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Mazurek M, Murray A, Heitman SJ, Ruan Y, Antoniou SA, Boyne D, Murthy S, Baxter NN, Datta I, Shorr R, Ma C, Swain MG, Hilsden RJ, Brenner DR, Forbes N. Association Between Endoscopist Specialty and Colonoscopy Quality: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2022; 20:1931-1946. [PMID: 34450297 DOI: 10.1016/j.cgh.2021.08.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS Colonoscopy quality indicators provide measurable assessments of performance, but significant provider-level variations exist. We performed a systematic review and meta-analysis to assess whether endoscopist specialty is associated with adenoma detection rate (ADR) - the primary outcome - or cecal intubation rate, adverse event rates, and post-colonoscopy colorectal cancer rates. METHODS We searched EMBASE, Google Scholar, MEDLINE, and the Cochrane Central Registry of Controlled Trials from inception to December 14, 2020. Two reviewers independently screened titles and abstracts. Citations underwent duplicate full-text review, with disagreements resolved by a third reviewer. Data were abstracted in duplicate. The DerSimonian and Laird random effects model was used to calculate pooled odds ratios (ORs) with respective 95% confidence intervals (CIs). Risk of bias was assessed using Risk of Bias in Non-randomised Studies of Interventions. RESULTS Of 11,314 citations, 36 studies representing 3,500,832 colonoscopies were included. Compared with colonoscopies performed by gastroenterologists, those by surgeons were associated with lower ADRs (OR, 0.81; 95% CI, 0.74-0.88) and lower cecal intubation rates (OR, 0.76; 95% CI, 0.63-0.92). Compared with colonoscopies performed by gastroenterologists, those by other (non-gastroenterologist, non-surgeon) endoscopists were associated with lower ADRs (OR, 0.91; 95% CI, 0.87-0.96), higher perforation rates (OR, 3.02; 95% CI, 1.65-5.51), and higher post-colonoscopy colorectal cancer rates (OR, 1.23; 95% CI, 1.14-1.33). Substantial to considerable heterogeneity existed for most analyses, and overall certainty in the evidence was low according to the Grading of Recommendations, Assessment, Development, and Evaluations framework. CONCLUSION Colonoscopies performed by surgeons or other endoscopists were associated with poorer quality metrics and outcomes compared with those performed by gastroenterologists. Targeted quality improvement efforts may be warranted.
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Affiliation(s)
- Matthew Mazurek
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alistair Murray
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada
| | - Steven J Heitman
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada
| | - Yibing Ruan
- Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stavros A Antoniou
- Surgical Service, Mediterranean Hospital of Cyprus, Limassol, Cyprus; Medical School, European University Cyprus, Nicosia, Cyprus
| | - Devon Boyne
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjay Murthy
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Nancy N Baxter
- St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Indraneel Datta
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada; Department of Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Christopher Ma
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mark G Swain
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada
| | - Robert J Hilsden
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, Alberta, Canada; Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicines, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Forzani & MacPhail Colon Cancer Screening Centre, University of Calgary, Calgary, Alberta, Canada.
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Li JW, Wang LM, Ang TL. Artificial intelligence-assisted colonoscopy: a narrative review of current data and clinical applications. Singapore Med J 2022; 63:118-124. [PMID: 35509251 PMCID: PMC9251247 DOI: 10.11622/smedj.2022044] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Colonoscopy is the reference standard procedure for the prevention and diagnosis of colorectal cancer, which is a leading cause of cancer-related deaths in Singapore. Artificial intelligence systems are automated, objective and reproducible. Artificial intelligence-assisted colonoscopy has recently been introduced into clinical practice as a clinical decision support tool. This review article provides a summary of the current published data and discusses ongoing research and current clinical applications of artificial intelligence-assisted colonoscopy.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- SingHealth Duke-NUS Medicine Academic Clinical Programme, Singapore
| | - Lai Mun Wang
- Pathology Section, Department of Laboratory Medicine, Changi General Hospital, Singapore
- SingHealth Duke-NUS Pathology Academic Clinical Programme, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- SingHealth Duke-NUS Medicine Academic Clinical Programme, Singapore
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Telford J, Gondara L, Pi S, Gentile L, Enns R. Higher adenoma detection, sessile serrated lesion detection and proximal sessile serrated lesion detection are associated with physician specialty and performance on Direct Observation of Procedural Skills. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000677. [PMID: 34193469 PMCID: PMC8246294 DOI: 10.1136/bmjgast-2021-000677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/07/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Adenoma detection rate (ADR) and sessile serrated lesion detection rate (SSLDR) vary among physicians. We sought to determine physician characteristics associated with ADR and SSLDR in a population-based colon screening programme. DESIGN Retrospective study of 50-74 year olds with positive faecal immunochemical test and colonoscopy from 15/11/2013 to 31/12/2018. Physician characteristics included: gender, specialty, year and country of medical school graduation, colonoscopy volume and Direct Observation of Procedural Skills (DOPS) performance. Multivariable regression was performed on the following dependent variables: ADR, advanced ADR, proximal and distal ADR, SSLDR, proximal and distal SSLDR. RESULTS 104 326 colonoscopies were performed by 261 physicians. A higher ADR was associated with gastroenterology (OR for general surgery 0.87, 95% CI 0.80 to 0.95; OR for general/family/internal medicine 0.70, 95% CI 0.55 to 0.88), fewer years since graduation (OR for graduation >2000 10.48, 95% CI 1.30 to 1.69 compared with <1980) and DOPS performance (OR for lowest DOPS performance 0.64, 95% CI 0.50 to 0.82 compared with highest DOPS performance). SSLDR was associated with gastroenterology (OR for general surgery 0.89, 95%, CI 0.81 to 0.97; OR for general/family/internal medicine 0.67, 95% CI 0.49 to 0.92) and DOPS performance (OR for lowest DOPS performance 0.71, 95% CI 0.51 to 0.99 compared with highest DOPS performance). Proximal SSLDR was associated with gastroenterology (OR for general surgery 0.90, 95% CI 0.82 to 0.99; OR for general/family/internal medicine 0.69, 95% CI 0.50 to 0.97) and DOPS performance (OR for lowest DOPS performance 0.68, 95% CI 0.47 to 0.99). CONCLUSION Higher ADR, SSLDR and proximal SSLDR was associated with gastroenterology specialty and improved performance on DOPS.
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Affiliation(s)
- Jennifer Telford
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada .,Cancer Screening Programs, BC Cancer, Vancouver, British Columbia, Canada
| | - Lovedeep Gondara
- Cancer Screening Programs, BC Cancer, Vancouver, British Columbia, Canada
| | - Steven Pi
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura Gentile
- Cancer Screening Programs, BC Cancer, Vancouver, British Columbia, Canada
| | - Robert Enns
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Li JW, Ang TL. Colonoscopy and artificial intelligence: Bridging the gap or a gap needing to be bridged? Artif Intell Gastrointest Endosc 2021; 2:36-49. [DOI: 10.37126/aige.v2.i2.36] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 03/27/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
Research in artificial intelligence (AI) in gastroenterology has increased over the last decade. Colonoscopy represents the most widely published field with regards to its use in gastroenterology. Most studies to date center on polyp detection and characterization, as well as real-time evaluation of adequacy of mucosal exposure for inspection. This review article discusses how advances in AI has bridged certain gaps in colonoscopy. In addition, the gaps formed with the development of AI that currently prevent its routine use in colonoscopy will be explored.
