Quality indicators for colonoscopy

Polypectomy rate as a quality measure for colonoscopy

BACKGROUND

The adenoma detection rate (ADR) has been proposed as a robust quality indicator for colonoscopy, but it is cumbersome to calculate and not available at the time of colonoscopy.

OBJECTIVE

To determine whether endoscopists' polypectomy rates (PRs) correlate with their ADRs and to calculate benchmark PRs that correlate with benchmark ADRs.

DESIGN

Retrospective study.

SETTING

University and Veterans Affairs endoscopy units in Portland, Oregon.

SUBJECTS

Fifteen endoscopists and their patients.

MAIN OUTCOME MEASUREMENTS

Proportion of patients with any adenoma and any polyp removed; correlation between ADRs and PRs.

RESULTS

Fifteen endoscopists performed 2706 average-risk screening colonoscopies during the study. There was variation in the ADR for men (15.4%-44.7%) and women (6.1%-25.8%) and in the PRs for men (17.9%-66.0%) and women (11.3%-43.1%). Endoscopists' PRs correlated well with their ADRs (r(s) = 0.86, P < .001). To attain the established benchmark ADRs for men (25%) and women (15%), endoscopists needed PRs of 40% and 30%, respectively. Endoscopists attaining the benchmark PRs had a higher ADR among men (32.1% vs 18.4%, P < .001) and a higher ADR among women (21.0% vs 9.8%, P = .01) than those who did not.

LIMITATIONS

Study endoscopists' approach to polypectomy may differ from that of endoscopists in other settings.

CONCLUSIONS

The PR is a useful quality measure with a high degree of correlation with the ADR.

Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program--Endoscopy

BACKGROUND

Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.

OBJECTIVE

To evaluate a colonoscopists' practice audit tool that provides point-of-care data collection and peer-comparator feedback.

METHODS

A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smartphones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.

RESULTS

Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference -11.3% [95% CI -2.8% to -19.9%]; P=0.01).

DISCUSSION

Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.

CONCLUSION

Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.

The Mayo Colonoscopy Skills Assessment Tool: validation of a unique instrument to assess colonoscopy skills in trainees

BACKGROUND

Defining competence in colonoscopy is elusive because there is no objective means by which to assess skills.

OBJECTIVE

We describe the development and validation of the Mayo Colonoscopy Skills Assessment Tool (MCSAT) designed for the assessment of cognitive and motor skills during colonoscopy training.

DESIGN

Prospective development and analysis of the validity evidence of a unique colonoscopy skills assessment tool.

SETTING

Outpatient endoscopy center, Mayo Clinic in Rochester, Minn, from July 2007 through May 2010.

SUBJECTS

All gastroenterology fellows in training at this institution during the study period.

INTERVENTION

The MCSAT was developed and used to assess fellow performance over a 3-year period.

MAIN OUTCOME MEASUREMENTS

A descriptive report of the form's development, correlation of each MCSAT assessment parameter with overall competency scores, and a comparison of MCSAT scores at various stages of training.

RESULTS

There is strong individual item correlation to overall skills assessment for many of the parameters as well as significant improvement in all parameter scoring at increasing stages of experience.

LIMITATIONS

Compliance with MCSAT completion was 62% of all colonoscopies performed.

CONCLUSIONS

The MCSAT provides a valid means to objectively assess individual cognitive and motor skills in a continuous manner throughout colonoscopy training. The resultant data can eventually be used to establish average learning curves in colonoscopic skills and define competency thresholds based on performance scores rather than basing assessment simply on numbers of procedures performed.

Quality assurance in colonoscopy for colorectal cancer diagnosis

Colonoscopy can prevent colorectal cancer, but its effectiveness is diminished by operator-dependent factors. Therefore, quality assurance programs should be implemented in all colonoscopy practices. Adherence to quality performance measures varies among different countries, and physicians seem reluctant to adopt them. We provide an overview of the existing guidelines for colonoscopy quality assurance, and a summary of the quality control initiatives in Belgium and the surrounding countries.

Complications of colonoscopy: magnitude and management

Although complications of colonoscopy are rare, they are potentially serious and life threatening. In addition, less serious adverse events may occur frequently and may have an impact on a patient's willingness to undergo future procedures. This article reviews the magnitude of and risk factors for major and minor colonoscopy complications, discusses management of complications, and suggests ways to design quality improvement programs to reduce the risk of complications.

Colonoscopy reports and current state of performance measures

Quality improvement of colonoscopy continues to be an important topic. This effort begins with creating detailed and accurate colonoscopy reports. Quality indicators are measurable endpoints that may be used in quality assurance and improvement plans. Key quality measures include cecal intubation rate, adenoma detection, withdrawal time, preparation quality, follow-up recommendations, and American Society of Anesthesiologists classification. Unresolved issues include establishing proper benchmarks, documenting the correlation between process measures and outcomes, aligning incentives to improved quality outcomes, and issues regarding access to quality data.

Advanced systems to assess colonoscopy

Colorectal cancer is the second major cause of cancer-related death in the United States. The long time involved in progression of mucosal dysplasia from a small polyp to an invasive cancer and the ability to image the colon mucosa are features that make early detection and prevention of colorectal cancer by colonoscopy possible. Although colonoscopy has contributed to a marked decline in the number of colorectal cancer-related deaths, the protective effect of colonoscopy, when used in routine clinical practice, has not lived up to the expectations raised by carefully controlled prospective research studies. Therefore new systems that assess quality of colonoscopy are needed.

