Mo1234 Endoscopist Variation in Bowel Preparation Quality Assessment and its Impact on Repeat Colonoscopy Recommendations

Abstract

Endoscopist Variation in Bowel Preparation Quality Assessment and its Impact on Repeat Colonoscopy Recommendations Otto S. Lin*, Richard A. Kozarek Gastroenterology, Virginia Mason Medical Center, Seattle, WA Background: Bowel preparation quality assessment is influenced by objective colon cleanliness and subjective endoscopist perception bias. Different endoscopists may have different thresholds for labeling a particular bowel preparation as “suboptimal” or worse. We assessed the variation in the proportion of “suboptimal” bowel preparations between different endoscopists and its possible impact on repeat colonoscopy recommendations. Methods: 6000 random patients who had routine colonoscopies performed in 2009-2010 by 9 endoscopists in our unit were included. The proportions of each endoscopist’s patients with “poor” (requiring abortion of the procedure or immediate repeat colonoscopy) and “mediocre” preparation (with “mediocre”, “fair” or “suboptimal” descriptors in the report, but not to the extent that the colonoscopy had to be aborted) were compared. For each endoscopist, we also assessed the pattern of recommended repeat colonoscopy intervals for patients with suboptimal preparations. Results: The percentage of “poor” preparations reported by each endoscopist was low and showed little variation (range 0-1.1%); however, there was wide (5-fold) variation in the percentage of mediocre preparations (3-15.5%) (Figure). Relevant patient characteristics, such as age, gender, history of constipation, previously failed bowel preparation, family history of colon cancer, and procedure indication, did not differ significantly between endoscopists’ patients, with the exception that the sole female endoscopist had more female patients (62%) than her male counterparts (50%). On logistic regression, the only two independent predictors of “suboptimal” (i.e. “poor” or “mediocre”) preparation were constipation history and the endoscopist. Furthermore, endoscopists with higher proportions of suboptimal preparations also had higher proportions of patients asked to return early for repeat colonoscopy (defined as endoscopist-recommended repeat colonoscopy intervals earlier than that recommended by guidelines) (correlation coefficient 0.68). Overall, for patients with “suboptimal” preparations, 33.5% were asked to return for colonoscopy in 1 year and 66.3% in 3 years. On logistic regression, preparation quality assessment was a predictor for early repeat colonoscopy, independent of adenoma detection at colonoscopy and family history of colon cancer. Conclusions: Since the laxative agent (polyethylene glycol), bowel preparation instructions and patient characteristics were almost identical for all endoscopists, the “objective” preparation quality is unlikely to differ significantly between endoscopists. Thus, the wide variation in “mediocre” bowel preparation assessment is probably due to variation in endoscopist perception, with implications regarding early repeat colonoscopy recommendations and overall endoscopic resource use.