Endoscopist Characteristics Research Articles

Patient, Procedure, and Endoscopist Risk Factors for Perforation, Bleeding, and Splenic Injury After Colonoscopies

We investigated perforations, bleeding, and splenic injuries after screening or diagnostic colonoscopies to identify patient-, procedure-, endoscopist-, and facility-associated risk factors. We analyzed data from the SNIIRAM-PMSI national claims databases in France. A total of 4,088,799 patients, 30 years or older, undergoing a first screening or diagnostic colonoscopy from 2010 through 2015 were identified. Rates of severe adverse events (SAEs) were estimated using stringent and broad definitions. Risk factors associated with perforations and major bleeding were estimated using multilevel logistic regression models, adjusted for patient, colonoscopy, and endoscopist characteristics. Perforation rates ranged from 3.5 (stringent definition) to 7.3 (broad definition) per 10,000 procedures, bleeding rates ranged from 6.5 to 23.1 per 10,000 procedures, and splenic injury rates ranged from 0.20 to 0.34 per 10,000 procedures. Rates of 30-day mortality were 13.2 per 1000 bleeds, 29.2 per 1000 perforations, and 36.1 per 1000 splenic injuries (stringent definitions). Patient characteristics associated with SAEs were increasing age (especially for perforation), cancer, and cardiovascular comorbidities. Procedure characteristics associated with SAEs included polypectomy-especially of polyps larger than 1 cm with an increased risk of perforation (odds ratio, 4.1; 95% CI, 3.4-5.0) and bleeding (odds ratio, 13.3; 95% CI, 11.7-15.1). Less-experienced endoscopists and endoscopists who performed a smaller number of colonoscopies were independently associated with a risk of SAEs. In an analysis of national claims databases in France, we found SAEs related to screening and diagnostic colonoscopies to be more frequent in older patients, in patients with comorbidities, and with less-experienced endoscopists. Patients at risk of SAE should be identified and colonoscopies should be performed or supervised by experienced endoscopists.

Mo1674 DIFFERENCES IN DETECTION OF POLYP PATHOLOGY BASED ON ENDOSCOPIST CHARACTERISTICS AND EXAMINATION OF THE ROLE OF WITHDRAWAL TIME IN EXPLAINING THESE DIFFERENCES

Previous studies have demonstrated adenoma detection (AD) to be operator dependent. In this study we examined endoscopist characteristics not only as they relate to AD, but also to sessile serrated adenoma detection (SSPD), and advanced adenoma detection (AAD--defined as ≥1cm diam., having villous component or high-grade dysplasia). Further, we examined the role of withdrawal time (amount of time spent viewing as colonoscope is withdrawn) as a possible explanation of these differences. Outpatient screening colonoscopies performed on average risk patients by providers who have performed ≥100 colonoscopies in the Cleveland Clinic between January 2015-August 2017 were reviewed. Patient and colonoscopic characteristics along with various endoscopist characteristics were obtained. Descriptive statistics were performed to compute differences in SSPD, AD, AAD, and withdrawal times (WT) based on endoscopist characteristics. This was followed by multivariate (MV) analysis adjusting for various endoscopist characteristics, as well as various patient and colonoscopy based characteristics: age, gender, ethnicity, insurance, BMI, comorbidities (diabetes, cirrhosis, dementia, stroke, constipation, CAD, CHF), aspirin use, opiate use, quality of bowel preparation, location/timing (AM v. PM) of colonoscopy, and number of polyps seen. MV analysis was repeated with inclusion of WT as a variable. N=18,501 colonoscopies were performed by 122 providers. Baseline characteristics and differences in SSPD, AD, AAD, and WT based on various endoscopist characteristics, were obtained (Table 1). MV analysis excluding the effect of WT but adjusting to afore mentioned variables (Table 2a) and including the effect of WT (Table 2b) is presented. Most notable of these associations include: After controlling for WT, odds of SSPD compared to gastroenterologists (GI) has increased from 56% to 67% in general surgeons(GS) and from 53% to 61% in colorectal surgeons (CS). Whereas GS had 17% decreased chance of AD compared to GI, this difference has become insignificant after adjusting to WT. Odds of AD for CS improved by 14% after adjusting for WT. Female providers noted to have higher WT (table-1) have seen 5% decreased chance of SSP after adjusting to WT. Compared to academic physicians, the odds of SSPD among private physicians increased 4% after adjusting to WT. After adjusting for multiple known risk factors, our study revealed significant differences in AD, SSPD, and AAD based on endoscopist characteristics. Comparison of these characteristics before and after controlling for WT demonstrated that many of the differences polyp detection may be partially or fully related to WT. This study emphasizes the need to educate endoscopists about appropriate WT during colonoscopy—especially in providers with characteristics associated lower polyp detection.Table 2- Adjusted analysis of factors associated with sessile serrated polyp detection rate (SSP), adenoma detection rate (AD), advanced adenoma detection rate (AAD)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Variable Endoscopist performance in proximal and distal adenoma detection during colonoscopy: a retrospective cohort study