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Affiliation(s)
- James Weiquan Li
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore 529889, Singapore
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore 529889, Singapore
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Abstract
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).
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Sarvepalli S, Garber A, Rothberg MB, Mankaney G, McMichael J, Morris-Stiff G, Vargo JJ, Rizk MK, Burke CA. Association of Adenoma and Proximal Sessile Serrated Polyp Detection Rates With Endoscopist Characteristics. JAMA Surg 2020; 154:627-635. [PMID: 30994911 DOI: 10.1001/jamasurg.2019.0564] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Research demonstrates adenoma detection rate (ADR) and proximal sessile serrated polyp detection rate (pSSPDR) are associated with endoscopist characteristics including sex, specialty, and years in practice. However, many studies have not adjusted for other risk factors associated with colonic neoplasia. Objective To assess the association between endoscopist characteristics and polyp detection after adjusting the factors included in previous studies as well as other factors. Design, Setting, and Participants This cohort study was conducted in the Cleveland Clinic health system with data from individuals undergoing screening colonoscopies between January 2015 and June 2017. The study analyzed data using methods from previous studies that have demonstrated significant associations between endoscopist characteristics and ADR or pSSPDR. Multilevel mixed-effects logistic regression was performed to examine 7 endoscopist characteristics associated with ADRs and pSSPDRs after controlling for patient demographic, clinical, and colonoscopy-associated factors. Exposures Seven characteristics of endoscopists performing colonoscopy. Main Outcomes and Measures The ADR and pSSPDR, with a hypothesis created after data collection began. Results A total of 16 089 colonoscopies were performed in 16 089 patients by 56 clinicians. Of these, 8339 patients were male (51.8%), and the median (range) age of the cohort was 59 (52-66) years. Analyzing the data by the methods used in 4 previous studies yielded an association between endoscopist and polyp detection; surgeons (OR, 0.49 [95% CI, 0.28-0.83]) and nongastroenterologists (OR, 0.50 [95% CI 0.29-0.85]) had reduced odds of pSSPDR, which was similar to results in previous studies. In a multilevel mixed-effects logistic regression analysis, ADR was not significantly associated with any endoscopist characteristic, and pSSPDR was only associated with years in practice (odds ratio, 0.86 [95% CI, 0.83-0.89] per increment of 10 years; P < .001) and number of annual colonoscopies performed (odds ratio, 1.05 [95% CI, 1.01-1.09] per 50 colonoscopies/year; P = .02). Conclusions and Relevance The differences in ADRs that were associated with 7 of 7 endoscopist characteristics and differences in pSSPDRs that were associated with 5 of 7 endoscopist characteristics in previous studies may have been associated with residual confounding, because they were not replicated in this analysis. Therefore, these characteristics should not influence the choice of endoscopist for colorectal cancer screening. However, clinicians further from their training and those with lower colonoscopy volumes have lower adjusted pSSPDRs and may need additional training to help increase pSSPDRs.
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Affiliation(s)
| | - Ari Garber
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Michael B Rothberg
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio.,Department of Value Based Care, Cleveland Clinic, Cleveland, Ohio
| | - Gautam Mankaney
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - John McMichael
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Maged K Rizk
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
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Josey MJ, Odahowski CL, Zahnd WE, Schootman M, Eberth JM. Disparities in Utilization of Medical Specialists for Colonoscopy. Health Equity 2019; 3:464-471. [PMID: 31501806 PMCID: PMC6729104 DOI: 10.1089/heq.2019.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist. Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested. Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64–0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67–0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant. Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.
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Affiliation(s)
- Michele J Josey
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Cassie L Odahowski
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Whitney E Zahnd
- Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
| | - Mario Schootman
- Department of Clinical Analytics and Insights, Center for Clinical Excellence, SSM Health System, St. Louis, Missouri
| | - Jan M Eberth
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.,Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina.,Rural and Minority Health Research Center, University of South Carolina, Columbia, South Carolina
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Siau K, Anderson JT, Valori R, Feeney M, Hawkes ND, Johnson G, McKaig BC, Pullan RD, Hodson J, Wells C, Thomas-Gibson S, Haycock AV, Beales IL, Broughton R, Dunckley P. Certification of UK gastrointestinal endoscopists and variations between trainee specialties: results from the JETS e-portfolio. Endosc Int Open 2019; 7:E551-E560. [PMID: 30957005 PMCID: PMC6449159 DOI: 10.1055/a-0839-4476] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction In the UK, endoscopy certification is administered by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG). Since 2011, certification for upper and lower gastrointestinal endoscopy has been awarded via a national (JETS) e-portfolio to the main training specialties of: gastroenterology, gastrointestinal surgeons (GS) and non-medical endoscopists (NME). Trends in endoscopy certification and differences between trainee specialties were analyzed. Methods This prospective UK-wide observational study identified trainees awarded gastroscopy, sigmoidoscopy, colonoscopy (provisional and full) certification between June 2011 - 2017. Trends in certification, procedures and time-to-certification, and key performance indicators (KPIs) in the 3-month pre- and post-certification period were compared between the three main training specialties. Results Three thousand one hundred fifty-seven endoscopy-related certifications were awarded to 1928 trainees from gastroenterology (52.3 %), GS (28.4 %) and NME (16.5 %) specialties. During the study period, certification numbers increased for all modalities and specialties, particularly NME trainees. For gastroscopy and colonoscopy, procedures-to-certification were lowest for GS ( P < 0.001), whereas time-to-certification was consistently shortest in NMEs ( P < 0.001). A post-certification reduction in mean cecal intubation rate (95.2 % to 93.8 %, P < 0.001) was observed in colonoscopy, and D2 intubation (97.6 % to 96.2 %, P < 0.001) and J-maneuver (97.3 % to 95.8 %, P < 0.001) in gastroscopy. Overall, average pre- and post-certification KPIs still exceeded national minimum standards. There was an increase in PDR for NMEs after provisional colonoscopy certification but a decrease in PDR for GS trainees after sigmoidoscopy and full colonoscopy certification. Conclusion Despite variations among trainee specialties, average pre- and post-certification KPIs for certified trainees met national standards, suggesting that JAG certification is a transparent benchmark which adequately safeguards competency in endoscopy training.
