High quality of screening colonoscopy in Austria is not dependent on endoscopist specialty or setting

Background and study aim: International studies have shown differences in the outcome of screening colonoscopies related to the endoscopist’s specialty and setting of colonoscopy. The aim of this study was to investigate the impact of these two factors on quality parameters for screening colonoscopy in a quality-assured screening program.

Methods: Adenoma detection rate (ADR), cecal intubation rate (CIR), polypectomy rate, flat polyp detection rate, carcinoma detection rate, sedation rate, complication rates, and other parameters of 59 901 screening colonoscopies performed by 178 endoscopists were analyzed in relation to specialty (35 gastroenterologists: 10 066 colonoscopies [16.8 %]; 84 nongastroenterologists: 26 271 colonoscopies [43.9 %]; 59 surgeons: 23 564 [39.3 %]), and setting (hospital: 12 580 [21.6 %] colonoscopies; office: 45 781 [78.4 %] colonoscopies).

Results: The overall ADR was 20.5 % and the CIR was 95.6 %. The ADR did not show any statistical significance, either in relation to specialty or to setting. A significant difference in the CIR was found between hospital-based and office-based internists (98.5 % vs. 96.8 %, respectively; P  = 0.0005; odds ratio [OR] 2.2, 95 % confidence interval [CI] 1.4 – 3.4). Hospital-based internists had a significantly higher flat polyp detection rate (7.5 % vs. 4.1 %; P  = 0.02; OR 1.9, 95 %CI 1.1 – 3.2) and a significantly lower carcinoma detection rate (0.4 % vs. 0.6 %; P  = 0.03; OR 0.7, 95 %CI 0.5 – 1.0) compared with office-based internists. Complication rates were significantly lower among surgeons than among internists (0.1 % vs. 0.2 %; P  = 0.03; OR 0.5, 95 %CI 0.3 – 1.0).

Conclusion: Endoscopists participating in the Austrian quality assurance program offered high quality screening colonoscopy regardless of their specialty and setting. The implementation of a standardized quality program is therefore a decisive factor in quality improvement of screening colonoscopy.