BackgroundAdenoma Detection Rate (ADR) is a validated colonoscopy quality indicator. In addition to overall ADR, Distal and Proximal Adenoma Detection Rates may provide important colonoscopy quality information. The goal of this study is to determine the association between distal and proximal adenoma detection (AD) and to identify factors contributing to overall, distal, and proximal AD.MethodsThis is a retrospective cohort study of patients with a noted family history of CRC or positive fecal occult blood test who underwent a screening colonoscopy at a regional colorectal cancer (CRC) screening center between May 2009 and December 2011. Data regarding patient demographics, procedure details, endoscopist characteristics and polyp histology were captured. The main outcomes measured were overall, distal, and proximal AD.Results1907 patients were included. The median age was 60 years and 42% were male. Endoscopist median overall ADR was 25% (30% male, 21% female). Endoscopist distal ADR was only modestly associated with their proximal ADR (Spearman Rank: 0.51 p = 0.11). Highest overall ADR (29 to 45%) was found for endoscopists whose distal and proximal ADRs were above the group median. In multivariate analysis, factors associated with overall, distal, and proximal AD included age, sex, and endoscopist practicing experience.ConclusionInclusion of distal and proximal ADRs, in addition to overall ADR, in colonoscopy quality assessment provides the more accurate feedback on endoscopist performance.

Mo1666 INTERVAL COLORECTAL CANCERS ARE INFREQUENT AND OCCUR DUE TO BOTH MISSED AND INCOMPLETELY RESECTED POLYPS

Although colonoscopy reduces colorectal cancer (CRC) risk, interval CRCs (iCRCs) still occur. Although uncommon, iCRCs can inform areas wherein colonoscopy quality improvements must occur. To determine the incidence and potential causes of iCRC. We performed a retrospective cohort study of all patients who underwent colonoscopy from April 1996 to March 2017 at a single academic medical center. Patients who developed an iCRC were identified through a review of our institutional data warehouse, an integrated database of clinical and research information from all patients receiving treatment through our healthcare system. An iCRC was defined as a cancer diagnosed 6-60 months after index colonoscopy; an early iCRC was defined as cancer first diagnosed 6-36 months after index colonoscopy. We manually reviewed all charts to confirm appropriateness for study inclusion and abstract patient, procedure, endoscopist, and cancer characteristics. A total of 252,256 colonoscopies were performed over the study period. We identified 203 patients diagnosed with iCRC with a median age at index colonoscopy of 65 (IQR 58-74). The overall iCRC rate was 0.12% and the early iCRC rate was 0.06%. This rate did not significantly improve over the study period (r=-0.3, p=0.4). However, the iCRC rates did vary significantly among providers performing ≥500 colonoscopies and correlated inversely with provider adenoma detection rates (ADR; Figure 1). Patients undergoing procedures by endoscopists in the highest ADR quartile (36-52%) had an iCRC risk five times lower (HR 0.21, 95% CI 0.08-0.52) than those undergoing colonoscopy by an endoscopist in the lowest quartile (11-19%). The iCRC-related mortality rate was 23% for both overall and early iCRC. Proximal (cecum to transverse colon) cancers accounted for a majority (54%) of iCRCs and rectal/rectosigmoid cancers represented 22% of iCRCs. One-third of cancers were diagnosed at an advanced stage (III and IV). In 42% of patients, gastrointestinal symptoms prompted an early repeat colonoscopy which identified the iCRC. One-third of iCRC cases (34%) were detected during surveillance exams. Incomplete polypectomy was the confirmed etiology for iCRC in 7.4% of cases and a possible etiology (prior polypectomy at same or adjacent colon segment) in 25% of cases. The most common modifiable etiology of iCRC during the study period was a missed polyp (65%). However, incomplete polypectomy was associated with 7-32% of iCRCs. Furthermore, higher provider ADRs were significantly associated with lower iCRC and early iCRC rates. Colonoscopy quality improvement measures aimed at reducing iCRC incidence should therefore target both improving polyp detection and resection.Table 1. Summary of iCRC patient, tumor, and endoscopic characteristics.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Endoscopist factors that influence serrated polyp detection: a multicenter study.

Serrated polyps are important colorectal cancer precursors that are variably detected during colonoscopy. We measured serrated polyp detection rate (SPDR) in a large, multicenter, cross-sectional study of colonoscopy quality to identify drivers of SPDR variation. Colonoscopy and pathology reports were collected for a 2-year period (10/2013-9/2015) from four sites across the United States. Data from reports, including size, location, and histology of polyps, were abstracted using a validated natural language processing algorithm. SPDR was defined as the proportion of colonoscopies with ≥ 1 serrated polyp (not including hyperplastic polyps). Multivariable logistic regression was performed to determine endoscopist characteristics associated with serrated polyp detection. A total of 104 618 colonoscopies were performed by 201 endoscopists who varied with respect to specialty (86 % were gastroenterologists), sex (18 % female), years in practice (range 1 - 51), and number of colonoscopies performed during the study period (range 30 - 2654). The overall mean SPDR was 5.1 % (SD 3.8 %, range 0 - 18.8 %). In multivariable analysis, gastroenterology specialty training (odds ratio [OR] 1.89, 95 % confidence interval [CI] 1.33 - 2.70), fewer years in practice (≤ 9 years vs. ≥ 27 years: OR 1.52, 95 %CI 1.14 - 2.04)], and higher procedure volumes (highest vs. lowest quartile: OR 1.77, 95 %CI 1.27 - 2.46)] were independently associated with serrated polyp detection. Gastroenterology specialization, more recent completion of training, and greater procedure volume are associated with serrated polyp detection. These findings imply that both repetition and training are likely to be important contributors to adequate detection of these important cancer precursors. Additional efforts to improve SPDR are needed.

