outcome inadequate cleansing, after adjusting for confoundment. The model presented an excellent discriminative power towards the outcome variable (AUC ROC 0.937 [CI 95% 0.899–0.975], p value < 0.001).

Conclusion

A previous inadequate colon cleansing, the use of chronic laxative and antidepressant, or impaired mobility are predictors of inadequate colon capsule cleansing, as assessed by the CC-CLEAR. These 4 predictors come together as a model enabling an accurate categorization of the patients at major risk of inadequate bowel preparation for capsule colonoscopy, with an excellent discriminative power and performance, which seems useful for the selection of patients for tailored optimization of the colon cleansing protocol.

Adenoma and Serrated Lesion Detection by Colonoscopy Indication: The ADR-ESS (ADR Extended to all Screening/Surveillance) Score

BACKGROUND

The adenoma detection rate at screening (ADR) predicts interval colorectal cancer. Monitoring other lesion detection rates and colonoscopy indications has been proposed. We developed a comprehensive, automated colonoscopy audit program based on standardized clinical documentation, explored detection rates across indications, and developed the Adenoma Detection Rate - Extended to all Screening / Surveillance (ADR-ESS) score.

METHODS

In a prospective cohort study, we calculated overall and advanced adenoma and sessile serrated lesion (SSL) detection rates among 15,253 colonoscopies by 35 endoscopists from 4 endoscopy units across all colonoscopy indications. We explored correlations between detection rates, and the precision and stability of ADR-ESS versus ADR.

RESULTS

The overall "screening, first" ADR was 36.3% (95% confidence interval [CI], 34.5%-38.1%). The adenoma detection rate was lower for "screening, not first" (relative rate [RR], 0.80; 95% CI, 0.74-0.87) and "family history" (RR, 0.84; 95% CI, 0.74-0.96), and higher for "surveillance" (RR, 1.22; 95% CI, 1.15-1.31) and "follow-up, FIT" (RR, 1.21; 95% CI, 1.07-1.37). For "screening, first," the detection rates for advanced adenoma, SSL, and advanced SSL were 6.7% (95% CI, 5.7%-7.7%), 7.2% (95% CI, 6.2%-8.2%), and 2.6% (95% CI, 2.0%-3.2%), respectively. Adenoma and SSL detection were correlated (r = 0.44; P = .008). ADR-ESS had substantially narrower confidence intervals and less period-to-period variability than ADR, and was not improved by weighting for indication volume and correction for detection by indication.

CONCLUSIONS

Comprehensive, automated colonoscopy audit based on standardized clinical documentation is feasible. Adenoma detection is a fair but imperfect proxy for SSL detection. ADR-ESS increases the precision of adenoma detection assessments and emphasizes quality across colonoscopy indications.

Simplifying Measurement of Adenoma Detection Rates for Colonoscopy

BACKGROUND

Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly.

AIMS

Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR.

METHODS

We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites.

RESULTS

Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05).

CONCLUSIONS

Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

The challenge of quantifying screening colonoscopy quality: Development and psychometric properties of the Colonoscopy Quality Score instrument

INTRODUCTION AND AIMS

Colonoscopy quality is measured by the degree in which the examination increases the likelihood of obtaining adequate results on health. Our aim was to develop an instrument for evaluating the quality of screening colonoscopies, taking into account the performance of endoscopists and endoscopy units.

MATERIALS AND METHODS

Mixed methodology was employed. The first stage (qualitative) consisted of a Medline search, from which a group of experts developed the quality score items. The second stage (quantitative) utilized a modified Delphi technique to reach consensus (3 rounds). We evaluated the psychometric properties of the instrument (reliability and construct validity) in elective screening colonoscopies (in patients≥50 years of age), performed within the January-April 2017 time frame.

RESULTS

A final instrument with 8 items was produced: 1) the Boston Bowel Preparation Scale score; 2) cecal intubation rate; 3) colonoscopy withdrawal time; 4) image documentation; 5) adenoma detection rate; 6) endoscopic surveillance planning; 7) perforation rate, and 8) continuous improvement programs. The instrument was evaluated in 323 colonoscopies performed by 31 endoscopists and found to be one-dimensional and reliable (Cronbach's alpha 0.76). Performance was compared between endoscopists (center 1) and an expert endoscopist from another center (center 2): Boston Bowel Preparation Scale score 8.3 vs. 7.36 (P<.001), cecal intubation rate 93.5 vs. 96%, colonoscopy withdrawal time 14.8 vs. 8.4min (P<.001), and adenoma detection rate 34 vs. 52.2% (P<.001), respectively.

CONCLUSION

The Colonoscopy Quality Score is a reliable and valid instrument for evaluating screening colonoscopy quality. Its results could be adapted to the usual endoscopic report to adjust monitorization frequency post-colonoscopy.

Predictive factors for adenoma detection rates: a video study of endoscopist practices

Background and study aims  In 2015, the American Society for Gastrointestinal Endoscopy (ASGE) and American College of Gastroenterology (ACG) Task Force on Quality in Endoscopy deemed adenoma detection rate (ADR) the most important quality measure for colonoscopy. There has been much interest in factors that can increase ADR. To date, however, few studies have looked at what intra-procedural endoscopist practices are associated with improving ADR. We conducted a retrospective review of colonoscopy videos to evaluate intra-procedural practices that could be associated with ADR. Methods  Videos were recorded of colonoscopies performed between September and December 2017 at the Palo Alto Veterans Affairs Health Care System. Colonoscopies for screening and surveillance were included for video review. Factors assessed included withdrawal time, intra-procedural cleaning, inspection technique, and other variables (colon distention, removal of equivocal/hyperplastic polyps). A series of multiple regression analyses was conducted on variables of interest before running a final model of significant predictors. Results  A total of 130 videos were reviewed from nine endoscopists whose ADRs ranged between 37.5 % and 73.7 %. The final regression model was significant (F = 15.35, df = 2, P  = 0.0044), R ²  = 0.8365) with close inspection of behind folds and quality of cecal inspection being the factors highly correlated with predicting ADR. Withdrawal and inspection times, colonic wall distention, removal of equivocal/hyperplastic polyps, quality of rectal inspection, suctioning, and washing were factors moderately correlated with predicting ADR. Conclusions  We found that behind-fold inspection and a meticulous cecal inspection technique were predictive of a high ADR.