Volume and accreditation, but not specialty, affect quality standards in colonoscopy

Case-mix adjustment to compare colonoscopy performance between endoscopy centers: a nationwide registry study

BACKGROUND : Nonmodifiable patient and endoscopy characteristics might influence colonoscopy performance. Differences in these so-called case-mix factors are likely to exist between endoscopy centers. This study aimed to examine the importance of case-mix adjustment when comparing performance between endoscopy centers. METHODS : Prospectively collected data recorded in the Dutch national colonoscopy registry between 2016 and 2019 were retrospectively analyzed. Cecal intubation rate (CIR) and adequate bowel preparation rate (ABPR) were analyzed. Additionally, polyp detection rate (PDR) was studied in screening colonoscopies following a positive fecal immunochemical test (FIT). Variation in case-mix factors between endoscopy centers and expected outcomes for each performance measure were calculated per endoscopy center based on case-mix factors (sex, age, American Society of Anesthesiologist [ASA] score, indication) using multivariable logistic regression. RESULTS:  363 840 colonoscopies were included from 51 endoscopy centers. Mean percentages per endoscopy center were significantly different for age > 65 years, male patients, ASA ≥ III, and diagnostic colonoscopies (all P < 0.001). In the FIT-positive screening population, significant differences were observed between endoscopy centers for age > 65 years, male patients, and ASA ≥ III (all P ≤ 0.001). The expected CIR, ABPR, and PDR ranged from 95.0 % to 96.9 %, from 93.6 % to 96.4 %, and from 76.2 % to 79.1 %, respectively. Age, sex, ASA classification, and indication were significant case-mix factors for CIR and ABPR. In the FIT-positive screening population, age, sex, and ASA classification were significant case-mix factors for PDR. CONCLUSION:  Our findings emphasize the importance of considering case-mix adjustment when comparing colonoscopy performance measures between endoscopy centers.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopists. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with 7 corresponding indicators that can be used to identify high-quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high-quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (≥90%) and terminal ileal intubation rate (≥85%).

DISCUSSION

It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.

Improvements in the Effectiveness of Early Detection in Colorectal Cancer with Open-Label Randomised Study

Introduction: The general objective of this research is to improve the quality of colorectal cancer screening (CRC) by assessing, as an indicator of effectiveness, the ability of colonoscopy to detect more advanced adenomas in the exposed group than in the control group. Material and Methods: The present work is designed as an open-label randomized study on cancer screening, using two groups based on their exposure to the protocol: an exposed to intervention group (EIG, 167), and a control group (CG, 167), without the intervention of the protocol and by 1:1 matching. Results: In 167 patients in the GEI, 449 polyps are visualized and 274 are adenomas (80.58%), of which 100 (36.49%) are advanced adenomas. In the CG (n = 174), there are 321 polyps and 152 adenomas (82.60%). The variables significantly associated by logistic regression to the detection of adenomas are the male sex with an OR of 2.52. The variable time to withdrawal, ≥9 min, is significant at 99% confidence (p = 0.002/OR 34.67) and the fractional dose is significant at 99% (p = 0.009, OR 7.81). Conclusion: Based on the observations made, our study suggests that the intervention in collaboration between primary care and hospital care is effective from a preventive point of view and achieves the objective of effectiveness and quality of the PCCR.

Medical professional liability in gastroenterology: definitions, trends, risk factors, provider behaviors, and implications

Introduction: Medical professional liability (MPL) is a notable concern for many clinicians, especially in procedure-intensive specialties such as gastroenterology (GI). Comprehensive understanding of the basis for MPL claims can improve gastroenterologists' practice, lower MPL risk, and improve the overall patient care experience. This is particularly relevant in the setting of the increasing average compensation per paid GI-related MPL claim, and evolving healthcare delivery patterns and regulations.Areas Covered: MPL claims are generally grounded in the concept of negligence, a broad term that may apply to situations involving medical errors, ameliorable adverse events, inadequate informed consent and/or refusal, and numerous others. Though often not directly discussed in GI training or thereafter, there are various mechanisms and behaviors that can alter (decrease or increase) MPL risk. Additional dimensions of MPL include telemedicine, social media, and vicarious liability. We discuss these topics as well as takeaways to mitigate risk, thus reducing unnecessary clinician anxiety, promoting professional development, and optimizing healthcare outcomes.Expert Opinion: MPL risk is modifiable. Strong provider-patient relationships, through effective communication, patient reassurance, and enhanced informed consent, decrease risk, as does thorough documentation. Conversely, provider 'defensive' mechanisms intended to decrease MPL risk, including assurance and avoidance behaviors, may paradoxically increase it.

[Position paper on endoscopic reporting in IBD]

The complete and reliable documentation of endoscopic findings make up the crucial foundation for the treatment of patients with inflammatory bowel diseases such as Crohn´s disease and ulcerative colitis. These findings are, on the one hand, a prerequisite for therapeutic decisions and, on the other hand, important as a tool for assessing the response to ongoing treatments. Endoscopic reports should, therefore, be recorded according to standardized criteria to ensure that the findings of different endoscopists can be adequately compared and that changes in the course of the disease can be traced back. In consideration of these necessities, fifteen members of the Imaging Working Group of the German Kompetenznetz Darmerkrankungen have created a position paper proposing a structure and specifications for the documentation of endoscopic exams. In addition to the formal report structure, the recommendations address a large number of attributes of acute and chronic inflammatory alterations as well as endoscopically detectable complications, which are explained in detail and illustrated using exemplary images. In addition, more frequently used endoscopic activity indices are presented and their use in everyday clinical practice is discussed.

Impact of the National Endoscopy Database (NED) on colonoscopy withdrawal time: a tertiary centre experience

OBJECTIVE

Colonoscopy withdrawal time (CWT) is a key performance indicator affecting polyp detection rate (PDR) and adenoma detection rate (ADR). However, studies have shown wide variation in CWT and ADR between different endoscopists. The National Endoscopy Database (NED) was implemented to enable quality assurance in all endoscopy units across the UK and also to reduce variation in practice. We aimed to assess whether CWT changed since the introduction of NED and whether CWT affected PDR.