Factors Associated with Surveillance Adenoma and Sessile Serrated Polyp Detection Rates.

Adenoma detection rate (ADR) and sessile serrated polyp detection rate (SSPDR) data in surveillance colonoscopy are limited. Our aim was to determine surveillance ADR and SSPDR and identify associated predictors. A retrospective review of subjects who underwent surveillance colonoscopy for adenoma and/or SSP at an academic center was performed. The following exclusion criteria were applied: prior colonoscopy ≤3years, incomplete examination, or another indication for colonoscopy. Patient, endoscopist, and procedure characteristics were collected. Predictors were identified using multivariable logistic regression. Of 3807 colonoscopies, 2416 met inclusion criteria. Surveillance ADR was 49% and, SSPDR was 8%. Higher ADR was associated with: age per year (OR 1.03; 95% CI 1.02-1.04), male gender (OR 1.55; 95% CI 1.29-1.88), BMI per kg/m2 (OR 1.02; 95% CI 1.01-1.04), withdrawal time per minute (OR 1.09; 95% CI 1.07-1.10), and endoscopists' screening ADR (OR 1.01; 95% CI 1.00-1.03). Years since training (OR 0.99; 95% CI 0.98-0.99) was associated with lower ADR. Family history of CRC (OR 1.58; 95% CI 1.02-2.27) and endoscopists' screening ADR (OR 1.40; 95% CI 1.15-1.74) were associated with higher SSPDR. African-American race (OR 0.36; 95% CI 0.10-0.75) and diabetes (OR 0.41; 95% CI 0.21-0.76) were associated with lower SSPDR. For surveillance colonoscopy, nearly half of patients had an adenoma and one in twelve had an SSP. In addition to established factors, BMI, endoscopists' screening ADR, and years since training were associated with ADR, whereas African-American race and diabetes were inversely associated with SSPDR. Further studies are needed prior to integrating surveillance ADR and SSPDR into quality metrics.

Gastroenterologists Have Higher Polyp Detection Rates During Screening Colonoscopy Than Non-gastroenterologists

Introduction: It has been reported that gastroenterologists are better at polyp detection and polyp removal as compared to Non-gastroenterologists. After a negative colonoscopy, those who have had their procedures performed by a gastroenterologist are less likely to develop interval CRC. However specific information about polypectomy rate (PR), adenoma detection rate (ADR), serrated polyp detection rate (SPDR) and sessile serrated adenoma detection rate (SSADR) and their variation by gender and colonic segment between gastroenterologist and non-gastroenterologists is not clearly defined. Methods: A retrospective review of all screening colonoscopies in patients ≥50 years of age performed at our institution between 2012 and 2014 was done. Patients with complete colonoscopy with excellent, good and adequate bowel preparation were included. Non-gastroenterologists included general surgeons, colorectal surgeons and primary care physicians. Serrated polyps included hyperplastic polyps and sessile serrated adenomas. Overall, gender and colon segment specific PR, ADR, SPDR and SSADR were calculated and compared using t-tests. Data are presented as mean ± standard deviation. All analyses were done using SAS (version 9.4, The SAS Institute, Cary, NC) and a P<0.05 was considered statistically significant.Table: Table. Characteristics of Endoscopists and PatientsTable: Table. Polyp Detection Rates by Specialty of the EndoscopistResults: A total of 4151 patients were included in the analysis. Average patient age was 60.0±7.7 years and 53.2% were females. Colonoscopies were performed by 54 gastroenterologists (63.5%) and 31 (36.5%) non-gastroenterologists (General Surgeons=9; Colorectal Surgeons=21; Primary care physician=1). Overall PR (49.3±14.9 vs. 37.5±14.9; P<0.05) and overall ADR (28.8±10.5 vs. 22.1±10.8; P=0.007) was significantly higher for gastroenterologists compared to non-gastroenterologists in both males and females; Overall SSADR and proximal SSADR was significantly higher for gastroenterologists compared to non-gastroenterologists. Overall SPDR is significantly higher for gastroenterologists; however proximal and distal SPDR did not vary significantly by the specialty of endoscopist or gender of the patient. Conclusion: Gastroenterologists have higher PR, ADR, SPDR, SSADR and proximal SSADR compared to non-gastroenterologists. These findings suggest a need for developing targeted programs to improve colonoscopy quality for non-gastroenterologists performing colonoscopy.