Quality assessment of colonoscopy reporting: results from a statewide cancer screening program

This paper aimed to assess quality of colonoscopy reports and determine if physicians in practice were already documenting recommended quality indicators, prior to the publication of a standardized Colonoscopy Reporting and Data System (CO-RADS) in 2007. We examined 110 colonoscopy reports from 2005-2006 through Maryland Colorectal Cancer Screening Program. We evaluated 25 key data elements recommended by CO-RADS, including procedure indications, risk/comorbidity assessments, procedure technical descriptions, colonoscopy findings, specimen retrieval/pathology. Among 110 reports, 73% documented the bowel preparation quality and 82% documented specific cecal landmarks. For the 177 individual polyps identified, information on size and morphology was documented for 87% and 53%, respectively. Colonoscopy reporting varied considerately in the pre-CO-RADS period. The absence of key data elements may impact the ability to make recommendations for recall intervals. This paper provides baseline data to assess if CO-RADS has an impact on reporting and how best to improve the quality of reporting.

Improving colonoscopy quality through health-care payment reform

Problems with the quality of colonoscopy are well recognized. Variation in colonoscopist performance is compounded by payment structures that reward volume rather than quality. Payment reform has emerged as one strategy to address these and more systemic problems in the quality of health care. Various forms of value-based purchasing might encourage a realignment of incentives, and allow reimbursement to be directly linked with clinically important goals of colonoscopy. This paper proposes criteria for the selection of quality measures, and three candidate indicators to define quality for the purpose of payment reform in colonoscopy: cecal intubation rate, adenoma detection rate, and recommended post-polypectomy surveillance interval. These measures represent valid, credible, and reliable indicators of the quality of colonoscopy for colorectal cancer screening and surveillance. Payment reform should explicitly link public reporting and performance on these quality measures to payment for colonoscopy.

Quality measures and credentialing in gastrointestinal endoscopy

PURPOSE OF REVIEW

Quality assessment and improvement are now mainstream activities in medicine. This review presents recent publications pertaining to quality, proposed quality measures, and associated topics in credentialing and delivery of endoscopic services.

RECENT FINDINGS

The literature continues to focus primarily on colonoscopy services. Surveillance colonoscopy continues to suffer from underuse in high-risk patients and overuse in average to moderate-risk patients, based upon current guidelines for application. Several series update and add to our understanding of adenoma detection rates as measures of quality. One study confirmed an inverse association between adenoma detection rates at screening endoscopy and the risk for identification of colorectal cancer at a subsequent diagnostic or surveillance procedure. Credentialing guidelines proposed for worldwide application are becoming uniform and similar to those from several national societies. Quality measures for use in endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are just beginning to be assessed in large series.

SUMMARY

Proposed quality measures for colonoscopy are maturing, with increasing emphasis on adenoma detection rates rather than indirect proxies for neoplasia detection. Personal and unit-based benchmarking appears to be gaining favor and is facilitated by use of automated reporting systems. Greater attention is being focused on individual performance and assuring competence of the endoscopy workforce.

Socioeconomic and other predictors of colonoscopy preparation quality

BACKGROUND

Suboptimal bowel preparation prior to colonoscopy is a common occurrence, with a deleterious impact on colonoscopy effectiveness. Established risk factors for suboptimal bowel preparation have been proposed, but social factors, such as socioeconomic status and marital status, have not been investigated.

AIMS

The aim of this study was to evaluate sociodemographic factors, including insurance status and marital status, as predictive of suboptimal preparation.

METHODS

We analyzed a database of 12,430 consecutive colonoscopies during a 28-month period at Columbia University Medical Center. We collected the following variables: age, gender, indication for colonoscopy, location (inpatient vs. outpatient), race, marital status, and Medicaid status. Preparation quality was recorded and dichotomized as optimal or suboptimal. We employed multivariate regression to determine independent risk factors for suboptimal bowel preparation.

RESULTS

Among the 10,921 examinations in which bowel preparation was recorded, suboptimal preparation occurred in 34% of Medicaid patients versus 18% of non-Medicaid patients (P < 0.0001); this remained significant in the multivariate analysis (odds ratio (OR) 1.84, 95% CI 1.61-2.11). Married patients had decreased rates of suboptimal preparation (OR 0.89, 95% CI 0.80-0.98). Other variables associated with suboptimal preparation included increased age (OR per 10 years 1.09, 95% CI 1.05-1.14), male gender (OR 1.44, 95% CI 1.31-1.59), inpatient status (OR 1.51, 95% CI 1.26-1.80), and later time of day (OR 1.89, 95% CI 1.71-2.09).

CONCLUSIONS

Unmarried status and Medicaid status are predictive of suboptimal bowel preparation. Future studies are warranted to identify how these social conditions predict bowel preparation quality and to implement interventions to optimize bowel preparation in vulnerable populations.

Development of expertise in the detection and classification of non-polypoid colorectal neoplasia: Experience-based data at an academic GI unit

At its core, quality improvement in gastrointestinal (GI) practice relies on continuous training, education, and information among all health care providers, whether gastroenterologists, GI trainees, endoscopy nurses, or GI pathologists. Over the past few years, it became clear that objective criteria are needed to assess the quality of colonoscopy, such as cecum intubation rate, quality of bowel preparation, withdrawal time, and adenoma detection rate. In this context, development of competence among practicing endoscopists to adequately detect and treat non-polypoid colorectal neoplasms (NP-CRNs) deserves special attention. We describe a summary of the path to develop expertise in detection and management of NP-CRNs, based on experience at our academic GI unit.

