Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy

BACKGROUND AND OBJECTIVES: Multiple factors influence the yield of colonoscopy for the detection of neoplasia. Few studies have addressed the impact of colonoscopy duration on procedure yield. The aim of our study was to determine whether endoscopist-specific procedure times correlate with the number and clinical significance of polyps detected at screening or surveillance colonoscopy. METHODS: Procedural data from screening or surveillance colonoscopies performed at Mayo Clinic, Rochester MN, between January 1, 1996 and June 30, 2000, were reviewed. Individual endoscopists were characterized by their personal endoscopist procedure mean time (EPMT) to perform a negative colonoscopy. Procedure time included patient's consent and sedation. EPMT was then correlated with individual polyp detection rates. RESULTS: Overall, 10,159 colonoscopies were reviewed of which 4,312 (42.4%) yielded polyps. Polyp detection varied among endoscopists between 19.0% and 62.3%. There was a close correlation between EPMT and polyp yield (all sizes), r = 0.64, although correlation was weaker for polyps >10 mm (r = 0.42) and polyps >20 mm (r = 0.20). On multivariate analysis, longer mean endoscopist time was associated with colonic lesion detection, OR = 1.54 (95% CI 1.37-1.62). Longer mean procedure duration demonstrated a looser association with identification of polyps >10 mm, OR = 1.40 (1.19-1.64) and polyps >20 mm, OR = 1.03 (0.74-1.43). CONCLUSIONS: There is a direct correlation between colonoscopy procedure time and yield, with a three-fold variation of polyp detection rates. These results should prompt future prospective studies assessing the impact of colonoscopic withdrawal time on lesion detection.     

An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve

BACKGROUND: Various training programs in colonoscopy recommend that trainees should perform at least 100 to 200 procedures to be considered technically competent at diagnostic colonoscopy. OBJECTIVE: Our purpose was to determine the adequate level of training for technical competence in screening and diagnostic colonoscopy. DESIGN: A prospective multicenter trial. SETTING: Fifteen tertiary care academic medical centers. PATIENTS: Over 8 months we prospectively evaluated the procedures of 24 first-year GI fellows in 15 tertiary care academic medical centers. A total of 4351 colonoscopies were assessed prospectively with variable clinical factors. INTERVENTION: Cecal intubation was documented by photographing the identified cecal landmarks, including the appendiceal orifice and the ileocecal valve. MAIN OUTCOME MEASUREMENTS: Acquisition of competence (success rate) was evaluated for colonoscopic training on the basis of 2 objective criteria: (1) adjusted completion rate (>90%) and (2) cecal intubation time (<20 minutes). RESULTS: The overall success rate was 83.5% (3635/4351). The mean cecal intubation time was 9.23 +/- 4.63 minutes. The success rate significantly improved and reached the requisite standard of competence after 150 procedures (71.5%, 82.6%, 91.3%, 94.4%, 98.4%, and 98.7%, respectively, for every 50 consecutive blocks). The polyp detection rate did not improve significantly during the 8 months and was not correlated with the learning curve. In addition, mean time to cecal intubation decreased significantly, from 11.16 to 8.39 minutes, after 150 procedures. Logistic regression analysis found that prolonged cecal intubation was caused by the following factors: elderly patients, female sex, low body mass index, poor bowel preparation, poor American Society of Anesthesiologists status, abdominal pain as an indication, instructor's supervision, and low case volume. LIMITATIONS: We did not record final pathologic reports of detected polyps and withdrawal time. CONCLUSIONS: Competence in technically efficient screening and diagnostic colonoscopy generally requires experience with more than 150 cases. Also, factors associated with prolonged cecal intubation for typical trainees did not differ from those for experienced colonoscopists.     

Variation in Colonoscopic Technique and Adenoma Detection Rates at an Academic Gastroenterology Unit

The purpose of this research is to evaluate the quality of colonoscopy at an academic institution with a focus on factors influencing withdrawal times and adenoma detection rates. Procedural data and pathologic results of 550 consecutive screening colonoscopies in average risks patients (mean [±SD] age, 57 ± 7.6, 44% male) completed by ten academic gastroenterologists were reviewed. Per individual gastroenterologist, the adenoma detection rates ranged widely from 0.09 to 0.82 adenomas per patient with a mean of 0.46 for the group. The mean withdrawal time was 7.0 min for the group and ranged from 3.4 to 9.6 min. There was a significant positive relationship between the number of adenomas detected and the withdrawal time (P = 0.006). Endoscopists with cecal intubation time to withdrawal time ratios of less than 1 detected significantly more adenomas compared to endoscopists with ratios greater than 1 (P = 0.001). (1) Significant variation in academic gastroenterologists’ abilities to detect adenomas during screening colonoscopies exists. (2) Colonoscopic withdrawal time and the cecal intubation to withdrawal time ratio are important factors associated with increased adenoma detection rates.     

