The effect of periodic monitoring and feedback on screening colonoscopy withdrawal times, polyp detection rates, and patient satisfaction scores

doi:10.1016/j.gie.2010.01.017

Gastrointestinal Endoscopy

Volume 71, Issue 7, June 2010, Pages 1253-1259

https://doi.org/10.1016/j.gie.2010.01.017 Get rights and content

Background

Previous studies showed a correlation between mean withdrawal times during screening colonoscopy and polyp/neoplasia detection rates.

Objectives

To assess the effect of a monitoring and feedback program on withdrawal times, polyp/neoplasia detection rates, and patient satisfaction.

Design

Comparison of retrospective and prospective data.

Setting

Teaching hospital.

Patients

Asymptomatic adults undergoing screening colonoscopy.

Interventions

Monitoring and feedback program.

Main Outcome Measurements

Withdrawal times, polyp and neoplasia detection rates, and patient satisfaction scores.

Methods

We retrospectively reviewed 850 screening colonoscopies, recording withdrawal times, polyp findings, and patient satisfaction scores. All procedures were performed by 10 experienced gastroenterologists who were then informed that periodic confidential monitoring and feedback of withdrawal times, polyp detection rates, and satisfaction scores would be started. We then prospectively collected data on another 541 screening colonoscopies. We compared pre- and postmonitoring outcome measures.

Results

Overall, after monitoring had begun, there was an increase in mean withdrawal times (from 6.57 to 8.07 minutes; P < .0001), and polyp detection rates (from 33.1% to 38.1%; P = .04, significance removed by Bonferroni correction). Nine of the 10 endoscopists increased their withdrawal times significantly. There was a small, nonsignificant increase in the neoplasia detection rate (from 19.6% to 22.7%; P = .17), but no significant change in mean satisfaction scores. Across endoscopists, there was a moderate correlation (r = 0.63; P = .04, significance removed by Bonferroni correction) between withdrawal times and polyp detection rates, but not between withdrawal times and satisfaction scores.

Limitations

No randomization, possible response bias, confounding of intervention effects, and sample size limitations.

Conclusions

Monitoring and feedback are associated with increases in mean withdrawal times and polyp detection rates, but not patient satisfaction scores. Neoplasia detection rates showed a statistically nonsignificant trend toward an increase.

Section snippets

Methods

This study was approved by the institutional review board of Virginia Mason Clinic. Because of its low-risk nature, this study received a waiver absolving it of the need for individual informed consent from subjects to include both patients and endoscopists. All involved endoscopists were aware of the study and agreed orally to the use of aggregate, anonymous data for research purposes.

Study population

The total number of screening colonoscopies performed at our downtown facility during the study period was 1892, of which 1391 were eventually found to be eligible for inclusion. The number of patients enrolled in the study ranged from 75 to 160 for each endoscopist, depending on what proportion of screening colonoscopies was performed downtown. Using analysis of variance or the χ² test, we found no significant differences in patient age and sex distribution, endoscopy volume, and prevalence of

Discussion

The sensitivity of screening colonoscopy for detecting large adenomas (≥1 cm) is estimated to be 98% in tandem colonoscopy studies and 88% in studies using CT colonography as the criterion standard.10, 11 Currently, the U.S. Multi-Society Task Force on Colorectal Cancer recommends 6 to 10 minutes as the minimal amount of time needed for adequate inspection during the withdrawal phase; competently performed colonoscopy should detect adenomas in at least 25% of average-risk men and 15% of women

Acknowledgments

The authors thank Drs. Kamran Ayub, John Brandabur, James Bredfeldt, Fred Drennan, Ian Gan, Shayan Irani, David Patterson, and Andrew Ross for their assistance and input.

References (23)

A. Sonnenberg et al.
Patterns of endoscopy in the United States: analysis of data from the Centers for Medicare and Medicaid Services and the National Endoscopic Database
Gastrointest Endosc
(2008)
D.K. Rex et al.
Quality indicators for colonoscopy
Gastrointest Endosc
(2006)
D.K. Rex
Colonoscopic withdrawal technique is associated with adenoma miss rates
Gastrointest Endosc
(2000)
D.K. Rex 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)
O.S. Lin et al.
Patient satisfaction scores for endoscopic procedures: impact of a survey-collection method
Gastrointest Endosc
(2007)
R.F. Yacavone et al.
Factors influencing patient satisfaction with GI endoscopy
Gastrointest Endosc
(2001)
B. Denis et al.
Quality assurance and gastrointestinal endoscopy: an audit of 500 colonoscopic procedures
Gastroenterol Clin Biol
(2004)
G. Cohen
Age and health status in a patient satisfaction survey
Soc Sci Med
(1996)
R.L. Barclay et al.
Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy
Clin Gastroenterol Hepatol
(2008)
M.S. Sawhney et al.
Effect of institution-wide policy of colonoscopy withdrawal time > or = 7 minutes on polyp detection
Gastroenterology
(2008)

D. Lieberman

Colonoscopy: as good as gold?

