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Arora A, McDonald C, Guizzetti L, Iansavichene A, Brahmania M, Khanna N, Wilson A, Jairath V, Sey M. Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis. Clin Gastroenterol Hepatol 2023; 21:3238-3257. [PMID: 37080261 DOI: 10.1016/j.cgh.2023.03.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND & AIMS Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator. RESULTS From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11). CONCLUSIONS The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.
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Affiliation(s)
- Anshul Arora
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Cassandra McDonald
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | | | - Alla Iansavichene
- Library Services, London Health Sciences Centre, London, Ontario, Canada
| | - Mayur Brahmania
- Division of Gastroenterology, Western University, London, Ontario, Canada; Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Nitin Khanna
- Division of Gastroenterology, Western University, London, Ontario, Canada
| | - Aze Wilson
- Division of Gastroenterology, Western University, London, Ontario, Canada; Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada; Division of Clinical Pharmacology, Western University, London, Ontario, Canada; Department of Physiology and Pharmacology, Western University, London, Ontario, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Western University, London, Ontario, Canada; Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Michael Sey
- Division of Gastroenterology, Western University, London, Ontario, Canada; Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
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Karamchandani U, Erridge S, Evans-Harvey K, Darzi A, Hoare J, Sodergren MH. Visual gaze patterns in trainee endoscopists - a novel assessment tool. Scand J Gastroenterol 2022; 57:1138-1146. [PMID: 35450506 DOI: 10.1080/00365521.2022.2064723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Colonoscopy proficiency is significantly influenced by skills achieved during training. Although assessment scores exist, they do not evaluate the impact of visual search strategies and their use is time and labour intensive. Eye-tracking has shown significant differences in visual gaze patterns (VGPs) between expert endoscopists with varying polyp detection rates, so may provide a means of automated assessment and guidance for trainees. This study aimed to assess the feasibility of eye-tracking as a novel assessment method for trainee endoscopists. METHODS Eye-tracking glasses were used to record 26 colonoscopies from 12 endoscopy trainees who were assessed with directly observed procedural scores (DOPS), devised by the Joint Advisory Group (JAG) on GI endoscopy, and a visual analogue score of overall competence. A 'total weighted procedure score' (TWPS) was calculated from 1 to 20. Primary outcomes of fixation duration (FixD) and fixation frequency (FixF) were analysed according to areas of interest (AOIs) with the bowel surface and lumen represented by three concentric rings. Correlation was assessed using Pearson's coefficient. Significance was set at p<.050. RESULTS Trainees displayed a significant positive correlation between TWPS and FixD (R = 0.943, p<.0001) and FixF (R = 0.936, p<.0001) in the anatomical bowel mucosa peripheries. Conversely, they had significant negative correlations between TWPS and the anatomical bowel lumen (FixD: R= -0.546, p=.004; FixF: R= -0.568, p=.002). CONCLUSIONS Higher objective performance scores were associated with VGPs focussing on bowel mucosa. This is consistent with prior analysis showing peripheral VGPs correspond with higher polyp detection rates. Analysis of VGPs, therefore, has potential for training and assessment in colonoscopy.
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Affiliation(s)
- Urvi Karamchandani
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Simon Erridge
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Keane Evans-Harvey
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Mikael Hans Sodergren
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
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Díaz-Tasende J. Colonoscopy - When quality matters. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:314-316. [PMID: 35638771 DOI: 10.17235/reed.2022.8942/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Colonoscopy technical quality is a primary determinant of clinical outcome. Unfortunately, there is enough evidence available for significant variability in endoscopists' performance. An assessment of the factors determining these differences will be crucial for designing measures to ensure effectiveness and safety in these procedures.