Quality indicators in pediatric colonoscopy: an Australian tertiary center experience

Objectives: Quality indicators for colonoscopy in adults are largely driven by colorectal cancer screening, and include cecal intubation rates, with rates of >90% recommended. In contrast, colorectal cancer is rare in childhood, with paucity of data on relevant quality indicators for pediatric colonoscopy. It is also unclear whether high rates of cecal intubation are achievable in small children. Our aim was to audit all colonoscopies performed in a tertiary pediatric center to examine clinical indications for procedure, completeness of examination with cecal and ileal intubation, significant findings, and complications.

Methods: Retrospective review of colonoscopies performed between November 2011 and October 2015 was undertaken.

Results: Total colonoscopy was performed in 652 patients, 53% male, with median age 13.0 (range 0.4–18.2) years. The most common indications for colonoscopy were assessment of inflammatory bowel disease (IBD) 57.9% (378/652), rectal bleeding 10% (68/652) and abdominal pain 10% (68/652). Trainees performed 69.8% (452/652) of procedures. Quality of bowel preparation was mentioned in 63% (410/652), of which 22% (90/410) were considered inadequate. Cecal intubation rate was 96.3% (628/652) and ileal intubation rate was 92.4% (603/652). Extent of procedure was confirmed in 99.2% of patients with photographs and/or ileal biopsy. Poor quality of bowel preparation (p?=?.001) and age <5years (p?=?.007) were inversely related to successful ileal intubation.

Conclusions: High rates of cecal and ileal intubation are achievable in pediatric colonoscopy. Ileal intubation should be considered a quality indicator since the main indicator for pediatric colonoscopy is to investigate IBD.     

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

Objective. The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). Material and methods. A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. Results. There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p<0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p<0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO₂ insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50–99 registered colonoscopies. Conclusions. In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.     

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

OBJECTIVE: The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). MATERIAL AND METHODS: A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. RESULTS: There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies. CONCLUSIONS: In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.     

The Introduction and Development of Colonoscopy within a Defined Population in Sweden

Background: Our aim was to describe, in a population-based setting, the use of colonoscopy over time with special emphasis on indications, the competence of the endoscopists, and the frequency of total colonoscopies and to compare the number of colonoscopies with that of barium enemas. Methods: All colonoscopy records during 1979-95 in a Swedish county (population, 258 000) were retrieved. Information was collected about the patients' demographics, the endoscopists, indications, findings, and type of colonoscopy. Results: A total of 6066 colonoscopies were performed in 4304 patients by 62 endoscopists. Of these, 562 were not intended to be complete; of the other 5504 colonoscopies, 4153 were complete (75%). Of the patients 77% had undergone colonoscopy once, 14% twice, and 9% three times or more. Among the endoscopists 73% never performed more than 50 colonoscopies, and 5% did more than 700 colonoscopies. Bleeding as an indication increased from 10% to 31%; polyps decreased from 30% to 10%, and unclear X-ray findings decreased from 28% to 4%. Diarrhoea and abdominal pain, both 0% in 1979, increased to 6% and 5%, respectively. Surveillance (cancer, polyps, colitis) was fairly stable, at 25%. Both the rate of complete colonoscopies and the proportion of colonoscopies done by experienced endoscopists increased with time. The annual number of barium enemas was relatively constant until 1992 but then decreased. Conclusions: The increased use of colonoscopy has resulted in a decrease in barium enemas. The competence of the endoscopists increased, resulting in a higher rate of complete colonoscopies.     

Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a university hospital

BACKGROUND: Despite increased emphasis on endoscopic performance indicators, e.g., cecal intubation rates, limited data from actual clinical practice have been published. OBJECTIVES: Retrospective database review to determine the rate and documentation of cecal intubation during colonoscopy at the University of Maryland Medical Center. METHODS: We reviewed 5,477 consecutive colonoscopies performed by 10 faculty gastroenterologists at a University hospital over a 6-yr period (March 1, 1999 to February 28, 2005). Unadjusted cecal intubation rates were analyzed as were rates that were adjusted based on the U.S. Multi-Society Task Force on Colorectal Cancer recommendations. We analyzed trends in overall and individual cecal intubation rates, circumstances that impact these rates, and the quality of documentation of cecal intubation. RESULTS: The overall adjusted cecal intubation rate for the entire 6 yr was 90.3%, and increased over the study period with the highest adjusted rate (93.7%) in the most recent year studied. There was no correlation between cecal intubation rate and patient age, gastroenterology fellow involvement, or endoscopist experience and number of procedures/year. In contrast, colon cancer screening, male gender, outpatient colonoscopy, and adequate bowel preparation predicted a higher cecal intubation rate. Written and photographic documentation of cecal intubation improved significantly after 2002. CONCLUSIONS: Our analysis revealed cecal intubation and documentation rates that meet current guidelines, and identified factors that may cause substantial variance in these rates depending on the nature of the practice. The present analysis confirms that computerized databases can be used to assess individual and group cecal intubation and documentation rates on an annual basis, and to make these data available to the public.     

Benefits and Limitations of Cap-Fitted Colonoscopy in Screening Colonoscopy

Background

Colonoscopy is widely used to detect colorectal cancer and to remove precancerous lesions to reduce the risk of colonic cancer.

Aims

To examine the benefits and limitations of cap-fitted colonoscopy compared to conventional colonoscopy in terms of technical performance and colorectal adenoma detection rate.

Methods

Screening colonoscopies performed from 2009 to 2010 with or without a transparent cap were retrospectively examined to compare the rate of successful intubation, cecal intubation time, and number, size, shape, and location of adenomas detected. An inclusion criterion was visualization of >95 % of the right colon.

Results

Data from 2,301 colonoscopies (1,165 with cap-fitted colonoscopy, 1,136 without the transparent cap) were retrospectively analyzed. Procedures were performed by four experienced endoscopists. The subjects’ demographic characteristics and technical performances were similar between the two methods. The only significant difference in the technical performance between the two techniques was a shorter cecal intubation time with cap-fitted colonoscopy (5.3 vs. 6.6 min; p = 0.045) by one endoscopist. The total number of adenomas detected was significantly higher with cap-fitted colonoscopy than without the cap (586 vs. 484, respectively; p < 0.0001). Adenoma detection with cap-fitted endoscopy was significantly higher in the right colon than in the left colon (19 vs. 12 %, respectively; p = 0.0001).

Conclusion

Cap-fitted colonoscopy did not improve the technical aspects of colonoscopy but significantly increased adenoma detection, especially in the right colon. It did not increase the detection rate of flat or depressed adenomas.     

Point-of-care, peer-comparator colonoscopy practice audit: The Canadian Association of Gastroenterology Quality Program--Endoscopy

BACKGROUND

Point-of-care practice audits allow documentation of procedural outcomes to support quality improvement in endoscopic practice.

OBJECTIVE

To evaluate a colonoscopists’ practice audit tool that provides point-of-care data collection and peer-comparator feedback.

METHODS

A prospective, observational colonoscopy practice audit was conducted in academic and community endoscopy units for unselected patients undergoing colonoscopy. Anonymized colonoscopist, patient and practice data were collected using touchscreen smart-phones with automated data upload for data analysis and review by participants. The main outcome measures were the following colonoscopy quality indicators: colonoscope insertion and withdrawal times, bowel preparation quality, sedation, immediate complications and polypectomy, and biopsy rates.

RESULTS

Over a span of 16 months, 62 endoscopists reported on 1279 colonoscopy procedures. The mean cecal intubation rate was 94.9% (10th centile 84.2%). The mean withdrawal time was 8.8 min and, for nonpolypectomy colonoscopies, 41.9% of colonoscopists reported a mean withdrawal time of less than 6 min. Polypectomy was performed in 37% of colonoscopies. Independent predictors of polypectomy included the following: endoscopy unit type, patient age, interval since previous colonoscopy, bowel preparation quality, stable inflammatory bowel disease, previous colon polyps and withdrawal time. Withdrawal times of less than 6 min were associated with lower polyp removal rates (mean difference −11.3% [95% CI −2.8% to −19.9%]; P=0.01).

DISCUSSION

Cecal intubation rates exceeded 90% and polypectomy rates exceeded 30%, but withdrawal times were frequently shorter than recommended. There are marked practice variations consistent with previous observations.

