Factors associated with the technical performance of colonoscopy: An EPAGE Study

Derivation and validation of a nomogram incorporating modifiable lifestyle factors to predict development of colorectal adenomas after negative index colonoscopy

This retrospective cohort study aimed to identify baseline patient characteristics involving modifiable lifestyle factors that are associated with the development of colorectal adenomas, and establish and validate a nomogram for risk predictions among high-risk populations with negative index colonoscopy. A total of 83,076 participants who underwent an index colonoscopy at the Tianjin Union Medical Center between 2004 and 2019 were collected. According to meticulous inclusion and exclusion criteria, 249 subjects were enrolled and categorized into the primary and validation cohorts. Based on the primary cohort, we utilized the LASSO-Cox regression and the univariate/multivariate Cox proportional hazards (Cox-PH) regression parallelly to select variables, and incorporated selected variables into two nomogram models established using the multivariate Cox-PH regression. Comparison of the Akaike information criterion and the area under the receiver operating characteristic curve of the two models demonstrated that the nomogram model constituted by four covariates retained by the LASSO-Cox regression, including baseline age, body mass index, physical activity and family history of colorectal cancer (CRC) in first-degree relatives, performed better at predicting adenoma-free survival probabilities. Further validation including the concordance index, calibration plots, decision curve analysis and Kaplan-Meier survival curves also revealed good predictive accuracy, discriminating ability, clinical utility and risk stratification capacity of the nomogram model. Our nomogram will assist high-risk individuals with negative index colonoscopy to prevent colorectal adenoma occurrence and CRC morbidity with improved cost-effectiveness.

Colonoscopy performance monitoring: do we need to adjust for case mix?

INTRODUCTION

Overall caecum intubation rate(oCIR) and overall polyp detection rate(oPDR) have been proposed as performance indicators, but varying complexity in case mix among endoscopists may potentially affect validity. The study aims to explore the effect of adjusting for case mix on individual endoscopist performance by calculating case mix-adjusted performance estimates (cmCIR and cmPDR) and comparing them to overall performance estimates (oCIR and oPDR). The study also provides an R program for case mix analysis.

METHODS

Logistic regression associated endoscopist, colonoscopy indication, patient age and patient gender with the binary outcomes of cecum intubation and polyp detection. Case mix-adjusted performance indicators were calculated for each endoscopist based on logistic regression and bootstraps. Endoscopists were ranked from best to worst by overall and case mix-adjusted performance estimates, and differences were evaluated using percentage points(pp) and rank changes.

RESULTS

The dataset consisted of 7376 colonoscopies performed by 47 endoscopists. The maximum rank change for an endoscopist comparing oCIR and cmCIR was eight positions, interquartile range (IQR 1-3). The maximum change in CIR was 1.95 percentage point (pp) (IQR 0.27-0.86). The maximum rank change in the oPDR versus cmPDR analysis was 17 positions (IQR 1.5-8.5). The maximum change in PDR was 11.21 pp (IQR 2.05-6.70). Three endoscopists improved their performance from significantly inferior to within the 95% confidence interval (CI) range of performance targets using case mix-adjusted estimates.

CONCLUSIONS

The majority of endoscopists were unaffected by adjustment for case mix, but a few unfortunate endoscopists had an unfavourable case mix that could invite incorrect suspicion of inferior performance.

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.

Variation in Colonoscopy Performance Measures According to Procedure Indication

BACKGROUND & AIMS

Most fulfillment and benchmarking information for colonoscopy quality indicators has been obtained from studies of primary screening colonoscopies. We analyzed differences in the fulfillment of colonoscopy quality indicators based on the indication for endoscopy.

METHODS

We performed an observational, multicenter, cross-sectional study of 14,867 patients who underwent endoscopy procedures for gastrointestinal symptoms (40.3%), a positive result from a fecal immunochemical test (36.0%), postpolypectomy surveillance (15.3%), or primary screening (8.4%), from February 2016 through December 2017 at 14 centers in Spain. We evaluated rates of adequate colon cleansing, cecal intubation, adenoma detection, and colorectal cancer detection, among others. We used findings from primary screening colonoscopies as the reference standard.