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Lim S, Tritto G, Zeki S, DeMartino S. Regular feedback to individual endoscopists is associated with improved adenoma detection rate and other key performance indicators for colonoscopy. Frontline Gastroenterol 2022; 13:509-516. [PMID: 36250166 PMCID: PMC9555132 DOI: 10.1136/flgastro-2022-102091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Monitoring of key performance indicators (KPIs) is a vital element of endoscopy quality improvement. Adenoma detection rate (ADR) is considered the best marker for colonoscopic quality as it inversely correlates with subsequent colonic cancer incidence and mortality, while polyp detection rate (PDR) is an easier-to-calculate surrogate for ADR. This study assessed whether regular feedback to individual endoscopists about their KPIs improved departmental performance. METHODS Individual KPIs were calculated for a period of 8 years (January 2012-December 2019) and fed back to all endoscopists at 6 monthly intervals, alongside anonymised indicators for other endoscopists, aggregate departmental performance data and benchmarks. An automated natural language processing software (EndoMineR) was used to identify adenomas in pathology reports and calculate ADR. Linear regressions were calculated for departmental ADR, PDR and other KPIs at 6 monthly intervals. RESULTS 39 359 colonoscopies (average 2460 in every 6-month period, range 1799-3059) were performed by an average of 42 (range 34-50) endoscopists. A continuous improvement in collective performance including ADR (12.7%-21.0%, R2 0.92, p<0.001) and PDR (19.0%-29.6%, R2 0.77, p<0.001) was observed throughout the study. Other KPIs showed similar improvement. The detection of non-neoplastic polyps did not increase. When analysed separately, ADR and PDR appeared to improve for gastroenterologists and nurse endoscopists but not for surgeons. CONCLUSION Regular feedback with individual and departmental KPIs was associated with improved ADR and overall performance throughout the 8-year study period. Concomitant monitoring of ADR and PDR may prevent 'gaming' behaviour and ensure that genuine improvement is achieved.
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Affiliation(s)
- Samuel Lim
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giovanni Tritto
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sebastian Zeki
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Sabina DeMartino
- Department of Gastroenterology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Spada C, Koulaouzidis A, Hassan C, Amaro P, Agrawal A, Brink L, Fischbach W, Hünger M, Jover R, Kinnunen U, Ono A, Patai Á, Pecere S, Petruzziello L, Riemann JF, Staines H, Stringer AL, Toth E, Antonelli G, Fuccio L. Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group. Diagnostics (Basel) 2022; 12:diagnostics12020503. [PMID: 35204593 PMCID: PMC8871420 DOI: 10.3390/diagnostics12020503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/30/2022] Open
Abstract
The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. Conclusions: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.
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Affiliation(s)
- Cristiano Spada
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, 25124 Brescia, Italy
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence:
| | - Anastasios Koulaouzidis
- Department of Medicine, OUH Svendborg Sygehus, 5700 Svendborg, Denmark;
- Department of Clinical Research, University of Southern Denmark (SDU), 5000 Odense, Denmark
- Surgical Research Unit, OUH, 5000 Odense, Denmark
- Department of Social Medicine and Public Health, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Cesare Hassan
- Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy;
| | - Pedro Amaro
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Anurag Agrawal
- Gastroenterology, Doncaster Royal Infirmary, Doncaster DN2 5LT, UK;
| | - Lene Brink
- Gastro Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, 2730 Herlev, Denmark;
| | | | - Matthias Hünger
- Independent Researcher for Internal Medicine, 97070 Würzburg, Germany;
| | - Rodrigo Jover
- Instituto de Investigación Sanitaria ISABIAL—Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, 03010 Alicante, Spain;
| | - Urpo Kinnunen
- Department of Gastroenterology, Tampere University Hospital, 33521 Tampere, Finland;
| | - Akiko Ono
- Department of Gastroenterology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, 30120 Murcia, Spain;
| | - Árpád Patai
- Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, 9700 Szombathely, Hungary;
| | - Silvia Pecere
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.P.); (L.P.)
| | - Lucio Petruzziello
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.P.); (L.P.)