Endoscopist Specialty Predicts Likelihood of Recommending Cessation of CRC Screening in Older Adults: An Analysis of the New Hampshire Colonoscopy Registry

Introduction: Although the US Preventive Services Task Force recommends that routine CRC screening for adults stop at 75 years, it is not clear what endoscopists are recommending in practice. Our goal was to examine current practice including patient- and endoscopist-related factors associated with cessation of screening in older adults. Methods: We included normal, screening colonoscopy exams in patients ≥ 50 years of age within the New Hampshire Colonoscopy Registry (NHCR), excluding incomplete exams or those with inadequate bowel preparation. We evaluated exams performed by endoscopists with at least 100 screening colonoscopies in NHCR. Primary outcome was endoscopists' recommendation against further screening. Main exposure variables included patient age and endoscopist characteristics. Other variables were patient gender, BMI, family history, smoking, alcohol, exercise, marital status, and education. We used descriptive statistics and chi square test for trend, and performed univariate and multivariable logistic regression models. Results: There were 19,112 normal, screening colonoscopy exams between 2009-2014, of which 4,038 (21%) were in adults age ≥65. These were performed by 73 endoscopists, of which 51 were gastroenterologists, 19 surgeons and 2 family medicine. Median [IQR] adenoma detection rate (ADR) was 24.4% [18.9-29.8]. Nearly 100% of adults aged 65-69 attending screening colonoscopy were recommended to return for another screening colonoscopy in the future (Table 1). Strikingly, only 15% of patients age 70-74 with no FH of CRC were told to stop receiving colonoscopy, while 85% were told to return in 10 years, when they would be 80-84. In univariate analyses, age, FH of CRC, BMI, marital status, endoscopist ADR and specialty were associated with the recommendation to stop colonoscopy (Table 2). In the multivariable model, advancing age and absence of FH of CRC were significantly associated with a recommendation to stop colonoscopy. Gastroenterologists were more likely to recommend stopping colonoscopy in accordance with guidelines than other non-gastroenterology endoscopists (aOR (95% CI) 2.1 (1.4-3.2)).Table: Table. Rates of endoscopists recommending no further CRC screening stratified by patient age and family history of CRCTable: Table. Patient and endoscopists-level factors associated with recommendation of no further CRC screening among adults age 65 and olderConclusion: In a large state-wide colonoscopy registry including 73 endoscopist, the overwhelming majority of patients ≥ age 65 and even age 75 are told to return for screening colonoscopy in 10 years. Having a FH of CRC or non-gastroenterology endoscopist increases the likelihood of being told to return for screening at advanced ages outside of current guideline recommendations.

Factors defining expertise in screening colonoscopy.

Background and study aims There is very little literature defining characteristics of expert endoscopists. It is hypothesised that previously undetermined human factors may correlate with high performance in screening colonoscopists. The aim of this study was to determine factors contributing towards expertise in screening colonoscopy. Materials and methods A focus group was used to hypothesise skills considered to be relevant to high performance in colonoscopy. The skills were then ranked in order of importance by an independent group of screening colonoscopists for both diagnostic and therapeutic colonoscopy. Twenty screening colonoscopists subsequently participated in individual semi-structured interviews to explore participants’ views of expertise and the factors contributing to it. Data extracted from the interview transcripts were used to identify the thematic framework associated with expertise. Results The 5 initial highest-ranked themes were low complication rates, high adenoma detection rates, interpersonal skills with staff, communication skills, and manner with patients. Interviewees considered technical skills (20/20), previous experience of colonoscopy (19/20), judgment/decision-making (18/20), communication (18/20), teamwork (15/20), resources (11/20) and leadership (8/20) to be the most important themes related to expertise. Conclusions Both technical and non-technical abilities are considered essential components of expertise by experienced colonoscopists. Further research into targeted interventions to improve the rate of acquisition of these skills in training endoscopists may be useful in improving performance.

Predictors of post-colonoscopy emergency department use

Unplanned hospital visits within 7 days of colonoscopy were recently proposed as a quality measure. It is unknown whether patient, procedure, or endoscopist characteristics predict post-colonoscopy emergency department (ED) visits. Our aim was to determine the incidence and relatedness of ED visits within 7 days of colonoscopy and to identify predictors of post-colonoscopy ED use. In this retrospective, single-center, cohort study, we evaluated outpatient colonoscopies performed at a tertiary academic medical center or affiliated facility between January 2008 and September 2013. We determined the incidence of ED visits within 7 days of colonoscopy and the relatedness of the ED visit to the procedure. We assessed for independent factors associated with ED use within 7 days using logistic regression analysis. We reviewed 50,319 colonoscopies performed on 44,082 individuals (47% male, median age 59 years) by 40 endoscopists. There were 382 (0.76%) ED visits after colonoscopy, of which 68% were related to the procedure. On multivariate analysis, recent ED visit (odds ratio [OR], 16.60; 95% confidence interval [CI], 12.83-21.48; P< .001), EMR (OR, 4.69; 95% CI, 2.82-7.79; P< .001), number of medication classes (OR, 1.18; 95% CI, 1.11-1.26; P< .001), endoscopist adenoma detection rate (ADR) (OR, 1.14; 95% CI, 1.01-1.29; P= .029), and white race (OR, 0.77; 95% CI, 0.62-0.97; P= .028) were identified as independent variables associated with ED visits after colonoscopy. Increased patient complexity, higher endoscopist ADR, and EMR were associated with increased ED use after colonoscopy. Patients at high risk for an unplanned hospital visit within 7 days should be targeted for quality improvement efforts to reduce adverse events and cost.

