Proportion Of Colonoscopies Research Articles

Endoscopic Detection of Proximal Serrated Lesions and Pathologic Identification of Sessile Serrated Adenomas/Polyps Vary on the Basis of Center

We investigated rates of detection of proximal serrated lesions in a cohort of average-risk patients undergoing screening colonoscopies. We reviewed results from screening colonoscopies performed by attending gastroenterologists at 32 endoscopy centers from 2008-2010. Pathology slides were interpreted at the individual centers. For this analysis, serrated lesions included hyperplastic polyps larger than 10 mm, those interpreted as sessile serrated adenomas (or sessile serrated polyp), and traditional serrated adenomas. Rates of detection for conventional adenomas and serrated lesions were compared among centers. A total of 5778 lesions were detected in 7215 screening colonoscopies. Of the 5548 lesions with pathology results, 3008 (54.2%) were conventional adenomas, 350 (6.3%) were serrated, and 232 (4.2%) were proximal serrated. The proportion of colonoscopies with at least 1 proximal serrated lesion was 2.8% (range among centers, 0%-9.8%). The number of serrated lesions per colonoscopy ranged from 0.00-0.11 (average, 0.05 ± 0.25). Overall lesion detection rates correlated with proximal serrated lesion detection rates (R = 0.91, P < .0001); conventional adenoma and proximal serrated lesion detection rates also correlated (R = .43, P = .025). The detection rate of proximal serrated lesions differed significantly among centers (P < .0001); odds ratios for detection ranged from 0-0.79. Some centers' pathologists never identified proximal serrated lesions as sessile serrated adenomas/polyps. In an average-risk screening cohort, detection of proximal serrated lesions varied greatly among endoscopy centers. There was also substantial variation among pathologists in identification of sessile serrated adenomas/polyps. Nationally, a significant proportion of proximal serrated lesions may be missed during colonoscopy examination or incorrectly identified during pathology assessment. ClinicalTrials.gov Number: NCT00855348.

Improving Measurement of Adenoma Detection: The Indiana University Experience

Purpose: The adenoma detection rate (ADR) is a validated measure of colonoscopy quality. However, the restriction to screening colonoscopy may be a barrier to uptake. Knowledge of the ADR in nonscreening groups, and its relation to the screening ADR, might allow expansion of the ADR to include surveillance and diagnostic indications and simplify calculations. The aims of this study were: (1) to study the correlation between ADRs for screening, surveillance, and diagnostic indications, and (2) explore the association of the screening ADR with an overall ADR inclusive of all colonoscopy indications. Methods: We performed a retrospective review of a prospectively updated database at a University hospital and associated ambulatory surgery center endoscopy units. Colonoscopies performed by 20 attending gastroenterologists on patients aged ≥ 50 between 1/1/1999 and 4/30/2012 were reviewed. ADR was defined as the proportion of colonoscopies in which at least one adenoma was detected. Pearson correlation coefficients were calculated to evaluate the association of the ADRs of the three colonoscopy indication categories (screening, surveillance, or diagnostic). The second study aim was addressed using a bootstrap analysis. We calculated the Pearson correlation coefficient of screening ADR with overall ADR, and estimated the overall ADR corresponding to screening ADRs of 15%, 20%, 25%, 30%, 40%, and 50% for patient populations with varying proportions of screening, surveillance, and diagnostic colonoscopies. Results: 21,766 colonoscopies were included; indication screening in 7,434 (34.2%), surveillance in 8,338 (38.3%), and diagnostic in 5,994 (27.5%). Endoscopist ADRs are shown in Table 1. A consistent pattern was observed, with ADR highest for surveillance, followed by screening, then diagnostic indications. ADRs for screening and surveillance, and screening and diagnostic indications, were significantly correlated (R=0.77, p<0.0001; R=0.56, p=0.01, respectively). The correlation between ADRs for surveillance and diagnostic was borderline significant (R=0.42, p=0.07). For males, screening ADR of 25% corresponded to surveillance ADR of 31.9% (95% CI: 24.8%-38.9%); for females, ADR of 15% corresponded to a surveillance ADR of 24.3% (18.3%-30.5%). The corresponding diagnostic ADRs were 17.0% (12.4%-21.6%) and 15.4% (11.5%-19.3%), respectively. The results of the bootstrap analysis exploring the association of screening ADR with the overall ADR are shown in Table 2.Table 1: ADRs for screening, surveillance, and diagnostic colonoscopiesTable 2: Screening ADR-Overall ADR associationsConclusion: ADRs for screening, surveillance, and diagnostic colonoscopy are correlated and can be used to derive a simplified overall ADR inclusive of all colonoscopy indications. Our findings provide a framework for endoscopists to calculate their ADRs in different practice settings.