Relationship of non-polypoid colorectal neoplasms to quality of colonoscopy

Colonoscopy is a dominant modality for colorectal cancer prevention in average-risk patients aged 50 years and older. Non-polypoid colorectal neoplasms (NP-CRNs) are likely a significant contributing factor to interval colorectal cancers because they have a higher prevalence in Western populations than previously thought, are more difficult to detect visually with conventional colonoscopy, and are more likely to contain advanced histology than polypoid neoplasms, regardless of size. The accurate identification and complete removal of NP-CRNs is thus an integral part of high-quality colonoscopy, and a critical component of the ongoing efforts to make colorectal cancer screening programs widely available, effective, and accepted by patients. In this article, the authors examine the quality indicators for colonoscopy, present the reasons for interval cancers, and discuss the relation between NP-CRNs and quality colonoscopy.

The effect of periodic monitoring and feedback on screening colonoscopy withdrawal times, polyp detection rates, and patient satisfaction scores

BACKGROUND

Previous studies showed a correlation between mean withdrawal times during screening colonoscopy and polyp/neoplasia detection rates.

OBJECTIVES

To assess the effect of a monitoring and feedback program on withdrawal times, polyp/neoplasia detection rates, and patient satisfaction.

DESIGN

Comparison of retrospective and prospective data.

SETTING

Teaching hospital.

PATIENTS

Asymptomatic adults undergoing screening colonoscopy.

INTERVENTIONS

Monitoring and feedback program.

MAIN OUTCOME MEASUREMENTS

Withdrawal times, polyp and neoplasia detection rates, and patient satisfaction scores.

METHODS

We retrospectively reviewed 850 screening colonoscopies, recording withdrawal times, polyp findings, and patient satisfaction scores. All procedures were performed by 10 experienced gastroenterologists who were then informed that periodic confidential monitoring and feedback of withdrawal times, polyp detection rates, and satisfaction scores would be started. We then prospectively collected data on another 541 screening colonoscopies. We compared pre- and postmonitoring outcome measures.

RESULTS

Overall, after monitoring had begun, there was an increase in mean withdrawal times (from 6.57 to 8.07 minutes; P < .0001), and polyp detection rates (from 33.1% to 38.1%; P = .04, significance removed by Bonferroni correction). Nine of the 10 endoscopists increased their withdrawal times significantly. There was a small, nonsignificant increase in the neoplasia detection rate (from 19.6% to 22.7%; P = .17), but no significant change in mean satisfaction scores. Across endoscopists, there was a moderate correlation (r = 0.63; P = .04, significance removed by Bonferroni correction) between withdrawal times and polyp detection rates, but not between withdrawal times and satisfaction scores.

LIMITATIONS

No randomization, possible response bias, confounding of intervention effects, and sample size limitations.

CONCLUSIONS

Monitoring and feedback are associated with increases in mean withdrawal times and polyp detection rates, but not patient satisfaction scores. Neoplasia detection rates showed a statistically nonsignificant trend toward an increase.

Study protocol: population screening for colorectal cancer by colonoscopy or CT colonography: a randomized controlled trial

Background

Colorectal cancer (CRC) is the second most prevalent type of cancer in Europe. Early detection and removal of CRC or its precursor lesions by population screening can reduce mortality. Colonoscopy and computed tomography colonography (CT colonography) are highly accurate exams and screening options that examine the entire colon. The success of screening depends on the participation rate. We designed a randomized trial to compare the uptake, yield and costs of direct colonoscopy population screening, using either a telephone consultation or a consultation at the outpatient clinic, versus CT colonography first, with colonoscopy in CT colonography positives.

Methods and design

7,500 persons between 50 and 75 years will be randomly selected from the electronic database of the municipal administration registration and will receive an invitation to participate in either CT colonography (2,500 persons) or colonoscopy (5,000 persons) screening. Those invited for colonoscopy screening will be randomized to a prior consultation either by telephone or a visit at the outpatient clinic. All CT colonography invitees will have a prior consultation by telephone. Invitees are instructed to consult their general practitioner and not to participate in screening if they have symptoms suggestive for CRC. After providing informed consent, participants will be scheduled for the screening procedure. The primary outcome measure of this study is the participation rate. Secondary outcomes are the diagnostic yield, the expected and perceived burden of the screening test, level of informed choice and cost-effectiveness of both screening methods.

Discussion

This study will provide further evidence to enable decision making in population screening for colorectal cancer.

Trial registration

Dutch trial register: NTR1829

Quality indicators for colonoscopy and the risk of interval cancer

BACKGROUND

Although rates of detection of adenomatous lesions (tumors or polyps) and cecal intubation are recommended for use as quality indicators for screening colonoscopy, these measurements have not been validated, and their importance remains uncertain.

METHODS

We used a multivariate Cox proportional-hazards regression model to evaluate the influence of quality indicators for colonoscopy on the risk of interval cancer. Data were collected from 186 endoscopists who were involved in a colonoscopy-based colorectal-cancer screening program involving 45,026 subjects. Interval cancer was defined as colorectal adenocarcinoma that was diagnosed between the time of screening colonoscopy and the scheduled time of surveillance colonoscopy. We derived data on quality indicators for colonoscopy from the screening program's database and data on interval cancers from cancer registries. The primary aim of the study was to assess the association between quality indicators for colonoscopy and the risk of interval cancer.