Factors Associated With Shorter Colonoscopy Surveillance Intervals for Patients With Low-Risk Colorectal Adenomas and Effects on Outcome

Endoscopists do not routinely follow guidelines to survey individuals with low-risk adenomas (LRAs; 1-2 small tubular adenomas, < 1 cm) every 5-10 years for colorectal cancer; many recommend shorter surveillance intervals for these individuals. We aimed to identify the reasons that endoscopists recommend shorter surveillance intervals for some individuals with LRAs and determine whether timing affects outcomes at follow-up examinations. We collected data from 1560 individuals (45-75 years old) who participated in a prospective chemoprevention trial (of vitamin D and calcium) from 2004 through 2008. Participants in the trial had at least 1 adenoma, detected at their index colonoscopy, and were recommended to receive follow-up colonoscopy examinations at 3 or 5 years after adenoma identification, as recommended by the endoscopist. For this analysis we collected data from only participants with LRAs. These data included characteristics of participants and endoscopists and findings from index and follow-up colonoscopies. Primary endpoints were frequency of recommending shorter (3-year) vs longer (5-year) surveillance intervals, factors associated with these recommendations, and effect on outcome, determined at the follow-up colonoscopy. A 3-year surveillance interval was recommended for 594 of the subjects (38.1%). Factors most significantly associated with recommendation of 3-year vs a 5-year surveillance interval included African American race (relative risk [RR] to white, 1.41; 95% confidence interval [CI], 1.14-1.75), Asian/Pacific Islander ethnicity (RR to white, 1.7; 95% CI, 1.22-2.43), detection of 2 adenomas at the index examination (RR vs 1 adenoma, 1.47; 95% CI, 1.27-1.71), more than 3 serrated polyps at the index examination (RR=2.16, 95% CI, 1.59-2.93), or index examination with fair or poor quality bowel preparation (RR vs excellent quality, 2.16; 95% CI, 1.66-2.83). Other factors that had a significant association with recommendation for a 3-year surveillance interval included family history of colorectal cancer and detection of 1-2 serrated polyps at the index examination. In comparisons of outcomes, we found no significant differences between the 3-year vs 5-year recommendation groups in proportions of subjects found to have 1 or more adenomas (38.8% vs 41.7% respectively; P=.27), advanced adenomas (7.7% vs 8.2%; P=.73) or clinically significant serrated polyps (10.0% vs 10.3%; P= .82) at the follow-up colonoscopy. Possibly influenced by patients' family history, race, quality of bowel preparation, or number or size of polyps, endoscopists frequently recommend 3-year surveillance intervals instead of guideline-recommended intervals of 5 years or longer for individuals with LRAs. However, at the follow-up colonoscopy, similar proportions of participants have 1 or more adenomas, advanced adenomas, or serrated polyps. These findings support the current guideline recommendations of performing follow-up examinations of individuals with LRAs at least 5 years after the index colonoscopy.

Endoscopist characteristics that influence the quality of colonoscopy.

Several factors have been shown to be related to colonoscopy quality; however, little is known about the effects of endoscopist factors. This study analyzed the influence of endoscopist-related characteristics on quality indicators for colonoscopy. The study included 48 endoscopists who each performed at least 20 colonoscopies in the colonoscopy arm of a randomized controlled trial comparing fecal immunochemical test vs. colonoscopy in colorectal cancer screening. These endoscopists performed a total of 3838 procedures in the trial. The following were calculated for each endoscopist: adenoma detection rate (ADR), advanced ADR, proximal ADR, distal ADR, and adenoma per colonoscopy rate (APCR). The characteristics of endoscopists were assessed with regard to colonoscopy quality using multivariate regression analysis. Endoscopist characteristics included age, sex, exclusive endoscopy practice, years as a physician, years as a specialist, specialty, total (life-long) number of colonoscopies performed, annual colonoscopy volume, number of hours/week dedicated to endoscopy and number of educational activities in the previous year. Factors associated with ADR were age of the endoscopist (odds ratio [OR] 1.11, 95 % confidence interval [CI] 1.01 - 1.21; P = 0.01) and life-long number of colonoscopies (OR 1.06, 95 %CI 1.01 - 1.11; P = 0.01). Only exclusive dedication to endoscopy practice was found to be independently related to proximal ADR (OR 1.71, 95 %CI 1.15 - 2.74; P = 0.001). Life-long number of colonoscopies was independently related to detection of distal adenomas (OR 1.07, 95 %CI 1.01 - 1.13; P = 0.01). None of the analyzed endoscopist characteristics was associated with advanced ADR or APCR. This study found that the experience of the endoscopist and exclusive dedication to endoscopy practice, but not annual colonoscopy volume, were associated with better colonoscopy quality.

