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Hsu YH, Cheng CH, Ko PH, Tang CP, Huang CW, Tseng CW. Assessment of the impact of power business intelligence on adenoma detection rate: a prospective observational trial. BMC Gastroenterol 2025; 25:275. [PMID: 40253361 PMCID: PMC12009522 DOI: 10.1186/s12876-025-03894-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2025] [Accepted: 04/14/2025] [Indexed: 04/21/2025] Open
Abstract
BACKGROUND Adenoma detection rate (ADR) is a key quality indicator in colonoscopy, with low ADRs linked to higher risks of post-colonoscopy colorectal cancers. Feedback to endoscopists has been shown to improve ADRs; however, many feedback systems lack automation and real-time interactivity. This study evaluates the effectiveness of Power Business Intelligence (Power BI) on ADR enhancement. METHODS This prospective observational study compared ADRs before (2021) and after (2022) the implementation of Power BI at Dalin Tzu Chi Hospital, Taiwan. Power BI automatically processed pathology data to calculate ADRs and provided real-time visual feedback on endoscopy quality indicators. A total of 4,306 colonoscopies performed by 10 endoscopists were analyzed. Logistic regression was employed to identify factors associated with ADR. RESULTS The overall ADR was high and comparable between the periods without and with Power BI (50.1% vs. 47.9%, P = 0.152). Individual performance was stable, though one low-performing endoscopist improved ADR by 20.0%. Adjusted multivariate analysis found no association between Power BI and ADR. Higher ADRs correlated with male gender (odds ratio [OR], 1.638; 95% confidence interval [CI], 1.438-1.864; p < 0.001), advanced age (OR, 1.642; CI, 1.439-1.875; p < 0.001), elevated BMI (OR, 1.642; CI, 1.439-1.875; p < 0.001), and positive stool occult blood (OR, 1.829; CI, 1.545-2.167; p < 0.001). Effective technical practices for improving ADRs included polyethylene glycol preparation (OR, 1.246; CI, 1.063-1.462; p = 0.007), water-method colonoscopy (OR, 1.321; CI, 1.134-1.538; p < 0.001), and withdrawal times ≥ 6 min (OR, 6.370; CI, 5.179-7.837; p < 0.001). CONCLUSIONS The use of Power BI was not associated with a higher ADR at a high-performing institution but may benefit low-performing endoscopists. Efforts should target behavioral changes in modifiable technical factors to drive meaningful ADR improvements.
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Affiliation(s)
- Ya-Hui Hsu
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Chia-Hsin Cheng
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Ping-Hung Ko
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Chia-Pei Tang
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Chih-Wei Huang
- Dalin Tzu Chi Hospital Smart Medical Innovation Center, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.
- School of Medicine, Tzu Chi University, Hualien City, Taiwan.
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Macatiag JJ, Mariño BAM, Pajes ANNI, Yasay EB. Adenoma Detection Rate and Polyp Detection Rate among Gastroenterology Fellows and Consultants in a Tertiary Hospital in the Philippines: A Cross-sectional Study. ACTA MEDICA PHILIPPINA 2024; 58:30-41. [PMID: 39399358 PMCID: PMC11467549 DOI: 10.47895/amp.vi0.8395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/15/2024]
Abstract
Background and Objective Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the fourth leading cause of cancer mortality worldwide. Likewise in the Philippines, the prevalence of CRC has shown to be increasing. Colonoscopy, a screening procedure for CRC, has parameters to gauge quality of detection. One of which is the Adenoma Detection Rate (ADR). Higher ADR has been linked to improved cancer detection. This study aimed to determine the ADR and Polyp Detection Rate (PDR) among Gastroenterology practitioners in a tertiary government university hospital in the Philippines, estimate ADR from PDR, and identify factors associated with ADR. Methods An analytical, cross-sectional study among patients who underwent colonoscopy for the years 2021 and the first half of 2022 at the Central Endoscopy Unit (CENDU) of the Philippine General Hospital. Demographic data of fellows and consultants were collected through an online form, while those from patients were obtained from electronic records. Colonoscopy details and histopathology results were accessed through the hospital's Open Medical Record System (MRS). ADR, PDR, and estimated ADR were computed using established formulas. To evaluate the strength of the relationship between the estimated and actual ADR, Pearson's correlation coefficient was used. Chi-square analysis, Mann-Whitney U test, and Kruskal-Wallis H test were performed to identify the factors that might influence the ADR. A cut-off of p <0.05 was considered statistically significant. Results The total computed ADR of consultants and fellows combined is 22%. The difference between the ADRs of Gastroenterology consultants and Fellows-in-Training is statistically significant at 31.6% and 18.7%, respectively (p= 0.017). The total Polyp Detection Rate is 57.6% while the weighted group average Adenoma to Polyp Detection Rate Quotient (APDRQ) is 0.4085 or 40.85%. The estimated ADR has a moderate degree of correlation with the actual ADR when an outlier was excluded (r=0.521 (95% CI, 0.072-0.795, p=0.0266). Significant factors related to ADR include endoscopists' years of practice (p=0.020), number of colonoscopies done (p=0.031), and patient tobacco use (p=0.014). Conclusion The overall ADR among consultants and fellows is at par with the standard guidelines. A moderate degree of correlation exists between actual and estimated ADR when an outlier is excluded; however, more studies are needed to determine the APDRQ in the wider local setting. Longer years in practice, total number of colonoscopies performed, and patient tobacco use are associated with increased ADR.