CONCLUSION

Real-time, point-of-care practice audits with prompt, confidential access to outcome data provide a basis for targeted educational programs to improve quality in colonoscopy practice.     

The introduction and development of colonoscopy within a defined population in Sweden

BACKGROUND: Our aim was to describe, in a population-based setting, the use of colonoscopy over time with special emphasis on indications, the competence of the endoscopists, and the frequency of total colonoscopies and to compare the number of colonoscopies with that of barium enemas. METHODS: All colonoscopy records during 1979-95 in a Swedish county (population, 258,000) were retrieved. Information was collected about the patients' demographics, the endoscopists, indications, findings, and type of colonoscopy. RESULTS: A total of 6066 colonoscopies were performed in 4304 patients by 62 endoscopists. Of these, 562 were not intended to be complete; of the other 5504 colonoscopies, 4153 were complete (75%). Of the patients 77% had undergone colonoscopy once, 14% twice, and 9% three times or more. Among the endoscopists 73% never performed more than 50 colonoscopies, and 5% did more than 700 colonoscopies. Bleeding as an indication increased from 10% to 31%; polyps decreased from 30% to 10%, and unclear X-ray findings decreased from 28% to 4%. Diarrhoea and abdominal pain, both 0% in 1979, increased to 6% and 5%, respectively. Surveillance (cancer, polyps, colitis) was fairly stable, at 25%. Both the rate of complete colonoscopies and the proportion of colonoscopies done by experienced endoscopists increased with time. The annual number of barium enemas was relatively constant until 1992 but then decreased. CONCLUSIONS: The increased use of colonoscopy has resulted in a decrease in barium enemas. The competence of the endoscopists increased, resulting in a higher rate of complete colonoscopies.     

Effect of hysterectomy on colonoscopy completion rate

BACKGROUND:

Several studies show that colonoscopies are technically more difficult to perform in women than men, especially in women who have undergone abdominal and gynecological surgeries. A review of the literature indicates an increased rate of noncompletion of colonoscopies in most cases; however, no studies have investigated the procedural complication rate, sedation requirements and perception of pain in colonoscopies.

OBJECTIVE:

To determine whether women who have undergone a previous hysterectomy have a higher noncompletion rate when undergoing a colonoscopy, and to assess whether there is a higher percentage of complications. Furthermore, the present study also aimed to ascertain whether these women required more sedation and whether their perception of pain is greater than that of women who did not undergo previous abdominal surgeries.

METHODS:

The present study was a prospective cohort study of women, 45 to 80 years of age, who underwent colonoscopy (n=508). A total of 229 patients were eligible for the study; they completed a questionnaire, and were subsequently divided into control and hysterectomy groups. Gastroenterologists performed all procedures. After colonoscopy, the patient and endoscopist completed a pain perception questionnaire. Cecal intubation rates were also recorded.

RESULTS:

No significant difference for cecal intubation rates were detected between the two groups (95.7% and 98.7% in hysterectomy and control groups, respectively; P=0.176). The crude OR for the success rate was 0.29 (95% CI 0.05 to 1.90). There was no significant difference between groups regarding sedation or the type of colonoscope. No correlation between the gastroenterologists’ evaluation of pain and patients’ pain was observed.

CONCLUSION:

Hysterectomy did not significantly diminish the cecal intubation rate, and there was no detectable difference in pain perception or sedative dose. Colonoscopy remains an excellent screening and diagnostic tool for all women.     

A prospective study of factors that determine cecal intubation time at colonoscopy

BACKGROUND: For outpatient colonoscopy, the time required to intubate the cecum is variable. The aim of this study was to determine factors associated with cecal intubation time. METHODS: A total of 693 consecutive outpatient colonoscopies performed from January to October 2002 at a tertiary care medical center were studied prospectively. Data gathered included time required to reach the cecum; patient age, gender, and body mass index; history of abdominal surgery; quality of bowel preparation; presence/absence of diverticula; and endoscopist experience. RESULTS: Complete data were available for 587 patients. Mean age was 59 years, 48% were men, and mean body mass index was 28. Median cecal intubation time was 9 minutes. Linear regression analysis was performed. Cecal intubation time is prolonged by the following factors: older patient age, female gender, lower body mass index, poor bowel preparation, and lower endoscopist annual case volume. CONCLUSIONS: This large, prospective study identified 5 factors that prolong the time required for cecal intubation at colonoscopy. These factors may be used to individualize scheduling of colonoscopy according to the time required.     

