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CC BY-NC-ND 4.0 · Endosc Int Open 2023; 11(01): E117-E127
DOI: 10.1055/a-1994-6084
Original article

Colonoscopy quality improvement after initial training: A cross-sectional study of intensive short-term training

Anna Lisa Schult 
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
 2   Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
,
Geir Hoff
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
 3   Institute of Clinical Medicine, University of Oslo, Oslo, Norway
 4   Department of Research and Development, Telemark Hospital Trust, Skien, Norway
,
Øyvind Holme
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
 5   Institute of Health and Society, University of Oslo, Oslo, Norway
 6   Department of Medicine, Sørlandet Hospital Trust, Kristiansand, Norway
,
Edoardo Botteri
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
 7   Department of Research, Cancer Registry of Norway, Oslo, Norway
,
Birgitte Seip
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
 8   Department of Medicine, Vestfold Hospital, Tønsberg, Norway
,
Kristin Ranheim Randel 
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
,
Ole Darre-Næss
 2   Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
,
Tanja Owen
 9   Department of Medicine, Østfold Hospital Trust, Grålum, Norway
,
Jens Aksel Nilsen
 2   Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
,
Dung Hong Nguyen
 9   Department of Medicine, Østfold Hospital Trust, Grålum, Norway
,
Kristin Johansen
 1   Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
,
Thomas de Lange 
10   Department of Medicine and Emergencies Sahlgrenska University Hospital-Mölndal, Region Västra Götaland, Sweden
11   Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
12   Department of Medical Research, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
› Author AffiliationsNorwegian Parliament

TRIAL REGISTRATION: Cross-sectional study NCT01538550 at ClinicalTrials.gov (http://www.clinicaltrials.gov/)
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Abstract

Background and study aims High-quality is crucial for the effectiveness of colonoscopy and can be achieved by high-quality training and verified with assessment of key performance indicators (KPIs) for colonoscopy such as cecum intubation rate (CIR), adenoma detection rate (ADR) and adequate polyp resection. Typically, trainees achieve adequate CIR after 275 procedures, but little is known about learning curves for KPIs after initial training.

Methods This cross-sectional study includes work-up colonoscopies after a positive screening test with fecal occult blood testing (FIT) or sigmoidoscopy, performed by either trainees after 300 training colonoscopies or by consultants. Outcome measures were KPIs. We assessed inter-endoscopist variation in trainees and learning curves for trainees as a group. We also compared KPIs for trainees and consultants as a group. 

Results Data from 6,655 colonoscopies performed by 21 trainees and 921 colonoscopies performed by 17 consultants were included. Most trainees achieved target standards for main KPIs. With time, trainees shortened cecum intubation time and withdrawal time without decreasing their ADR, reduced the proportion of painful colonoscopies, and increased the adequate polyp resection rate (all P < 0.01). Compared to consultants, trainees had higher CIR (97.7 % vs. 96.3 %, P = 0.02), ADR after positive FIT (57.6 % vs. 50.3 %, P < 0.01), and proximal ADR after sigmoidoscopy screening (41.1 % vs. 29.8 %; P < 0.01), higher adequate polyp resection rate (94.9 % vs. 93.1 %, P = 0.01) and fewer serious adverse events (0.65 % vs. 1.41 %, P = 0.02).

Conclusions Trainees performed high-quality colonoscopies and achieved international target standards. Several KPIs continuously improved after initial training. Trainees outperformed consultants on several KPIs.