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Affiliation(s)
- Keith Siau
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Endoscopy, Dudley Group Hospitals NHSFT, Dudley, UK
- Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - John T. Anderson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Hospitals NHSFT, Gloucester, UK
| | - Roland Valori
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Hospitals NHSFT, Gloucester, UK
| | - Mark Feeney
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Neil D. Hawkes
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cwm Taf University Health Board, Llantrisant, UK
| | - Gavin Johnson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, University College London Hospitals NHSFT, London, UK
| | - Brian C. McKaig
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Rupert D. Pullan
- General and Colorectal Surgery, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Christopher Wells
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, North Tees and Hartlepool NHS Foundation Trust, Stockton on Tees, UK
| | - Siwan Thomas-Gibson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK
- Imperial College London, London, UK
| | - Adam V. Haycock
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK
- Imperial College London, London, UK
| | - Ian L.P. Beales
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Raphael Broughton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Paul Dunckley
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Hospitals NHSFT, Gloucester, UK
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Siau K, Green JT, Hawkes ND, Broughton R, Feeney M, Dunckley P, Barton JR, Stebbing J, Thomas-Gibson S. Impact of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) on endoscopy services in the UK and beyond. Frontline Gastroenterol 2019; 10:93-106. [PMID: 31210174 PMCID: PMC6540274 DOI: 10.1136/flgastro-2018-100969] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 09/18/2018] [Accepted: 09/24/2018] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
- Keith Siau
- Endoscopy Unit, Dudley Group NHS Foundation Trust, Dudley, UK
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - John T Green
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cardiff and Vale University Health Board, Cardiff, UK
| | - Neil D Hawkes
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Cwm Taf University Health Board, Llantrisant, UK
| | - Raphael Broughton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Mark Feeney
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, South Devon Healthcare NHS Foundation Trust, Torquay, UK
| | - Paul Dunckley
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK
| | - John Roger Barton
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Newcastle University Medicine Malaysia, Nusajaya, Johor, Malaysia
| | - John Stebbing
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Department of GI Surgery, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Siwan Thomas-Gibson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
- Wolfson Unit for Endoscopy, St Marks Hospital, Harrow, UK
- Imperial College London, London, UK
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10
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Patel K, Ward S, Gash K, Ferguson H, Mason M, McKay SC, Kumar B, Sudlow A, Sutton PA, Humm G, Mohan HM. Prospective cohort study of surgical trainee experience of access to gastrointestinal endoscopy training in the UK and Ireland. Int J Surg 2019; 67:113-116. [PMID: 30708061 DOI: 10.1016/j.ijsu.2019.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Surgical trainees are reporting barriers to training in gastrointestinal (GI) endoscopy. This snapshot survey aimed to gather data on variation in access to quality GI endoscopy training for Colorectal and Upper Gastrointestinal (GI) surgical trainees across the UK and Ireland. MATERIALS AND METHODS An online 20-point survey was designed and distributed nationally to surgical trainee members of the Association of Surgeons in Training (ASiT), Dukes and The Roux Group (formerly Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland Trainees). The survey was designed in collaboration with The Roux Group for Upper GI trainees and the Dukes' Club for Colorectal trainees. RESULTS 218 responses were received, most with a Colorectal or Upper GI sub-specialty interest (colorectal 56.0%; upper GI surgery 25.7%). Only 28.6% of trainees attended a dedicated training endoscopy list at least once a week with 28.1% not attending any at all. Less than half of trainees reported having endoscopy formally timetabled on rotas (36.9%). Most trainees (88.0%) encountered difficulties in gaining endoscopy training including lack of available lists (77.2%), conflicting operative commitments (59.4%), preferential allocation of lists to gastroenterology trainees (57.9%) and resistance from endoscopy departmental leads (38.6%). Regarding JAG accreditation, 77.1% respondents felt it should be mandatory prior to CCT with 80.3% believing this would lead to better access to dedicated endoscopy training equivalent to gastroenterology trainees. 93.1% trainees felt that attaining JAG accreditation by surgical trainees was important to patient care. DISCUSSION This study demonstrates significant barriers in accessing GI endoscopy training for general surgical trainees which urgently needs to be improved. In order to meet JAG training requirements for surgical trainees, a multifaceted collaborative approach from surgical and gastroenterology training bodies, local JAG trainers and the General Surgery SAC and JCST is required. This is to ensure that endoscopy is promoted and a robust model of training is successfully designed and delivered to general surgery trainees.
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Affiliation(s)
- K Patel
- The Association of Surgeons in Training(ASiT), UK
| | | | | | | | - M Mason
- The Roux Group (Formerly AUGISt), UK
| | - S C McKay
- The Roux Group (Formerly AUGISt), UK
| | - B Kumar
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | - A Sudlow
- Norfolk and Norwich University Hospitals NHS Foundation Trust, UK
| | - P A Sutton
- The Association of Surgeons in Training(ASiT), UK
| | - G Humm
- The Association of Surgeons in Training(ASiT), UK
| | - H M Mohan
- The Association of Surgeons in Training(ASiT), UK.
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11
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Lee AHH, Lojanapiwat N, Balakrishnan V, Chandra R. Is there a difference in adenoma detection rates between gastroenterologists and surgeons? World J Gastrointest Endosc 2018; 10:109-116. [PMID: 29988847 PMCID: PMC6033718 DOI: 10.4253/wjge.v10.i6.109] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/05/2018] [Accepted: 04/11/2018] [Indexed: 02/06/2023] Open
Abstract
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, 1st 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.
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Affiliation(s)
- Adele Hwee Hong Lee
- Eastern Health Clinical School, Monash University Clayton Campus, Melbourne 3128, Australia
| | - Nuttaradee Lojanapiwat
- Eastern Health Clinical School, Monash University Clayton Campus, Melbourne 3128, Australia
| | - Vikram Balakrishnan
- Department of Colorectal Surgery, Box Hill Hospital, Melbourne 3128, Australia
| | - Raaj Chandra
- Department of Colorectal Surgery, Box Hill Hospital, Melbourne 3128, Australia
- Royal Melbourne Hospital, Melbourne 3050, Australia
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12
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Eberth JM, Josey MJ, Mobley LR, Nicholas DO, Jeffe DB, Odahowski C, Probst JC, Schootman M. Who Performs Colonoscopy? Workforce Trends Over Space and Time. J Rural Health 2017; 34:138-147. [PMID: 29143383 DOI: 10.1111/jrh.12286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/01/2017] [Accepted: 10/16/2017] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Jan M Eberth
- Department of Epidemiology and Biostatistics, Statewide Cancer Prevention and Control Program, and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Michele J Josey
- Department of Epidemiology and Biostatistics, Statewide Cancer Prevention and Control Program, and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Lee R Mobley
- Department of Health Management and Policy, School of Public Health, Georgia State University, Atlanta, Georgia
| | - Davidson O Nicholas
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri.,Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Donna B Jeffe
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Cassie Odahowski
- Department of Epidemiology and Biostatistics, Statewide Cancer Prevention and Control Program, and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Janice C Probst
- Department of Health Services Policy and Management and South Carolina Rural Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Mario Schootman
- Department of Epidemiology, College for Public Health and Social Justice, St. Louis University, St. Louis, Missouri
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13
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Affiliation(s)
- Snorri Olafsson
- a Division of Gastroenterology , Telemark Hospital , Skien , Norway
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14
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Polyp detection at colonoscopy: Endoscopist and technical factors. Best Pract Res Clin Gastroenterol 2017; 31:425-433. [PMID: 28842052 DOI: 10.1016/j.bpg.2017.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/31/2017] [Indexed: 01/31/2023]
Abstract
The adenoma detection rate (ADR) has emerged as the most important quality measure in colonoscopy, as it predicts the risk of interval cancer after colonoscopy. Measuring and improving ADR is the central focus of the current quality movement in colonoscopy. High ADRs can be achieved by a colonoscopist with a thorough understanding of the wide range of endoscopic appearances of precancerous lesions in the colorectum, effective bowel preparation, and meticulous technique using high definition colonoscopes. The knowledgeable and effective examiner needs no adjunctive devices or techniques to achieve master level ADRs. However, measurement reveals that many colonoscopists have ADRs that are below recommended minimum thresholds or below master levels. These colonoscopists, and even master level performers, can choose from a variety of adjunctive tools to improve ADR. This review describes these tools according to whether they are non-device methods (e.g. double right colon examination, patient position change, water exchange), mucosal exposure devices (wide angle colonoscopy, fold flattening devices), and lesion highlighting techniques (e.g. chromoendoscopy, electronic chromoendoscopy).
