Increasing the recommended colon withdrawal time to improve colonoscopy quality: Is it high time?

Background. Quality indicators for colonoscopy have been developed, but the uptake of these metrics into practice is uncertain. Our aims were to assess physician perceptions regarding colonoscopy quality measurement and to quantify the perceived impact of quality measurement on clinical practice.Methods. We conducted in-person interviews with 15 gastroenterologists about their perceptions regarding colonoscopy quality. Results from these interviews informed the development of a 34-question web-based survey that was emailed to 1,500 randomlyselected members of the American College of Gastroenterology.Results. 160 invitations were undeliverable, and 167 out of 1340 invited physicians (12.5%) participated in the survey. Respondents and nonrespondents did not differ in age, sex, practice setting, or years since training. 38.8% of respondents receive feedback on their colonoscopy quality. The majority of respondents agreed with the use of completion rate (90%) and adenoma detection rate (83%) as quality indicators but there was less enthusiasm for withdrawal time (61%). 24% of respondents reported usually or always removing diminutive polyps solely to increase their adenoma detection rate, and 20% reported prolonging their procedure time to meet withdrawal time standards.Conclusions. A minority of respondents receives feedback on the quality of their colonoscopy. Interventions to increase continuous quality improvement in colonoscopy screening are needed.

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Colonoscopy Quality and Adherence to Postpolypectomy Surveillance Guidelines in an Underinsured Clinic System

Gastroenterology Research and Practice ◽

10.1155/2020/6240687 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Jaison John ◽

Abdul Al-Douri ◽

Bretta Candelaria ◽

Saurin Gandhi ◽

Paul Guzik ◽

...

Keyword(s):

Bowel Preparation ◽

Detection Rate ◽

Safety Net ◽

Adenoma Detection Rate ◽

Evidence Based ◽

High Quality ◽

Cecal Intubation ◽

Withdrawal Time ◽

Adenoma Detection ◽

Colonoscopy Quality

Background. Delivery of high-quality colonoscopy and adherence to evidence-based surveillance guidelines is essential to a high-quality screening program, especially in safety net systems with limited resources. We sought to assess colonoscopy quality and ensure appropriate surveillance in a network of safety net practices. Methods. We identified age-eligible patients ages 50-75 within a Federally Qualified Health Center (FQHC) clinic system with evidence of colonoscopy in preceding 10 years. We performed chart reviews to assess key aspects of colonoscopy quality: bowel preparation quality, evidence of cecal intubation, cecal withdrawal time, and the adenoma detection rate. We then utilized established guidelines to assess and revise surveillance colonoscopy intervals, determine whether appropriate surveillance had taken place, and schedule overdue patients as appropriate. Results. Of 26,394 age-eligible patients, a total of 3,970 patients had evidence of prior colonoscopy and 1,709 charts were selected and reviewed. Mean age was 57, 54% identified as women and 51% identified as Hispanic. Of 1709 colonoscopies reviewed, 77% had data on bowel preparation, and of those, 85% had adequate preparation quality. Cecal intubation was documented in 89% of procedures. Adequate cecal withdrawal time was documented in 59% of those with documented cecal intubation. Overall adenoma detection rate was 42%. Initial surveillance interval was clearly stated in 72% ( n = 1238 ) of procedures. Of these, initial recommended intervals were too short in 24.5% ( n = 304 ) and too long in 3.6% ( n = 45 ). A total of 132 patients (10.7%) were overdue for appropriate surveillance and were referred for follow-up colonoscopy. Conclusions. Overall, the quality of screening colonoscopy was high, but reporting was incomplete. We found fair adherence to evidence-based surveillance guidelines, with significant opportunities to extend surveillance intervals and improve adherence to best practices.

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Sustained colonoscopy quality improvement using a simple intervention bundle

Endoscopy ◽

10.1055/a-1098-2101 ◽

2020 ◽

Vol 52 (04) ◽

pp. 285-292 ◽

Cited By ~ 1

Author(s):

Laura J. Neilson ◽

James E. East ◽

Praveen T. Rajasekhar ◽

Paul Bassett ◽

Simon Dunn ◽

...