^* for the Austrian Quality Assurance Working Group

• References

• 1 Baxter NN, Goldwasser MA, Paszat LF et al. Association of colonoscopy and death from colorectal cancer. Ann Internal Med 2009; 150: 1-8
• 2 Baxter NN, Warren JL, Barrett MJ et al. Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. J Clin Oncol 2012; 30: 2664-2669
• 3 Zauber AG, Winawer SJ, O’Brien MJ et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. New Engl J Med 2012; 366: 687-696
• 4 Winawer SJ, Zauber AG, Ho MN et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. New Engl J Med 1993; 329: 1977-1981
• 5 Brenner H, Chang-Claude J, Seiler CM et al. Interval cancers after negative colonoscopy: population-based case-control study. Gut 2012; 61: 1576-1582
• 6 Rex DK, Petrini JL, Baron TH et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006; 101: 873-885
• 7 Baxter NN, Sutradhar R, Forbes SS et al. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology 2011; 140: 65-72
• 8 Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. New Engl J Med 2010; 362: 1795-1803
• 9 de Jonge V, Sint Nicolaas J, Cahen DL et al. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc 2012; 75: 98-106
• 10 Jover R, Herraiz M, Alarcon O et al. Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening. Endoscopy 2012; 44: 444-451
• 11 Lee TJ, Rutter MD, Blanks RG et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012; 61: 1050-1057
• 12 Williams JE, Le TD, Faigel DO. Polypectomy rate as a quality measure for colonoscopy. Gastrointest Endosc 2011; 73: 498-506
• 13 Sanchez W, Harewood GC, Petersen BT. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy. Am J Gastroenterol 2004; 99: 1941-1945
• 14 Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. New Engl J Med 2006; 355: 2533-2541
• 15 Jover R, Zapater P, Polania E et al. Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies. Gastrointest Endosc 2013; 77: 381-389
• 16 Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007; 102: 856-861
• 17 Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. New Engl J Med 1992; 326: 658-662
• 18 Bretagne JF, Hamonic S, Piette C et al. Variations between endoscopists in rates of detection of colorectal neoplasia and their impact on a regional screening program based on colonoscopy after fecal occult blood testing. Gastrointest Endosc 2010; 71: 335-341
• 19 Imperiale TF, Glowinski EA, Juliar BE et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc 2009; 69: 1288-1295
• 20 Leyden JE, Doherty GA, Hanley A et al. Quality of colonoscopy performance among gastroenterology and surgical trainees: a need for common training standards for all trainees?. Endoscopy 2011; 43: 935-940
• 21 Millan MS, Gross P, Manilich E et al. Adenoma detection rate: the real indicator of quality in colonoscopy. Dis Colon Rectum 2008; 51: 1217-1220
• 22 Ko CW, Dominitz JA, Green P et al. Specialty differences in polyp detection, removal, and biopsy during colonoscopy. Am J Med 2010; 123: 528-535
• 23 Cooper GS, Xu F, Barnholtz SloanJS et al. Prevalence and predictors of interval colorectal cancers in medicare beneficiaries. Cancer 2012; 118: 3044-3052
• 24 Singh H, Nugent Z, Demers AA et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology 2010; 139: 1128-1137
• 25 Bressler B, Paszat LF, Chen Z et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology 2007; 132: 96-102
• 26 Shah HA, Paszat LF, Saskin R et al. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 2007; 132: 2297-2303
• 27 Ferlitsch M, Reinhart K, Pramhas S et al. Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy. JAMA 2011; 306: 1352-1358
• 28 Atkin W, Rogers P, Cardwell C et al. Wide variation in adenoma detection rates at screening flexible sigmoidoscopy. Gastroenterology 2004; 126: 1247-1256
• 29 Hassan C, Rex DK, Zullo A et al. Loss of efficacy and cost-effectiveness when screening colonoscopy is performed by nongastroenterologists. Cancer 2012; 118: 4404-4411
• 30 Bannert C, Reinhart K, Dunkler D et al. Sedation in screening colonoscopy: impact on quality indicators and complications. Am J Gastroenterol 2012; 107: 1837-1848
• 31 Valori R, Rey JF, Atkin WS et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition – quality assurance in endoscopy in colorectal cancer screening and diagnosis. Endoscopy 2012; 44 Suppl 3: E88-E105
• 32 Ekkelenkamp VE, Dowler K, Valori RM et al. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013; 19: 2355-2361
• 33 Rosenthal E. The $2.7 trillion medical bill. Colonoscopies explain why U.S. leads the world in health expenditures. The New York Times 01.06.2013; Available from: http://www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html?pagewanted=all&_r=1& Accessed 27: July 27 2013
• 34 Bianco MA, Cipolletta L, Rotondano G et al. Prevalence of nonpolypoid colorectal neoplasia: an Italian multicenter observational study. Endoscopy 2010; 42: 279-285
• 35 Nicolas-Perez D, Parra-Blanco A, Gimeno-Garcia AZ et al. Risk factors associated with colorectal flat adenoma detection. Eur J Gastroenterol Hepatol 2013; 25: 302-308
• 36 Kaltenbach T, McGill SK, Kalidindi V et al. Proficiency in the diagnosis of nonpolypoid colorectal neoplasm yields high adenoma detection rates. Dig Dis Sci 2012; 57: 764-770
• 37 Reinhart K, Bannert C, Dunkler D et al. Prevalence of flat lesions in a large screening population and their role in colonoscopy quality improvement. Endoscopy 2013; 45: 350-356
• 38 Fyock CJ, Draganov PV. Colonoscopic polypectomy and associated techniques. World J Gastroenterol 2010; 16: 3630-3637