RESULTS

Fewer than 90% of patients had adequate bowel preparation; 83.1% of patients with gastrointestinal symptoms had adequate bowel preparation (odds ratio [OR] compared with patients with primary screening colonoscopies, 0.62; 95% CI, 0.49-0.78) and 85.3% of patients receiving postpolypectomy surveillance had adequate bowel preparation (OR, 0.71; 95% CI, 0.55-0.91). The cecal intubation rate was also lower in patients with gastrointestinal symptoms (93.1%) (OR, 0.34; 95% CI, 0.22-0.52). The adenoma detection rate was higher in patients with a positive result from a fecal immunochemical test (46.4%) (OR, 2.01; 95% CI, 1.71-2.35) and in patients undergoing postpolypectomy surveillance (48.2%) (OR, 1.41; 95% CI, 1.20-1.67). The highest proportion of patients with colorectal cancer was in the gastrointestinal symptom group (5.1%) (OR, 5.24; 95% CI, 2.30-11.93) and the lowest was in patients undergoing surveillance (0.8%) (OR, 0.83; 95% CI, 0.32-2.14).

CONCLUSIONS

Fulfillment of colonoscopy performance measures varies substantially by indication. Policies addressing performance measures beyond colonoscopy screening procedures should be developed. Benchmarking recommendations could be adjusted according to colonoscopy indication.

Cecal intubation rates in different eras of endoscopic technological development

Introduction

Colonoscopy plays a critical role in colorectal cancer (CRC) screening and has been widely regarded as the gold standard. Cecal intubation rate (CIR) is one of the well-defined quality indicators used to assess colonoscopy.

Aim

To assess the impact of new technologies on the quality of colonoscopy by assessing completion rates.

Material and methods

This was a dual-center study at the 2^nd Department of Surgery at Jagiellonian University Medical College and at the Specialist Center “Medicina” in Krakow, Poland. The CIR and cecal intubation time (CIT) in three different eras of technological advancement were determined. The study enrolled 27 463 patients who underwent colonoscopy as part of a national CRC screening program. The patients were divided into three groups: group I – 3408 patients examined between 2000 and 2003 (optical endoscopes); group II – 10 405 patients examined between 2004 and 2008 (standard electronic endoscopes); and group III – 13 650 patients examined between 2009 and 2014 (modern endoscopes).

Results

There were statistically significant differences in the CIR between successive eras. The CIR in group I (2000–2003) was 69.75%, in group II (2004–2008) was 92.32%, and in group III (2009–2014) was 95.17%. The mean CIT was significantly reduced in group III.

Conclusions

Our study shows that the technological innovation of novel endoscopy devices has a great influence on the effectiveness of the CRC screening program. The new era of endoscopic technological development has the potential to reduce examination-related patient discomfort, obviate the need for sedation and increase diagnostic yields.

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.

Impact of responsive insertion technology (RIT) on reducing discomfort during colonoscopy: randomized clinical trial

Background

In many countries, colonoscopies for colorectal cancer screening are performed without sedation due to the cost. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, reduce the duration of the procedure, and improve the imaging of the intestinal lumen. The variable stiffness of the endoscope and the recently introduced responsive insertion technology (RIT) are features aimed at easing colonoscope insertion and reducing the discomfort and pain during the examination. The aim of the study is to analyze whether the new RIT system can improve the practice of colonoscopy under no anesthesia with respect to the widely available variable stiffness colonoscopes.

Materials and methods

This analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using endoscopes equipped with responsive insertion technology (RIT), and group II included patients who were examined using conventional variable stiffness colonoscopies. The main objective was to evaluate the cecal intubation time, the number of loops, the requirement to apply manual pressure to different areas of the abdomen and the degree of discomfort and pain expressed on a visual analogue scale (VAS). ClinicalTrials.gov number, NCT01688557.

Results

Group I consisted of 329 patients, and group II included 318 patients. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, and BMI. The mean cecal intubation time was 209 s in group I and 224 s in group II (p < 0.05). Increased loop formation was observed upon endoscope insertion in group II (1.7 vs. 1.35) (p < 0.05) and required more manual pressure to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, less discomfort and pain, as graded on a VAS (2.3 vs. 2.6), were noted.

Conclusions

The implementation of RIT reduced of the cecal intubation time. The modified structure of the endoscope rendered the colonoscopic examination easier by reducing loop formation upon insertion with a subsequently reduced rate of auxiliary maneuvers.

