Quality indicators for colonoscopy in a tunisian endoscopy unit
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Abstract
Background: Colonoscopy is a powerful tool for prevention and early diagnosis of colorectal cancer. However, the effectiveness of colonoscopy is dependent on the quality of the procedure, which is assessed by a number of key quality indicators. Among them, cecal intubation and adenoma detection rate are historically the most commonly used indicators of quality of colonoscopy. The aim of our study was to evaluate these two indicators of quality of colonoscopy in a Tunisian endoscopy center.
Methods : We conducted a retrospective study from January 2009 to March 2013. Data were collected from colonoscopies reports. Demographic data, indication of the procedure, and endoscopic diagnosis were collected. The quality of bowel preparation was subjectively classified at the time of the examination by each endoscopist as good, fair, or poor. Procedure related quality indicators considered for analysis were: cecal intubation rate (CIR) and polyp detection rate.
Results: During the period of the study, 859 colonoscopies were performed without sedation. The average age was 54.76 ± 17.5 years. Males represented the majority of our population (50.2%). Colic preparation was judged good, fair and poor in respectively 24 %, 61% and 15% of cases. The cecal intubation rate was 61.1 %. Causes of incomplete colonoscopy were especially poor preparation (47.3%) and poor tolerance (34.4%). Univariate analysis disclosed 3 predictive factors of CIR : the quality of bowel preparation (good vs fair or poor( (67.2 % vs 31.3%, p = 0.0001,OR: 4.5, 95% CI: 3.3-6), the screening indication (72.9% vs 60.1% , p = 0.03, OR: 1.7, 95% CI: 1-3) and the presence of alarming signs (55% vs 43%, p=0.04; OR: 1.1, 95% CI:0.9-2.5). By multivariate analysis, the factors influencing independently the CIR were the quality of bowel preparation (p=10-3, OR=2.23, 95% CI: 1.47-3.3) and the screening indication (p=0.02, OR: 1.9, 95% CI: 1.1-3.4). The polyp detection rate was 21% and was correlated, in univariate analysis with: age over 47 years (p=10-3, OR:3.2, 95 % CI:2-4.9), male gender (25.1% vs 16.8%, p=0.001, OR:2.36, 95% CI: 1.4–4), the quality of the preparation (26.5% vs 19.1%, p=0.03 OR:1.4, 95% CI:0.9 –2), the presence of colorectal cancer (50.9% vs 18.2%, p=0.0001, OR:4.6, 95% CI: 2.6-8) and the screening indication (35.7% vs 19%, p=0.001 OR: 2.36, 95% CI: 1.4– 4). By multivariate analysis, 3 independent factors associated with polyp detection rate were identified: age over 47 years (p=10-3, OR: 3.5 95% CI:2-5.9), bowel preparation (p=10-3 OR=5, 95% IC:2.7-9.6) and the screening indication( p=0.01, OR 2.5, 95% IC 1.4-4.7).
Conclusion: In our cohort, the quality of bowel preparation, tolerance of the procedure, age and the indication of colonoscopy were significantly associated with the indicators of quality. Bowel preparation and tolerance are targets on which we should act to improve performance
Methods : We conducted a retrospective study from January 2009 to March 2013. Data were collected from colonoscopies reports. Demographic data, indication of the procedure, and endoscopic diagnosis were collected. The quality of bowel preparation was subjectively classified at the time of the examination by each endoscopist as good, fair, or poor. Procedure related quality indicators considered for analysis were: cecal intubation rate (CIR) and polyp detection rate.