Ann Intern Med

(2004)

Cited by (63)

Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis
2023, Clinical Gastroenterology and Hepatology
Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs.
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator.
From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13–1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09–1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00–1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93–1.96; P = .11).
The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.
Quality of upper GI endoscopy: a prospective cohort study on impact of endoscopist education
2022, Gastrointestinal Endoscopy
Guidelines on quality of upper GI (UGI) endoscopy have been proposed by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE). However, these guidelines have not been evaluated in clinical practice. We aimed to measure the impact of endoscopist education on the quality of gastroscopy based on these guidelines and the association between compliance with guidelines and the detection of clinically significant premalignant pathology such as Barrett’s esophagus (BE), esophageal squamous dysplasia, gastric intestinal metaplasia (GIM), and Helicobacter pylori.
Endoscopists participated in a 1-hour education session on recommended performance measures and endoscopic detection of premalignant pathologies. A controlled before and after study was performed, measuring compliance with guidelines and rates of detection of pathology in control and intervention groups.
Over 2 years, 2719 procedures were performed: 1412 in the control group and 1307 in the intervention group. The proportion of procedures complying with guidelines was higher in the intervention group. The use of biopsy sampling protocols (eg, management of precancerous conditions of the stomach, 52% vs 91%; P = .007) and standardized terminology (eg, Forrest classification, 24% vs 68%; P < .001) was significantly higher. Detection of H pylori was higher in the intervention group (5.5% vs 9.8%, P = .003). Minimum inspection time of 7 minutes was associated with detection of BE (7.4% vs 2.0%, P < .001).
A simple endoscopist education session enhanced the quality of UGI endoscopy by improving compliance with BSG and ESGE recommendations and increasing the detection of clinically significant pathology. A minimum inspection time of 7 minutes was associated with increased diagnostic yield and may be a feasible quality indicator for clinical practice.
Colonoscope retraction technique and predicting adenoma detection rate: a multicenter study
2022, Gastrointestinal Endoscopy
The success of preventing colorectal cancer relies on the expertise of the colonoscopists. Studies suggest that the retraction technique is a powerful indicator of expertise in distinguishing endoscopists with various adenoma detection rates (ADRs). We aimed to develop a retraction technique score and explore the correlation between endoscopists’ retraction technique and their ADRs.
In a prospective, multicenter study, 8 colonoscopist nurses and physicians with various ADRs were included. Data from patients admitted for a colonoscopy, as part of the Danish nationwide screening program, were gathered directly from the Olympus ScopeGuide system (UPD-3; Olympus Optical, Tokyo, Japan) providing XYZ-coordinates from the coils along the length of the colonoscope. Motor skill measures were developed based on tip retraction, retraction efficiency, and retraction distance. The principal component analysis was used to study the association among the 3 measures and the historical ADR to create a combined score, the colonoscopy retraction score (CoRS).
Three hundred thirty-three recordings were analyzed. We demonstrated a significant and strong correlation between CoRS and ADR (.90, P < .01). Conversely, withdrawal time did not correlate significantly with ADR (.33, P = .42). In procedures without polypectomies or biopsy sampling, a significant and strong correlation was found between CoRS and ADR (.88, P < .01) and between withdrawal time and ADR (.75, P = .03).
This study presents a novel, real-time computerized and unbiased assessment tool for colonoscopy withdrawal. CoRS strongly correlated with ADR with and without therapeutic interventions during withdrawal and could be used to ensure quality instead of minimal withdrawal time. (Clinical trial registration number: NCT03587935.)
Implementation effect of institutional policy of EGD observation time on neoplasm detection
2021, Gastrointestinal Endoscopy
The observation time in EGD is associated with detection rate of premalignant or neoplastic lesions in the upper GI (UGI) tract. The aim of this study was to evaluate an institutional policy of EGD observation time on the detection rate of UGI neoplasms.
From July 2017 to March 2019, all endoscopists were requested to comply with our institutional policy of spending more than 3 minutes of observation time in every screening EGD. Observation time was defined as the time from when the endoscope reached the duodenum to when it was withdrawn. We obtained a neoplasm detection rate (NDR) during this period and compared it with that of a baseline period from 2009 to 2015.