RESULTS

A total of 42 interval colorectal cancers were identified during a period of 188,788 person-years. The endoscopist's rate of detection of adenomas was significantly associated with the risk of interval colorectal cancer (P=0.008), whereas the rate of cecal intubation was not significantly associated with this risk (P=0.50). The hazard ratios for adenoma detection rates of less than 11.0%, 11.0 to 14.9%, and 15.0 to 19.9%, as compared with a rate of 20.0% or higher, were 10.94 (95% confidence interval [CI], 1.37 to 87.01), 10.75 (95% CI, 1.36 to 85.06), and 12.50 (95% CI, 1.51 to 103.43), respectively (P=0.02 for all comparisons).

CONCLUSIONS

The adenoma detection rate is an independent predictor of the risk of interval colorectal cancer after screening colonoscopy.

Quality indicators for colonoscopy and the risk of interval cancer

BACKGROUND

Although rates of detection of adenomatous lesions (tumors or polyps) and cecal intubation are recommended for use as quality indicators for screening colonoscopy, these measurements have not been validated, and their importance remains uncertain.

METHODS

We used a multivariate Cox proportional-hazards regression model to evaluate the influence of quality indicators for colonoscopy on the risk of interval cancer. Data were collected from 186 endoscopists who were involved in a colonoscopy-based colorectal-cancer screening program involving 45,026 subjects. Interval cancer was defined as colorectal adenocarcinoma that was diagnosed between the time of screening colonoscopy and the scheduled time of surveillance colonoscopy. We derived data on quality indicators for colonoscopy from the screening program's database and data on interval cancers from cancer registries. The primary aim of the study was to assess the association between quality indicators for colonoscopy and the risk of interval cancer.

RESULTS

A total of 42 interval colorectal cancers were identified during a period of 188,788 person-years. The endoscopist's rate of detection of adenomas was significantly associated with the risk of interval colorectal cancer (P=0.008), whereas the rate of cecal intubation was not significantly associated with this risk (P=0.50). The hazard ratios for adenoma detection rates of less than 11.0%, 11.0 to 14.9%, and 15.0 to 19.9%, as compared with a rate of 20.0% or higher, were 10.94 (95% confidence interval [CI], 1.37 to 87.01), 10.75 (95% CI, 1.36 to 85.06), and 12.50 (95% CI, 1.51 to 103.43), respectively (P=0.02 for all comparisons).

CONCLUSIONS

The adenoma detection rate is an independent predictor of the risk of interval colorectal cancer after screening colonoscopy.

Colorectal cancer screening in evolution: Japan and the USA

Colorectal cancer (CRC) is one of the most common cancers in both Japan and the USA. Age-adjusted incidence of CRC has been in decline in the USA since 1985, while rates in Japan have been increasing. The decline in the USA is commonly attributed to CRC screening programs but there is little direct evidence to support this assertion. The current screening recommendations in the USA cover several options including colonoscopy and computerized tomographic colonography (CTC). The Japanese CRC screening program is centered on fecal immunochemistry testing (FIT). The US government Medicare program's approval of colonoscopy as a primary screening test has lead to a large increase in the number of patients undergoing the procedure. However, the benefit achieved from this change in screening program emphasis is not clear. Simulation models demonstrate that a screening program centered on FIT achieves 94% of the benefit that an all-colonoscopy program is able to accomplish but at a lower cost per life year gained. Clinical studies of colonoscopy have failed to demonstrate the 76-90% declines in CRC incidence predicted by the National Polyp Study published in 1993. A potential reason for this failure is the quality of colonoscopy performance. Until more compelling data becomes available demonstrating the utility of colonoscopy as a primary screening modality, there is little incentive to alter the proven cost-effective approach to CRC screening currently in practice in Japan.

Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment

OBJECTIVE

To evaluate the use and impact of the recommended withdrawal time of at least 6 minutes from the cecum in colonoscopy in multiple gastroenterology endoscopy ambulatory surgery centers serving a wide geographical area.

METHODS

An observational prospective multicenter quality assurance review was conducted in 49 ambulatory surgery centers in 17 states with 315 gastroenterologists. There was no intervention with this quality assessment program as care of patients and the routine of gastroenterologists continued as standard practice. Multivariable analysis was applied to the database to examine factors affecting withdrawal time and polyp detection.

RESULTS

There were 15,955 consecutive qualified patients receiving colonoscopies in a designated 4-week period. Gastroenterologists with average withdrawal times of 6 minutes or more in patients with no polyps were 1.8 times more likely to detect 1 or more polyps and had a significantly higher rate (P<0.0001) of polyp detection in patients with findings of polyps compared to gastroenterologists with average withdrawal times of less than 6 minutes in patients with no polyps. For patients with no pathology, the mean time of withdrawal was 6.98 (SD=4.34) minutes and for patients with pathology mean time of withdrawal was 11.27 (SD=6.71) minutes. Strongest predictors of withdrawal time of 6 minutes or more were presence of carcinoma (3.7 times more likely than those with no pathology), adenoma (2.0 times more likely than those with no pathology), and number of polyps visualized (1.7 times more likely for each polyp).

CONCLUSIONS

This quality assurance assessment from standard colonoscopy practices of 315 gastroenterologists in 49 endoscopic ambulatory surgery centers serving a wide geographical area provides support for the merits of a colonoscopy withdrawal time from the cecum of 6 minutes or more to improve the detection of polyps.