METHODS

We used NED to retrospectively collect data regarding CWT and PDR of 25 endoscopists who performed (n=4459 colonoscopies) in the four quarters of 2019. We then compared this data to their performance in 2016, before using NED (n=4324 colonoscopies).

RESULTS

Mean CWT increased from 7.66 min in 2016 to 9.25 min in 2019 (p=0.0001). Mean PDR in the two periods was 29.9% and 28.3% (p=0.64). 72% of endoscopists (18/25) had CWT>6 min in 2016 versus 100% (25/25) in 2019, the longer CWT in 2019 positively correlated with the PDR (r=0.50, p=0.01). Gastroenterology consultants and trainee endoscopists had longer CWT compared with colorectal surgeons both before and after using NED.

CONCLUSION

NED usage increased withdrawal times in colonoscopy. Longer withdrawal times were associated with higher PDR. A national colonoscopy audit using data from NED is required to evaluate whether wide variations in practice across endoscopy units in the UK still exist and to ensure minimum colonoscopy quality standards are achieved.

Impact of cumulative experience on the quality of screening colonoscopy: A 13-year observational study

OBJECTIVE

To investigate trends in quality of screening colonoscopy (using the Global Rating Score) in the 13 years since introduction of the Bowel Cancer Screening Programme in England.

SETTING

An English Bowel Cancer Screening Programme colonoscopy service from 2007 to 2019.

METHODS

A retrospective observational study was undertaken using a prospectively collected database in order to analyse trends in screening endoscopies (including patients following positive faecal occult blood test or with high-risk findings on flexible sigmoidoscopy). The Global Rating Score quality indicators for Bowel Cancer Screening Programme colonoscopy were used as outcome measures, and trends over time were analysed. These included caecal intubation rate, adenoma detection rate, colorectal cancer detection rate, proportion of patients with minimal or mild discomfort scores, proportion of patients who required intravenous sedation, and adverse events.

RESULTS

There were 5352 colonoscopies included, performed by 3 endoscopists; 73.8% were index procedures (i.e. first Bowel Cancer Screening Programme colonoscopy) and the remainder were follow-up or surveillance colonoscopies. The mean age of patients was 66 (standard deviation 5) years, and 59.8% were male. Mean age increased over time (R²=0.033; p < 0.001). There were significant trends over time towards higher caecal intubation rate (p = 0.015), higher adenoma detection rate (p < 0.001), lower proportion requiring intravenous sedation (p < 0.001). There were no significant trends in comfort scores (p = 0.606), adverse events (p = 0.503) or colorectal cancer detection (p = 0.089).

CONCLUSION

There was a consistent improvement in the Global Rating Score for Bowel Cancer Screening Programme colonoscopies since the start of the programme, even when quality was already high at the start. Patients can expect high-quality colonoscopy when participating in the Bowel Cancer Screening Programme.

Trends in spatial access to colonoscopy in South Carolina, 2000-2014

BACKGROUND

Colonoscopy use has increased since Medicare began covering screening for average-risk persons. Our objective was to describe changes in spatial access to colonoscopy in South Carolina (SC) between 2000 and 2014.

METHODS

Using data from the SC Ambulatory Surgery Database, we created annual ZIP Code Tabulation Area (ZCTA) spatial accessibility scores. We assessed changes in accessibility, colonoscopy supply, and potential demand, overall and by metropolitan designation. Spatial clustering was also explored.

RESULTS

Spatial accessibility decreased across both small rural and metropolitan ZCTAs but was significantly higher in metropolitan areas during the first part of the study period . The proportion of persons with no access to colonoscopy within 30 min increased over time but was consistently higher in small rural areas. Clusters of low accessibility grew over time.

CONCLUSIONS

The supply of colonoscopy facilities decreased relative to the potential demand, and clusters of low access increased, indicating a contraction of services.

The Impact of Sedation on Adenoma Detection Rate and Cecal Intubation Rate in Colonoscopy

Purpose

To explore the effect of sedation on the quality of colonoscopy.

Methods

The data collected from the Digestive Endoscopy Center of Shanghai Tongji Hospital from March 2012 to June 2019 were retrospectively analyzed. The rate of sedation and quality metrics of colonoscopy such as adenoma detection rate (ADR) and cecal intubation rate (CIR) were calculated. The logistic regression model was used to explore the relationship between sedation and quality metrics of colonoscopy. The interaction effects between experience of endoscopists and sedation on quality of colonoscopy was also investigated in subgroups stratified by total number of colonoscopies during career using the logistic regression model.

Results

A total of 63,417 colonoscopies including 11,417 colonoscopies without sedation and 52,000 colonoscopies with sedation were enrolled in our study. The proportion of colonoscopy with sedation was 82.0%. The ADR and CIR were all significantly higher in cases with sedation compared with cases without sedation (ADR, 22.5% vs. 17.0%, p < 0.001; CIR, 94.7% vs. 91.2%, p < 0.001). Multivariate analysis showed that the sedation was an independent factor associated with adenoma detection (OR = 1.448, 95% CI: 1.372~1.529, p < 0.001) and cecal intubation (OR = 1.560, 95% CI: 1.446~1.683, p < 0.001). A total of 14 endoscopists with complete colonoscopy data in our database and corresponding 20,949 colonoscopies data were enrolled for further analysis. The logistic regression model yielded a similar result that sedation was an independent factor on adenoma detection and cecal intubation when the factor, experience of endoscopists, was also entered into the model as a confounder (adenoma detection, OR = 1.408, 95% CI: 1.333~1.487, p < 0.001; cecal intubation, OR = 1.601, 95% CI: 1.482-1.729, p < 0.001).

Conclusion

Colonoscopy with sedation has a positive effect on ADR and CIR in all endoscopists with different experience of colonoscopy, which makes the quality of colonoscopy better.

Rural Standards and the Quality Equation

The article describes the barriers rural surgeons face when attempting to measure, analyze, and benchmark the quality and value of the care they provide for their patients. Examples of suboptimal care are presented as well as special geographic and resource-related circumstances for many of these disparities of care. The article includes in-depth descriptions of the American College of Surgeons (ACS) Optimal Resources for Surgical Quality and Safety Program and the ACS Rural Hospital Surgical Verification and Quality Improvement Program. The article concludes by discussing several documented clinical, economic, and social advantages of keeping surgical care local.