During the study period, 30,506 EGDs were performed. Mean subject age was 49.9 ± 10.5 years, and 56.5% were men. All endoscopists achieved an average EGD observation time of more than 3 minutes during this period. Mean observation time was 3:35 ± 0:50, which was significantly longer than the baseline (2:38 ± 0:21, P < .001). NDR was .33%, which was higher than the baseline (.23%, P < .001). Even after adjusting for subjects’ age and gender, smoking history, and endoscopists’ biopsy sampling rate, prolonged EGD observation time of more than 3 minutes increased the NDR of UGI neoplasms (odds ratio, 1.51; 95% confidence interval, 1.21-1.75).
This study provides evidence that implementing a protocol of a prolonged observation time could increase NDR. Observation time should be an important quality indicator of the EGD examination.
Symptom Severity, Mood, and Healthcare Use Are Associated With Satisfaction in Patients With Irritable Bowel Syndrome
2020, Clinical Gastroenterology and Hepatology
Patient satisfaction is an important, but largely overlooked, component of management of functional gastrointestinal disorders. We aimed to identify demographic, clinical, psychosocial, and health-care use factors associated with satisfaction of patients with irritable bowel syndrome (IBS).
We collected data from consecutive patients at an outpatient gastroenterology clinic of a tertiary care center from 2017 through 2019; the patients completed an electronic symptom survey at their initial visit and 3–6 months later. Patients were included in the study if they met Rome IV criteria for IBS with no organic cause for their symptoms. Patient satisfaction was measured using the irritable bowel syndrome satisfaction with care scale. We collected demographic, clinical, psychosocial, and healthcare use information from survey responses and review of medical records.
Of the 137 patients who completed the study, most were satisfied a great deal (34.9%) or completely (18.6%), whereas 6.2% were not satisfied at all and 14.7% were a little satisfied. Among the 5 satisfaction subscales, the highest proportion of patients were satisfied with connection with their provider (93.4%). The subscale benefits of the visit had the lowest satisfaction rate (70.8%). Factors associated with overall satisfaction scores in the 3–6 months after initial consultation included decreased severity of IBS, higher number of follow-up gastroenterology visits, higher number of diagnostic tests during the follow-up period, and higher number of recommendations made at initial visit. Additionally, lower depression score at initial visit associated with higher satisfaction after 3–6 months.
Based on a survey of 137 patients with IBS, factors associated with satisfaction 3–6 months after establishing care with a gastroenterologist include reduced IBS severity, lower depression score at initial visit, higher number of recommendations, and higher number of follow-up gastroenterology visits.
Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis
2020, Gastrointestinal Endoscopy
Colonoscopy quality indicators such as adenoma detection rate (ADR) are surrogates for the effectiveness of screening-related colonoscopy. It is unclear whether endoscopist feedback on these indicators improves performance. We performed a meta-analysis to determine whether associations exist between endoscopist feedback and colonoscopy performance.
We conducted a search through May 2019 for studies reporting on endoscopist feedback and associations with ADR or other colonoscopy quality indicators. Pooled rate ratios (RRs) and weighted mean differences were calculated using DerSimonian and Laird random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to assess for potential methodological or clinical factors associated with outcomes.
From 1326 initial studies, 12 studies were included in the meta-analysis for ADR, representing 33,184 colonoscopies. Endoscopist feedback was associated with an improvement in ADR (RR, 1.21; 95% confidence interval [CI], 1.09-1.34). Low performers derived a greater benefit from feedback (RR, 1.62; 95% CI, 1.18-2.23) compared with moderate performers (RR, 1.19; 95% CI, 1.11-1.29), whereas high performers did not derive a significant benefit (RR, 1.06; 95% CI, 0.99-1.13). Feedback was not associated with increases in withdrawal time (weighted mean difference, +0.43 minutes; 95% CI, −0.50 to +1.36 minutes) or improvements in cecal intubation rate (RR, 1.00; 95% CI, 0.99-1.01).
Endoscopist feedback is associated with modest improvements in ADR. The implementation of routine endoscopist audit and feedback should be considered alongside other quality improvement interventions in institutions dedicated to the provision of high-quality screening-related colonoscopy.

View all citing articles on Scopus

: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

View full text

Original articleClinical endoscopyThe effect of periodic monitoring and feedback on screening colonoscopy withdrawal times, polyp detection rates, and patient satisfaction scores

Background

Objectives

Design

Setting

Patients

Interventions

Main Outcome Measurements

Methods

Results

Limitations

Conclusions

Section snippets

Methods

Study population

Discussion

Acknowledgments

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Gastroenterol Clin Biol

Soc Sci Med

Clin Gastroenterol Hepatol

Gastroenterology

Colonoscopy: as good as gold?

Ann Intern Med

Original article
Clinical endoscopy
The effect of periodic monitoring and feedback on screening colonoscopy withdrawal times, polyp detection rates, and patient satisfaction scores