Factors influencing challenging colonoscopies during anesthesiologist-assisted deep sedation

BACKGROUND/AIM

Increased demand for colon cancer screening procedures can significantly impact on routine colonoscopy management at dedicated facilities, prompting a review of the factors that can negatively affect workflow. Although potential adverse effects and impact on costs of deep sedation have been documented elsewhere, this study focuses on variables that can influence performance of colonoscopy in deep sedation and interfere with normal procedure scheduling in settings where the presence of an anesthesiologist is mandatory.

PATIENTS AND METHODS

We performed a cross-sectional study of the activities of a colonoscopy screening unit, applying Bayesian Network (BN) analysis, designed to assess interdependencies among variables that can affect a process in complex, multidimensional systems. The study was performed at a teaching hospital where endoscopists and anesthesiologists of varying work experience operate on a rota basis. During a six-month period, we analyzed 1485 consecutive colonoscopies performed under deep propofol sedation, administered by an anesthesiologist via hand-controlled syringe. The BN was constructed with the variables: Gender, age, ASA status, bowel preparation, baseline blood pressure, endoscopist's experience, anesthesiologist's experience, presence of polypectomy, and the target node, "challenging procedure." This previously undefined category refers to any events disrupting the scheduled rota.

RESULT AND CONCLUSION

Two distinct networks were identified. One deals mainly with relationships among the variables, patients' demographic and clinical characteristics (procedures with polypectomy, ASA and baseline blood pressure). The other explains relationships among the variables, "challenging procedure," bowel preparation, and endoscopist's experience. The factors associated with the anesthesiologist's activity do not influence challenging colonoscopies.

A novel quality scoring system for the evaluation of individual colonoscopy: A multicenter retrospective study

BACKGROUND AND AIM

It is essential to develop a novel evaluation system for the quality of individual colonoscopy and provide guidelines on whether and when to follow up the patient after the initial colonoscopy. This study aimed to establish and validate a scoring system for the quality of individual colonoscopy in terms of the adenoma miss rate (AMR).

METHODS

Patients undergoing two consecutive colonoscopies within 90 days between 2009 and 2011 from different levels of hospitals in China were enrolled into this study. Potential risk factors for adenoma miss at the individual colonoscopy in a cohort of patients were evaluated in univariate and multivariate analyses. Corresponding scores for the procedure-related factors were generated based on their weights, and a scoring system was established and then validated by correlating the system with AMR.

RESULTS

A total of 2093 patients were enrolled. Procedure-related factors at the individual colonoscopy (including bowel preparation and imaging methods), doctor experience, retroflexion, and withdrawal time were identified to be independent risk factors, and each of these factors was scored from 0 to 3. Then, a novel scoring system for the quality of individual colonoscopy (ranging from 0 to 9) was established, which was closely correlated with the AMRs in the establishment (adjusted R(2) = 0.845) and validation databases (adjusted R(2) = 0.733).

CONCLUSIONS

The developed and validated evaluation system, consisting of procedure-related independent factors, successfully assesses the quality of individual colonoscopy in terms of AMRs.

Open-access colonoscopy on Ontario: associated factors and quality

BACKGROUND

Open-access (OA) colonoscopy may increase efficiency and decrease wait times; however, because the patient is seen for the first time at the endoscopy appointment, previous processes, such as information about the procedure, preparation and appropriate triage, may be suboptimal.

OBJECTIVE

To identify factors associated with OA colonoscopy and to determine the relationship between OA colonoscopy and an important quality measure, incomplete colonoscopy.

METHODS

A population-based analysis of all adult outpatients undergoing a first-time colonoscopy between 1997 and 2007 in Ontario was performed. Colonoscopy was considered to be OA if there were no visits in the preceding five years with the physician performing the colonoscopy. Using logistic regression, patient, physician and institution factors associated with OA colonoscopy were identified. Using propensity score matching, the relationship between OA colonoscopy and incomplete colonoscopy in 2006 was examined.

RESULTS

A total of 1,079,259 colonoscopies were performed. Of these, 14% were OA in 1997 compared with 26% in 2007. Patients 50 to 69 years of age, those from higher-income neighbourhoods and those with less comorbidity were more likely to undergo OA colonoscopy. The odds of receiving OA colonoscopy were six times greater in a nonhospital clinic compared with a community hospital. Colonoscopy was more likely to be complete if the procedure was OA (OR 1.3 [95% CI 1.2 to 1.4]; P<0.0001).