Results: During the period of the study, 859 colonoscopies were performed without sedation. The average age was 54.76 ± 17.5 years. Males represented the majority of our population (50.2%). Colic preparation was judged good, fair and poor in respectively 24 %, 61% and 15% of cases. The cecal intubation rate was 61.1 %. Causes of incomplete colonoscopy were especially poor preparation (47.3%) and poor tolerance (34.4%). Univariate analysis disclosed 3 predictive factors of CIR : the quality of bowel preparation (good vs fair or poor( (67.2 % vs 31.3%, p = 0.0001,OR: 4.5, 95% CI: 3.3-6), the screening indication (72.9% vs 60.1% , p = 0.03, OR: 1.7, 95% CI: 1-3) and the presence of alarming signs (55% vs 43%, p=0.04; OR: 1.1, 95% CI:0.9-2.5). By multivariate analysis, the factors influencing independently the CIR were the quality of bowel preparation (p=10-3, OR=2.23, 95% CI: 1.47-3.3) and the screening indication (p=0.02, OR: 1.9, 95% CI: 1.1-3.4). The polyp detection rate was 21% and was correlated, in univariate analysis with: age over 47 years (p=10-3, OR:3.2, 95 % CI:2-4.9), male gender (25.1% vs 16.8%, p=0.001, OR:2.36, 95% CI: 1.4–4), the quality of the preparation (26.5% vs 19.1%, p=0.03 OR:1.4, 95% CI:0.9 –2), the presence of colorectal cancer (50.9% vs 18.2%, p=0.0001, OR:4.6, 95% CI: 2.6-8) and the screening indication (35.7% vs 19%, p=0.001 OR: 2.36, 95% CI: 1.4– 4). By multivariate analysis, 3 independent factors associated with polyp detection rate were identified: age over 47 years (p=10-3, OR: 3.5 95% CI:2-5.9), bowel preparation (p=10-3 OR=5, 95% IC:2.7-9.6) and the screening indication( p=0.01, OR 2.5, 95% IC 1.4-4.7).
Conclusion: In our cohort, the quality of bowel preparation, tolerance of the procedure, age and the indication of colonoscopy were significantly associated with the indicators of quality. Bowel preparation and tolerance are targets on which we should act to improve performance
Keywords:
Endoscopy; colonoscopy; quality indicators.##plugins.themes.academic_pro.article.details##
References
- Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N Engl J Med 2000; 343: 162-8
- Faigel DO, Pike IM, Baron TH, Chak A, Cohen J, et al. Quality indicators for gastrointestinal endoscopic procedures: an introduction. Am J Gastroenterol 2006; 101: 866-72
- De Jonge V, Sint Nicolaas J, Cahen DL, Moolenaar W,et al. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc 2012; 75: 98-106
- Romero RV, Mahadeva S.Factors influencing quality of bowel preparation for colonoscopy. World J Gastrointest Endosc 2013; 5: 39- 46
- Rex DK, Petrini JL, Baron TH, Chak A, Cohen J, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873-85
- Marshall JB, Barthel JS. The frequency of total colonoscopy and terminal ileal intubation in the 1990s. Gastrointest Endosc 1993; 39:518-20
- Johnson DA, Gurney MS, Volpe RJ. A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk. Am J Gastroenterol 1990; 85:969-74
- Niv Y, Hazazi R, Levi Z, Fraser G. Screening colonoscopy for colorectal cancer in asymptomatic people: a meta-analysis. Dig Dis Sci 2008; 53:3049-54
- Aslinia F, Uradomo L, Steele A, Greenwald BD, Raufman JP. Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a university hospital. Am J Gastroenterol 2006; 101:721-31
- Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533-41.
- Cotton PB, Connor P, McGee D. Colonoscopy: practice variation among 69 hospital-based endoscopists. Gastrointest Endosc 2003;57:352-7.
- Chung YW, Han DS, Yoo KS, Park CK. Patient factors predictive of pain and difficulty during sedation-free colonoscopy: a prospective study in Korea. Dig Liver Dis 2007; 39:872-6
- Schoenfeld P and Cohen J. Quality indicators for colorectal cancer screening for colonoscopy . Tech Gastrointest Endosc. 2013 April ; 15(2): 59-68.
- . Williams JE, Le TD, Faigel DO. Polypectomy rate as a quality measure for colonoscopy. Gastrointest Endosc 2011;73:498-506
- Francis DL, Rodriguez-Correa DT, Buchner A, Harewood GC, Wallace M. Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. Gastrointest Endosc 2011;73:493-7
- Williams JE, Holub JL, Faigel DO. Polypectomy rate is a valid quality measure for colonoscopy: results from a national endoscopy database. Gastrointest Endosc 2012; 75:576-82
- Gonçalves AR, Ferreira C, Marques A, Ribeiro LC, Velosa J. Assessment of quality in screening colonoscopy for colorectal cancer. Clin Exp Gastroenterol. 2011;4:277-81.
- Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest Endosc 2003; 58:76-9.
- Froehlich F, Wietlisbach V, Gonvers JJ, Burnand B, Vader JP. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005; 61:378-84.
- Lebwohl B, Kastrinos F, Glick M, Rosenbaum AJ, Wang T, Neugut AI. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointest Endosc 2011;73:1207-14.
- Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143:844-57
- Barclay R, Vicari JJ, Johanson JF, et al. Variation in adenoma detection rates and colonoscopic withdrawal times during screening colonoscopy. Gastrointest Endosc 2005;61:AB107.