Repeat colonoscopy after a colonoscopy with a negative result in Ontario: a population-based cohort study.

Data suggest the overuse of repeat colonoscopies, especially in patients at low risk for colorectal cancer. Our objective was to evaluate the time to repeat colonoscopies in low-risk patients aged 50-79 years old and the associated patient- and endoscopist-related factors. All patients aged 50-79 years of age who underwent a complete outpatient colonoscopy with a negative result between 2000 and 2007 were identified from the Ontario Health Insurance Plan database. A colonoscopy performed within 5.5 years of follow-up after the index colonoscopy was considered an early repeat colonoscopy. Patient, endoscopist and endoscopy setting characteristics were recorded and their association with an early repeat colonoscopy was determined using an extended Cox proportional hazards regression model. The cohort consisted of 546 467 patients: 55.4% of the patients were female with a mean age of 61.1 years (95% confidence interval [CI] 61.1-61.2). The cumulative percentage of early repeat colonoscopy after 5.5 years was 33.7%. The rate decreased significantly between 2000 and 2007 (hazard ratio [HR] 0.35, 95% CI 0.34-0.36). General surgeons were associated with a higher risk of early repeat colonoscopy than gastroenterologists (HR 1.27, 95% CI 1.25-1.28). Endoscopists practising in a nonhospital setting were more likely to perform an early repeat colonoscopy (HR 1.26, 95% CI 1.22-1.30) than endoscopists at a hospital. This study showed that there was overuse of early repeat colonoscopy in more than 30% of patients who were at low risk for colorectal cancer. The risk decreased significantly between 2000 and 2007 but was still greater than 20% in 2007. Our findings can be used to develop targeted educational interventions among subgroups of endoscopists with a higher rate of early repeat colonoscopy.

Anesthesiologist-Administered Gastrointestinal Sedation: Time to Put It to Sleep?

In the ongoing debate regarding sedation administered during gastrointestinal (GI) endoscopy, supporters of sedation administered by anesthesia providers (AAP) argue that anesthesiologists best handle complications involving the airways. Furthermore, the product label for propofol, the most commonly used sedative for GI endoscopy, states: ‘‘it should be administered only by persons trained in the administration of general anesthesia.’’ Supporters of nonanesthesiologist-administered propofol (NAAP) sedation, specifically nurse-administered propofol administration under the guidance of the endoscopist, argue that the safety profile of NAAP is equivalent to AAP while being costeffective. For lowand average-risk procedures, overwhelming worldwide data support the hypothesis that NAAP has a comparable safety profile to AAP if sedation is administered after proper training, and according to implemented guidelines [1]. In this issue of Digestive Diseases and Sciences, Goudra et al. [2] conducted a comparative meta-analysis evaluating respiratory complications of AAPor NAAP-administered sedation during advanced GI endoscopic procedures. The authors provide data with regard to 3018 advanced GI endoscopic procedures carried out using NAAP-administered sedation and 2374 AAP-administered procedures. Regarding non-advanced GI endoscopy, a prior populationbased analysis studying complications of sedation reported that the use of anesthesiologist services was associated with a higher complication frequency, specifically respiratory adverse events [3], a finding not supported by the data reported by Goudra et al. who described similar pooled hypoxia rates in patients undergoing advanced endoscopic procedures sedated with propofol, irrespective of administering provider, although the rate of airway interventions such as jaw thrust, chin lift, mask ventilation, or endotracheal intubation was higher in the AAP group. As AAPs administered higher doses of propofol, patient satisfaction and endoscopist satisfaction were increased if AAP-administered sedation was used. Satisfaction might have been further influenced by the observed preference for co-administration of adjuvants used in AAP sedation, whereas propofol alone was preferentially administered in the NAAP group. Nevertheless, higher dosages of propofol administered during GI sedation usually increase complication rates [4], particularly hypotension and bradycardia, which were not evaluated in the study by Goudra et al. It would have been interesting to see whether the observed beneficial satisfaction of AAP sedation came at the expense of higher cardiovascular adverse events. Limitations to the study of Goudra et al. include the exclusive selection of non-randomized prospective trials for analysis as there exist no randomized control trials comparing hypoxia, airway intervention rates, and patient satisfaction after endoscopic sedation. Furthermore, potential biases such as differences in baseline patient and endoscopist characteristics were not analyzed. While NAAP sedation for GI endoscopy has successfully and safely been introduced to countries such as Germany [5], it remains unlikely that NAAP will be soon introduced in other countries despite literature supporting its safety and lower cost, due to financial and political issues. When moderate sedation is provided by a US endoscopist, a separate charge for this service is not permitted & Kilian Friedrich Kilian.Friedrich@med.uni-heidelberg.de