Surgical resident's training in colonoscopy: numbers, competency, and perceptions

BACKGROUND

There is currently great discrepancy in the training requirements between medical societies regarding the recommended threshold number of colonoscopies needed to assess for technical competence. Our goal was to determine the number of colonoscopies performed by surgical residents, rate of cecal intubation, as well as trainee perceptions of colonoscopy training after completion of their training period.

METHODS

This study consisted of a 12-item electronic survey completed by 21 surgical residents after their 2-month endoscopy rotation at a tertiary care, urban referral center. This survey assessed numbers of colonoscopies performed, number successful to the cecum, and perceptions of training in colonoscopy. The cecal intubation rate was used as a surrogate marker of technical competence.

RESULTS

Twenty-one surgical residents performed a mean of 80 ± 35 total colonoscopies during the 2-month rotation. The average cecal intubation rate was 47% (range 9-78%). Resident comfort level for independently performing a total colonoscopy was scored a mean 3.6 on scale of 1-5 (5 = most comfortable), and 43% of the surgical residents planned on performing colonoscopy after residency training.

CONCLUSIONS

Surgical residents can obtain the recommended threshold for colonoscopy (N = 50) during a standard 2-month rotation. However, no resident was able to achieve technical competence in colonoscopy as defined by a 90% cecal intubation rate. These data suggest that the method of training of general surgery residents in colonoscopy may need reappraisal.

A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation (with videos)

BACKGROUND

Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope.

OBJECTIVE

To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device.

DESIGN

Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope.

SETTING

Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office.

PATIENTS

A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy.

INTERVENTIONS

After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.

MAIN OUTCOME MEASUREMENTS

The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER.

RESULTS

In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P < .0001) including 15 additional adenomas (an 11.0% increase; P < .0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively.

LIMITATIONS

There was no randomization or comparison with a separate control group.

CONCLUSIONS

A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00657371.).

The effect of nonmedical factors on variations in the performance of colonoscopy among different health care settings

BACKGROUND

Previous published studies have shown significant variations in colonoscopy performance, even when medical factors are taken into account. This study aimed to examine the role of nonmedical factors (ie, embodied in health care system design) as possible contributors to variations in colonoscopy performance.

METHODS

Patient data from a multicenter observational study conducted between 2000 and 2002 in 21 centers in 11 western countries were used. Variability was captured through 2 performance outcomes (diagnostic yield and colonoscopy withdrawal time), jointly studied as dependent variables, using a multilevel 2-equation system.

RESULTS

Results showed that open-access systems and high-volume colonoscopy centers were independently associated with a higher likelihood of detecting significant lesions and longer withdrawal durations. Fee for service (FFS) payment was associated with shorter withdrawal durations, and so had an indirect negative impact on the diagnostic yield. Teaching centers exhibited lower detection rates and longer withdrawal times.

CONCLUSIONS

Our results suggest that gatekeeping colonoscopy is likely to miss patients with significant lesions and that developing specialized colonoscopy units is important to improve performance. Results also suggest that FFS may result in a lower quality of care in colonoscopy practice and highlight the fact that longer withdrawal times do not necessarily indicate higher quality in teaching centers.

Colonoscopy training in gastroenterology fellowships: determining competence

BACKGROUND

Although 140 colonoscopies is the recommended minimal requirement for gastroenterology fellows, it is unclear whether this minimum is a surrogate for competence.

OBJECTIVE

To assess whether 140 colonoscopies is an adequate threshold to determine > or =90% colonoscopy performance independence.

DESIGN

Retrospective analysis on a database constructed for quality control/improvement.

SETTING

Gastroenterology fellowship training program at a veterans hospital.

PATIENTS

Consecutive patients who underwent colonoscopy primarily for symptoms, previous polyps, or family history of cancer (a minority were performed for screening only) from April 2007 to September 2008. This study involved 11 gastroenterology fellows who performed 770 colonoscopies during 18 individual month-long rotations.

INTERVENTION

Assessment of various procedure-related parameters.

MAIN OUTCOME MEASUREMENTS

Determining when > or =90% independence in colonoscopy performance was reached.

RESULTS

Total colonoscopy time, time to cecal intubation, withdrawal time, and independent completion rates all significantly improved when first and third years of training were compared (P < .001 for all comparisons). The adenoma detection rate did not change between years of training. Independent completion was achieved in > or =90% of cases for all fellows after 500 colonoscopies, whereas no fellow reached a > or =90% independent colonoscopy completion rate after 140 colonoscopies.

LIMITATIONS

Number of participants, single center.

CONCLUSIONS

Becoming a competent colonoscopist requires repeated practice. Our study suggests that, although there is variability between a trainee's ability to become colonoscopy independent, 500 colonoscopies are likely required to ensure reliable (> or =90%) independent completion rates. Competency requires more than a single parameter.

Cecal intubation rate with the double-balloon endoscope after incomplete conventional colonoscopy: a study in 45 patients

BACKGROUND AND AIM

Conventional colonoscopy is the gold standard for colorectal cancer screening. However, a failure rate to complete conventional colonoscopy of more than 10% is reported in the literature. We evaluated whether the therapeutic Fujinon double-balloon endoscope EN-450T5/20 is a valuable tool to intubate the cecum and to carry out all conventional endoscopic procedures after incomplete conventional colonoscopy.