Computer-based virtual reality colonoscopy simulation improves patient-based colonoscopy performance

BACKGROUND:

Colonoscopy simulators that enable one to perform computer-based virtual colonoscopy now exist. However, data regarding the effectiveness of this virtual training are limited.

OBJECTIVE:

To determine whether virtual reality simulator training translates into improved patient-based colonoscopy performance.

METHODS:

The present study was a prospective controlled trial involving 18 residents between postgraduate years 2 and 4 with no previous colonoscopy experience. These residents were assigned to receive 16 h of virtual reality simulator training or no training. Both groups were evaluated on their first five patient-based colonoscopies. The primary outcome was the number of proctor ‘assists’ required per colonoscopy. Secondary outcomes included insertion time, depth of insertion, cecal intubation rate, proctor- and nurse-rated competence, and patient-rated pain.

RESULTS:

The simulator group required significantly fewer proctor assists than the control group (1.94 versus 3.43; P≤0.001), inserted the colonoscope further unassisted (43 cm versus 24 cm; P=0.003) and there was a trend to intubate the cecum more often (26% versus 10%; P=0.06). The simulator group received higher ratings of competence from both the proctors (2.28 versus 1.88 of 5; P=0.02) and the endoscopy nurses (2.56 versus 2.05 of 5; P=0.001). There were no significant differences in proctor-, nurse- or patient-rated pain, or attention to discomfort.

CONCLUSIONS:

Computer-based colonoscopy simulation in the initial stages of training improved novice trainees’ patient-based colonoscopy performance.     

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients

Background and Aim: The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation. Methods: A total of 5352 consecutive subjects who underwent a screening colonoscopy as part of a health check‐up between January 2008 and December 2008 at an academic hospital were reviewed. All endoscopies were performed with deep sedation using combination propofol or propofol alone. Data collected included characteristics of the patients (age, gender, body mass index, bowel habits, history of abdominal or pelvic surgery, quality of bowel preparation, and presence/absence of colonic diverticula) and characteristics of the colonoscopists (experience level, colonoscopy procedure volume, and instrument handling method). These factors were analyzed to evaluate their impact on cecal intubation rates. Results: The crude cecal intubation rate was 98% and the adjusted cecal intubation rate was 98.3%. The mean cecal intubation time was 5.6 ± 3.2 min. Multivariate logistic regression analysis demonstrated that patient age greater than 60 years, constipation, poor colon preparation and a two‐person colonoscopy procedure were independently associated with lower cecal intubation rates. Conclusions: Colonoscopy performed under deep sedation by experienced colonoscopists results in high cecal intubation rates. Among the significant patient‐related predictors influencing the cecal intubation, the quality of the bowel preparation was the only modifiable factor. When performed by experienced hands, the one‐person method was associated with higher cecal intubation rates than the two‐person method.     

Colonoscopy: practice variation among 69 hospital-based endoscopists

BACKGROUND: The medical profession, payers, and patients are interested increasingly in the quality of endoscopic procedures, including colonoscopy. The American Society for Gastrointestinal Endoscopy has recommended "report cards" by which endoscopists may keep track of certain key elements of their practice including indications, findings, duration, technical end points, complications, and patient satisfaction. METHODS: The GI-Trac endoscopy reporting database includes many of the data points recommended by ASGE for report cards. Seven hospital centers in North America have been collecting data prospectively for varying periods since 1994. These data were aggregated and analyzed by individual endoscopist. A total of 69 endoscopists performed 17,868 colonoscopies. RESULTS: Twelve percent of the endoscopists reported that more than 20% of procedures they performed were completely normal. The average time taken by 27% of endoscopists was more than 40 minutes (without trainees involved), and only 55% achieved a cecal intubation rate of over 90%; for 9% the rate was less than 80%. Complication rates were too low for individual comparisons. CONCLUSION: These data provide an idea of colonoscopy performance by individual endoscopists in mainly academic centers. Incorporating all recommended data elements in future reporting databases will contribute to meaningful bench marking and to quality improvement efforts.     