Association Between Endoscopist Annual Procedure Volume and Colonoscopy Quality: Systematic Review and Meta-analysis

BACKGROUND & AIMS

In addition to monitoring adverse events (AEs) and post-colonoscopy colorectal cancers (PCCRC), indicators for assessing colonoscopy quality include adenoma detection rate (ADR) and cecal intubation rate (CIR). It is unclear whether there is an association between annual colonoscopy volume and ADR, CIR, AEs, or PCCRC.

METHODS

We searched publication databases through March 2019 for studies assessing the relationship between annual colonoscopy volume and outcomes, including ADR, CIR, AEs, or PCCRC. Pooled odds ratios (ORs) were calculated using DerSimonian and Laird random effects models. Sensitivity analyses were performed to assess for potential methodological or clinical factors associated with outcomes.

RESULTS

We performed a systematic review of 9235 initial citations, generating 27 retained studies comprising 11,276,244 colonoscopies. There was no association between procedural volume and ADR (OR, 1.00; 95% CI, 0.98-1.02 per additional 100 annual procedures). CIR improved with each additional 100 annual procedures (OR, 1.17; 95% CI, 1.08-1.28). There was a non-significant trend toward decreased overall AEs per additional 100 annual procedures (OR, 0.95; 95% CI, 0.90-1.00). There was considerable heterogeneity among most analyses.

CONCLUSIONS

In a systematic review and meta-analysis, we found higher annual colonoscopy volumes to correlate with higher CIR, but not with ADR or PCCRC. Trends toward fewer AEs were associated with higher annual colonoscopy volumes. There are few data available from endoscopists who perform fewer than 100 annual colonoscopies. Studies are needed on extremes in performance volumes to more clearly elucidate associations between colonoscopy volumes and outcomes.

Quality of Colonoscopy: A Comparison Between Gastroenterologists and Nongastroenterologists

BACKGROUND

Colonoscopy performance by gastroenterologists has been shown to be associated with lower rates of developing interval colorectal cancer. However, it is unclear if this difference among specialists stems from a difference in meeting colonoscopy quality indicators.

OBJECTIVE

The purpose of this study is to determine and compare the rates of colonoscopy quality indicators between different specialties.

DESIGN

This is a cohort study of patients undergoing screening colonoscopy investigating quality metrics as compared by the proceduralist specialty.

SETTING

All screening colonoscopies performed at the Cleveland Clinic between 2012 and 2014 were followed by manual chart review.

PATIENTS

Average-risk patients, ≥50 years of age, who had a complete screening colonoscopy were included.

MAIN OUTCOME MEASURES

Adenoma detection rate, cecal intubation rate, withdrawal time, and other nonestablished overall and segment-specific rates were calculated and compared using t tests.

RESULTS

A total of 4151 patients were included in the analysis. Colonoscopies were performed by 54 (64.3%) gastroenterologists, 21 (25%) colorectal surgeons, and 9 (10.7%) general surgeons. Gastroenterologists had the highest overall adenoma detection rate (28.6 ± 1.2; p < 0.001), followed by colorectal surgeons (24.3 ± 1.5) and general surgeons (18.4 ± 2.3), as well as the highest adenoma detection rate in men (34.7 ± 1.3; p < 0.001), followed by colorectal surgeons (28.2 ± 1.6) and general surgeons (23.7 ± 2.6). Similarly, gastroenterologists had the highest adenoma detection rate in women (24.3 ± 1.1; p < 0.001), followed by colorectal surgeons (21.6 ± 1.4) and general surgeons (12.9 ± 2.0). Withdrawal time was the longest among general surgeons (11.1 ± 5.5; p = 0.041), followed by colorectal surgeons (10.94 ± 5.2) and gastroenterologists (10.16 ± 1.26).

LIMITATIONS

We could not adjust for some procedure-related details such as retroflexion in the right colon and the use of end-of-scope devices.

CONCLUSIONS

In this study, only gastroenterologists met the currently accepted overall and sex-specific adenoma detection rate benchmarks. They also outperformed nongastroenterologists in many other nonestablished quality metrics. See Video Abstract at http://links.lww.com/DCR/B232.

CALIDAD DE LA COLONOSCOPIA

UNA COMPARACIÓN ENTRE GASTROENTERÓLOGOS Y NO GASTROENTERÓLOGOS: Se ha demostrado que el rendimiento de la colonoscopia por parte de los gastroenterólogos, se asocia con tasas más bajas de cáncer colorrectal en intervalos de desarrollo. Sin embargo, no está claro si esta diferencia entre especialistas, se deriva de una diferencia en el cumplimiento de los indicadores de calidad de la colonoscopia.El propósito del estudio, es determinar y comparar las tasas de indicadores de calidad de colonoscopia entre diferentes especialidades.Este es un estudio de cohorte de pacientes sometidos a una colonoscopia de detección, que investiga métricas de calidad en comparación con la especialidad de procesos.Todas las colonoscopias de detección realizadas en la Clínica Cleveland entre 2012 y 2014, fueron seguidas por una revisión manual del expediente.Pacientes de riesgo promedio, ≥50 años de edad que se sometieron a una colonoscopia de detección completa.La tasa de detección de adenomas, tasa de intubación cecal, tiempo de retirada y otras tasas generales y específicas de segmento no establecidas, se calcularon y compararon usando pruebas t.Un total de 4,151 pacientes fueron incluidos en el análisis. Las colonoscopias fueron realizadas por 54 (64.3%) gastroenterólogos, 21 (25%) cirujanos colorrectales y 9 (10.7%) cirujanos generales. Los gastroenterólogos tuvieron la tasa de detección más alta de adenomas en general (28.6 ± 1.2; p < 0.001), seguidos por los cirujanos colorrectales (24.3 ± 1.5) y los cirujanos generales (18.4 ± 2.3), así como la tasa de detección más alta de adenoma en hombres (34.7 ± 1.3; p < 0.001) seguido por cirujanos colorrectales (28.2 ± 1.6) y cirujanos generales (23.7 ± 2.6). Del mismo modo, los gastroenterólogos tuvieron la tasa más alta de detección de adenoma en mujeres (24.3 ± 1.1; p < 0.001), seguidos por los cirujanos colorrectales (21.6 ± 1.4) y los cirujanos generales (12.9 ± 2.0). El tiempo de extracción fue el más largo entre los cirujanos generales (11.1 ± 5.5; p = 0.041) seguido por los cirujanos colorrectales (10.94 ± 5.2) y los gastroenterólogos (10.16 ± 1.26).No pudimos ajustar algunos detalles relacionados con el procedimiento, tales como la retroflexión en el colon derecho y el uso de accesorios endoscópicos.En este estudio, solo los gastroenterólogos cumplieron con los índices de referencia actualmente aceptados, de detección de adenomas en general y específicas de género. También superaron a los no gastroenterólogos en muchas otras métricas no establecidas de calidad. Consulte Video Resumen en http://links.lww.com/DCR/B232. (Traducción-Dr. Fidel Ruiz Healy).