METHODS

Forty-five consecutive patients with prior incomplete conventional colonoscopy were prospectively enrolled. All but three procedures were carried out under conscious sedation with the patient in the left lateral decubitus position without fluoroscopic guidance.

RESULTS

The cecum was reached in 42 of 45 patients (93%) and in 62% additional therapeutic interventions were carried out. Double-balloon colonoscopy required less conscious sedation compared to conventional colonoscopy. No external abdominal compression nor fluoroscopic control was used. The insertion depth of the double-balloon endoscope did not exceed the working length of a conventional colonoscope.

CONCLUSIONS

The present study illustrates that the concept of double-balloon endoscopy is a valuable alternative to reach the cecum after prior incomplete conventional colonoscopy, especially due to redundant colon and colonic loop formation. The procedure requires less conscious sedation and no fluoroscopic control, but allows all conventional endoscopic interventions.

SVM based colon polyps classifier in a wireless active stereo endoscope

This work focuses on the recognition of three-dimensional colon polyps captured by an active stereo vision sensor. The detection algorithm consists of SVM classifier trained on robust feature descriptors. The study is related to Cyclope, this prototype sensor allows real time 3D object reconstruction and continues to be optimized technically to improve its classification task by differentiation between hyperplastic and adenomatous polyps. Experimental results were encouraging and show correct classification rate of approximately 97%. The work contains detailed statistics about the detection rate and the computing complexity. Inspired by intensity histogram, the work shows a new approach that extracts a set of features based on depth histogram and combines stereo measurement with SVM classifiers to correctly classify benign and malignant polyps.

[Development and validation of quality standards for colonoscopy]

BACKGROUND AND OBJECTIVES

Before starting programs for colorectal cancer screening it is necessary to evaluate the quality of colonoscopy. Our objectives were to develop a group of quality indicators of colonoscopy easily applicable and to determine the variability of their achievement.

PATIENTS AND METHODS

After reviewing the bibliography we prepared 21 potential indicators of quality that were submitted to a process of selection in which we measured their facial validity, content validity, reliability and viability of their measurement. We estimated the variability of their achievement by means of the coefficient of variability (CV) and the variability of the achievement of the standards by means of chi(2).

RESULTS

Six indicators overcome the selection process: informed consent, medication administered, completed colonoscopy, complications, every polyp removed and recovered, and adenoma detection rate in patients older than 50 years. 1928 colonoscopies were included from eight endoscopy units. Every unit included the same number of colonoscopies selected by means of simple random sampling with substitution. There was an important variability in the achievement of some indicators and standards: medication administered (CV 43%, p<0.01), complications registered (CV 37%, p<0.01), every polyp removed and recovered (CV 12%, p<0.01) and adenoma detection rate in older than fifty years (CV 2%, p<0.01).

CONCLUSIONS

We have validated six quality indicators for colonoscopy which are easily measurable. An important variability exists in the achievement of some indicators and standards. Our data highlight the importance of the development of continuous quality improvement programmes for colonoscopy before starting colorectal cancer screening.

Measuring objective quality of colonoscopy

Advances in video technology are being incorporated into today's healthcare practices. Colonoscopy is regarded as one of the most important diagnostic tools for colorectal cancer. Indeed, colonoscopy has contributed to a decline in the number of colorectal-cancer-related deaths. Although colonoscopy has become the preferred screening modality for prevention of colorectal cancer, recent data suggest that there is a significant miss rate for the detection of large polyps and cancers, and methods to investigate why this occurs are needed. To address this problem, we present a new computer-based method that analyzes a digitized video file of a colonoscopic procedure and produces a number of metrics that likely reflect the quality of the procedure. The method consists of a set of novel image-processing algorithms designed to address new technical challenges due to uncommon characteristics of videos captured during colonoscopy. As these measurements can be obtained automatically, our method enables future quality control in large-scale day-to-day medical practice, which is currently not feasible. In addition, our method can be adapted to other endoscopic procedures such as upper gastrointestinal endoscopy, enteroscopy, and bronchoscopy. Last but not least, our method may be useful to assess progress during colonoscopy training.

Assessing colonoscopy training outcomes using quality indicators

PURPOSE

Training numbers for colonoscopy vary among specialties. Tracking colonoscopy quality indicators for program graduates may provide reliable outcome data to improve educational programs and establish training requirements. The purpose of this study was to measure specific colonoscopy quality indicators for a family medicine graduate to determine if outcome can be used to assess the quality of procedure training and contribute to more objective means of establishing training numbers.

METHODS

We present a case series of the first 800 colonoscopies performed by a newly credentialed family physician who had performed 101 procedures during residency training. Procedure reports and medical records were reviewed for all patients receiving a colonoscopy by this physician from September 2003 to September 2007. Selected quality indicators were compared to recommended colonoscopy standards.

RESULTS

The overall reach-the-cecum rate was 98.6%. Adenomas were detected in 21.6% of females and 33.7% of males. All polyps measuring less than 2 cm were removed. Epinephrine was used for 3 patients with hemostasis after polypectomy. There were no perforations.

CONCLUSIONS

Quality indicators for colonoscopy were met after 101 supervised procedures. Postgraduate tracking of nationally recognized colonoscopy quality indicators can provide valuable outcome data to improve residency training and assist in establishing uniform training requirements among specialties.

Does trainee participation during colonoscopy affect adenoma detection rates?

INTRODUCTION

Training future endoscopists is essential to meeting the increasing demands for colonoscopy. It remains unknown whether adenoma detection rates are adversely affected by trainee participation.