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15
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Patel K, Faiz O, Rutter M, Dunckley P, Thomas-Gibson S. The impact of the introduction of formalised polypectomy assessment on training in the UK. Frontline Gastroenterol 2017; 8:104-109. [PMID: 28250907 PMCID: PMC5318649 DOI: 10.1136/flgastro-2016-100718] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/12/2016] [Accepted: 06/27/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The aim was to describe the impact on polypectomy experience by the mandatory introduction of the Directly Observed Polypectomy Skills tool (DOPyS) and electronic portfolio as part of the formal colonoscopy certification process. DESIGN Applications for colonoscopy certification in the UK in the year prior to the introduction of DOPyS were analysed retrospectively and compared with data collected prospectively for those in the following year. SETTING UK National Health Service. PATIENTS None. INTERVENTIONS None. MAIN OUTCOME MEASURES The outcomes studied included whether evidence of exposure to polypectomy, endoscopic mucosal resection (EMR) and colonoscopy changed over the 2-year period. The nature of the polyps removed by trainees was also studied. RESULTS Thirty two per cent of candidates in the first year had evidence of any observed polypectomy with 7% of candidates referring to training in EMR. The median number of formative colonoscopy assessments was 3 (range 0-16). All of these candidates in the second year had evidence of polypectomy assessment, with a median number of DOPyS of 7 (range 3-27). Eighty nine per cent of applicants had evidence of assessed EMR. The median number of formative colonoscopy assessments in this cohort was 32 (range 9-199). There was a significant increase in the number of logged polypectomy assessments (p<0.001), experience of EMR (p<0.001) and formative colonoscopy assessments (p<0.001). There was no significant difference in the total number of colonoscopy procedures performed. CONCLUSIONS Structured polypectomy assessment improves trainees' documented exposure to therapeutic endoscopy as well as providing formal evidence of skills acquisition. As polypectomy plays an increasing role globally in colorectal cancer prevention, the DOPyS provides an effective means of assessing and certifying polypectomy.
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Affiliation(s)
- Kinesh Patel
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
| | - Omar Faiz
- Wolfson Unit for Endoscopy, St Mark's Hospital, Harrow, UK
| | - Matt Rutter
- University Hospital of North Tees, Stockport, UK
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16
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Post-Colonoscopy Complications: A Systematic Review, Time Trends, and Meta-Analysis of Population-Based Studies. Am J Gastroenterol 2016; 111:1092-101. [PMID: 27296945 DOI: 10.1038/ajg.2016.234] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 05/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Many studies around the world addressed the post-colonoscopy complications, but their pooled prevalence and time trends are unknown. We performed a systematic review and meta-analysis of population-based studies to examine the pooled prevalence of post-colonoscopy complications ("perforation", "bleeding", and "mortality"), stratified by colonoscopy indication. Temporal variability in the complication rate was assessed. METHODS We queried Pubmed, Embase, and the Cochrane library for population-based studies examining post-colonoscopy complications (within 30 days), performed from 2001 to 2015 and published by 1 December 2015. We determined pooled prevalence of perforations, post-colonoscopy bleeding, post-polypectomy bleeding, and mortality. RESULTS We retrieved 1,074 studies, of which 21 met the inclusion criteria. Overall, pooled prevalences for perforation, post-colonoscopy bleeding, and mortality were 0.5/1,000 (95% confidence interval (CI) 0.4-0.7), 2.6/1,000 (95% CI 1.7-3.7), and 2.9/100,000 (95% CI 1.1-5.5) colonoscopies. Colonoscopy with polypectomy was associated with a perforation rate of 0.8/1,000 (95% CI 0.6-1.0) and a post-polypectomy bleeding rate of 9.8/1,000 (95% CI 7.7-12.1). Complication rate was lower for screening/surveillance than for diagnostic examinations. Time-trend analysis showed that post-colonoscopy bleeding declined from 6.4 to 1.0/1,000 colonoscopies, whereas the perforation and mortality rates remained stable from 2001 to 2015. Overall, considerable heterogeneity was observed in most of the analyses. CONCLUSIONS Worldwide, the post-colonoscopy complication rate remained stable or even declined over the past 15 years. The findings of this meta-analysis encourage continued efforts to achieve and maintain safety targets in colonoscopy practice.
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Patient Comorbidity and Serious Adverse Events after Outpatient Colonoscopy: Population-based Study From Three States, 2006 to 2009. Dis Colon Rectum 2016; 59:677-87. [PMID: 27270521 DOI: 10.1097/dcr.0000000000000603] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Serious GI adverse events in the outpatient setting were examined for patients with a full spectrum of comorbid conditions and combinations of multiple comorbidities. DESIGN This is a retrospective follow-up study. SETTING Ambulatory surgery and hospital discharge data sets from California, Florida, and New York, 2006 to 2009, were used. PATIENTS The outpatient colonoscopies of 4,234,084 adults aged 19 to 85 and over and payers were examined. MAIN OUTCOME Thirty-day hospitalizations due to colonic perforations and GI bleeding, measured as cumulative outcomes, were investigated. RESULTS About 24% of patients undergoing outpatient colonoscopy had a comorbid condition. In comparison with patients without comorbidities, the adjusted risks of adverse events were greater for patients with several single comorbidities and combinations of multiple comorbid conditions. Elderly patients and those treated in freestanding Ambulatory Surgery Centers had higher odds of colonic perforations and GI bleeding than younger patients and patients treated in hospital outpatient departments. LIMITATION The study was constrained by limitations inherent in administrative data. CONCLUSIONS Given the large number of outpatient colonoscopies performed in the United States, these procedures should be provided with caution to patients with chronic and multiple comorbidities and the elderly, because these populations are associated with higher rates of colonic perforations and GI bleeding.