Significant Variation in the Detection Rates of Proximal Serrated Polyps Among Academic Gastroenterologists, Community Gastroenterologists, and Colorectal Surgeons in a Single Tertiary Care Center

INTRODUCTION

Recent studies have demonstrated that the protective effect of colonoscopy against colorectal cancer is lower in the proximal colon. Proximal serrated polyps, including sessile serrated adenomas and proximal hyperplastic polyps, can be frequently missed and pose a risk of interval cancers.

AIM

To investigate the overall adenoma detection rate (ADR) and the proximal serrated polyp detection rate (PSPDR) among academic gastroenterologists, community gastroenterologists, and colorectal surgeons from a single institution, all of whom have received formal training in colonoscopy during their fellowship.

METHODS

All complete screening colonoscopies for patients aged 50 or older with a good to excellent bowel preparation performed by different endoscopists at Medstar Washington Hospital Center (Washington, DC) from July 2015 to December 2017 were reviewed. Pathology reports of the resected polyps were manually reviewed.

RESULTS

A total of 2850 screening colonoscopies meeting the inclusion criteria were performed by 18 endoscopists (6 academic, 7 community, and 5 colorectal surgeons). There was no significant difference in the mean ADR among the three groups of endoscopists: academic gastroenterologists, community gastroenterologists, and colorectal surgeons (40.3% vs 36.0% vs 39.6%, respectively). However, academic gastroenterologists had a significantly higher PSPDR compared to community gastroenterologists or colorectal surgeons (12.3% vs 5.4% vs 4.5%, respectively, ANOVA p = 0.006).

CONCLUSION

Our novel data show that academic gastroenterologists had a significantly higher PSPDR compared to community gastroenterologists or colorectal surgeons despite a comparable overall ADR among the three groups. PSPDR may be considered as an important quality indicator for colonoscopy, apart from ADR.

Association Between Endoscopist Personality and Rate of Adenoma Detection

BACKGROUND & AIMS

There is significant variation among endoscopists in their adenoma detection rates (ADRs). We explored associations between ADR and characteristics of endoscopists, including personality traits and financial incentives.

METHODS

We collected electronic health record data from October 2013 through September 2015 and calculated ADRs for physicians from 4 health systems. ADRs were risk-adjusted for differences in patient populations. Physicians were surveyed to assess financial motivations, knowledge and perceptions about colonoscopy quality, and personality traits. Of 140 physicians sent the survey, 117 responded.

RESULTS

The median risk-adjusted ADR for all surveyed physicians was 29.3% (interquartile range, 24.1%-35.5%). We found no significant association between ADR and financial incentives, malpractice concerns, or physicians' perceptions of ADR as a quality metric. ADR was associated with the degree of self-reported compulsiveness relative to peers: among endoscopists who described themselves as much more compulsive, the ADR was 33.1%; among those who described themselves as somewhat more compulsive, the ADR was 32.9%; among those who described themselves as about the same as others, the ADR was 26.4%; and among those who described themselves as somewhat less compulsive, the ADR was 27.3%) (P = .0019). ADR was also associated with perceived thoroughness (much more thorough than peers, ADR = 31.5%; somewhat more, 31.9%; same/somewhat less, 27.1%; P = .0173). Physicians who reported feeling rushed, having difficulty pacing themselves, or having difficulty in accomplishing goals had higher ADRs. A secondary analysis found the same associations between personality and adenomas per colonoscopy.

CONCLUSIONS

We found no significant association between ADR and financial incentives, malpractice concerns, or perceptions of ADR as a quality metric. However, ADRs were higher among physicians who described themselves as more compulsive or thorough, and among those who reported feeling rushed or having difficulty accomplishing goals.

Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond

The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) was initially established in 1994 to standardise endoscopy training across specialties. Over the last two decades, the position of JAG has evolved to meet its current role of quality assuring all aspects of endoscopy in the UK to provide the highest quality, patient-centred care. Drivers such as changes to healthcare agenda, national audits, advances in research and technology and the advent of population-based cancer screening have underpinned this shift in priority. Over this period, JAG has spearheaded various quality assurance initiatives with support from national stakeholders. These have led to the achievement of notable milestones in endoscopy quality assurance, particularly in the three major areas of: (1) endoscopy training, (2) accreditation of endoscopy services (including the Global Rating Scale), and (3) accreditation of screening endoscopists. These developments have changed the landscape of UK practice, serving as a model to promote excellence in endoscopy. This review provides a summary of JAG initiatives and assesses the impact of JAG on training and endoscopy services within the UK and beyond.

Should Measures of Health Care Availability Be Based on the Providers or the Procedures? A Case Study with Implications for Rural Colorectal Cancer Disparities

PURPOSE

Patients with colorectal cancer (CRC) living in rural areas have lower survival rates than those in urban areas, potentially because of lack of access to quality CRC screening and treatment. The purpose of this study was to compare traditional physician density (ie, colonoscopy provider availability per capita) against a new physician density measure using an example case of colonoscopy volume and quality. The latter is particularly relevant for rural providers, who may have fewer patients and are more frequently nongastroenterologists.