METHODS

This is a single-center, prospective study. The primary aim of this study was to investigate whether adenoma detection rates differed between procedures with or without trainee involvement. A total of 368 consecutive patients entered the analysis (181 with trainee participation and 187 without).

RESULTS

Adenomas were detected in 19.3% of experienced physician-only procedures and in 14.9% of procedures with trainee participation. Advanced adenomas were detected in 8.6% of experienced physicians' procedures vs. 4.9% of trainee procedures. Polyp detection was nearly identical in both groups (32% for experienced physicians; 33% for trainees). Trainee participation delayed the procedure by a mean of seven minutes.

CONCLUSION

Adenoma detection rates did not differ significantly, whether there was trainee involvement or not. A trend toward finding more adenomas or advanced adenomas in the absence of a trainee was observed, but it was lower than previously reported interobserver variability among experienced physicians. The small difference in adenoma detection was not observed for polyp detection, which may be explained by the more frequent removal of hyperplastic polyps by trainees.

[Colorectal adenomas: postpolypectomy surveillance strategies and chemoprevention]

Colorectal adenomas are the most fully characterized premalignant lesions in the development of colorectal cancer. Consequently, the identification and resolution of these lesions, as well as the follow-up of affected patients, are a priority in the prevention of this neoplasm. The studies presented in the annual meeting of the American Gastroenterological Association 2008 show that the results of current surveillance strategies can be improved with a view to reducing the rate of interval neoplasia. Improvement of these results includes optimization of the endoscopic technique (colonic preparation, cecal intubation, withdrawal time, etc.) as well as the incorporation of new diagnostic methods and the possible administration of chemopreventive drugs.

Implementation of population screening for colorectal cancer by repeated fecal occult blood test in the Netherlands

Background

Colorectal cancer (CRC) is the third most prevalent type of cancer in the world. Its prognosis is closely related to the disease stage at the time of diagnosis. Early detection of symptomless CRC or precursor lesions through population screening could reduce CRC mortality. However, screening programs are only effective if enough people are willing to participate. This study aims to asses the uptake of a second round of fecal occult blood test (FOBt) based screening and to explore factors that could potentially increase this uptake.

Methods and design

Two years after the first screening round, 10.000 average risk persons, aged 50 to 75, will again receive an invitation to participate in immunohistochemical FOBt (iFOBt) based screening. Eligible persons will be recruited through a city population database. Invitees will be randomized to receive either an iFOBt with a faeces collection paper or an iFOBt without a collection paper. The iFOBts will be analyzed in a specialized laboratory at the Academic Medical Centre. Positive iFOBts will be followed by a consultation at our outpatient clinic and, in the absence of contra-indications and after informed consent, by a colonoscopy. The primary outcome measure is the participation rate. Secondary outcome measures are the effect of the addition of a collection paper on the participation rate, reasons for participation and non-participation, measures of informed choice and psychological consequences of screening and measures of psychological and physical burden associated with the iFOBt and the colonoscopy. Another secondary outcome measure is the diagnostic yield of the program.

Discussion

In order to implement population screening for colorectal cancer in the Netherlands, information is needed on the uptake of repeated rounds of FOBt-based screening and on factors that could potentially increase this uptake in the future since effectiveness of such a program depends on the willingness of persons to participate. This study will provide information on the actual uptake and perception of a second round of iFOBt-based screening. The results of this study will contribute to the future implementation of a national colorectal screening program in the Netherlands.

Trial registration

Dutch Trial register: NTR1327

Colonoscopy training for nurse endoscopists: a feasibility study

BACKGROUND

Screening by using colonoscopy is recommended in many countries to reduce the risk of death from colorectal cancer. Given the limited supply of medical endoscopists, nurse endoscopists may represent an economic alternative.

OBJECTIVE

To develop a colonoscopy training program for nurse endoscopists and to evaluate the feasibility of this program.

DESIGN

Two nurse endoscopists and 1 first-year GI fellow were enrolled in a colonoscopy training protocol, including computer-simulator training, flexible sigmoidoscopies, and colonoscopies under direct supervision.

SETTING

A single-center prospective study.

PATIENTS

The first 150 complete colonoscopies of each trainee endoscopist were evaluated and compared with 150 colonoscopies performed by an experienced endoscopist.

MAIN OUTCOME MEASUREMENTS

Objective criteria for competency were diagnostic accuracy, cecal-intubation rate, cecal-intubation time, the need for assistance, and complications. Subjective criteria included patient satisfaction, pain, and discomfort scores.

RESULTS

The nurse endoscopists' unassisted cecal-intubation rate was 80% for the first 25 procedures, gradually increasing in subsequent cases to 96% for the last 25 procedures. The mean cecal-intubation time at the end of the training period was 10 minutes. Cecal-intubation rates and times were comparable between the nurse trainees and the fellow. The patients reported low degrees of pain and discomfort, and high satisfaction scores, irrespective of the type of endoscopist. Diagnostic accuracy of the trainees was good. The complication rate was 0.3%.

LIMITATION

Nonrandomized design.

CONCLUSIONS

This pilot study suggests that nurses can be trained to perform colonoscopy in an effective manner, with results similar to a GI fellow. The learning curve indicated that 150 procedures are required before independent examinations are attempted.

Assessment of the quality of colonoscopy reports: results from a multicenter consortium

BACKGROUND

To improve colonoscopy quality, reports must include key quality indicators that can be monitored.