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Affiliation(s)
- Jonathan J. Macatiag
- Department of Medicine, Philippine General Hospital, University of the Philippines Manila
| | | | - A. Nico Nahar I. Pajes
- Division of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
| | - Eric B. Yasay
- Division of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines Manila
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Khouri A, Dickson C, Green A, Hanjar A, Sonnier W. Effect of computer aided detection device on the adenoma detection rate and serrated detection rate among trainee fellows. JGH Open 2024; 8:e70018. [PMID: 39253018 PMCID: PMC11382257 DOI: 10.1002/jgh3.70018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/13/2024] [Accepted: 08/07/2024] [Indexed: 09/11/2024]
Abstract
Background and Aims The utilization of artificial intelligence (AI) with computer-aided detection (CADe) has the potential to increase the adenoma detection rate (ADR) by up to 30% in expert settings and specialized centers. The impact of CADe on serrated polyp detection rates (SDR) and academic trainees ADR & SDR remains underexplored. We aim to investigate the effect of CADe on ADR and SDR at an academic center with various levels of providers' experience. Methods A single-center retrospective analysis was conducted on asymptomatic patients between the ages of 45 and 75 who underwent screening colonoscopy. Colonoscopy reports were reviewed for 3 months prior to the introduction of GI Genius™ (Medtronic, USA) and 3 months after its implementation. The primary outcome was ADR and SDR with and without CADe. Results Totally 658 colonoscopies were eligible for analysis. CADe resulted in statistically significant improvement in SDR from 8.92% to 14.1% (P = 0.037). The (ADR + SDR) with CADe and without CADe was 58% and 55.1%, respectively (P = 0.46). Average colonoscopy (CSC) withdrawal time was 17.33 min (SD 10) with the device compared with 17.35 min (SD 9) without the device (P = 0.98). Conclusion In this study, GI Genius™ was associated with a statistically significant increase in SDR alone, but not in ADR or (ADR + SDR), likely secondary to the more elusive nature of serrated polyps compared to adenomatous polyps. The use of CADe did not affect withdrawal time.
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Affiliation(s)
- Anas Khouri
- Department of Internal Medicine and Division of Gastroenterology University of South Alabama Frederick P. Whiddon College of Medicine Mobile Alabama USA
| | - Chance Dickson
- Department of Internal Medicine and Division of Gastroenterology University of South Alabama Frederick P. Whiddon College of Medicine Mobile Alabama USA
| | - Alvin Green
- Department of Internal Medicine and Division of Gastroenterology University of South Alabama Frederick P. Whiddon College of Medicine Mobile Alabama USA
| | - Abrahim Hanjar
- Department of Internal Medicine and Division of Gastroenterology University of South Alabama Frederick P. Whiddon College of Medicine Mobile Alabama USA
| | - William Sonnier
- Department of Internal Medicine and Division of Gastroenterology University of South Alabama Frederick P. Whiddon College of Medicine Mobile Alabama USA
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Mehta CH, Tumin D, Regan KA, Honaker MD. Should the adenoma detection rate quality metric vary by age? J Gastrointest Surg 2024; 28:1172-1173. [PMID: 38653338 DOI: 10.1016/j.gassur.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Charmee H Mehta
- Department of Surgery, East Carolina University School of Medicine, Greenville, NC, United States
| | - Dimtry Tumin
- Department of Pediatrics, East Carolina University Brody School of Medicine, Greenville, NC, United States
| | - Kara A Regan
- Division of Gastroenterology, Department of Internal Medicine, ECU Health, Greenville, NC, United States
| | - Michael D Honaker
- Division of Surgical Oncology, Department of Surgery, East Carolina University Brody School of Medicine, Greenville, NC, United States.