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18
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Weber CN, Lev-Toaff AS, Levine MS, Sudarsky S, Guendel L, Geiger B, Zafar HM. Detailed quantitative assessment of colonic morphology at CT colonography using novel software: a feasibility and reproducibility study. Med Biol Eng Comput 2016; 55:507-515. [PMID: 27289590 DOI: 10.1007/s11517-016-1529-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 05/18/2016] [Indexed: 12/14/2022]
Abstract
The aim of this study was to evaluate feasibility and reproducibility of quantitative assessment of colonic morphology on CT colonography (CTC). CTC datasets from 60 patients with optimal colonic distension were assessed using prototype software. Metrics potentially associated with poor endoscopic performance were calculated for the total colon and each segment including: length, volume, tortuosity (number of high curvature points <90°), and compactness (volume of box containing centerline divided by centerline length). Sigmoid apex height relative to the lumbosacral junction was also measured. Datasets were quantified twice each, and intra-reader reliability was evaluated using concordance correlation coefficient and Bland-Altman plot. Complete quantitative datasets including the five proposed metrics were generated from 58 of 60 (97 %) CTC examinations. The sigmoid and transverse segments were the longest (55.9 and 51.4 cm), had the largest volumes (0.410 and 0.609 L), and were the most tortuous (3.39 and 2.75 high curvature points) and least compact (3347 and 3595 mm2), noting high inter-patient variability for all metrics. Mean height of the sigmoid apex was 6.7 cm, also with high inter-patient variability (SD 6.8 cm). Intra-reader reliability was high for total and segmental lengths and sigmoid apex height (CCC = 0.9991) with excellent repeatability coefficient (CR = 3.0-3.3). There was low percent variance of metrics dependent upon length (median 5 %). Detailed automated quantitative assessment of colonic morphology on routine CTC datasets is feasible and reproducible, requiring minimal reader interaction.
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Affiliation(s)
- Charles N Weber
- Department of Radiology, The Hospital of the University of Pennsylvania, One Silverstein, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Anna S Lev-Toaff
- Department of Radiology, The Hospital of the University of Pennsylvania, One Silverstein, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Marc S Levine
- Department of Radiology, The Hospital of the University of Pennsylvania, One Silverstein, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Sandra Sudarsky
- Medical Imaging Technologies, Siemens Healthcare, Princeton, NJ, USA
| | | | - Bernhard Geiger
- Medical Imaging Technologies, Siemens Healthcare, Princeton, NJ, USA
| | - Hanna M Zafar
- Department of Radiology, The Hospital of the University of Pennsylvania, One Silverstein, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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Ekkelenkamp VE, Koch AD, de Man RA, Kuipers EJ. Training and competence assessment in GI endoscopy: a systematic review. Gut 2016; 65:607-15. [PMID: 25636697 DOI: 10.1136/gutjnl-2014-307173] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 01/08/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Training procedural skills in GI endoscopy once focused on threshold numbers. As threshold numbers poorly reflect individual competence, the focus gradually shifts towards a more individual approach. Tools to assess and document individual learning progress are being developed and incorporated in dedicated training curricula. However, there is a lack of consensus and training guidelines differ worldwide, which reflects uncertainties on optimal set-up of a training programme. AIMS The primary aim of this systematic review was to evaluate the currently available literature for the use of training and assessment methods in GI endoscopy. Second, we aimed to identify the role of simulator-based training as well as the value of continuous competence assessment in patient-based training. Third, we aimed to propose a structured training curriculum based on the presented evidence. METHODS A literature search was carried out in the available medical and educational literature databases. The results were systematically reviewed and studies were included using a predefined protocol with independent assessment by two reviewers and a final consensus round. RESULTS The literature search yielded 5846 studies. Ninety-four relevant studies on simulators, assessment methods, learning curves and training programmes for GI endoscopy met the inclusion criteria. Twenty-seven studies on simulator validation were included. Good validity was demonstrated for four simulators. Twenty-three studies reported on simulator training and learning curves, including 17 randomised control trials. Increased performance on a virtual reality (VR) simulator was shown in all studies. Improved performance in patient-based assessment was demonstrated in 14 studies. Four studies reported on the use of simulators for assessment of competence levels. Current simulators lack the discriminative power to determine competence levels in patient-based endoscopy. Eight out of 14 studies on colonoscopy, endoscopic retrograde cholangiopancreatography and endosonography reported on learning curves in patient-based endoscopy and proved the value of this approach for measuring performance. Ten studies explored the numbers needed to gain competence, but the proposed thresholds varied widely between them. Five out of nine studies describing the development and evaluation of assessment tools for GI endoscopy provided insight into the performance of endoscopists. Five out of seven studies proved that intense training programmes result in good performance. CONCLUSIONS The use of validated VR simulators in the early training setting accelerates the learning of practical skills. Learning curves are valuable for the continuous assessment of performance and are more relevant than threshold numbers. Future research will strengthen these conclusions by evaluating simulation-based as well as patient-based training in GI endoscopy. A complete curriculum with the assessment of competence throughout training needs to be developed for all GI endoscopy procedures.
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Affiliation(s)
| | - Arjun D Koch
- Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Robert A de Man
- Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Ernst J Kuipers
- Erasmus MC-University Medical Center, Rotterdam, The Netherlands
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20
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Cha JM. [Quality improvement of gastrointestinal endoscopy in Korea: past, present, and future]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 64:320-32. [PMID: 25530583 DOI: 10.4166/kjg.2014.64.6.320] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The motivation for improving quality of gastrointestinal endoscopy begins with the desire to provide patients with the best possible care. Gastrointestinal endoscopy is an excellent area for quality improvement because of its high volume, significant associated risk and expense, and variability in its performance affecting outcomes. Therefore, the assurance that high-quality endoscopic procedures are performed has taken increased importance. The 'Korean Gastrointestinal Endoscopy Research Foundation' and 'Korean Society of Gastrointestinal Endoscopy', as ladders in promoting the highest quality patient care, formed endoscopy quality evaluation in 'National Cancer Screening Program' and'Endoscopy Unit Accreditation' in Korea. However, both new systems have not settled down despite efforts of many years and support by the government. In this article, the past and present of quality improvement of gastrointestinal endoscopy will be reviewed, and the future of quality improvement of gastrointestinal endoscopy will be illuminated.
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Affiliation(s)
- Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gang Dong, Kyung Hee University School of Medicine, Seoul, Korea
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Stanford SB, Lee S, Masaquel C, Lee RH. Achieving competence in colonoscopy: Milestones and the need for a new endoscopic curriculum in gastroenterology training. World J Gastrointest Endosc 2015; 7:1279-1286. [PMID: 26675559 PMCID: PMC4673390 DOI: 10.4253/wjge.v7.i18.1279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/05/2015] [Accepted: 10/27/2015] [Indexed: 02/05/2023] Open
Abstract
Colonoscopy is considered to be the most effective tool for reducing colorectal cancer (CRC) morbidity and mortality. As a result, certifying trainee competence in the performance of colonoscopy is critical to maximizing CRC screening and prevention efforts. Guidelines on training and accreditation around the world have been revised to emphasize the attainment of milestones in the technical and cognitive skills necessary to perform the procedure. To meet this challenge, new evaluation systems have been developed to measure trainee competence through all aspects of colonoscopy training. These changes stem from increased recognition that procedural numbers alone do not necessarily guarantee trainees’ proficiency in the performance of colonoscopy. Variability in endoscopic practice and in CRC screening outcomes also point to deficiencies in the current approach towards colonoscopy instruction. However, technological innovations hold great promise in training endoscopists to perform high quality colonoscopy. Furthermore, potential advances in the use of feedback as a training tool provide new avenues for research. This review summarizes the latest evidence on the effort to define, evaluate and promote the achievement of competence in colonoscopy among trainees.