PTU-014 Impact of Primary Care Education on the Two Week wait Referral Process for GI Cancers

IntroductionThe two week wait referral process was introduced in 2000 to improve cancer prognosis in the UK with an anticipated 20% reduction in cancer-related deaths. The cancer yield has in...

Endoscopist specialty is associated with colonoscopy quality

BackgroundSome studies have shown that endoscopist specialty is associated with colorectal cancers missed by colonoscopy. We sought to examine the relationship between endoscopist specialty and polypectomy rate, a colonoscopy quality indicator. Polypectomy rate is defined as the proportion of colonoscopies that result in the removal of one or more polyps.MethodsA cross-sectional study was conducted of endoscopists and their patients from 7 Montreal and 2 Calgary endoscopy clinics. Eligible patients were aged 50–75 and covered by provincial health insurance. A patient questionnaire assessed family history of colorectal cancer, history of large bowel conditions and symptoms, and previous colonoscopy. The outcome, polypectomy status, was obtained from provincial health administrative databases. For each city, Bayesian hierarchical logistic regression was used to estimate the odds ratio for polypectomy comparing surgeons to gastroenterologists. Model covariates included patient age, sex, family history of colorectal cancer, colonoscopy indication, and previous colonoscopy.ResultsIn total, 2,113 and 538 colonoscopies were included from Montreal and Calgary, respectively. Colonoscopies were performed by 38 gastroenterologists and 6 surgeons in Montreal, and by 31 gastroenterologists and 5 surgeons in Calgary. The adjusted odds ratios comparing surgeons to gastroenterologists were 0.48 (95% CI: 0.32–0.71) in Montreal and 0.73 (95% CI: 0.43–1.21) in Calgary.ConclusionsAn association between endoscopist specialty and polypectomy was observed in both cities after adjusting for patient-level covariates. Results from Montreal suggest that surgeons are half as likely as gastroenterologists to remove polyps, while those from Calgary were associated with a wide, non-significant Bayesian credible interval. However, residual confounding from patient-level variables is possible, and further investigation is required.

Mo1113 Impact of Primary Care Education on the Two Week Wait Referral Process for GI Cancers

Introduction The two week wait referral process was introduced in 2000 to improve cancer prognosis in the UK with an anticipated 20% reduction in cancer-related deaths. The cancer yield has in fact been reported as 9–16%. Referrals should be made on the basis of NICE guidance. Previous studies have highlighted that as few as 53% of referrals from Primary Care have been within NICE guidance. The Government’s nine-week “Be clear on cancer” campaign launched in January 2012 via online, TV and radio adverts to increase public awareness of bowel cancer symptoms impacted our service. The proportion of colonoscopies done for the two-week wait service increased from 27% to 48% in the month after the campaign. It is clearly important that referrals made are appropriate to justify this service requirement. This study compares referrals and outcomes before and after a GP education session. Methods Two week wait GI Referrals to the Horton General Hospital between December 2011 and February 2012 were assessed. A presentation was given to Primary Care Practitioners in May highlighting NICE guidance and referrals were re-audited in June 2012. Results 100% of referrals met the two week wait target (to clinic, CT scan or endoscopy) and the mean time to first test was 9 days. The results are summarised below. 24% of Upper GI referrals did not meet NICE guidance, mostly patients referred with anaemia above the referral threshold or for dyspepsia without concerning features. The cancer pick-up was 8.6% (2 oesophageal, 2 gastric and 4 pancreatico-biliary). 26% of Lower GI referrals were non-compliant with guidance (mostly due to rectal bleeding or change in bowel habit shorter than the required time). Cancer pick-up was 5.1%. All but one GI cancer was detected in appropriately referred patients. In June 2012 compliance improved to 81% of upper GI and 79% of lower GI referrals. Reasons for referral outside NICE guidance were similar to the previous cohort. Cancer detection rose to 12.9% for Upper GI and 8.6% for Lower GI cancers. All cancers in the second audit were in appropriately referred patients. Conclusion The study highlights the importance of communication with Primary Care Practitioners who are responsible for referrals for GI cancer exclusion. There have been previous education sessions but despite this there remains an advantage in re-stating the message and keeping regular contact. The cancer detection rate improved with better compliance with NICE guidance and may indicate the value of adhering to this guidance. Larger studies are required to validate this. Disclosure of Interest None Declared

Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis

Propofol for colonoscopy is largely administered by anesthesiologists or anesthesiology nurses in the United States (US) and Europe. Endoscopist-directed administration of propofol (EDP) by nonanesthesiologists has recently been proposed, with potential savings of anesthetist reimbursement costs. We aimed to assess potential EDP-related benefit in a screening setting. In a Markov model the total number of screening and follow-up colonoscopies in a cohort of 100 000 US subjects were estimated. Anesthetist-assisted colonoscopy was compared with an EDP strategy. Model outputs were projected onto the 50 - 80-year-old US population, assuming 27 % as the current uptake for colonoscopy screening. Anesthetist costs were estimated using the mean reimbursement for the corresponding Medicare code (≥ 65-year-olds) and from commercial insurance information (50 - 64-year-olds). The proportion of colonoscopies with anesthesiologist assistance was estimated from the Medicare database. Mean nurse salary was used to estimate the cost of a 2-week EDP training. The absolute number of US endoscopists was estimated by inflating by 33 % the number of board-certified gastroenterologists. No EDP mortality was assumed in the reference scenario, and 0.0008 % mortality in the sensitivity analysis. US census data were adopted. Analogous inputs were used for France to assess EDP-related benefit in a European country. EDP training for 17 166 nurses (one for each US endoscopist) showed a cost of $ 47 million. Cost estimates for anesthesiologist assistance for colonoscopy were $ 95 (Medicare) and $ 450 (non-Medicare commercial insurance), with 34.8 % of colonoscopies requiring anesthesiologist assistance. US implementation of an EDP policy showed a 10-year saving of $ 3.2 billion (Monte Carlo analysis 5 - 95 % percentiles $ 2.7 - $ 11.9 billion). In the sensitivity analysis, assuming 50 % of colonoscopies were anesthetist-assisted showed an EDP benefit of $ 4.6 billion. Assuming a 0.0008 % mortality rate, the incremental cost - effectiveness of anesthetist-assisted colonoscopy versus an EDP policy was $ 1.5 million per life-year gained, supporting EDP as the optimal choice. A 31-fold increase of EDP-related mortality or a 17-fold cost reduction for anesthetist-assisted colonoscopy was required for EDP to become not cost-effective in this scenario. Implementation of an EDP policy in France, within a guaiac-fecal occult blood test (g-FOBT) screening program, was estimated to save € 0.8 billion in 10 years. The absolute economic benefit of EDP implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in the US and €0.8 billion in France. The impact of an eventual EDP-related mortality on EDP cost - effectiveness seems marginal. The huge economic and medical resources entailed by anesthetist-assisted colonoscopy could be more efficiently invested in other clinical fields.

725 Measurement of Polypectomy Rate Using Administrative Claims Data With Validation Against the Adenoma Detection Rate

Among the quality indicators for colonoscopy the adenoma detection rate (ADR) has been advocated as the most important. However, ADR is not available at the time of the procedure, cannot be calculated from claims data, and is limited by the need to correlate pathology with endoscopy reports. Polypectomy rate (PR), the proportion of colonoscopies at which at least one polyp was removed, has been shown to correlate with ADR and be associated with protection from right sided colon cancer. PR may be calculable from administrative claims data but this has not been validated against ADR.

Different Screening Definitions have Little Impact on Polypectomy Rate Estimates

Polypectomy rate is a surrogate quality indicator for screening colonoscopy. Various methods for identifying screening colonoscopies have been used and it is unclear how different definitions affect the estimated polypectomy rate. To estimate polypectomy rates and how they vary according to the definition of a screening colonoscopy, using patient- and endoscopist-reported indications. A cross-sectional analysis of endoscopists and their patients 50 to 75 years of age who underwent colonoscopy was conducted. Based on questionnaire responses, four patient indications were derived: perceived screening; perceived nonscreening; medical history indicating nonscreening; and combination of the three indications. Endoscopist indication was derived from a questionnaire completed immediately after colonoscopy. Polypectomy status was obtained from provincial physician billing records. Polypectomy rates were computed, while accounting for physician and hospital level clustering, using all four patient indications, endoscopist indication, and the agreement between patient and endoscopist indications. The effect of indications on polypectomy rate was estimated adjusting for age, sex and family history of colorectal cancer. A total of 2134 patients and 45 endoscopists were included. The proportion of colonoscopies classified as screening according to the nine indications ranged from 32.2% to 70.9%. Polypectomy rates ranged between 22.6% and 26.2% for screening colonoscopy, and between 27.1% and 30.8% for nonscreening colonoscopy. Adjusted ORs for indication ranged between 0.74 and 0.94. Although the proportion of colonoscopies identified as screening varied considerably among the indications, the estimated polypectomy rates were similar. The findings suggest that the way screening is defined does not greatly affect the estimates of polypectomy rate.