Sa1669 Endoscopist Characteristics and Quality Indicators in Pediatric Colonoscopy

Sa1669 Endoscopist Characteristics and Quality Indicators in Pediatric Colonoscopy

Prevalence and risk factors for musculoskeletal injuries related to endoscopy

There are limited data regarding work-related injury among endoscopists. To define the prevalence of endoscopy-related musculoskeletal injuries and their impact on clinical practice and to identify physician and practice characteristics associated with their development. Survey. Electronic survey of active members of the American Society for Gastrointestinal Endoscopy with registered e-mail addresses. Physicians who currently or ever performed endoscopy and responded to the survey between February 2013 and November2013. A 25-question, self-administered, electronic survey. Prevalence, location, and ramifications of work-related injuries and endoscopist characteristics and workload parameters associated with endoscopy-related injury. The survey was completed by 684 endoscopists. Of those, 362 (53%) experienced a musculoskeletal injury perceived definitely (n= 204) or possibly (n= 158) related to endoscopy. Factors associated with a higher rate of endoscopy-related injury included higher procedure volume (>20 cases/week; P < .001), greater number of hours per week spent performing endoscopy (>16 hours/week; P < .001), and total number of years performing endoscopy (P= .004). The most common sites of injury were neck and/or upper back (29%) and thumb (28%). Only 55% of injured endoscopists used practice modifications in response to injuries. Specific treatments included medications (57%), steroid injection (27%), physiotherapy (45%), rest (34%), splinting (23%), and surgery (13%). Self-reported data of endoscopy-related injury. Among endoscopists there is a high prevalence of injuries definitely or potentially related to endoscopy. Higher procedure volume, more time doing endoscopy per week, and cumulative years performing endoscopy are associated with more work-related injuries.

Mo1200 Demographic and Behavioural Predictors of Ongoing Adherence to Faecal Occult Blood Test Screening for Colorectal Cancer

cancers as those diagnosed in patients with colonoscopy between 6-36 months previously, and all others to have detected cancers. The presence of diverticulosis was identified through diagnosis codes during the previous three years. We compared the prevalence of diverticulosis in interval and detected cancers according to tumor location. The independent association of diverticulosis was then evaluated in a logistic model with generalized estimating equations accounting for clustering by endoscopists and stratified by tumor location. The model adjusted for demographics, comorbidity and endoscopist characteristics. Results: We identified 57,839 patients, including 53,647 with detected cancers and 4,192 (7.2%) with interval cancers. A previous diagnosis of diverticulosis was documented in 69.3% of interval cancers and 26.9% of detected cancers (p,0.001). In all segments of the colon, the prevalence of a diverticulosis diagnosis was higher in interval cancers than in detected cancers (Table) (p,0.001 for all comparisons). In the multivariable analysis, diverticulosis was strongly associated with interval cancer risk in both the proximal colon (cecum to splenic flexure) (Adjusted Odds Ratio (AOR) 5.43, 95% CI 4.98-5.93) and distal colon (descending, sigmoid) (AOR 6.59, CI 5.65-7.69). Conclusions: A previous diagnosis of diverticulosis is a strong risk factor for interval colon cancer regardless of tumor location. Given the greater prevalence and extent of diverticulosis in the left colon, it suggests that factors other than impaired visualization of neoplasia between diverticuli are involved in the pathogenesis of interval cancer. Prevalence of Diverticulosis

The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: a population‐based study

Eosinophilic oesophagitis (EoE) has evolved from a supposedly rare entity to one whose incidence rates are approaching that of inflammatory bowel disease. The factors responsible for this apparent increase in the incidence remain obscure. To assess various endoscopist and pathologist factors that might affect the frequency of EoE being detected in a well-defined North American population. Increased endoscopist and pathologist awareness has contributed to the increased clinical recognition of EoE. Cases of EoE were identified systematically using population-based pathology and endoscopy databases from January 2004 to December 2008 in Calgary, Canada (population 1.25 million). EoE frequency was estimated with time trend analysis. Characteristics of individual endoscopists (n = 45) were compared with diagnostic rates. Crude population incidence of EoE increased from 2.1 per 10(5) in 2004 to 11.0 per 10(5) in 2008: an annual increase of 39% (P < 0.0001). The frequency in men was 4.5 times higher than in women (95% CI: 3.51-5.76). In patients presenting with dysphagia oesophageal biopsy rates increased from 17.0% in 2004 to 41.3% of EGDs in 2008: an annual rise of 26% (P < 0.0001). On multivariate regression analysis, those endoscopists with higher biopsy rates were more likely to make the diagnosis of EoE (P = 0.008). To include or exclude the diagnosis, typical histological features of EoE were reported more often by pathologists in 2008 as compared to 2004 (P = 0.01 & P < 0.0001 respectively). The incidence of eosinophilic oesophagitis continues to rise in the general population, in part due to increasing oesophageal biopsy rates and a more detailed histological evaluation of specimens. The biopsy rate of an endoscopist is an indicator for a higher diagnostic yield.