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Zorzi M, Senore C, Da Re F, Barca A, Bonelli LA, Cannizzaro R, Fasoli R, Di Furia L, Di Giulio E, Mantellini P, Naldoni C, Sassatelli R, Rex D, Hassan C, Zappa M. Quality of colonoscopy in an organised colorectal cancer screening programme with immunochemical faecal occult blood test: the EQuIPE study (Evaluating Quality Indicators of the Performance of Endoscopy). Gut 2015; 64:1389-96. [PMID: 25227521 DOI: 10.1136/gutjnl-2014-307954] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 08/31/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To assess variation in the main colonoscopy quality indicators in organised colorectal cancer (CRC) screening programmes based on faecal immunochemical test (FIT). DESIGN Data from a case-series of colonoscopies of FIT-positive subjects were provided by 44 Italian CRC screening programmes. Data on screening history, endoscopic procedure and histology results, and additional information on the endoscopy centre and the endoscopists were collected. The adenoma detection rate (ADR) and caecal intubation rate (CIR) were assessed for the whole population and the individual endoscopists. To explore variation in the quality indicators, multilevel analyses were performed according to patient/centre/endoscopist characteristics. RESULTS We analysed 75 569 (mean age: 61.3 years; men: 57%) colonoscopies for positive FIT performed by 479 endoscopists in 79 centres. ADR ranged from 13.5% to 75% among endoscopists (mean: 44.8%). ADR was associated with gastroenterology specialty (OR: 0.87 for others, 95% CI 0.76 to 0.96) and, at the endoscopy centre level, with the routine use of sedation (OR: 0.80 if occasional (<33%); 95% CI 0.64 to 1.00) and availability of screening-dedicated sessions (OR: 1.35; 95% CI 1.11 to 1.66). CIR ranged between 58.8% and 100% (mean: 93.1%). Independent predictors of CIR at the endoscopist level were the yearly number of screening colonoscopies performed (OR: 1.51 for endoscopists with >600 colonoscopies; 95% CI 1.11 to 2.04) and, at the endoscopy centre level, screening-dedicated sessions (OR: 2.18; 95% CI 1.24 to 3.83) and higher rates of sedation (OR: 0.47 if occasional; 95% CI 0.24 to 0.92). CONCLUSIONS The quality of colonoscopy was affected by patient-related, endoscopist-related and centre-related characteristics. Policies addressing organisational issues should improve the quality of colonoscopy in our programme and similar programmes.
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Affiliation(s)
| | - Carlo Senore
- CPO Piemonte and San Giovanni Battista University Hospital, Turin, Turin, Italy
| | - Filippo Da Re
- Settore promozione e sviluppo igiene e sanità pubblica, Regione Veneto, Venice, Italy
| | | | - Luigina Ada Bonelli
- SS Prevenzione Secondaria e Screening, IRCCS AOU San Martino-IST, Genova, Italy
| | - Renato Cannizzaro
- Department of Oncological Gastroenterology, National Cancer Institute, IRCCS, Centro di Riferimento Oncologico, Aviano, Italy
| | - Renato Fasoli
- U.O. multizonale di Gastroenterologia, Ospedale S. Chiara, Trento, Italy
| | - Lucia Di Furia
- Agenzia Regionale Sanitaria, Regione Marche, Ancona, Italy
| | - Emilio Di Giulio
- Endoscopia Digestiva, Università di Roma "Sapienza", Azienda Ospedaliera Sant'Andrea, Rome, Italy
| | - Paola Mantellini
- Department of Clinical Epidemiology, Cancer Prevention and Research Institute (ISPO), Florence, Italy
| | - Carlo Naldoni
- Assessorato alle politiche per la salute, Regione Emilia-Romagna, Bologna, Italy
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Douglas Rex
- Indiana University School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA
| | - Cesare Hassan
- Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy, Rome, Italy
| | - Marco Zappa
- SS Valutazione Screening, Istituto per lo Studio e la Prevenzione Oncologica, Florence, Italy
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Klare P, Ascher S, Wagenpfeil S, Rapp D, Bajbouj M, Neu B, Schmid RM, von Delius S. Trainee colonoscopists fulfil quality standards for the detection of adenomatous polyps. BMC MEDICAL EDUCATION 2015; 15:26. [PMID: 25882580 PMCID: PMC4347549 DOI: 10.1186/s12909-015-0312-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/18/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND The detection of adenomatous lesions is a major indicator for quality and competence in colonoscopy. Little is known about adenoma detection rates (ADR) of endoscopy trainees. The aim of our study was to investigate the performance of trainee colonoscopists in detecting adenomas and to depict the shape of adenoma detection learning curves during apprenticeship. METHODS We retrospectively investigated a prospectively maintained database of a single tertiary referral center to reveal colonoscopies performed by trainee endoscopists during 2001 and 2013. Colonoscopy reports were chronologically retrieved and separately analyzed for each trainee. Using cumulative curves, courses of trainee's Adenoma detection rates (ADR) during apprenticeship were displayed. Additionally, procedural data including cecal intubation rate and occurrence of complications were assessed. RESULTS We retrospectively analyzed 4354 colonoscopies conducted by 10 trainee endoscopists (TE). A median number of 371 investigations were performed by each apprentice. Group ADR was 23%. No significant difference between aggregated ADRs at the beginning (23%) and at the end (22%) of apprenticeship could be determined (p = 0.70). However, individual learning curves showed considerable different slopes. Personal ADR values ranged between 17% and 31%. Overall cecum intubation rate was 99.0 %. Complication rates were low and fulfilled quality requirements recommended in guidelines. CONCLUSION From the beginning of education, trainee colonoscopists are capable to provide high-quality investigations considering the detection of adenomas as a benchmark quality indicator. Nevertheless, performance differs markedly between investigators. Therefore, individual detection rates should be reviewed regularly to reveal further need for training.