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Sadri H, Fraser ND. The role of innovative technologies in reducing health system inequity. Healthc Manage Forum 2024; 37:101-107. [PMID: 37861228 DOI: 10.1177/08404704231207509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
The scarcity of Health Human Resources (HHR), regional disparities, and decentralized healthcare systems have profoundly affected health equity in Canada. Adequate HHR allocation is essential for equitable healthcare delivery, and the COVID-19 pandemic has revealed the importance of resilient and culturally diverse organizational HHR. Geography and infrastructure shortcomings aggravate healthcare equity. This study examines the role of innovative technologies in reducing inequity and provides four practice-based examples in different therapeutic areas. Long-term solutions such as collaborative networks, infrastructure improvements, and effective HHR planning can mitigate current challenges. However, in the short and medium terms, advanced medical technologies, digital health, and artificial intelligence can reduce health inequities by improving access, reducing disparities, optimizing resource utilization, and providing skill development opportunities for healthcare professionals.
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Affiliation(s)
| | - Neil D Fraser
- Independent MedTech Consultant, Toronto, Ontario, Canada
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Barkun AN, von Renteln D, Sadri H. Cost-effectiveness of Artificial Intelligence-Aided Colonoscopy for Adenoma Detection in Colon Cancer Screening. J Can Assoc Gastroenterol 2023; 6:97-105. [PMID: 37273970 PMCID: PMC10235593 DOI: 10.1093/jcag/gwad014] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND AND AIMS Artificial intelligence-aided colonoscopy significantly improves adenoma detection. We assessed the cost-effectiveness of the GI Genius technology, an artificial intelligence-aided computer diagnosis for polyp detection (CADe), in improving colorectal cancer outcomes, adopting a Canadian health care perspective. METHODS A Markov model with 1-year cycles and a lifetime horizon was used to estimate incremental cost-effectiveness ratio comparing CADe to conventional colonoscopy polyp detection amongst patients with a positive faecal immunochemical test. Outcomes were life years (LYs) and quality-adjusted life years (QALY) gained. The analysis applied costs associated with health care resource utilization, including procedures and follow-ups, from a provincial payer's perspective using 2022 Canadian dollars. Effectiveness and cost data were sourced from the literature and publicly available databases. Extensive probabilistic and deterministic sensitivity analyses were performed, assessing model robustness. RESULTS Life years and QALY gains for the CADe and conventional colonoscopy groups were 19.144 versus 19.125 and 17.137 versus 17.113, respectively. CADe and conventional colonoscopies' overall per-case costs were $2990.74 and $3004.59, respectively. With a willingness-to-pay pre-set at $50,000/QALY, the incremental cost-effectiveness ratio was dominant for both outcomes, showing that CADe colonoscopy is cost-effective. Deterministic sensitivity analysis confirmed that the model was sensitive to the incidence risk ratio of adenoma per colonoscopy for large adenomas. Probabilistic sensitivity analysis showed that the CADe strategy was cost-effective in up to 73.4% of scenarios. CONCLUSION The addition of CADe solution to colonoscopy is a dominant, cost-effective strategy when used in faecal immunochemical test-positive patients in a Canadian health care setting.
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Affiliation(s)
- Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, Montreal, Quebec, Canada
- Clinical Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Daniel von Renteln
- Division of Gastroenterology, the University of Montreal Hospital and University of Montreal Hospital Research Center, Montreal, Quebec, Canada
| | - Hamid Sadri
- Department of Health Economics and Outcomes Research, Medtronic Canada, Brampton, Ontario, Canada
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Xu C, Tang D, Xie Y, Ni M, Chen M, Shen Y, Dou X, Zhou L, Xu G, Wang L, Lv Y, Zhang S, Zou X. Sedation Is Associated with Higher Polyp and Adenoma Detection Rates during Colonoscopy: A Retrospective Cohort Study. Gastroenterol Res Pract 2023; 2023:1172478. [PMID: 36852194 PMCID: PMC9966568 DOI: 10.1155/2023/1172478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 11/13/2022] [Accepted: 01/31/2023] [Indexed: 03/01/2023] Open
Abstract
Background and Aims Currently sedation is a common practice in colonoscopy to reduce pain of patients and improve the operator satisfaction, whereas its impact on examination quality, especially adenoma detection rate (ADR) is still controversial. Thus, we aimed to investigate the association of sedation with ADR. Methods Consecutive patients receiving colonoscopy between January 2017 and January 2020 at the Nanjing Drum Tower Hospital, Nanjing, China, were collected. Univariate and multivariate logistic regression models were performed to investigate the association between sedation and ADR. Subgroup analysis and propensity score matching (PSM) analysis, as sensitivity analysis, were performed to validate the independent effect. Results The ADR was significantly higher in cases with sedation (ADR: 36.9% vs. 29.1%, odds ratio [OR]: 1.42, 95% confidence interval [CI]: 1.31-1.55, P < 0.001). Multivariate analysis showed that the sedation was an independent factor associated with ADR (OR: 1.49, 95% CI: 1.35-1.65, P < 0.001). The effect was consistent in subgroup analyses (P > 0.05) and PSM analysis (ADR: 37.6% vs. 29.1%, OR: 1.47, 95% CI: 1.33-1.63, P < 0.001). Conclusion Sedation was associated with a higher polyp and ADR s during colonoscopy, which can promote the quality of colonoscopy.