Keyword(s):

Quality Improvement ◽

Statistical Significance ◽

Post Intervention ◽

Withdrawal Time ◽

Hyoscine Butylbromide ◽

The United Kingdom ◽

Adenoma Detection ◽

Change In Practice ◽

Sustained Change ◽

Colonoscopy Quality

Abstract Background Unacceptable variation in colonoscopy quality exists. The Quality Improvement in Colonoscopy (QIC) study in 2011 improved quality by introducing an evidence-based “bundle” of measures into routine colonoscopy practice. The QIC bundle included: minimal cecal withdrawal time of ≥ 6 minutes; hyoscine butylbromide use; supine patient position for transverse colon examination; rectal retroflexion. Colonoscopy quality was measured by adenoma detection rate (ADR). The current study measured whether these effects led to a sustained change in practice 3 years following implementation. Methods This observational study collected data from eight hospital trusts (sites) in the United Kingdom for a 6-month period, 3 years following QIC bundle implementation. Use of the antispasmodic, hyoscine butylbromide, was measured as a marker of bundle uptake. Bundle effectiveness was measured by ADR change. Comparisons were made between data before and immediately after implementation of the bundle. Results 28 615 colonoscopies by 188 colonoscopists were studied. Hyoscine butylbromide use increased from 15.8 % pre-implementation to 47.4 % in the sustainability phase (P < 0.01) indicating sustained engagement with QIC measures. ADR was higher in the sustainability period compared with pre-intervention, but only reached statistical significance among the poorest-performing colonoscopists. Conclusions The introduction of a simple, inexpensive, pragmatic intervention significantly changed practice over a sustained period, improving colonoscopy quality as measured by ADR, particularly in poorer performers. QIC demonstrates that an easy-to-implement quality improvement approach can deliver a sustained change in practice for many years post intervention.

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The Effect of Midyear Report Cards on Colonoscopy Quality Measures

Gastroenterology Research and Practice ◽

10.1155/2019/4276520 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6

Author(s):

Kunal Suradkar ◽

Benjamin Lebwohl ◽

Ravi P. Kiran ◽

Steven Lee-Kong

Keyword(s):

National Standards ◽

Report Cards ◽

Annual Reports ◽

Withdrawal Time ◽

Mean Values ◽

Adenoma Detection ◽

Standardized Reporting ◽

Periodic Feedback ◽

Colonoscopy Quality ◽

The Impact

Introduction. Since 2011, our institution has distributed annual reports, in June, to providers with personalized data regarding adenoma detection rate (ADR), colonoscope withdrawal time (CW), and cecal intubation (CI) rate, using standardized reporting systems. We examined the impact of distribution of individualized reports at the midpoint of each year on colonoscopy outcomes in the latter half of each year. Methods. Providers with endoscopy privileges, performing ≥20 colonoscopies/year, at our center throughout a five-year period (2011-2015) were included. The three metrics recorded and reported were ADR, CW, and CI using standard benchmark rates. The mean values of each metric from January through June (1st half) and July through December (2nd half) were calculated. Curve estimation test was used to determine the significance of ADR in the respective time period. Results. Fifteen providers were eligible for the study. Collective ADR in the 1st half of all years was 26.9% and in the second half of all years was 28.1% (p=0.476). CW for all years was more than 9 minutes while CI was above 90% for all providers. There was no significant increase in the CI and CW during the 5-year study period. Overall, ADR increased from 26.43% (2011) to 33.47% (2015) (p=0.137). When examining ADR during each of the 12 months following the June report cards, there was no month-to-month trend observed (p=0.893). Conclusion. Endoscopists at our institutions met/exceeded the quality metrics in the first half of each year from the beginning of the study. Routine reporting may maintain, but not improve, outcomes. Long-term studies to determine if periodic feedback to endoscopists improves the quality of endoscopy as per national standards for detection of early colorectal cancers are required.

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Colonoscopy quality across Europe: a report of the European Colonoscopy Quality Investigation (ECQI) Group

Endoscopy International Open ◽

10.1055/a-1486-6729 ◽

2021 ◽

Vol 09 (10) ◽

pp. E1456-E1462

Author(s):

Cristiano Spada ◽

Anastasios Koulaouzidis ◽

Cesare Hassan ◽

Pedro Amaro ◽

Anurag Agrawal ◽

...

Keyword(s):

Bowel Preparation ◽

Detection Rate ◽

Gastrointestinal Endoscopy ◽

Polyp Detection ◽

Cecal Intubation ◽

Withdrawal Time ◽

Polyp Detection Rate ◽

Adenoma Detection ◽

Cecal Intubation Rate ◽

Colonoscopy Quality

Abstract Background and study aims The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires. Methods The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites. Results We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received.Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively.Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing. Conclusions Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.

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Association between Endoscopist Specialty and Colonoscopy Quality: Protocol for a Systematic Review and Meta-analysis

10.21203/rs.3.rs-281768/v1 ◽

2021 ◽

Author(s):

Nauzer Forbes ◽

Matthew Mazurek ◽

Alistair Murray ◽

Yibing Ruan ◽

Robert J Hilsden ◽

...