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Affiliation(s)
- Peter Klare
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 München, Germany
| | - Stefan Ascher
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 München, Germany
| | - Stefan Wagenpfeil
- Institut für Medizinische Biometrie, Epidemiologie und Medizinische Informatik, Medizinische Fakultät der Universität des Saarlands, Kirrberger Straße 100, 66424 Homburg/Saar, Germany
| | - Daniel Rapp
- Institut für Medizinische Biometrie, Epidemiologie und Medizinische Informatik, Medizinische Fakultät der Universität des Saarlands, Kirrberger Straße 100, 66424 Homburg/Saar, Germany
| | - Monther Bajbouj
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 München, Germany
| | - Bruno Neu
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 München, Germany
| | - Roland M Schmid
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 München, Germany
| | - Stefan von Delius
- II. Medizinische Klinik, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 München, Germany
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Preisler L, Svendsen MBS, Nerup N, Svendsen LB, Konge L. Simulation-based training for colonoscopy: establishing criteria for competency. Medicine (Baltimore) 2015; 94:e440. [PMID: 25634177 PMCID: PMC4602958 DOI: 10.1097/md.0000000000000440] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of this study was to create simulation-based tests with credible pass/fail standards for 2 different fidelities of colonoscopy models. Only competent practitioners should perform colonoscopy. Reliable and valid simulation-based tests could be used to establish basic competency in colonoscopy before practicing on patients. Twenty-five physicians (10 consultants with endoscopic experience and 15 fellows with very little endoscopic experience) were tested on 2 different simulator models: a virtual-reality simulator and a physical model. Tests were repeated twice on each simulator model. Metrics with discriminatory ability were identified for both modalities and reliability was determined. The contrasting-groups method was used to create pass/fail standards and the consequences of these were explored. The consultants significantly performed faster and scored higher than the fellows on both the models (P < 0.001). Reliability analysis showed Cronbach α = 0.80 and 0.87 for the virtual-reality and the physical model, respectively. The established pass/fail standards failed one of the consultants (virtual-reality simulator) and allowed one fellow to pass (physical model). The 2 tested simulations-based modalities provided reliable and valid assessments of competence in colonoscopy and credible pass/fail standards were established for both the tests. We propose to use these standards in simulation-based training programs before proceeding to supervised training on patients.
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Affiliation(s)
- Louise Preisler
- From the Department of Surgical Gastroenterology and transplantation, Rigshospitalet, and Copenhagen University (LP,LBS), Centre for Clinical Education (CEKU) and Copenhagen University (MBSS,LK), Department of Surgical Gastroenterology, University hospital of Herlev (NN), Copenhagen University Hospital, Herlev, The Capital Region of Denmark
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Abstract
Since the implementation of screening programmes, both the incidence and mortality of colorectal cancer have been decreasing. The choice of the preferred screening tool, however, is divergent and the adherence to screening programmes in most countries is still low. Cancer detection tests such as the guaiac faecal occult blood test (gFOBT) and the immunohistochemical FOBT (iFOBT) achieve higher acceptance than endoscopy. The sensitivity and specificity of iFOBT are higher than those of gFOBT, but gFOBT is cheaper and easier to perform. Endoscopic screening, which represents cancer prevention tests, has higher sensitivity for premalignant lesions than gFOBT and iFOBT and enables diagnosis and therapy in one single procedure. Since screening colonoscopy and sigmoidoscopy are invasive procedures with potentially severe adverse events, the highest possible quality must be provided. High-tech equipment, experience, training, quality control programmes, excellent bowel preparation and low adverse event rates are pivotal. Alternative screening tools such as CT colonography, barium enema CT and multitarget stool DNA tests have not been established as routine screening tools to date.
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Affiliation(s)
- Elisabeth Waldmann
- Division of Gastroenterology and Hepatology, Internal Medicine III, Medical University of Vienna, Vienna, Austria
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26
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CHUKMAITOV ASKAR, BRADLEY CATHYJ, DAHMAN BASSAM, SIANGPHOE UMAPORN, BOUHAIDAR DOUMIT, WARREN JOANL. Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events. J Surg Oncol 2014; 110:207-13. [PMID: 24706376 PMCID: PMC4852307 DOI: 10.1002/jso.23615] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 03/12/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND A use of polypectomy techniques by endoscopist specialty (primary care, surgery, and gastroenterology) and experience (volume), and associations with serious gastrointestinal adverse events, were examined. METHODS A retrospective follow-up study with ambulatory surgery and hospital discharge datasets from Florida, 1999-2001, was used. Thirty-day hospitalizations due to colonic perforations and gastrointestinal bleeding were investigated for 323,585 patients. RESULTS Primary care endoscopists and surgeons used hot biopsy forceps/ablation, while gastroenterologists provided snare polypectomy or complex colonoscopy. Low-volume endoscopists were more likely to use simpler rather than complex procedures. For hot forceps/ablation and snare polypectomy, low- and medium-volume endoscopists reported higher odds of adverse events. For complex colonoscopy, higher odds of adverse events were reported for primary care endoscopists (1.74 [95% CI, 1.18-2.56]) relative to gastroenterologists. CONCLUSIONS Endoscopists regardless of specialty and experience can safely use cold biopsy forceps. For hot biopsy and snare polypectomy, low volume, but not specialty, contributed to increased odds of adverse events. For complex colonoscopy, primary care specialty, but not low volume, added to the odds of adverse events. Comparable outcomes were reported for surgeons and gastroenterologists. Cross-training and continuing medical education of primary care endoscopists in high-volume endoscopy settings are recommended for complex colonoscopy procedures.
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Affiliation(s)
- ASKAR CHUKMAITOV
- Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - CATHY J. BRADLEY
- Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - BASSAM DAHMAN
- Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - UMAPORN SIANGPHOE
- Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - DOUMIT BOUHAIDAR
- Advanced Therapeutic Endoscopy, Division of Gastroenterology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - JOAN L. WARREN
- Health Services and Economics Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
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Chukmaitov A, Bradley CJ, Dahman B, Siangphoe U, BouHaidar D, Warren JL. Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events. J Surg Oncol 2014. [PMID: 24706376 DOI: 10.1002/jso.23615.epub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND A use of polypectomy techniques by endoscopist specialty (primary care, surgery, and gastroenterology) and experience (volume), and associations with serious gastrointestinal adverse events, were examined. METHODS A retrospective follow-up study with ambulatory surgery and hospital discharge datasets from Florida, 1999-2001, was used. Thirty-day hospitalizations due to colonic perforations and gastrointestinal bleeding were investigated for 323,585 patients. RESULTS Primary care endoscopists and surgeons used hot biopsy forceps/ablation, while gastroenterologists provided snare polypectomy or complex colonoscopy. Low-volume endoscopists were more likely to use simpler rather than complex procedures. For hot forceps/ablation and snare polypectomy, low- and medium-volume endoscopists reported higher odds of adverse events. For complex colonoscopy, higher odds of adverse events were reported for primary care endoscopists (1.74 [95% CI, 1.18-2.56]) relative to gastroenterologists. CONCLUSIONS Endoscopists regardless of specialty and experience can safely use cold biopsy forceps. For hot biopsy and snare polypectomy, low volume, but not specialty, contributed to increased odds of adverse events. For complex colonoscopy, primary care specialty, but not low volume, added to the odds of adverse events. Comparable outcomes were reported for surgeons and gastroenterologists. Cross-training and continuing medical education of primary care endoscopists in high-volume endoscopy settings are recommended for complex colonoscopy procedures.
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Affiliation(s)
- Askar Chukmaitov
- Department of Healthcare Policy and Research, School of Medicine, Virginia Commonwealth University, Richmond, Virginia
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Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis. Clin Gastroenterol Hepatol 2014; 12:85-92. [PMID: 23891916 PMCID: PMC4050305 DOI: 10.1016/j.cgh.2013.06.030] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 06/03/2013] [Accepted: 06/17/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training. METHODS We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol. RESULTS We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation. CONCLUSIONS In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.