CONCLUSIONS

Rates of OA colonoscopy have increased substantially since 1997. Institution type was most strongly associated with OA colonoscopy. Colonoscopy completeness, a recognized quality indicator, does not appear to be compromised by OA colonoscopy.

[Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?]

INTRODUCTION

Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate.

PATIENTS AND METHODS

A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed.

RESULTS

The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group» (n= 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83.

CONCLUSIONS

In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.

Endoscopic detection of colorectal adenomas: standards and sophisticated methods

Colorectal cancer represents one of the leading malignancies worldwide. Early endoscopic detection and removal of its precursor lesions, adenomas, and serrated hyperplastic polyps results in a decrease of colon cancer-related death. However, miss rates in adenoma detection up to 26% underline the need for high compliance to basic measures and further improvement in methodology and technology. Basic parameters affecting adenoma detection rates include sufficient training and awareness of the endoscopist, use of high-definition endoscopes, careful examination behind folds, cleansing the colon wall, accurate distention of the colon, and adequate withdrawal time. Advanced imaging techniques, introduced to further improve adenoma detection, have yielded mixed results. These include wide-angle colonoscopes, cap-assisted colonoscopy, and retroscopic methods which may add new obstacles to colonoscopy. Moreover, chromoendoscopy either 'virtual' or by topically applied dyes has been suggested to enhance the detection of colonic neoplasia. Yet, studies on patients with average cancer risk have failed to reproduce promising initial results. Similarly, although autofluorescence has not enhanced the diagnostic yield in screening a population at average risk, it may be useful in patients at increased cancer risk. Recently, technical feasibility of molecular imaging employing 'biomarkers' has been demonstrated, but needs further evaluation. The newest developments, employing light-scattering spectroscopy, suggest the existence of a 'field effect' of colonic carcinogenesis and may enable detection of the earliest neoplastic events and distant adenomas even when applied to normal-appearing mucosa. Upon confirmation, these technologies may result in a substantial change in patient management and risk stratification.

Quality in colonoscopy reporting: an assessment of compliance and performance improvement

BACKGROUND

An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined.

AIMS

To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention.

METHODS

300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance.

RESULTS

Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16).

CONCLUSION

This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.

Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction

BACKGROUND

Although self-expandable metal stent (SEMS) insertion is widely used for relief of malignant colorectal obstructions, the immediate technical and clinical failure rates of SEMSs and the associated risk factors remain largely unknown.

OBJECTIVE

To identify rates and factors predictive of technical and clinical failure of SEMSs when their use is attempted for the decompression of malignant colorectal obstruction.

DESIGN

Retrospective chart review.

SETTING

A tertiary-care academic medical center in South Korea.

PATIENTS

This study involved a total of 412 patients with malignant colorectal obstruction in whom SEMS insertion was attempted.

INTERVENTION

Placement of colonic SEMSs.

MAIN OUTCOME MEASUREMENTS

Technical success and immediate and long-term clinical success rates.

RESULTS

Technical and clinical failures were found in 36 of 276 patients (13.0%) and 39 of 240 patients (16.3%) in the palliative group, respectively, and in 3 of 136 patients (2.2%) and 7 of 133 patients (5.3%) in the preoperative group, respectively. Factors associated with technical failure were extracolonic origin of tumor, the presence of carcinomatosis, and a proximal obstruction site. Factors associated with long-term clinical failure in the palliative group were combined dilation procedure, no additional chemotherapy, and extracolonic origin of the tumor. In the preoperative group, only older patients had both higher technical failure and clinical failure rates.

LIMITATIONS

This was a single-institution, retrospective analysis.

CONCLUSION

Although colorectal SEMS placement is generally safe and effective, it is associated with clinically important technical and clinical failure rates. The identification of risk factors for the failure of colorectal SEMSs found in this study might help physicians decide between surgical decompression and endoscopic stenting in patients with malignant colorectal obstruction.

Queue position in the endoscopic schedule impacts effectiveness of colonoscopy

OBJECTIVES

Endoscopist fatigue potentially impacts colonoscopy. Fatigue is difficult to quantitate, but polyp detection rates between non-fatigued and fatigued time periods could represent a surrogate marker. We assessed whether timing variables impacted polyp detection rates at a busy tertiary care endoscopy suite.