Keyword(s):

Colorectal Cancer ◽

Systematic Review ◽

Meta Analysis ◽

A Priori ◽

Study Data ◽

Related Factors ◽

Withdrawal Time ◽

Adenoma Detection ◽

Meta Analyses ◽

Colonoscopy Quality

Abstract Background Colonoscopy is an important modality in the provision of colorectal cancer screening. Though effective and safe, the performance of screening-related colonoscopy is variable in terms of its overall quality, with endoscopist-related factors playing an important role in this variation. The purpose of this study is to systematically review the association between endoscopist specialty and colonoscopy quality and outcomes. Methods A comprehensive electronic search will be carried out to determine the association between endoscopist specialty and colonoscopy quality metrics and/or outcomes in adult patients undergoing colonoscopy. Two abstracters will independently determine study eligibility, assess study quality, and abstract study data. The primary outcome will be the adenoma detection rate (ADR); secondary outcomes will include cecal intubation rate (CIR), withdrawal time (WT), adverse events (AEs) and post-colonoscopy colorectal cancer (PCCRC). Rates of the above metrics and outcomes will also be compared between clinically relevant subgroups determined a priori. DerSimonian and Laird models will be used to perform meta-analyses for each outcome. Sources of heterogeneity will be explored via meta-regression analyses, if possible. Discussion Given the significant established variation in colonoscopy quality, endoscopist-related factors need to be explored. Our meta-analysis will address the important question of whether the specialty of the endoscopist impacts colonoscopy quality and/or outcomes. Systematic Review Registration PROSPERO CRD42021226251.

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Educational interventions are associated with improvements in colonoscopy quality indicators: a systematic review and meta-analysis

Endoscopy International Open ◽

10.1055/a-1221-4922 ◽

2020 ◽

Vol 08 (10) ◽

pp. E1321-E1331

Author(s):

Natalia S. Causada-Calo ◽

Emmanuel I. Gonzalez-Moreno ◽

Kirles Bishay ◽

Risa Shorr ◽

Catherine Dube ◽

...

Keyword(s):

Quality Indicators ◽

Prediction Interval ◽

Meta Analysis ◽

Educational Interventions ◽

Eligibility Criteria ◽

Related Factors ◽

Withdrawal Time ◽

Adenoma Detection ◽

Improvement Programs ◽

Colonoscopy Quality

Abstract Background and study aims The quality of screening-related colonoscopy depends on several physician- and patient-related factors. Adenoma detection rate (ADR) varies considerably between endoscopists. Educational interventions aim to improve endoscopists’ ADRs, but their overall impact is uncertain. We aimed to assess whether there is an association between educational interventions and colonoscopy quality indicators. Methods A comprehensive search was performed through August 2019 for studies reporting any associations between educational interventions and any colonoscopy quality indicators. Our primary outcome of interest was ADR. Two authors assessed eligibility criteria and extracted data independently. Risk of bias was also assessed for included studies. Pooled rate ratios (RR) with 95 % confidence intervals (CI) were reported using DerSimonian and Laird random effects models. Results From 2,253 initial studies, eight were included in the meta-analysis for ADR, representing 86,008 colonoscopies. Educational interventions were associated with improvements in overall ADR (RR 1.29, 95 % CI 1.25 to 1.42, 95 % prediction interval 1.09 to 1.53) and proximal ADR (RR 1.39, 95 % CI 1.29 to 1.48), with borderline increases in withdrawal time, ([WT], mean difference 0.29 minutes, 95 % CI – 0.12 to 0.70 minutes). Educational interventions did not affect cecal intubation rate ([CIR], RR 1.01, 95 % CI 1.00 to 1.01). Heterogeneity was considerable across many of the analyses. Conclusions Educational interventions are associated with significant improvements in ADR, in particular, proximal ADR, and are not associated with improvements in WT or CIR. Educational interventions should be considered an important option in quality improvement programs aiming to optimize the performance of screening-related colonoscopy.

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The Impact of Colonoscopy Quality Control Table on Adenoma Detection Rates

Gastroenterology Research and Practice ◽

10.1155/2016/2548109 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Bin Deng ◽

Jiehua Zhi ◽

Yaosheng Chen ◽

Lanyu Liang ◽

Jian Wu ◽

...

