Endoscopist characteristics that influence the quality of colonoscopy

Background and study aim: 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.

Patients and methods: 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.

Results: 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.

Conclusions: 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.

• References

• 1 Atkin WS, Edwards R, Kralj-Hans I et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
• 2 Shaukat A, Mongin SJ, Geisser MS et al. Long-term mortality after screening for colorectal cancer. N Engl J Med 2013; 369: 1106-1114
• 3 van Rijn JC, Reitsma JB, Stoker J et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006; 101: 343-350
• 4 Baxter NN, Goldwasser MA, Paszat LF et al. Association of colonoscopy and death from colorectal cancer. Ann Intern Med 2009; 150: 1-8
• 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
• 6 Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 7 Sanduleanu S, le Clercq CM, Dekker E et al. Definition and taxonomy of interval colorectal cancers: a proposal for standardising nomenclature. Gut 2015; 64: 1257-1267
• 8 Rex DK, Schoenfeld PS, Cohen J et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31-53
• 9 Quintero E, Castells A, Bujanda L et al. Colonoscopy versus fecal immunochemical testing in colorectal-cancer screening. N Engl J Med 2012; 366: 697-706
• 10 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
• 11 Atkin W, Rogers P, Cardwell C et al. Wide variation in adenoma detection rates at screening flexible sigmoidoscopy. Gastroenterology 2004; 126: 1247-1256
• 12 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
• 13 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
• 14 Imperiale TF, Glowinski EA, Juliar BE et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc 2009; 69: 1288-1295
• 15 Adler A, Wegscheider K, Lieberman D et al. Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12,134 examinations [Berlin colonoscopy project 3, BECOP-3]. Gut 2013; 62: 236-241
• 16 American Society for Gastrointestinal Endoscopy. Guidelines for credentialing and granting privileges for gastrointestinal endoscopy. Gastrointest Endosc 1998; 48: 679-682
• 17 Eisen GM, Baron TH, Dominitz JA et al. Methods of granting hospital privileges to perform gastrointestinal endoscopy. Gastrointest Endosc 2002; 55: 780-783
• 18 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: E88-105
• 19 Birkmeyer JD, Stukel TA, Siewers AE et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349: 2117-2127
• 20 Rodgers M, Jobe BA, O’Rourke RW et al. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg 2007; 142: 829-839
• 21 Freeman ML, Nelson DB, Sherman S et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335: 909-918
• 22 Kapral C, Duller C, Wewalka F et al. Case volume and outcome of endoscopic retrograde cholangiopancreatography: results of a nationwide Austrian benchmarking project. Endoscopy 2008; 40: 625-630
• 23 Bhangu A, Bowley DM, Horner R et al. Volume and accreditation, but not specialty, affect quality standards in colonoscopy. Br J Surg 2012; 99: 1436-1444
• 24 Zorzi M, Senore C, Da RF et al. Quality of colonoscopy in an organised colorectal cancer screening programme with immunochemical faecal occult blood test: the EQuIPE study [Evaluating Quality Indicators of the Performance of Endoscopy]. Gut 2015; 64: 1389-1396
• 25 Barton JR, Corbett S, van der Vleuten CP et al. The validity and reliability of a Direct Observation of Procedural Skills assessment tool: assessing colonoscopic skills of senior endoscopists. Gastrointest Endosc 2012; 75: 591-597
• 26 Vassiliou MC, Kaneva PA, Poulose BK et al. How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy?. Am J Surg 2010; 199: 121-125
• 27 Belsey J, Epstein O, Heresbach D. Systematic review: oral bowel preparation for colonoscopy. Aliment Pharmacol Ther 2007; 25: 373-384
• 28 Ahnen DJ. The American College of Gastroenterology Emily Couric Lecture – the adenoma–carcinoma sequence revisited: has the era of genetic tailoring finally arrived?. Am J Gastroenterol 2011; 106: 190-198
• 29 O’Brien MJ, Winawer SJ, Zauber AG et al. Flat adenomas in the National Polyp Study: is there increased risk for high-grade dysplasia initially or during surveillance?. Clin Gastroenterol Hepatol 2004; 2: 905-911
• 30 Lee RH, Tang RS, Muthusamy VR et al. Quality of colonoscopy withdrawal technique and variability in adenoma detection rates [with videos]. Gastrointest Endosc 2011; 74: 128-134
• 31 Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest Endosc 2000; 51: 33-36
• 32 Jover R, Herraiz M, Alarcon O et al. Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening. Endoscopy 2012; 44: 444-451
• 33 Do A, Weinberg J, Kakkar A et al. Reliability of adenoma detection rate is based on procedural volume. Gastrointest Endosc 2013; 77: 376-380