| | - Jürgen F. Riemann
- Department of Medicine C, Klinikum Ludwigshafen, 67063 Ludwigshafen, Germany;
- LebensBlicke Foundation, 67063 Ludwigshafen, Germany
| | - Harry Staines
- Sigma Statistical Services Ltd., Saint Andrews KY16 0BD, UK;
| | | | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden;
| | - Giulio Antonelli
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, “Sapienza” University of Rome, 00185 Rome, Italy;
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, 00040 Rome, Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy;
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Almario CV, Shergill J, Oh J. Measuring and Improving Quality of Colonoscopy for Colorectal Cancer Screening. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:269-283. [PMID: 36778081 PMCID: PMC9910391 DOI: 10.1016/j.tige.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colorectal cancer (CRC) is largely preventable, yet it remains a major public health issue as it is the third most common and deadly malignancy in the United States. While there are many ways to screen for CRC, colonoscopy remains the gold standard as it is the only test that is both cancer-detecting and cancer-preventing through removal of precancerous polyps. Through identifying and removing neoplastic lesions, colonoscopy reduces CRC incidence by 31%-91% and CRC mortality by 65%-88%. However, colonoscopy is not an infallible test-there is a chance for missed lesions during the exam and there is substantial variation in outcomes among endoscopists. To enhance the quality of colonoscopic exams, and ultimately to improve CRC outcomes, quality indicators have been developed for measuring endoscopists' performance. In this review, we describe the colonoscopic quality indicators and benchmarks recommended by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy for screening colonoscopies in average-risk individuals. Measuring and monitoring endoscopists' performance on these measures are critical first steps in striving toward conducting high quality exams. We also review the evidence for interventions that aim to improve critical measures including adenoma detection rate, withdrawal time, cecal intubation, and bowel preparation quality. Finally, we provide a preview of the forthcoming Advancing Care for Appropriate Colon Health Merit-Based Incentive Payment System Value Pathway by the Centers for Medicare & Medicaid Services and its potential impact on clinical practice.
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Affiliation(s)
- Christopher V. Almario
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California;,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California;,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California;,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California;,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, California;,Cancer Prevention & Control Program, Cedars-Sinai Cancer, Los Angeles, California
| | - Jaspreet Shergill
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Janice Oh
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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7
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Shiha MG, Al-Rifaie A, Thoufeeq M. Impact of the National Endoscopy Database (NED) on colonoscopy withdrawal time: a tertiary centre experience. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000699. [PMID: 34215571 PMCID: PMC8256742 DOI: 10.1136/bmjgast-2021-000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/08/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Colonoscopy withdrawal time (CWT) is a key performance indicator affecting polyp detection rate (PDR) and adenoma detection rate (ADR). However, studies have shown wide variation in CWT and ADR between different endoscopists. The National Endoscopy Database (NED) was implemented to enable quality assurance in all endoscopy units across the UK and also to reduce variation in practice. We aimed to assess whether CWT changed since the introduction of NED and whether CWT affected PDR. METHODS We used NED to retrospectively collect data regarding CWT and PDR of 25 endoscopists who performed (n=4459 colonoscopies) in the four quarters of 2019. We then compared this data to their performance in 2016, before using NED (n=4324 colonoscopies). RESULTS Mean CWT increased from 7.66 min in 2016 to 9.25 min in 2019 (p=0.0001). Mean PDR in the two periods was 29.9% and 28.3% (p=0.64). 72% of endoscopists (18/25) had CWT>6 min in 2016 versus 100% (25/25) in 2019, the longer CWT in 2019 positively correlated with the PDR (r=0.50, p=0.01). Gastroenterology consultants and trainee endoscopists had longer CWT compared with colorectal surgeons both before and after using NED. CONCLUSION NED usage increased withdrawal times in colonoscopy. Longer withdrawal times were associated with higher PDR. A national colonoscopy audit using data from NED is required to evaluate whether wide variations in practice across endoscopy units in the UK still exist and to ensure minimum colonoscopy quality standards are achieved.
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Affiliation(s)
- Mohamed G Shiha
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ammar Al-Rifaie
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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8
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Boregowda U, Desai M, Nutalapati V, Paleti S, Olyaee M, Rastogi A. Impact of feedback on adenoma detection rate: a systematic review and meta-analysis. Ann Gastroenterol 2021; 34:214-223. [PMID: 33654362 PMCID: PMC7903562 DOI: 10.20524/aog.2021.0591] [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: 07/20/2020] [Accepted: 08/17/2020] [Indexed: 12/24/2022] Open
Abstract
Background Adenoma detection rate (ADR) is one of the most important quality indicators of colonoscopy. Monitoring endoscopists and providing feedback has shown to improve ADR. We performed a systematic review of the literature and meta-analysis to determine the effect of any form of feedback on ADR. Methods A literature search for comparative studies that employed any form of feedback to assess the impact on ADR before and after the feedback was done on MEDLINE, EMBASE, and Cochrane Database. The primary outcome of interest was ADR. Secondary outcomes included polyp detection rate, advanced adenoma detection rate, sessile serrated adenoma detection rate, withdrawal time, and cecal intubation rate. Cochrane Revman 5.3 software was used for statistical analysis. Results A total of 12 studies met the inclusion criteria for the analysis of primary outcomes. There were 78,355 subjects (45.42% male) with a mean age of 59.52 years. There was a significant improvement in ADR after any form of feedback compared to no feedback: 36.18% vs. 26.75%; pooled odds ratio 1.51, 95% confidence interval 1.37-1.66; P<0.001. There was a substantial heterogeneity (I2=82%). ADR improved in both active or passive feedback, irrespective of whether endoscopists knew about being monitored for their performance or not. Conclusions Monitoring and providing feedback to endoscopists in any form leads to improvement in ADR. Feedback is an easy and effective way of improving the ADR of endoscopists, especially in those not achieving the recommended benchmarks.