METHODS

Consecutive patients undergoing colonoscopy were retrospectively identified. Indications, clinical demographics, pre-procedural, and procedural variables were extracted from chart review; colonoscopy findings were determined from the procedure reports. Three separate timing variables were assessed as surrogate markers for endoscopist fatigue: morning vs. afternoon procedures, start times throughout the day, and queue position, a unique variable that takes into account the number of procedures performed before the colonoscopy of interest. Univariate and multivariate analyses were performed to determine whether timing variables and other clinical, pre-procedural, and procedural variables predicted polyp detection.

RESULTS

During the 4-month study period, 1,083 outpatient colonoscopy procedures (57.5±0.5 years, 59.5% female) were identified, performed by 28 endoscopists (mean 38.7 procedures/endoscopist), with a mean polyp detection rate of 0.851/colonoscopy. At least, one adenoma was detected in 297 procedures (27.4%). A 12.4% reduction in mean detected polyps was detected between morning and afternoon procedures (0.90±0.06 vs. 0.76±0.06, P=0.15). Using start time on a continuous scale, however, each elapsed hour in the day was associated with a 4.6% reduction in polyp detection (P=0.005). When queue position was assessed, a 5.4% reduction in polyp detection was noted with each increase in queue position (P=0.016). These results remained significant when controlled for each individual endoscopist.

CONCLUSIONS

Polyp detection rates decline as time passes during an endoscopist's schedule, potentially from endoscopist fatigue. Queue position may be a novel surrogate measure for operator fatigue.

Maximizing the general success of cecal intubation during propofol sedation in a multi-endoscopist academic centre

BACKGROUND

Achieving the target of 95% colonoscopy completion rate at centres conducting colorectal screening programs is an important issue. Large centres and teaching hospitals employing endoscopists with different levels of training and expertise risk achieving worse results. Deep sedation with propofol in routine colonoscopy could maximize the results of cecal intubation.

METHODS

The present study on the experience of a single centre focused on estimating the overall completion rate of colonoscopies performed under routine propofol sedation at a large teaching hospital with many operators involved, and on assessing the factors that influence the success rate of the procedure and how to improve this performance, analyzing the aspects relating to using of deep sedation. Twenty-one endoscopists, classified by their level of specialization in colonoscopic practice, performed 1381 colonoscopies under deep sedation. All actions needed for the anaesthesiologist to restore adequate oxygenation or hemodynamics, even for transient changes, were recorded.

RESULTS

The "crude" overall completion rate was 93.3%. This finding shows that with routine deep sedation, the colonoscopy completion rate nears, but still does not reach, the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs.Factors interfering with cecal intubation were: inadequate colon cleansing, endoscopists' expertise in colonoscopic practice, patients' body weight under 60 kg or age over 71 years, and the need for active intervention by the anaesthesiologist. The most favourable situation--a patient less than 71 years old with a body weight over 60 kg, an adequate bowel preparation, a "highly experienced specialist" performing the test, and no need for active anaesthesiological intervention during the procedure--coincided with a 98.8% probability of the colonoscopy being completed.

CONCLUSIONS

With routine deep sedation, the colonoscopy completion rate nears the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs. Organizing the daily workload to prevent negative factors affecting the success rate from occurring in combination may enable up to 85% of incomplete procedures to be converted into successful colonoscopies.

An endoscopic training model to improve accuracy of colonic polyp size measurement

PURPOSE

Most studies of colonic polyps rely on visual estimation when regarding polyp size; however, the reliability of a visual estimate is questionable. Our study aims to develop a training model to improve the accuracy of size estimation of colonic polyps in vivo.

METHODS

Colon polyps were recorded on 160 video clips during colonoscopy. The size of each polyp was estimated by visual inspection and subsequently measured with a flexible linear measuring probe. The study included a pretest, an intervention, and a posttest. The pretest included 160 video clips, which comprised the visual-estimation portion of the study. The intervention was an educational model consisting of 30 video clips which included a visual-estimation section and a linear-measuring-probe section, designed to help the endoscopists to compare their visual estimate of size with the measured size of the polyps. The posttest included the 160 video clips used in the pretest, presented in random order. Intraobserver agreement and diagnostic accuracy were compared before and after the training session.