MiraLAX vs. Golytely: is there a significant difference in the adenoma detection rate?

In recent clinical trials (RCT) of bowel preparation, Golytely was more efficacious than MiraLAX. We hypothesised that there is a difference in adenoma detection between Golytely and MiraLAX. To compare the adenoma detection rate (ADR) between these bowel preparations, and to identify independent predictors of bowel preparation quality and adenoma detection. This was a post hoc analysis of an RCT that assessed efficacy and patient tolerability of Golytely vs. MiraLAX/Gatorade in average risk screening colonoscopy patients. Bowel preparation quality was measured with the Boston Bowel Preparation Scale (BBPS). An excellent/good equivalent BBPS score was defined as ≥ 7. Polyp pathology review was performed. ADR was defined as the proportion of colonoscopies with an adenoma. Univariate and multivariate analyses were conducted. One hundred and ninety patients were prospectively enrolled (87 MiraLAX, 103 Golytely). Golytely had a higher rate of a BBPS score ≥ 7 (82.5% vs. MiraLAX 67.8%, P=0.02). The ADR in the Golytely cohort was 26.2% (27/103), and was 16.1% (14/87) for MiraLAX (P = 0.091). On multivariate analyses, Golytely was 2.13 × more likely to be associated with a BBPS ≥ 7 (95% CI 1.05-4.32, P = 0.04) and 2.28 × more likely to be associated with adenoma detection (95% CI 1.05-4.98, P = 0.04) than MiraLAX. Golytely was more efficacious than MiraLAX in bowel cleansing, and was independently associated with both bowel prep quality (BBPS ≥ 7) and higher adenoma detection. Golytely should be used as first line for bowel prep for colonoscopy. Studies with larger populations are needed to confirm these results.

Prevalence and Variable Detection of Proximal Colon Serrated Polyps during Screening Colonoscopy

Purpose: Studies suggest that colonoscopy may have a greater protective effect for distal colorectal cancer (CRC) than proximal CRC. Serrated polyps are frequently located in the proximal colon, can be missed during colonoscopy, and may progress to CRC via the serrated pathway. The aims of this study were to determine the prevalence of proximal serrated polyps, and compare the proximal serrated polyp detection rates of individual endoscopists in a large cohort of average-risk patients undergoing screening colonoscopy. Methods: Screening colonoscopies performed by 15 attending gastroenterologists at two academic endoscopy units between 2000 and 2009 were reviewed. Individual endoscopist detection rates for adenomas and serrated polyps were calculated. Pearson correlation coefficients were calculated to evaluate the associations of adenoma and proximal serrated polyp detection rates. Logistic regression was used to compare the endoscopists for the detection of at least 1 serrated polyp in the proximal colon. Results: A total of 11,049 polyps were detected in 6681 colonoscopies (adenomas: 5637, 51%; serrated: 3984, 36%; proximal serrated: 1238, 11%). The overall proportion of colonoscopies with at least one proximal serrated polyp was 13% and ranged from 1% to 18% for individual endoscopists. Proximal serrated polyp detection rates per colonoscopy ranged from 0.01 to 0.26. Adenoma and proximal serrated polyp detection rates per colonoscopy were strongly correlated (R=0.76, p=0.0005). The odds of detecting at least one proximal serrated polyp for individual endoscopists ranged from 0.05 to 0.67 compared to the highest level detector. Endoscopist (p<0.0001), but not patient age (p=0.76) or patient gender (p=0.95), was strongly associated with proximal serrated polyp detection. Conclusion: In this average-risk screening cohort, the detection of proximal serrated polyps was highly variable and endoscopist-dependent. A significant proportion of proximal serrated polyps may be missed during colonoscopy. This highlights the importance of a high quality colonoscopy to allow the detection and resection of all polyps with neoplastic potential.