Keyword(s):

Success Rate ◽

Detection Rate ◽

Intervention Group ◽

Withdrawal Time ◽

Detection Rates ◽

Adenoma Detection ◽

Significant Difference ◽

Adenoma Detection Rates ◽

Colonoscopy Quality ◽

The Impact

Objective. This study aims to investigate the effects of reporting colonoscopy findings and the regular review of outcomes on adenoma detection rates.Methods. Patients who underwent colonoscopy from August 2013 to February 2014 were selected as the intervention group. The preintervention group included patients who underwent colonoscopy from January 2013 to July 2013, in which the procedure sheet for this group of patients was not accomplished. The primary outcome was adenoma detection rate (ADR), and secondary outcomes included the success rate of intubation and withdrawal time.Results. This study included 2,467 cases: 1,302 cases in the intervention group and 1,165 cases in the preintervention group. There was no significant difference in demographic characteristics between the two groups. In the intervention group, withdrawal time of colonoscopy was longer (P<0.01), and the success rate of intubation (92.5% versus 89.1%,P<0.05) and detection rate of polyps (32.6% versus 27.6%,P<0.05) and adenomas (20.0% versus 16.1%,P<0.05) were higher. Significantly high detection rates for proximal adenomas, flat adenomas, and adenomas with a diameter <5 mm were observed in the intervention group (allP<0.01).Conclusion. The reporting and review of procedure details help to improve quality indicators of colonoscopy.

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A147 ENDOSCOPIST FEEDBACK IS ASSOCIATED WITH IMPROVEMENTS IN COLONOSCOPY QUALITY INDICATORS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwz047.146 ◽

2020 ◽

Vol 3 (Supplement_1) ◽

pp. 10-11

Author(s):

K Bishay ◽

N Calo ◽

M A Scaffidi ◽

C M Walsh ◽

J Anderson ◽

...

Keyword(s):

Systematic Review ◽

Quality Indicators ◽

Meta Analysis ◽

Audit And Feedback ◽

Screening Colonoscopy ◽

Withdrawal Time ◽

Random Effects Models ◽

Manual Search ◽

Adenoma Detection ◽

Colonoscopy Quality

Abstract Background Colonoscopy quality indicators such as adenoma detection rate (ADR) are surrogates for the effectiveness of screening-related colonoscopy. Endosocpist feedback may be associated with improvements in ADR and other quality indicators. Aims To conduct a systematic review and meta-analysis to determine whether an association exists between endoscopist feedback and improvements in colonoscopy quality indicators. Methods An electronic and manual search was conducted through May 2019 for studies reporting on endoscopist feedback and associations with ADR or other colonoscopy quality indicators. Studies primarily assessing the effect of audit and feedback on trainees and studies that included interventions other then feedback were excluded from the analysis. Pooled rate ratios (RR) and weighted mean differences (WMD) 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 Of 1,326 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 to 1.34). Low performers derived a greater benefit from feedback (RR 1.62, 95% CI 1.18 to 2.23) compared to moderate performers (RR 1.19, 95% CI 1.11 to 1.29), while high performers did not derive a significant benefit (RR 1.06, 95% CI 0.99 to 1.13). Feedback was not associated with increases in withdrawal time (WMD +0.43 minutes, 95% CI -0.50 to +1.36 minutes) or improvements in cecal intubation rate (RR 1.00, 95% CI 0.99 to 1.01). Conclusions Endoscopist feedback is associated with modest improvements in ADR. Routine audit and feedback may be a feasible strategy to optimize outcomes in screening colonoscopy. Funding Agencies None

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Improved detection of adenomas and sessile serrated polyps is maintained with continuous audit of colonoscopy

BMJ Open Gastroenterology ◽

10.1136/bmjgast-2020-000425 ◽

2020 ◽

Vol 7 (1) ◽

pp. e000425

Author(s):

Alan Gordon Fraser ◽

Toby Rose ◽

Philip Wong ◽

Mark Lane ◽

Paul Frankish

Keyword(s):

Detection Rate ◽

Adenoma Detection Rate ◽

Polyp Detection ◽

Audit Process ◽

Withdrawal Time ◽

Serrated Polyps ◽

Serrated Polyp ◽

Polyp Detection Rate ◽

Adenoma Detection ◽

Colonoscopy Quality

BackgroundThe audit process may help improve performance indicators for colonoscopy quality but it is unclear whether this is sustained over several years.Methods44138 procedures for 28 endoscopists from 2004 to 2019 were analysed for polyp detection rate and withdrawal time. From 2012, 14 endoscopists were analysed with additional data on polyp histology and number of polyps removed.ResultsPolyp detection increased from 40.7% in 2004 to 62.2% in 2019; removal of polyps>1 cm remained constant (11%). Adenoma detection rate was 25.8% in 2012 and 28.3% in 2019. Sessile serrated polyp (SSP) detection rate increased from 4.5% to 14.7%; most of the increase was in the first 2 years of the histology part of the audit. There was a significant correlation of adenoma detection rate with mean number of adenomas (r=0.72, p=0.004) and a significant correlation of SSP detection with mean number of SSPs (r=0.85, p=0.0001).ConclusionThe audit process appears to encourage a higher rate of polyp detection. This was due to increased detection of smaller polyps and increased detection of SSPs.

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