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Affiliation(s)
- Umesha Boregowda
- Department of Medicine, Bassett Medical Center, NY (Umesha Boregowda)
| | - Madhav Desai
- Division of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO (Madhav Desai)
| | - Venkat Nutalapati
- Division of Gastroenterology, Hepatology, and Motility, Department of Medicine, University of Kansas Medical Center, Kansas City, KS (Venkat Nutalapati, Mojtaba Olyaee)
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, NM (Swathi Paleti), USA
| | - Mojtaba Olyaee
- Division of Gastroenterology, Hepatology, and Motility, Department of Medicine, University of Kansas Medical Center, Kansas City, KS (Venkat Nutalapati, Mojtaba Olyaee)
| | - Amit Rastogi
- Division of Gastroenterology, Hepatology, and Motility, Department of Medicine, University of Kansas Medical Center, Kansas City, KS (Venkat Nutalapati, Mojtaba Olyaee)
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9
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Bishay K, Causada-Calo N, Scaffidi MA, Walsh CM, Anderson JT, Rostom A, Dube C, Keswani RN, Heitman SJ, Hilsden RJ, Shorr R, Grover SC, Forbes N. Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis. Gastrointest Endosc 2020; 92:1030-1040.e9. [PMID: 32330506 DOI: 10.1016/j.gie.2020.03.3865] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Colonoscopy quality indicators such as adenoma detection rate (ADR) are surrogates for the effectiveness of screening-related colonoscopy. It is unclear whether endoscopist feedback on these indicators improves performance. We performed a meta-analysis to determine whether associations exist between endoscopist feedback and colonoscopy performance. METHODS We conducted a search through May 2019 for studies reporting on endoscopist feedback and associations with ADR or other colonoscopy quality indicators. Pooled rate ratios (RRs) and weighted mean differences were calculated using DerSimonian and Laird random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to assess for potential methodological or clinical factors associated with outcomes. RESULTS From 1326 initial studies, 12 studies were included in the meta-analysis for ADR, representing 33,184 colonoscopies. Endoscopist feedback was associated with an improvement in ADR (RR, 1.21; 95% confidence interval [CI], 1.09-1.34). Low performers derived a greater benefit from feedback (RR, 1.62; 95% CI, 1.18-2.23) compared with moderate performers (RR, 1.19; 95% CI, 1.11-1.29), whereas high performers did not derive a significant benefit (RR, 1.06; 95% CI, 0.99-1.13). Feedback was not associated with increases in withdrawal time (weighted mean difference, +0.43 minutes; 95% CI, -0.50 to +1.36 minutes) or improvements in cecal intubation rate (RR, 1.00; 95% CI, 0.99-1.01). CONCLUSION Endoscopist feedback is associated with modest improvements in ADR. The implementation of routine endoscopist audit and feedback should be considered alongside other quality improvement interventions in institutions dedicated to the provision of high-quality screening-related colonoscopy.