Prevalence and Variable Detection of Proximal Colon Serrated Polyps During Screening Colonoscopy

Colonoscopy may have a greater protective effect for distal colorectal cancer (CRC) than proximal CRC. Serrated polyps are frequently located in the proximal colon, can be missed during colonoscopy, and may progress to CRC. We investigated the prevalence and endoscopist detection rates of proximal serrated polyps in a large cohort of average risk patients undergoing screening colonoscopy. Screening colonoscopies performed by 15 attending gastroenterologists at 2 academic endoscopy units between 2000 and 2009 were reviewed. Serrated polyps included hyperplastic polyps, sessile serrated adenomas, and traditional serrated adenomas. Endoscopist-level detection rates for adenomas and serrated polyps were calculated. Pearson correlation coefficients were calculated to evaluate the associations of adenoma and proximal serrated polyp detection rates. Logistic regression was used to compare endoscopists' detection rates. A total of 11,049 polyps were detected in 6681 colonoscopies (adenomas: 5637, 51%; serrated: 3984, 36%; proximal serrated: 1238, 11%). The proportion of colonoscopies with at least one proximal serrated polyp was 13% (range 1%-18%). Proximal serrated polyp detection rates per colonoscopy ranged from 0.01 to 0.26. Adenoma and proximal serrated polyp detection rates per colonoscopy were strongly correlated (R = 0.76, P = .0005). The odds of detecting at least one proximal serrated polyp for individual endoscopists ranged from 0.05 to 0.67 compared to the highest level detector. Endoscopist (P < .0001), but not patient age (P = .76) or gender (P = .95), was associated with proximal serrated polyp detection. In an average-risk screening cohort, the detection of proximal serrated polyps was highly variable and endoscopist dependent. A significant proportion of proximal serrated polyps may be missed during colonoscopy. High-quality colonoscopy is important for the detection and resection of all polyps with neoplastic potential.

Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: A randomized trial of patients referred for colonoscopy

Objective. Use of magnetic endoscope imaging (MEI) during colonoscopy has the potential to ease caecal intubation and patient discomfort and to reduce dependence on sedation and/or analgesics (SAs). However, pain reduction by using MEI has not been demonstrated so far, probably because of the liberal use of SAs. The aim of the present study was to evaluate the effect of MEI on caecal intubation and patient pain during unsedated colonoscopy performed by experienced and inexperienced colonoscopists. Material and methods. A consecutive series of outpatients referred for colonoscopy were randomly allocated to examination with (imager group) or without (standard group) the use of MEI. Patients agreeing to SAs being given only on demand were included in the study. End-points were caecal intubation and pain, the latter to be graded by category on a form to be completed on the day after the examination. Results. The proportion of colonoscopies performed without SAs was similar when comparing imager and standard groups and experienced with inexperienced colonoscopists; altogether 367(88%) out of 419 colonoscopies. The caecal intubation rate was higher in the imager group (190/212 (90%)) than in the standard group (153/207(74%)) (p<0.001), both collectively and separately for experienced and inexperienced colonoscopists. A pain-reducing effect of MEI was shown only when performed by experienced colonoscopists, with severe pain in 10/137 patients (7.3%) in the imager group and 21/132 patients (16%) in the standard group (p=0.03). Conclusions. In colonoscopy without the routine use of SAs, MEI significantly improves the caecum intubation rate and reduces pain during the procedure.

Lack of Seasonal Variation in the Endoscopic Diagnoses of Crohn's Disease and Ulcerative Colitis

Conflicting data have been reported about the seasonal variation of inflammatory bowel diseases (IBD). The purpose of the present analysis was to assess the occurrence of seasonal variations in the endoscopic diagnosis of Crohn's disease (CD) and ulcerative colitis (UC). The Clinical Outcomes Research Initiative (CORI) uses a computerized endoscopic report generator to collect endoscopic data from 73 diverse practice sites throughout the United States. We utilized the CORI database to analyze the date-specific occurrence of colonoscopy, as well as the colonoscopic diagnoses of CD and UC. Time trends were analyzed by autocorrelation, linear, and nonlinear regression. Between January 2000 and December 2003, the number of colonoscopies increased 4.1-fold. The proportion of colonoscopies with a CD diagnosis fell by 28%, and the proportion of colonoscopies with a UC diagnosis fell by 50%. The occurrence of neither CD nor UC was shaped by any clear-cut seasonal periodicity. However, the trends of the two diseases revealed strikingly similar patterns with four resembling peaks superimposed on their monthly fluctuations. Endoscopic diagnosis of IBD is unaffected by any seasonal variation. The decline in the diagnostic rate of colonic IBD may reflect a relative increase in the utilization of colonoscopy for colon cancer screening. The similarity in the monthly fluctuations of both IBD suggests that their incidence or flare-ups may be influenced by identical exogenous risk factors.

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.