METHODS

We conducted a secondary data analysis of the 2014 Medicare Provider Utilization and Payment Database and the National Cancer Institute State Cancer Profile Database. Volume-weighted physician density scores at the state and county levels were created, accounting for (1) the physician's annual colonoscopy volume and (2) whether the physician performs ≥100 procedures per year. We compared volume-weighted versus traditional density, overall and by rurality, and examined their correlation with CRC screening, incidence, and mortality rates.

FINDINGS

The difference between volume-weighted and traditional density scores was particularly large in rural parts of the West and Midwest, and it was most similar in the Northeast. Although weak, correlations with CRC outcomes were stronger for volume-weighted density, and they did not differ by rurality.

CONCLUSIONS

Our new method is an improvement over traditional methods because it considers the variation of physician procedure volume, and it has a stronger correlation with population health outcomes. Weighted density scores portray a more realistic picture of physician supply, particularly in rural areas.

Colorectal cancer screening program using FIT: quality of colonoscopy varies according to hospital type

Background and study aims  To compare the quality of colonoscopy in a population-based coordinated program of colorectal cancer screening according to type of hospital (academic or non-academic). Patients and methods  Consecutive patients undergoing colonoscopy after positive FIT (≥ 20 ug Hb/g feces) between January 2009 and September 2016 were prospectively included at five academic and seven non-academic public hospitals. Screening colonoscopy quality indicators considered were adenoma detection rate, cecal intubation rate, complications and bowel preparation quality. Results  A total of 48,759 patients underwent colonoscopy, 34,616 (80 %) in academic hospitals and 14,143 in non-academic hospitals. Among these cases, 19,942 (37.1 %) advanced adenomas and 2,607 (5.3 %) colorectal cancers (CRCs) were detected, representing a total of 22,549 (46.2 %) cases of advanced neoplasia. The adenoma detection rate was 64 %, 63.1 % in academic hospitals and 66.4 % in non-academic hospitals ( P  < 0.001). Rates of advanced adenoma detection, cecal intubation and adequate colonic preparation were 45.8 %, 96.2 % and 88.3 %, respectively, and in all cases were lower (implying worse quality care) in academic hospitals (45.3 % vs 48.7 %; odds ratio [OR] 0.87, 95 % confidence interval [CI] 0.84 - 0.91; 95.9 % vs 97 %; OR 0.48, 95 % CI 0.38 - 0.69; and 86.4 % vs 93 %; OR 0.48, 95 % CI 0.45 - 0.5; respectively; P  < 0.001 in all cases). In 13 patients, all in the academic hospital group, CRC was diagnosed after colonoscopy (0.26 cases × 1000 colonoscopies). Rates of CRC treated by endoscopy were similar in both types of hospital (30 %). The rate of severe complication was 1.2 % (602 patients), with no significant differences by hospital type: bleeding occurred in 1/147 colonoscopies and perforation in 1/329. One patient died within 30 days after screening colonoscopy. Conclusions  The quality of colonoscopy was better in non-academic hospitals. The rate of detection of advanced neoplasia was higher in non-academic hospitals and correlated with the rate of post-colonoscopy CRC.

Is there a difference in adenoma detection rates between gastroenterologists and surgeons?

AIM

To compare the adenoma detection rate (ADR) between gastroenterologists and colorectal surgeons at Box Hill Hospital, Melbourne, Australia.

METHODS

A total of 300 colonoscopies performed by gastroenterologists and colorectal surgeons at Box Hill Hospital were retrospectively reviewed from May 2016 to June 2017. Exclusion criteria were: Patients ≤ 50 years old, colonoscopies with failure of caecal intubation, patients who previously had colon cancer and/or a colonic resection, history of polyposis syndromes or inflammatory bowel disease, or a colonoscopy within the last 10 years. Patient demographics, indications, symptoms and procedural-related outcomes were measured.

RESULTS

The ADR was not significantly different between gastroenterologists and colorectal surgeons (34% vs 34.67%; P = 0.90). The adjusted odds ratio correcting for gender, age, 1^st degree relative with colorectal cancer, previous colonoscopy, trainee involvement and caecal or terminal ileum intubation rate was 1.19 (0.69-2.05).

CONCLUSION

Both specialties at our institution exceed benchmark standards suggested by published Australian and American guidelines. An association between endoscopist specialty and ADR was not observed.

Variable Endoscopist performance in proximal and distal adenoma detection during colonoscopy: a retrospective cohort study

BACKGROUND

Adenoma Detection Rate (ADR) is a validated colonoscopy quality indicator. In addition to overall ADR, Distal and Proximal Adenoma Detection Rates may provide important colonoscopy quality information. The goal of this study is to determine the association between distal and proximal adenoma detection (AD) and to identify factors contributing to overall, distal, and proximal AD.

METHODS

This is a retrospective cohort study of patients with a noted family history of CRC or positive fecal occult blood test who underwent a screening colonoscopy at a regional colorectal cancer (CRC) screening center between May 2009 and December 2011. Data regarding patient demographics, procedure details, endoscopist characteristics and polyp histology were captured. The main outcomes measured were overall, distal, and proximal AD.

RESULTS

1907 patients were included. The median age was 60 years and 42% were male. Endoscopist median overall ADR was 25% (30% male, 21% female). Endoscopist distal ADR was only modestly associated with their proximal ADR (Spearman Rank: 0.51 p = 0.11). Highest overall ADR (29 to 45%) was found for endoscopists whose distal and proximal ADRs were above the group median. In multivariate analysis, factors associated with overall, distal, and proximal AD included age, sex, and endoscopist practicing experience.

CONCLUSION

Inclusion of distal and proximal ADRs, in addition to overall ADR, in colonoscopy quality assessment provides the more accurate feedback on endoscopist performance.

Proximal Sessile Serrated Adenomas Are More Prevalent in Caucasians, and Gastroenterologists Are Better Than Nongastroenterologists at Their Detection

Background and Aim

Proximal sessile serrated adenomas (PSSA) leading to colorectal cancer (CRC) represent an alternate pathway for CRC development. In this study, we aim to determine the prevalence of PSSAs and the impact of patient, colonoscopy, and endoscopist-related factors on PSSA detection.