OBJECTIVE

To determine the quality of colonoscopy reports in diverse practice settings.

SETTING

The consortium of the Clinical Outcomes Research Initiative, which includes 73 U.S. gastroenterology practice sites that use a structured computerized endoscopy report generator, which includes fields for specific quality indicators.

DESIGN

Prospective data collection from 2004 to 2006.

MAIN OUTCOMES MEASUREMENTS

Reports were queried to determine if specific quality indicators were recorded. Specific end points, including quality of bowel preparation, cecal intubation rate, and detection of polyp(s) >9 mm in screening examinations were compared for 53 practices with more than 100 colonoscopy procedures per year.

RESULTS

Of the 438,521 reports received during the study period, 13.9% did not include bowel-preparation quality and 10.1% did not include comorbidity classification. The overall cecal intubation rate was 96.3%, but cecal landmarks were not recorded in 14% of the reports. Missing polyp descriptors included polyp size (4.9%) and morphology (14.7%). Reporting interventions for adverse events during the procedure varied from 0% to 6.5%. Among average-risk patients who received screening examinations, the detection rate of polyps >9 mm, adjusted for age, sex, and race, was between 4% and 10% in 81% of practices.

LIMITATION

Bias toward high rates of reporting because of the standard use of a computerized report generator.

CONCLUSIONS

There is significant variation in the quality of colonoscopy reports across diverse practices, despite the use of a computerized report generator. Measurement of quality indicators in clinical practice can identify areas for quality improvement.

Quality in EUS: an assessment of baseline compliance and performance improvement by using the American Society for Gastrointestinal Endoscopy-American College of Gastroenterology quality indicators

BACKGROUND

An American Society for Gastrointestinal Endoscopy-American College of Gastroenterology (ASGE-ACG) task force recently developed quality indicators for the preprocedure, intraprocedure, and postprocedure phases of each endoscopic procedure. Benchmark rates and clinical significance of compliance have not been determined.

OBJECTIVES

To establish baseline compliance rates to the preprocedure and intraprocedure quality indicators in our EUS cases, identify indicators with the lowest compliance rates, and establish change in compliance rates with a targeted performance improvement plan.

METHODS

We measured baseline compliance to each of the preprocedure and intraprocedure EUS quality indicators in the EUS procedures performed at Mayo Clinic Jacksonville from March 1996 through August 2006. We developed a performance improvement plan that targeted the 4 indicators with the lowest compliance over the entire time period. Compliance rates in the year after plan implementation were compared with those from January 2004 to August 2006, when adjusting for endoscopist and direct access.

RESULTS

We demonstrated areas of high quality as well as areas for improvement in compliance with the ASGE-ACG quality metrics in a large cohort of EUS cases. We achieved improvement in all 4 areas targeted for quality improvement, statistically significant at the 5% level for two of the quality indicators.

LIMITATIONS

Limitations included our retrospective design and the use of unstructured procedure dictations that may limit application of our results. It is also unclear whether compliance was truly synonymous with performance.

CONCLUSIONS

We established reference levels of compliance rate within our practice and showed that a targeted performance improvement plan that consisted of awareness, individual accountability, and documentation can result in improvement.

Edge cross-section features for detection of appendiceal orifice appearance in colonoscopy videos

Colonoscopy is an endoscopic technique that allows a physician to inspect the inside of the human colon. The appearance of the appendiceal orifice during colonoscopy indicates a complete traversal of the colon, which is one of important quality indicators of examination of the colon. In this paper, we propose a new algorithm that detects appendix images-images showing the appendiceal orifice. We introduce new features based on geometric shape, saturation and intensity changes along the norm direction (cross-section) of an edge to discriminate appendix images. Our experimental results on real colonoscopic images show the average sensitivity and specificity of 88.12% and 94.25%, respectively.

Screening colonoscopies by primary care physicians: a meta-analysis

PURPOSE

There is currently too few endoscopists to enact a national colorectal cancer screening program with colonoscopy. Primary care physicians could play an important role in filling this shortage by offering screening colonoscopy in their practice. The purpose of this study was to examine the safety and effectiveness of colonoscopies performed by primary care physicians.

METHODS

We identified relevant articles through searches of MEDLINE and EMBASE bibliographic databases to December 2007 and through manual searches of bibliographies of each citation. We found 590 articles, 12 of which met inclusion criteria. Two authors independently abstracted data on study and patient characteristics. Descriptive statistics were performed. For each outcome measure, a random effects model was used to determine estimated means and confidence intervals.

RESULTS

We analyzed 12 studies of colonoscopies performed by primary care physicians, which included 18,292 patients (mean age 59 years, 50.5% women). The mean estimated adenoma and adenocarcinoma detection rates were 28.9% (95% confidence interval [CI], 20.4%-39.3%) and 1.7% (95% CI, 0.9%-3.0%), respectively. The mean estimated reach-the-cecum rate was 89.2% (95% CI, 80.1%-94.4%). The major complication rate was 0.04% (95% CI, 0.01%-0.07%); no deaths were reported.

CONCLUSIONS

Colonoscopies performed by primary care physicians have quality, safety, and efficacy indicators that are comparable to those recommended by the American Society of Gastrointestinal Endoscopy, the American College of Gastroenterology, and the Society of American Gastrointestinal Endoscopic Surgeons. Based on these results, colonoscopy screening by primary care physicians appears to be safe and effective.