Supplementary material



Publication History

Received: 24 June 2022

Accepted after revision: 06 December 2022

Accepted Manuscript online:
07 December 2022

Article published online:
26 January 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. United Europ Gastroenterol J 2017; 5: 309-3342
    CrossrefPubMedGoogle Scholar
  • 2 Rex DK, Schoenfeld PS, Cohen J. et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31-53
    CrossrefPubMedGoogle Scholar
  • 3 Rex DK, Bond JH, Winawer S. et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002; 97: 1296-1308
    CrossrefPubMedGoogle Scholar
  • 4 Gavin DR, Valori RM, Anderson JT. et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
    Google Scholar
  • 5 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
    Google Scholar
  • 6 Robertson DJ, Lieberman DA, Winawer SJ. et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014; 63: 949-9567
    Google Scholar
  • 7 Tollivoro TA, Jensen CD, Marks AR. et al. Index colonoscopy-related risk factors for postcolonoscopy colorectal cancers. Gastrointest Endosc 2019; 89: 168-176 e1638
    Google Scholar
  • 8 Shaukat A, Rector TS, Church TR. et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology 2015; 149: 952-957
    CrossrefPubMedGoogle Scholar
  • 9 Ekkelenkamp VE, Dowler K, Valori RM. et al. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013; 19: 2355-2361
    CrossrefPubMedGoogle Scholar
  • 10 Faulx AL, Lightdale JR. ASGE Standard of Practice Committee. et al. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85: 273-281
    Google Scholar
  • 11 Rees CJ, Thomas Gibson S, Rutter MD. et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65: 1923-1929
    Google Scholar
  • 12 Patwardhan VR, Feuerstein JD, Sengupta N. et al. Fellowship colonoscopy training and preparedness for independent gastroenterology practice. J Clin Gastroenterol 2016; 50: 45-51
    Google Scholar
  • 13 Sedlack RE, Coyle WJ. Group ACE Research Group. Assessment of competency in endoscopy: establishing and validating generalizable competency benchmarks for colonoscopy. Gastrointest Endosc 2016; 83: 516-523 e511
    Google Scholar
  • 14 Ward ST, Mohammed MA, Walt R. et al. An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014; 63: 1746-1754
    Google Scholar
  • 15 Rajendran A, Pannick S, Thomas-Gibson S. et al. Systematic literature review of learning curves for colorectal polyp resection techniques in lower gastrointestinal endoscopy. Colorectal Dis 2020; 22: 1085-1100
    CrossrefPubMedGoogle Scholar
  • 16 Nasca TJ, Philibert I, Brigham T. et al. The next GME accreditation system--rationale and benefits. N Engl J Med 2012; 366: 1051-1056
    CrossrefPubMedGoogle Scholar
  • 17 Ekkelenkamp VE, Koch AD, de Man RA. et al. Training and competence assessment in GI endoscopy: a systematic review. Gut 2016; 65: 607-61518
    Google Scholar
  • 18 Randel KR, Schult AL, Botteri E. et al. Colorectal cancer screening with repeated fecal immunochemical test versus sigmoidoscopy: baseline results from a randomized trial. Gastroenterology 2021; 160: 1085-1096 e1085
    CrossrefPubMedGoogle Scholar
  • 19 Waschke KA, Anderson J, Macintosh D. et al. Training the gastrointestinal endoscopy trainer. Best Pract Res Clin Gastroenterol 2016; 30: 409-419
    Google Scholar
  • 20 Nagtegaal ID, Odze RD, Klimstra D. et al. The 2019 WHO classification of tumours of the digestive system. Histopathology 2020; 76: 182-188
    CrossrefPubMedGoogle Scholar
  • 21 Hoff G, Bretthauer M, Huppertz-Hauss G. et al. The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres. Scand J Gastroenterol 2006; 41: 481-487
    CrossrefPubMedGoogle Scholar
  • 22 Robertson DJ, Lee JK, Boland CR. et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2017; 152: 1217-1237 e1213
    CrossrefPubMedGoogle Scholar
  • 23 Bretthauer M, Skovlund E, Grotmol T. et al. Inter-endoscopist variation in polyp and neoplasia pick-up rates in flexible sigmoidoscopy screening for colorectal cancer. Scand J Gastroenterol 2003; 38: 1268-1274
    CrossrefPubMedGoogle Scholar
  • 24 Gianotti RJ, Oza SS, Tapper EB. et al. A longitudinal study of adenoma detection rate in gastroenterology fellowship training. Digest Dis Sci 2016; 61: 2831-2837
    CrossrefPubMedGoogle Scholar
  • 25 Lee TJ, Blanks RG, Rees CJ. et al. Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England. Endoscopy 2013; 45: 20-26
    PubMedGoogle Scholar
  • 26 Kawamura T, Takeuchi Y, Asai S. et al. A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study). Gut 2018; 67: 1950-1957
    Google Scholar
  • 27 McLachlan SA, Clements A, Austoker J. Patientsʼ experiences and reported barriers to colonoscopy in the screening context -- a systematic review of the literature. Patient Educ Couns 2012; 86: 137-146
    CrossrefPubMedGoogle Scholar
  • 28 Pylvanainen K, Kairaluoma M, Mecklin JP. Compliance and satisfaction with long-term surveillance in Finnish HNPCC families. Fam Cancer 2006; 5: 175-178
    CrossrefPubMedGoogle Scholar
  • 29 Cadoni S, Leung FW. Water-assisted colonoscopy. Curr Treatment Options Gastroenterol 2017; 15: 135-154
    CrossrefPubMedGoogle Scholar
  • 30 Garborg KK, Loberg M, Matre J. et al. Reduced pain during screening colonoscopy with an ultrathin colonoscope: a randomized controlled trial. Endoscopy 2012; 44: 740-746
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Jetelina KK, Yudkin JS, Miller S. et al. Patient-reported barriers to completing a diagnostic colonoscopy following abnormal fecal immunochemical test among uninsured patients. J Gen Int Med 2019; 34: 1730-173632
    CrossrefPubMedGoogle Scholar
  • 32 Muthukrishnan M, Arnold LD, James AS. Patientsʼ self-reported barriers to colon cancer screening in federally qualified health center settings. Prev medicine Rep 2019; 15: 100896
    CrossrefPubMedGoogle Scholar
  • 33 Rutter MD, Nickerson C, Rees CJ. et al. Risk factors for adverse events related to polypectomy in the English Bowel Cancer Screening Programme. Endoscopy 2014; 46: 90-97
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Hoff G, Botteri E, Huppertz-Hauss G. et al. The effect of train-the-colonoscopy-trainer course on colonoscopy quality indicators. Endoscopy 2021; 53: 1229-1234
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Kaminski MF, Anderson J, Valori R. et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomised trial. Gut 2016; 65: 616-624
    Google Scholar