Methods

Patients ≥ 50 years of age undergoing a screening colonoscopy between 2012 and 2014 were included. Detection rates based on patient gender, race, colonoscopy timing, fellow participation, bowel preparation quality, and specialty of the endoscopist were calculated. t-tests were used to compare detection rates and a multivariate-adjusted analysis was performed.

Results

140 PSSAs were detected from 4151 colonoscopies, with a prevalence of 3.4%. Detection rate was higher in Caucasians compared to African-Americans (AA) (3.7 ± 4.1 versus 0.96 ± 3.5; p < 0.001). Gastroenterologists detected more PSSAs compared to nongastroenterologists (3.9 ± 3.5 versus 2.2 ± 3.0; p = 0.028). These findings were still significant after adjusted multivariate analysis. The rest of the factors did not make significant difference in PSSA detection rate.

Conclusions

PSSAs are more prevalent in Caucasians compared to AAs. Racial difference in prevalence of PSSAs is intriguing and warrants further investigation. Gastroenterologists have a significantly higher PSSADR compared to nongastroenterologists. Educational measures should be implemented in nongastroenterologists to improve their PSSA detection rates.

Who Performs Colonoscopy? Workforce Trends Over Space and Time

PURPOSE

With the increased availability of colonoscopy to average risk persons due to insurance coverage benefit changes, we sought to identify changes in the colonoscopy workforce. We used outpatient discharge records from South Carolina between 2001 and 2010 to examine shifts over time and in urban versus rural areas in the types of medical providers who perform colonoscopy, and the practice settings in which they occur, and to explore variation in colonoscopy volume across facility and provider types.

METHODS

Using an all-payer outpatient discharge records database from South Carolina, we conducted a retrospective analysis of all colonoscopy procedures performed between 2001 and 2010.

FINDINGS

We identified a major shift in the type of facilities performing colonoscopy in South Carolina since 2001, with substantial gains in ambulatory surgery settings (2001: 15, 2010: 34, +127%) versus hospitals (2001: 58, 2010: 59, +2%), particularly in urban areas (2001: 12, 2010: 27, +125%). The number of internists (2001: 46, 2010: 76) and family physicians (2001: 34, 2010: 106) performing colonoscopies also increased (+65% and +212%, respectively), while their annual procedures volumes stayed fairly constant. Significant variation in annual colonoscopy volume was observed across medical specialties (P < .001), with nongastroenterologists having lower volumes versus gastroenterologists and colon and rectal surgeons.

CONCLUSIONS

There have been substantial changes over time in the number of facilities and physicians performing colonoscopy in South Carolina since 2001, particularly in urban counties. Findings suggest nongastroenterologists are meeting a need for colonoscopies in rural areas.

Adenoma detection rate and risk of colorectal cancer

GOALS

The aim of this paper was to discuss association between adenoma detection rate (ADR) and interval colorectal cancer risk.

BACKGROUND

Adenoma detection rate is being used as a benchmark quality measure for colonoscopy. There are three studies showing inverse association between ADR and interval colorectal cancer risk. One recent study reports significant impact of increased ADR on decreasing interval colorectal cancer risk.

STUDY

We discussed evidence for using ADR as a quality measures in colonoscopy and flexible sigmoidoscopy. We revised three studies (Kaminski et al., N Engl J Med 2010; Corley et al., N Engl J Med 2014 and Rogal et al., Clin Gastroenterol Hepatol, 2013) analyzing association between ADR and interval colorectal cancer. We collated strengths and weaknesses of these studies with the perspective of clinical impact of their results.

RESULTS

Kaminski et al. and Corley et al. reported inverse association between ADR at colonoscopy and interval colorectal cancer. Kaminski et al. showed that patients examined by endoscopists with ADR of less than 20% had over 10 times greater risk of interval colorectal cancer during the follow-up time than those examined by endoscopists with ADR ≥20%. Additionally, Corley et al. showed that ADR ≥28% resulted in a significantly lower risk of colorectal cancer death than ADR of less than 19%. In parallel, Rogal et al. reported similar association for flexible sigmoidoscopy, with 2.4 higher odds of interval colorectal cancer diagnosis during follow-up time in patients examined by endoscopists with distal ADR <7.2% than those with distal ADR ≥7.2%. Apart from inevitable clinical importance of the studies, they are not without disadvantages. In Kaminski et al. study cohort and study endpoint are well defined, but there is lack of statistical power to provide more robust results. In Rogal et al. study cohort is well defined, but approximation of the study endpoint was used. Finally, Corley et al. study has both poorly defined study cohort and study endpoint, but has the highest statistical power of all three to detect the differences for both interval colorectal cancer and colorectal cancer death.

CONCLUSION

Both, inverse relationship between ADR and ADR improvement and colorectal cancer risk and death reaffirm ADR as a crucial quality control parameter.

Cecum intubation rate as quality indicator in clinical versus screening colonoscopy

BACKGROUND AND STUDY AIMS

Some guidelines recommend a minimum standard of 90 % cecal intubation rate (CIR) in routine clinics and 95 % in screening colonoscopy, while others have not made this distinction - both with limited evidence to support either view. This study questions the rationale for making such differentiation.

PATIENTS AND METHODS

 We assessed cecum intubation rates amongst colonoscopies recorded in the Norwegian national quality register Gastronet by 35 endoscopists performing both clinical and screening colonoscopies. Colonoscopies were categorized into primary screening colonoscopy, work-up colonoscopy of screen-positives and clinical colonoscopy or surveillance. Cases with insufficient bowel preparation or mechanical obstruction were excluded. Endoscopists were categorized into "junior" and "senior" endoscopists depending on training and experience. Univariable and multivariable logistic regression analyses were applied.

RESULTS

During a 2-year period, 10,267 colonoscopies were included (primary screening colonoscopy: 746; work-up colonoscopy of screen-positives: 2,604; clinical colonoscopy or surveillance: 6917). The crude CIR in clinical routine colonoscopy, primary screening colonoscopy and work-up colonoscopy was 97.1 %, 97.1 % and 98.6 %, respectively. In a multiple logistic regression analysis, there were no differences in CIR between the 3 groups. Poor bowel cleansing and female sex were independent predictors for intubation failure.

CONCLUSION

Cecal intubation rate in clinical colonoscopies and colonoscopy screening are similar. There is no reason to differentiate between screening and clinical colonoscopy with regard to CIR.