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Affiliation(s)
- Kirles Bishay
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario
| | | | | | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Learning Institute, and Research Institute, Hospital for Sick Children, Toronto, Ontario; The Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - John T Anderson
- Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London; Department of Gastroenterology, Gloucestershire Hospitals NHSFT, Gloucester, United Kingdom
| | - Alaa Rostom
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario
| | - Catherine Dube
- Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, Ontario; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario
| | - Rajesh N Keswani
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta
| | - Robert J Hilsden
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario
| | - Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital, Toronto, Ontario; Li Ka Shing Knowledge Institute, University of Toronto, Toronto, Ontario, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta; Department of Community Health Sciences, University of Calgary, Calgary, Alberta
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10
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Abstract
Colonoscopy is a safe and effective tool, but operator dependent. Room for improvement in the quality of colonoscopy is the impetus for the development and measurement of colonoscopy quality indicators and the focus of many efforts to improve colonoscopy quality indicator prevention and control in provider practices and health systems. We present the preprocedural, intraprocedural, and postprocedural quality indicators and benchmarks for colonoscopy. Every provider and practice must make a commitment to performing high-quality colonoscopy and implement and monitor quality metrics. There are a variety of tools available to assist in improving quality indicators that range from distal attachment devices to education and feedback. Although technology can help, it is not a substitute for proper technique. The commitment also requires provider feedback through audits and report cards. The impact of these efforts on patient outcomes is an important area of further research.
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11
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Then EO, Brana C, Dadana S, Maddika S, Ofosu A, Brana S, Wexler T, Sunkara T, Culliford A, Gaduputi V. Implementing visual cues to improve the efficacy of screening colonoscopy: exploiting the Hawthorne effect. Ann Gastroenterol 2020; 33:374-378. [PMID: 32624657 PMCID: PMC7315716 DOI: 10.20524/aog.2020.0491] [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: 01/15/2020] [Accepted: 02/27/2020] [Indexed: 01/10/2023] Open
Abstract
Background: Colonoscopy is the gold standard for colon cancer screening. Adenoma detection rate and a withdrawal time of 6 min are quality metrics to measure the efficacy of colonoscopy in colon cancer screening. The aim of our study was to exploit the Hawthorne effect in an effort to ensure adherence to a minimum 6-min withdrawal time and subsequently increase adenoma detection rate. Methods: This was a retrospective single-center study where we reviewed the records of patients who underwent screening colonoscopy in 2015 and 2017. We divided our patient population into 2 groups. The first group of patients from 2015 underwent screening colonoscopy with no visual cues on the colonoscopy monitor. The second group of patients from 2017 had visual cues indicating withdrawal time on the colonoscopy monitor. Results: Screening colonoscopy had a statistically significantly higher adenoma detection rate when performed with visual cues compared to without visual cues (25.3% vs. 19.45, P=0.04). Polyp detection rate was also higher in the group where visual cueing was used (52.9% vs. 22.9%, P<0.001). There were no statistically significant differences in actual withdrawal time or cecal intubation rates. Conclusions: Visual cues indicating withdrawal time are a useful intervention that results in an increased adenoma detection rate. Given its practicality and cost effectiveness, we recommend universally implementing visual cues to ensure adherence to a minimum 6-min withdrawal time.
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Affiliation(s)
- Eric Omar Then
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Christopher Brana
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Sriharsha Dadana
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Srikanth Maddika
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Andrew Ofosu
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, NY (Andrew Ofosu, Tagore Sunkara), USA
| | - Sabrina Brana
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Tina Wexler
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Tagore Sunkara
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, NY (Andrew Ofosu, Tagore Sunkara), USA
| | - Andrea Culliford
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
| | - Vinaya Gaduputi
- Division of Gastroenterology and Hepatology, SBH Health System, New York (Eric Omar Then, Christopher Brana, Sriharsha Dadana, Srikanth Maddika, Sabrina Brana, Tina Wexler, Andrea Culliford, Vinaya Gaduputi)
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12
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Ishibashi F, Fukushima K, Kobayashi K, Kawakami T, Tanaka R, Kato J, Sato A, Konda K, Sugihara K, Baba S. Individual feedback and monitoring of endoscopist performance improves the adenoma detection rate in screening colonoscopy: a prospective case-control study. Surg Endosc 2020; 35:2566-2575. [PMID: 32468263 DOI: 10.1007/s00464-020-07672-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/22/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Previous reports have suggested that a longer withdrawal time (WT) during colonoscopy led to an improved adenoma detection rate (ADR); however, there are few controlled studies that substantiated monitoring WT as an educational method. We aimed to validate a feedback and monitoring system to improve the ADR in screening colonoscopy in a prospective case-control setting. METHODS After collecting data in the pre-feedback period (3.5 months), the individual performance and the average ADR and WT values of the facility were provided to 6 endoscopists in the intervention group, while 3 endoscopists were isolated as the control group during the feedback period (2 weeks). The intervention group consisted of two subgroups, the Fast and Slow WT groups, according to the results from the pre-feedback period. The endoscopists in the intervention group were instructed to be aware of their own WT in each examination during the post-feedback period (4 months). The performances of all endoscopists in the post-feedback period were analyzed and compared with those in the pre-feedback period. RESULTS Among the initial analyses, the correlation analysis and multivariate analysis revealed that WT was an independent predictor for the ADR (P = 0.0101). After providing individual performance feedback and instruction regarding real-time WT monitoring, the WT was significantly prolonged in the Fast WT group (P = 0.0346) but did not change in the Slow WT and control groups. In addition, the ADR of the Fast WT group significantly improved after the intervention (P = 0.024), whereas the ADR of the Slow WT and control groups did not change. CONCLUSION Providing individual feedback on ADR and WT and monitoring WT helped improve the endoscopists' ADRs.