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Kim YD, Bae WK, Choi YH, Jwa YJ, Jung SK, Lee BH, Paik WH, Kim JW, Kim NH, Kim KA, Lee JS. Difference in Adenoma Detection Rates according to Colonoscopic Withdrawal Times and the Level of Expertise. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 64:278-83. [DOI: 10.4166/kjg.2014.64.5.278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Young Doo Kim
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Won Ki Bae
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yun Ho Choi
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Yoon Jung Jwa
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Sang Kyung Jung
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Bu Hyun Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jong Wook Kim
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Nam-Hoon Kim
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Kyung-Ah Kim
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - June Sung Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Abstract
Optimization of training and teaching methods in colonoscopy at all levels of experience is critical to ensure consistent high-quality procedures in practice. Competency in colonoscopy may not be achieved until more than 250 colonoscopies are performed by trainees. Such tools as computer-based endoscopic simulators can aid in accelerating the early phases of training in colonoscopy, and magnetic endoscopic imaging technology can guide the position of the colonoscope and aid with loop reduction. Periodic feedback and retraining experienced endoscopists can improve the detection of colonic lesions.
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Affiliation(s)
- Victoria Gómez
- Department of Gastroenterology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
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Jiang M, Sewitch MJ, Barkun AN, Joseph L, Hilsden RJ. Endoscopist specialty is associated with colonoscopy quality. BMC Gastroenterol 2013; 13:78. [PMID: 23638769 PMCID: PMC3646699 DOI: 10.1186/1471-230x-13-78] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 04/22/2013] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Mengzhu Jiang
- Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, 687 Pine Avenue West, V Building, Room V2.15, Montreal, QC H3A 1A1, Canada
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Bhangu A, Bowley DM, Horner R, Baranowski E, Raman S, Karandikar S. Volume and accreditation, but not specialty, affect quality standards in colonoscopy. Br J Surg 2012; 99:1436-44. [PMID: 22961527 DOI: 10.1002/bjs.8866] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The Global Rating Scale, defined by the Joint Advisory Group for Gastrointestinal Endoscopy, requires monitoring of endoscopic performance indicators. There are known variations in colonoscopic performance, and investigation of factors causing this is needed. This study aimed to analyse the impact of endoscopist specialty and procedural volume on the quality of colonoscopy. METHODS Data collected prospectively from a UK hospital endoscopy service between June 2007 and January 2010 were analysed. The main endpoint was the adenoma detection rate (ADR). Secondary endpoints were polyp detection rate (PDR), reported caecal intubation rate (CIR) and reported complications. Multivariable binary regression models were built to adjust for confounding patient-level and endoscopist-level variation. RESULTS A total of 10,026 colonoscopies were included, with an overall ADR of 19.2 per cent, a CIR of 90.2 per cent and a perforation rate of 0.06 per cent. In univariable analyses, surgeons had a higher ADR and higher PDR, but lower CIR, compared with physicians. Surgeons had a significantly different case mix in terms of age, sex and indication for colonoscopy. After adjusting for this case mix in multivariable analysis, specialty was no longer a significant predictor of ADR; however, surgeons retained their higher PDR and physicians their higher CIR. Endoscopists accredited for screening and those performing more than 100 colonoscopies per year had a higher ADR. CONCLUSION Adjusting for case mix, physicians and surgeons performed equally well in terms of ADR. Accreditation and a higher annual number of colonoscopies were more important factors in achieving quality standards.
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Affiliation(s)
- A Bhangu
- Department of General Surgery, Birmingham Heartlands Hospital, Heart of England NHS Trust, Bordesley Green East, Birmingham B9 5SS, UK
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Abstract
PURPOSE OF REVIEW This review concerns quality assurance for gastrointestinal endoscopic procedures, especially colonoscopy and will emphasize research and guidelines published since January 2011. Important articles from previous years have been included for background. RECENT FINDINGS Critical lapses in endoscope processing and administration of intravenous sedation alerted us to the infection risk of endoscopy. Increases in cost of colonoscopy, evidence for overuse and studies demonstrating missed cancers have led some to question the value of endoscopy. Despite these setbacks, the National Polyp Study (NPS) consortium published their long-term follow-up of the original NPS patients and confirmed that colonoscopy with polyp removal can reduce the risk of colorectal cancer for an extended period. In this article, we will focus on ways to improve the value of outpatient colonoscopy. SUMMARY The United States national quality improvement agenda recently became organized into a more coordinated effort spearheaded by several public and private entities. They comprise the infrastructure by which performance measures are developed and implemented as accountability standards. Understanding wherein a gastroenterology (GI) practice fits into this infrastructure and learning ways we can improve our endoscopic practice is important for physicians who provide this vital service to patients. This article will provide a roadmap for developing a quality assurance program for endoscopic practice.
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Hassan C, Rex DK, Zullo A, Cooper GS. Loss of efficacy and cost-effectiveness when screening colonoscopy is performed by nongastroenterologists. Cancer 2012; 118:4404-11. [PMID: 22707430 DOI: 10.1002/cncr.27664] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 04/18/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Specialty of the endoscopist has been related to the postcolonoscopy interval risk of colorectal cancer (CRC). However, the impact of such a difference on the long-term CRC prevention rate by screening colonoscopy is largely unknown. METHODS A Markov model was constructed to simulate the efficacy and cost of colonoscopy screening according to the specialty of the endoscopist in 100,000 individuals aged 50 years until death. The postcolonoscopy interval CRC risk (0.02%) and the relative risk (1.4) of interval CRC between gastroenterologist (GI) endoscopists and non-GI endoscopists were extracted from the literature. Both efficacy and costs were projected over a steady-state US population. Eventual increase in endoscopic capacity when assuming all procedures to be performed by GI endoscopists was simulated. RESULTS According to the simulation model, screening colonoscopy performed by non-GI endoscopists resulted in a 11% relative reduction in the long-term CRC incidence prevention rate compared with the same procedure performed by GI endoscopists. When projected on the US population, the reduced non-GI efficacy resulted in an additional 3043 CRC cases and the loss of $200 million per year. When increasing the relative risk from 1.4 to 2.0, the difference in the prevention rate between GI endoscopists and non-GI endoscopists increased to 19%. It increased further to 38% when also assuming a 3-fold increase in the risk of interval CRC. An additional 165 screening colonoscopies per endoscopist per year would be required to shift all non-GI procedures to GI endoscopists. CONCLUSIONS When screening colonoscopy is performed by non-GI endoscopists, a substantial reduction in the long-term CRC prevention rate may be expected. Such difference appeared to be greater when a suboptimal efficacy of colonoscopy in preventing CRC was assumed. A 10-year saving of $2 billion may be expected when shifting all screening colonoscopies from non-GI endoscopists to GI endoscopists.
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Affiliation(s)
- Cesare Hassan
- Division of Gastroenterology, Nuovo Regina Margherita Hospital, Rome, Italy.
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