Adenoma Detection Rate in Colonoscopy: Is Indication a Predictor?

PURPOSE

To describe factors that may influence adenoma detection rate (ADR), with an emphasis on the indication for colonoscopy.

METHODS

Consecutive colonoscopies performed by a single endoscopist between January 2008 and December 2014 were reviewed. Indications for colonoscopy were tested for association with ADR after adjusting for age and sex.

RESULTS

A total of 2648 colonoscopies were analyzed. Adenomas were detected in 630 patients (23.8%). Overall ADR was 22.9% in patients undergoing screening colonoscopy. ADR was higher in fecal occult blood test-triggered screening colonoscopies (32%) than colonoscopies performed for patients with a family history of colorectal cancer (21.7%) or asymptomatic average-risk individuals (20.4%) (P=0.05). ADR was 36.1% in patients undergoing surveillance colonoscopy and ranged from 12% to 30% in patients with gastrointestinal symptoms undergoing diagnostic colonoscopy.

CONCLUSIONS

ADR differs depending on whether the indication is screening, surveillance, or diagnosis. Within screening colonoscopies, ADR seems to be higher in patients with a positive fecal occult blood test.

Expert opinions and scientific evidence for colonoscopy key performance indicators

Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards.

Annual colonoscopy volume and maintenance of competency for surgeons

INTRODUCTION

To determine whether the annual case volume of general surgeons (greater or less than 200 colonoscopies) is associated with quality outcomes.

METHODS

This retrospective cohort study involved all adults who underwent colonoscopy by a surgeon in the city of St. John's, NL, during the first 6 months of 2012. Subjects were identified through records from the health authority, and data were recorded on a standardized data sheet. Univariate analysis followed by stepwise multivariable logistic regression was performed to determine whether there was an association between quality outcomes (colonoscopy completion rate, adenoma detection rate) and predictors of these outcomes including annual colonoscopy volume, patient age, gender, indication for colonoscopy, and ASA score. A Chi-squared test was used to determine whether other outcomes were associated with annual colonoscopy volume.

RESULTS

Data were collected on 1060 patients. Mean age was 59.5 (sd 12.2) years with 550 females. A total of 13 surgeons were studied, of which 7 performed less than 200 annual colonoscopies over the previous 2 years (low-volume group) and 6 performed more than 200 annual colonoscopies over the previous 2 years (high-volume group). While there was a significant difference in the colonoscopy completion rate favoring the high-volume group (82.2 vs. 91.1 %, p < 0.001), no difference was noted in the adenoma detection rate between groups (16.7 vs. 17.7 %, p = 0.762). The regression model revealed that colonoscopy completion was also associated with an indication of screening or surveillance and an ASA score of 1 or 2. The adenoma detection rate was associated with older age and male gender. There was no statistically significant association between annual colonoscopy volume and other safety outcome measures.

CONCLUSION

Performing over 200 colonoscopies annually is associated with higher colonoscopy completion rates, but does not appear to be associated with other quality measures.

Differences in screening vs non-screening colonoscopy: scope for improvement?

AIM

Colonoscopy performed as part of the NHS Bowel Cancer Screening Programme (BCSP) is of high standard as measured using global rating scale (GRS) criteria. Screening practitioners also provide a non-screening colonoscopy service. The current study compares colonoscopy quality indicators between screening and non-screening groups performed by a single practitioner using the GRS.

METHOD

Patient details were obtained for all consecutive colonoscopies between 2007 and 2014 performed by a single screening practitioner. Data were collected retrospectively from electronic patient records; BCSP Exeter database and non-screening colonoscopies were compared. Data included patient demographics (age, gender), sedation, and the GRS data including caecal intubation, adenoma and neoplasia detection rates.

RESULTS

In all, 1961 colonoscopy procedures (1067 screening and 894 non-screening) were identified; 57% were men. Mean (SD) age for all patients was 64 (± 10.4) years. Non-screening patients were younger [62 (± 14) vs 66 (± 4.8) years; P < 0.05] and were less likely to be men (51.5% vs 61.9%; P < 0.05) than their screening counterparts. Caecal intubation was more successful in screening patients [1027/1067 (96.3%)] than non-screening patients [805/894 (90%)]; P < 0.05. Adenoma detection rate was higher in the screening (46.8 ± 4.4) than non-screening (26.3 ± 11.8) group; P < 0.05. There were no differences in neoplasia detection. Polypectomy was more likely (55.5% vs 30.2%) and polyp retrieval more successful (97.5% vs 86.7%) in the screening group.

CONCLUSION

Screening and non-screening colonoscopy differ in the GRS domains of completion and pathology detection. These differences need to be acknowledged when comparing screeners and non-screeners using GRS within units.

Effect of Colonoscopy Volume on Quality Indicators

Background. The purpose of this study is to determine if colonoscopy quality is associated with the annual case volume of endoscopists. Methods. A retrospective cohort study was performed on 3235 patients who underwent colonoscopy in the city of St. John's, NL, between January and June 2012. Data collected included completion of colonoscopy (CCR) and adenoma detection rates (ADR). Endoscopists were divided into quintiles based on annual case volume. To account for potential confounding variables, univariate analyses followed by multivariable logistic regression were used to identify variables independently associated with CCR and ADR. Results. A total of 13 surgeons and 8 gastroenterologists were studied. There was a significant difference in CCR (p < 0.001) and ADR (p < 0.001) based on annual volume. Following multivariable regression, predictors of successful colonoscopy completion included annual colonoscopy volume, lower age, male sex, an indication of screening or surveillance, and a low ASA score. Predictors of adenoma detection included older age, male sex, an indication of screening or surveillance, and gastroenterology specialty. Conclusion. Higher annual case volume is associated with better quality of colonoscopy in terms of completion. However, gastroenterology specialty appears to be a better predictor of ADR than annual case volume.

Surgeon specialization impacts the management but not outcomes of acute complicated diverticulitis

BACKGROUND

The management and outcomes of patients receiving nonelective surgical treatment of acute complicated diverticulitis by surgeon specialization have received little attention.