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Affiliation(s)
- Chenghu Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Dehua Tang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Ying Xie
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Muhan Ni
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Min Chen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Yonghua Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Xiaotan Dou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Lin Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Guifang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
| | - Ying Lv
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
- Jiangsu Medical Quality Control Center (Digestive Diseases), Nanjing, Jiangsu 210008, China
| | - Shu Zhang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
- Jiangsu Medical Quality Control Center (Digestive Diseases), Nanjing, Jiangsu 210008, China
| | - Xiaoping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210008, China
- Jiangsu Medical Quality Control Center (Digestive Diseases), Nanjing, Jiangsu 210008, China
- Department of Gastroenterology, Taikang Xianlin Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu 210046, China
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Lim WS, Liew JJL, Loh CYL, Teoh SE, Koh FHX. How does artificial intelligence-aided colonoscopy help to improve adenoma detection rates? ANZ J Surg 2022; 92:3130-3131. [PMID: 36468306 DOI: 10.1111/ans.17953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/17/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Wei Shyann Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Seth En Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Frederick Hong-Xiang Koh
- Colorectal Service, Department of General Surgery, Sengkang General Hospital, SingHealth Services, Singapore
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Tarhini H, Alrazim A, Ghusn W, Hosni M, Kerbage A, Soweid A, Sharara AI, Mourad F, Francis F, Shaib Y, Barada K, Daniel F. Impact of sedation type on adenoma detection rate by colonoscopy. Clin Res Hepatol Gastroenterol 2022; 46:101981. [PMID: 35728761 DOI: 10.1016/j.clinre.2022.101981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/07/2022] [Accepted: 06/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS Endoscopic detection of polyps and adenomas decreases the incidence and mortality of colorectal cancer. The available data concerning the relationship between the sedation type and adenoma detection rate (ADR) or polyp detection rate (PDR) is inconclusive. The aim of our study was to evaluate the impact of conscious vs. deep (propofol) sedation on the ADR/PDR in diagnostic and screening colonoscopies. METHODS This was a retrospective cohort study. Patients aged 50-75 years old presenting for a first screening or diagnostic colonoscopy were included. Baseline demographic characteristics were collected, as well as PDR and ADR. Endoscopic withdrawal time and quality of bowel preparation rated in a binary fashion were also collected. Two multivariate logistic regression models were used to evaluate the independent predictors of endoscopic detection of polyps and adenomas. RESULTS 574 patients met our inclusion criteria. Mean age was 59.26 ± 7.21 with 52.4% females and an average BMI of 28.08 ± 4.89. 374 patients (65.2%) underwent screening colonoscopies, and deep sedation was performed in 200 patients (34.8%). Only 4.7% had bad bowel preparation. PDR was 70% and ADR was 52%. On bivariate analysis, no significant difference was shown in PDR and ADR between conscious and deep sedation groups (0.70, 0.71; p = 0.712 and 0.50, 0.54; p = 0.394, respectively). On multivariate analysis for PDR, age and withdrawal time were independent predictors. For ADR, age, female sex, and withdrawal time were independent predictors. Sedation type and the indication did not reach statistical significance in both models. CONCLUSION The use of deep sedation didn't influence the ADR/PDR quality metrics in our mixed cohort of screening and diagnostic colonoscopies.
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Affiliation(s)
- Hawraa Tarhini
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ayman Alrazim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wissam Ghusn
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mohammad Hosni
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Anthony Kerbage
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Assaad Soweid
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ala-I Sharara
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Mourad
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Francis
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yasser Shaib
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Kassem Barada
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fady Daniel
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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