RESULTS

Eight beginners and four experienced colonoscopists were enrolled. The overall kappa (kappa) values of intraobserver agreement for pretest and posttest were 0.74 and 0.85 for beginner group as well as 0.83 and 0.88 for experienced group, respectively. The overall diagnostic accuracy improved from 0.52 to 0.78 for beginner group and 0.71 to 0.87 for experienced group (P < 0.05) after education with the training model.

CONCLUSIONS

This training model could help endoscopists improve the accuracy of measurement of polyps on colonoscopy in a short period. The durability of learning effect needs further investigation.

Fewer polyps detected by colonoscopy as the day progresses at a Veteran's Administration teaching hospital

BACKGROUND & AIMS

One objective of colonoscopy is to identify and remove polyps-this process requires attention to detail and prolonged concentration. Providers are predisposed to cognitive errors because the procedure is often performed repetitively throughout the day. We measured the adjusted relationship between colonoscopy start time and polyp yield.

METHODS

We performed a prospective study of 477 patients that received screening, surveillance, or diagnostic colonoscopies at a Veteran's Administration (VA) teaching hospital. The primary outcome measure was polyp yield. We collected data on colonoscopy start times, which were analyzed both as a dichotomous time period ("early-morning case" vs "later case") and as a continuous variable (start time). We identified significant risk factors using univariate analysis and performed Poisson multivariable regression to measure the independent effect of colonoscopy start time on polyp yield. We evaluated evidence of decreasing polyp yield as the day progressed throughout pre-specified time intervals.

RESULTS

In univariate analysis, early-morning cases yielded 27% more polyps per patient than later cases (95% confidence interval, 11%-45%; P < .001). The total numbers of, hyperplastic and adenomatous polyps found decreased hour-by-hour as the day progressed. Multivariable analysis demonstrated that early-morning cases yielded 20% more polyps per patient than later cases (95% confidence interval, 5%-38%; P = .007).

CONCLUSIONS

At a VA medical center, more polyps were detected in patients that received colonoscopies early in the morning compared with later in the day. Moreover, adenoma detection reduced as the day progressed. Providers might be most adept at detecting polyps at the beginning of the day; further validation in other practice settings is required.

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.

Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators

BACKGROUND

It is essential to identify the factors in clinical practice that influence the technical performance of colonoscopy as a basis for quality improvement programs.

AIMS

To assess the factors linked to two key indicators of colonoscopy performance, i.e., cecal intubation and polyp diagnosis.

DESIGN AND SETTING

Consecutives colonoscopies performed over a 2-wk period in 278 unselected practice sites throughout Italy were prospectively evaluated. A multivariate model was developed to identify determinants of the performance indicators of colonoscopy.

RESULTS

In total, 12,835 patients (mean age 60.5 yr, standard deviation [SD] 15.1, 53% men) were studied. Sedation and/or analgesia was administered in 55.3% of procedures: 28.8% of patients received intravenous (IV) benzodiazepines, 15.4% received benzodiazepines in combination with narcotics, 3.1% received propofol, and 7.5% received other sedation regimens. Overall, cecal intubation was achieved in 80.7% of procedures, and the polyp detection rate was 27.3%. Multivariate analysis showed that the strongest predictors of cecal intubation were the quality of bowel preparation (inadequate vs excellent: odds ratio [OR] 0.013, 95% confidence interval [CI] 0.009-0.018; fair vs excellent: OR 0.246, 95% CI 0.209-0.290; and good vs excellent: OR 0.586, 95% CI 0.514-0.667) and the use of sedation (IV benzodiazepines vs no sedation: OR 1.460, 95% CI 1.282-1.663; IV benzodiazepines and narcotics vs no sedation: OR 2.128, 95% CI 1.776-2.565; and propofol vs no sedation: OR 2.355, 95% CI 1.590-3.488). The colonoscopy setting (workload and organizational complexity of the center) and the endoscopist colonoscopy volume were other factors independently correlated with completion of the procedure. Detection of polyps partially depended on the quality of bowel cleansing (inadequate vs excellent: OR 0.511, 95% CI 0.404-0.647) and use of sedation (OR 1.172, 95% CI 1.074-1.286).

CONCLUSION

In usual clinical practice, the use of sedation/analgesia, the colon-cleansing quality, the endoscopist experience, and some features related to the colonscopy setting decisively influence the quality of colonoscopy. These factors indicate the targets of future corrective measures to boost the quality of this examination.