Evaluation of Endoscopist and Pathologist Factors Affecting the Incidence of Microscopic Colitis

Microscopic colitis (MC) is an umbrella term for collagenous colitis (CC) and lymphocytic colitis (LC). The incidence of these diseases is increasing for unclear reasons. To identify factors that may impact diagnosis rates of MC in a North American population. Population-based pathology and endoscopy databases were searched to identify all cases of MC and the number of lower endoscopy (LE) procedures performed over a five-year period (January 2004 to December 2008) in a catchment area of 1.2 million people. Endoscopist characteristics were compared with diagnostic rates. MC incidence increased from 1.68 per 10,000 in 2004, to 2.68 per 10,000 in 2008, with an average annual increase of 12% per year (95% CI 7% to 16%; P<0.0001). The incidence rate of LC increased but the rate of CC remained stable over the study period. Approximately one-half of the cases were probable and one-half were definite based on pathologists' reports - a proportion that remained stable over time. The number of LEs per population increased by 4.6% annually over the study period (95% CI 2.8% to 6.4%; P<0.0001), and biopsy rates in LE for MC indications (eg, unexplained diarrhea, altered bowel habits) increased over time (3.4% annual increase [95% CI 1.8% to 6.0%]; P<0.001). Endoscopists with an academic practice, gastroenterologists and those with lower annual endoscopy volumes were more likely to make a diagnosis of MC. The incidence of MC is rising due to increased diagnosis of LC, while CC incidence remains stable. Patients with MC symptoms have stable endoscopy rates but are being biopsied more often. Physician training, practice type and endoscopy volume impact the diagnostic rates of MC.

Isn’t It Time to Stop Talking About Colonoscopy Quality and Start Doing Something About It?

Colonoscopy is central to one of the great success stories of the war on cancer. Although colorectal cancer (CRC) is still the second leading cause of cancer death in the United States, both the incidence and mortality has been declining by 2–3% per year for the last 15 years. This decline has been largely attributed to increasing rates of CRC screening. Although guidelines list other screening options (stool tests/imaging/flexible sigmoidoscopy) colonoscopy has become the dominant CRC screening test in the US while fecal testing has declined slowly, and flexible sigmoidoscopy has declined markedly over the last decade [1]. Colonoscopy is widely viewed in the US as the single best test for both detection and removal of pre-cancerous lesions. The efficacy of colonoscopic polypectomy was initially highlighted by the National Polyp Study (NPS), which estimated a 76–90% reduction in incidence of colorectal cancer after polyp removal [2]. Subsequent studies [3], which often have not shown as robust a CRC risk reduction as the NPS, have highlighted the importance of the quality of colonoscopy as a critical element in its efficacy. There is compelling evidence that colonoscopy quality is highly variable [4] and guidelines for a high-quality colonoscopy have been published [5], but in the end, quality needs to be assessed by whether a test accomplishes its primary goal. In the case of colonoscopy, directly measuring whether a colonoscopy has prevented a CRC is not feasible in the short term. Instead, more measurable surrogates of quality such as cecal intubation rates, withdrawal times, and particularly adenoma detection rates (ADR) have been used as quality measures. Kaminski et al. found that ADR appeared to be an acceptable surrogate for real colonoscopy quality as it was an independent predictor of the risk of interval colorectal cancer [6]. Numerous studies have demonstrated marked (twofold to sixfold) variability in ADRs among endoscopists working in the same endoscopy unit [4]. Although some of this variability might be due to patient factors such as age, gender, or adequacy of bowel preparation, individual endoscopists appear to be the single most predictive factor in adenoma detection [7], implying that the efficacy of colonoscopy is highly dependent on the individual skill of the endoscopist. To compound matters, Brenner [8] and Lakoff [9] presented data from Germany and Canada that showed that while colonoscopy does decrease the rate of distal CRCs by approximately 67–79%, it was not at all protective for proximal colon cancers, suggesting that there is a substantial need for improvement in colonoscopy quality by all endoscopists. The variability in colonoscopy quality among providers and the dubious utility of colonoscopy in preventing rightsided colon cancers have called into question the overall efficacy of colonoscopy as it is used today and would seem to be a clear mandate for endoscopists and professional organizations to critically examine colonoscopist performance and address areas in need of improvement. Is it possible to identify provider characteristics that are predictive of quality procedures? If so, can we incorporate these findings into endoscopic training, continuing medical education and ultimately ongoing quality assurance programs? Any such efforts are dependent, in part, on an understanding of the relationships between endoscopist characteristics and quality outcomes and there is growing literature examining one aspect of this relationship—the S. G. Patel D. J. Ahnen (&) Department of Medicine, Division of Gastroenterology, Denver VA Medical Center and University of Colorado School of Medicine, Denver, CO, USA e-mail: dennis.ahnen@ucdenver.edu