METHODS

A retrospective review was performed of consecutive patients with acute complicated diverticulitis who underwent surgery from 2006 to 2013. Patients were analyzed based on surgeon specialty: general surgery (GS) or colorectal surgery (CRS).

RESULTS

One hundred fifteen patients met criteria for study; 62 patients in the CRS and 53 in the GS group. GS were more likely to perform Hartmann's procedures or primary anastomosis and less likely to perform primary anastomosis with diverting ileostomy than CRS. There were no differences between groups for any outcome measures on univariate analysis. CRS patients had shorter operative time (P = .001) and length of stay (P ≤ .001) for stoma reversal procedures. Surgeon specialization was not associated with morbidity, readmission, or length of stay on multivariate analysis.

CONCLUSIONS

Although surgical management differed significantly between CRS and GS, comparable outcomes were observed at the index hospital admission.

Detection rates of premalignant polyps during screening colonoscopy: time to revise quality standards?

BACKGROUND

Standards for the detection of adenomas during screening colonoscopy are widely used to measure examination quality. No such standards exist for sessile serrated adenomas (SSAs).

OBJECTIVE

To measure both the adenoma detection rate (ADR) and SSA detection rate (SSADR) during screening colonoscopy before and after quality improvement/financial incentive measures.

DESIGN

Retrospective determination of baseline ADR/SSADR by the endoscopist, followed by prospective collection of data after informing physicians of baseline detection rates.

SETTING

Tertiary cancer center with a large cancer screening program.

PATIENTS

A total of 2833 average-risk colorectal cancer screening patients 50 to 75 years of age undergoing initial colonoscopy.

DATA COLLECTION

Electronic medical records for indication and demographics, endoscopy report, and pathology report.

MAIN OUTCOME MEASUREMENTS

Detection rates of adenomas and SSAs by sex.

RESULTS

The overall ADR in male and female patients was 50.6% and 36.6%, respectively. The overall detection rate of advanced adenomas in male and female patients was 12.4% and 6.5%, respectively. The overall SSADR in male and female patients was 10.1% and 7.1%, respectively. In 108 patients (3.8% of entire group), SSAs were the only premalignant lesions found. Detection rates of both types of premalignant polyps improved over time but did not reach statistical significance.

LIMITATIONS

Single-center experience with limited sample size and small group of endoscopists.

CONCLUSION

ADRs far in excess of current standards are achievable. Cecal withdrawal time is associated with the ADR. Prevalence of SSA rivals that of advanced adenomas and is greater than current medical literature suggests. The combination of monitoring and financial incentives did not result in statistically significant improvement in ADRs.

Experience of the endoscopist increases detection rates of smaller size and higher histological grade polyps

BACKGROUND

Adenoma and polyp detection rates (ADR and PDR, respectively) are important indicators of endoscopy quality, particularly in colorectal carcinoma screening.

OBJECTIVE

To assess the influence of the endoscopist's experience on the ADR and PDR.

PATIENTS AND METHODS

In this study, 9635 colonoscopies were screened during a 5-year period. Only 5738 were finally analyzed due to exclusion criteria. The endoscopists were separated in three groups of experience according to the number of colonoscopies performed in the past (yearly and total). The number of polyps and adenomas, as well as the size and histology of these polyps were recorded.

RESULTS

The ADR and PDR were similar regardless of the experience of the endoscopist, but those with more experience clearly found more polyps of less than 10 mm (P = 0.01) and of less than 3 mm (P < 0.0001). Most of the differences were due to a higher number of flat polyps detected by the experienced group. This study also shows that more experienced endoscopists detect adenomas with more advanced histology (P < 0.0001).

CONCLUSION

Even though the ADR and PDR are similar in all groups of endoscopists, the less experienced endoscopists could be missing some of the smaller polyps, sometimes with more advanced histology.

Screening colonoscopy: should we focus more on technique and less on technology?

Several large studies have confirmed that high quality colonoscopic surveillance can improve outcomes with substantial reduction in colorectal cancer rates. In order to improve outcomes from screening colonoscopy and help detect adenomas, the emphasis has been mainly on improvements in technology like high-resolution scopes, computerized as well as dye-based chromoendoscopy and wide-angle endoscopes. In addition to the equipment and technological innovation in the equipment used, a number of other factors like experience of the endoscopist, optimal withdrawal techniques, position changes during colonoscopy and bowel preparation can all influence adenoma detection and thereby the quality of colonoscopic surveillance. In this review we will focus on recent studies investigating these aspects of colonoscopy and their impact on adenoma or polyp detection.

Endoscopist specialty is associated with colonoscopy quality

Background

Some studies have shown that endoscopist specialty is associated with colorectal cancers missed by colonoscopy. We sought to examine the relationship between endoscopist specialty and polypectomy rate, a colonoscopy quality indicator. Polypectomy rate is defined as the proportion of colonoscopies that result in the removal of one or more polyps.

Methods

A cross-sectional study was conducted of endoscopists and their patients from 7 Montreal and 2 Calgary endoscopy clinics. Eligible patients were aged 50–75 and covered by provincial health insurance. A patient questionnaire assessed family history of colorectal cancer, history of large bowel conditions and symptoms, and previous colonoscopy. The outcome, polypectomy status, was obtained from provincial health administrative databases. For each city, Bayesian hierarchical logistic regression was used to estimate the odds ratio for polypectomy comparing surgeons to gastroenterologists. Model covariates included patient age, sex, family history of colorectal cancer, colonoscopy indication, and previous colonoscopy.

Results

In total, 2,113 and 538 colonoscopies were included from Montreal and Calgary, respectively. Colonoscopies were performed by 38 gastroenterologists and 6 surgeons in Montreal, and by 31 gastroenterologists and 5 surgeons in Calgary. The adjusted odds ratios comparing surgeons to gastroenterologists were 0.48 (95% CI: 0.32–0.71) in Montreal and 0.73 (95% CI: 0.43–1.21) in Calgary.

Conclusions

An association between endoscopist specialty and polypectomy was observed in both cities after adjusting for patient-level covariates. Results from Montreal suggest that surgeons are half as likely as gastroenterologists to remove polyps, while those from Calgary were associated with a wide, non-significant Bayesian credible interval. However, residual confounding from patient-level variables is possible, and further investigation is required.