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Affiliation(s)
- Fumiaki Ishibashi
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan. .,Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan. .,Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.
| | - Keita Fukushima
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan.,Mirraza Shinjuku Tsurukame Clinic, 3-36-10, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
| | - Konomi Kobayashi
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan.,Mirraza Shinjuku Tsurukame Clinic, 3-36-10, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
| | - Tomohiro Kawakami
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan
| | - Ryu Tanaka
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan
| | - Junko Kato
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan
| | - Ayako Sato
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Kenichi Konda
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Department of Gastroenterology, Showa University Hospital, 1-5-8, Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan
| | - Kazuaki Sugihara
- Koganei Tsurukame Clinic, Endoscopy Center, 6-14-28-3F, Honcho, Koganei-shi, Tokyo, 184-0004, Japan.,Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Mirraza Shinjuku Tsurukame Clinic, 3-36-10, Shinjuku, Shinjuku-ku, Tokyo, 160-0022, Japan
| | - Satoshi Baba
- Shinjuku Tsurukame Clinic, Digestive Disease Center, 2-11-15, Yoyogi, Shibuya-ku, Tokyo, 151-0053, Japan.,Yotsuya Medical Cube, Endoscopy Center, 7-7, Nibancho, Chiyoda-ku, Tokyo, 102-0084, Japan
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13
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Shine R, Bui A, Burgess A. Quality indicators in colonoscopy: an evolving paradigm. ANZ J Surg 2020; 90:215-221. [PMID: 32086869 DOI: 10.1111/ans.15775] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/14/2019] [Accepted: 01/20/2020] [Indexed: 12/27/2022]
Abstract
The year 1969 marked a revolution in the diagnosis of colorectal cancer (CRC). It is when Dr Wolff developed the colonoscope and quickly realized its potential in both diagnosis and treatment of colonic neoplasms. Over the past 50 years there has been exponential increase in utilization of colonoscopy with over 1 million colonoscopies performed annually throughout Australasia. Endoscopic removal of pre-malignant lesions has been proven to reduce the incidence and mortality of colorectal. Although timing and frequency of surveillance colonoscopy plays a crucial role in risk reduction of CRC, this is dependent upon the findings of the index colonoscopy. The goal of screening colonoscopy is to detect CRC and identify and remove pre-malignant neoplasms that risk progression to CRC. With increasing uptake of bowel screening throughout Australasia, there is increasing pressure to ensure all endoscopists and endoscopy units perform at a universal high-quality. All too often high demand and constant delays compromise colonoscopy quality. Without clear and concise quality indicators with transparent measurement and audit, these flaws can quickly jeopardize screening goals and patient outcomes. This review aims to explore six key quality indicators and explore the evidence behind the current recommended standards. These key indicators include; rate of adequate bowel preparation, caecal intubation rate, adenoma detection rate, withdrawal time, complication rates and surveillance intervals.
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Affiliation(s)
- Rebecca Shine
- General Surgery, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Andrew Bui
- Colorectal Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Adele Burgess
- Colorectal Surgery, Austin Health, Melbourne, Victoria, Australia
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14
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Umar SB, Ramirez FC. The proof is in the pudding: improving adenoma detection rates reduces interval colon cancer development. Transl Gastroenterol Hepatol 2017; 2:99. [PMID: 29264437 DOI: 10.21037/tgh.2017.11.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/15/2017] [Indexed: 12/27/2022] Open
Affiliation(s)
- Sarah B Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Arizona, USA
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