Validation of a colonoscopy simulation model for skills assessment

OBJECTIVE: The purpose is to provide initial validation of a novel simulation model's fidelity and ability to assess competence in colonoscopy skills. METHODS: In a prospective, cross-sectional design, each of 39 endoscopists (13 staff, 13 second year fellows, and 13 novices) performed a colonoscopy on a novel bovine simulation model. Staff endoscopists also completed a survey examining different aspects of the model's realism as compared to human colonoscopy. The groups' simulation performances were compared. Additionally, individual performances were correlated to patient-based performance data. RESULTS: Median model realism evaluation scores were favorable for nearly all parameters evaluated with mucosa appearance, endoscopic view, and paradoxical motion parameters receiving the highest scores. During simulation procedures, each group outperformed the less experienced groups in all parameters evaluated. Specifically, median cecal intubation times were: staff 226 s (IQR [interquartile range] 179-273), fellows 340 s (282-568), and novices 1,027 s (970-1,122) (P < 0.05). Median total procedure times on the model were: staff 468 s (416-501), fellows 527 s (459-824), and novices 1,350 s (1,318-1,428) (P < 0.05). Finally, individual cecal intubation times on the simulation model had a very high correlation to their respective patient-based times (r = 0.764). CONCLUSIONS: Overall, this model possesses a favorable degree of realism and is able to easily differentiate users based on their level of colonoscopy experience. More impressive, however, is the strong correlation between individual's simulated intubation times and actual patient-based colonoscopy data. In light of these findings, we speculate that this model has potential to be an effective tool for assessment of colonoscopic competence.     

The quality of screening colonoscopies in an office-based endoscopy clinic

BACKGROUND:

Wait times for hospital screening colonoscopy have increased dramatically in recent years, resulting in an increase in patient referrals to office-based endoscopy clinics. There is no formal regulation of office endoscopy, and it has been suggested that the quality of service in some office locations may be inferior to hospital procedures.

OBJECTIVE:

To compare the quality of office-based screening colonos-copies at a clinic in Oakville, Ontario, with published benchmarks for cecal intubation, withdrawal times, polyp detection, adenoma detection, cancer detection and patient complications.

METHODS:

Demographic information on consecutive patients and colonoscopy reports by all nine gastroenterologists at the Oakville Endoscopy Centre between August 2006 and December 2007 were prospectively obtained.

RESULTS:

A total of 3741 colonoscopies were analyzed. The mean age of patients was 57.1 years and 51.9% were women. The cecal intubation rate was 98.98% with an average withdrawal time of 9.75 min. A total of 3857 polyps were retrieved from 1725 patients (46.11%), and 1721 adenomas were detected in 953 patients (25.47%). A total of 126 patients (3.37%) had advanced polyps and 18 (0.48%) were diagnosed with colon cancer. One patient (0.027%) had a colonic perforation and two patients had postpolypectomy bleeding (0.053%). These results meet or exceed published benchmarks for quality colonoscopy.

CONCLUSIONS:

The Oakville Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.     

Comparison of Colonoscopy Quality Measures Across Various Practice Settings and the Impact of Performance Scorecards

Background

Quality performance measures for screening colonoscopy vary among endoscopists. The impact of practice setting is unknown.

Aims

We aimed to (1) compare screening colonoscopy performance measures among three different US practice settings; (2) evaluate factors associated with adenoma detection; and (3) assess a scorecard intervention on performance metrics.

Methods

This multi-center prospective study compared patient, endoscopist, and colonoscopy characteristics performed at a tertiary care hospital (TCH), community-based hospital (CBH), and private practice group (PPG). Withdrawal times (WT), cecal intubation, and adenoma detection rates (ADR) were compared by site at baseline and 12 weeks following scorecard distribution. Generalized linear mixed models identified factors associated with adenoma detection.

Results

Twenty-eight endoscopists performed colonoscopies on 1987 asymptomatic, average-risk individuals ≥50 years. Endoscopist and patient characteristics were similar across sites. The PPG screened more men (TCH: 42.8%, CBH: 45.0%, PPG: 54.2%; p < 0.0001). Preparation quality varied with good/excellent results in 70.6, 88.3, and 92% of TCH, CBH, and PPG cases, respectively (p < 0.0001). Male ADRs, cecal intubation, and WT exceeded recommended benchmarks despite variable results at each site; female ADRs were <15% at the PPG which screened the fewest females. Performance remained unchanged following scorecard distribution. Adenoma detection was associated with increasing patient age, male gender, WT, adequate preparation, but not practice setting.

Conclusions

Each practice performed high-quality screening colonoscopy. Scorecards did not improve performance metrics. Preparation quality varies among practice settings and can be modified to improve adenoma detection.

     

¿Influye el posible cansancio del endoscopista en la frecuencia de colonoscopias incompletas y de las lesiones polipoideas diagnosticadas?

Introduction

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

Patients and methods

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

Results

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

Conclusions

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