Effect of a Patient Navigator Program on the Volume and Quality of Colonoscopy

High Resolution Colonoscopy With Chromoscopy Versus Standard Colonoscopy for the Detection of Colonic Neoplasia: A Randomized Study

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear. We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly. Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%. Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice

Factors Associated With Incomplete Colonoscopy: A Population-Based Study

Several add-on devices have been developed to increase rates of colon adenoma detection. We aimed to compare the endocuff-assisted colonoscopy with cap-assisted colonoscopy through a pairwise meta-analysis of randomized trials. We searched the PubMed/Medline and Embase database through March 2020 and identified 6 randomized controlled trials (comprising 2,027 patients). The primary outcome was adenoma detection rate; secondary outcomes included sessile serrated adenoma detection rate, mean adenoma per colonoscopy, cecal intubation rate and time to reach cecum. Safety data were also analyzed. We performed pairwise meta-analysis through a random effects model and expressed data as risk ratio and 95% confidence interval. Overall, pooled adenoma detection rate was 48.1% (39.3-56.8%) with endocuff and 40.5% (30.4- 50.6%; risk ratio 1.14, 0.96-1.35) with cap. Proximal adenoma detection rate was 45.7% (36.8-54.7%) and 24% (17-45.1%) with endocuff and cap, respectively (risk ratio 2.04, 0.93-4.49), whereas endocuff outperformed cap-assisted colonoscopy in detecting diminutive (≤ 5 mm) adenomas (risk ratio 2.74, 1.53-4.90) and in terms of mean adenoma per colonoscopy (mean difference 0.31, 0.05 -0.57; p=0.02). Sessile serrated adenoma detection rate (risk ratio 1.36, 0.72-2.59), cecal intubation rate (risk ratio 0.99, 0.98-1.00), and time to reach cecum (6.87 min versus 6.87 min) were similar between the two groups. No serious adverse event was observed. Endocuff-assisted colonoscopy seems to provide a higher adenoma detection rate as compared to cap-assisted colonoscopy, in particular concerning smaller diminutive polyps.

Patient navigation can increase colorectal cancer screening rates. The net economic impact of a colonoscopy patient navigator program was evaluated in an urban public hospital setting. Cost, cost-effectiveness, and cost-benefit analyses were performed of a colonoscopy patient navigation program at 3 urban public hospitals in the period from 2003 to 2007. Program effectiveness was assessed in a 2-group, pre- and post-program, nonrandomized evaluation, comparing program hospitals with comparison hospitals that served similar populations. Costs were assessed from the provider's perspective. Outcomes included colonoscopy volume, colonoscopy completion rate, program cost, incremental cost-effectiveness, and net monetary benefit. Patient navigation was associated with a 61% increase in average monthly colonoscopy volume at program hospitals, from 114 procedures to 184 procedures, compared with a 12% increase at comparison hospitals. Adjusted for other factors, the navigator program increased colonoscopy volume by 44 to 67 additional procedures per month. Average program cost varied from $50 to $300 per patient referred to a navigator. Incremental cost-effectiveness varied from $200 to $700 per additional colonoscopy. At 2 hospitals, net revenue associated with increased colonoscopy volume exceeded the program cost per additional colonoscopy, yielding a net financial benefit; at the third hospital, the program yielded a net cost. Variation between hospitals in the program's economic impact was primarily attributable to differences in personnel costs. Economic evaluation of this colonoscopy patient navigator program in an urban public hospital setting suggests that such programs can be a cost-effective use of limited resources and yield a net financial benefit for providers.

A Prospective System for Tracking Colonoscopy Performance Among Trainees Using Key Colonoscopy Quality Indicators

Split-dose regimens (SpDs) were recommended as a first choice for bowel preparation, whereas same-day regimens (SaDs) were recommended as an alternative; however, randomized trials compared them with mixed results. The meta-analysis was aimed at clarifying efficacy level between the 2 regimens. We used MEDLINE/PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and Web of Science to identify randomized trials published from 1990 to 2016, comparing SaDs to SpDs in adults. The pooled odds ratios (ORs) were calculated for preparation quality, cecal intubation rate (CIR), adenoma detection rate (ADR), and any other adverse effects. Fourteen trials were included. The proportion of individuals receiving SaDs and SpDs with adequate preparation in the pooled analysis were 79.4% and 81.7%, respectively, with no significant difference [OR=0.92; 95% confidence interval (CI), 0.62-1.36] in 11 trials. Subgroup analysis revealed that the odds of adequate preparation for SaDs with bisacodyl were 2.45 times that for SpDs without bisacodyl (95% CI, 1.45-4.51, in favor of SaDs with bisacodyl). Subjects received SaDs experienced better sleep. SaDs were comparable with SpDs in terms of bowel cleanliness, CIR, and ADR, and could also outperform SpDs in preparation quality with bisacodyl. SaDs also offered better sleep the previous night than SpDs did, which suggests that SaDs might serve as a superior alternative to SpDs. The heterogenous regimens and measurements likely account for the low rates of optimal bowl preparations in both arms. Further studies are needed to validate these results and determine the optimal purgatives and dosages.

BackgroundThe negative effect of diabetes mellitus (DM) on the colonoscopy preparation has been previously established. Metabolic syndrome has been shown to increase risk for malignancy and possibly for premalignant lesions. This study aimed to investigate the impact of DM control on colonoscopy outcomes including bowel preparation and adenoma detection rate (ADR).MethodsWe included patients with DM who underwent colonoscopy in our hospital and had a documented glycated hemoglobin (HbA1C) within 3 months. Patients were categorized into three groups based on their HbA1C level. The clinical and endoscopic data were collected and analyzed.ResultsOur cohort included 352 DM patients. The mean age was 63.5 years. When patients were analyzed based on HBA1C, bowel preparation was poor in 46.7% of patients with good glycemic control, 52.1% of patients with fair control and 50% of patients with poor control. ADR was 24.3% in patients with good glycemic control, 20.2% in patients with fair glycemic control and 27.1% in patients with poor glycemic control. There was no statistically significant difference in the quality of preparation or adenoma detection amongst the groups.ConclusionThe degree of glycemic control did not impact the quality of bowel preparation or ADR.

Background/AimsThe adenoma detection rate (ADR) of screening colonoscopies performed by trainees is often lower than that of colonoscopies performed by experts. The effcacy of cap-assisted colonoscopy (CAC) in adenoma detection is well documented, especially that of CACs performed by trainees. Endocuff, a new endoscopic cap, is reportedly useful for adenoma detection; however, no trials have compared the effcacy of Endocuff-assisted colonoscopy (EAC) and CAC conducted by trainees. Therefore, the present study retrospectively compared the effcacy between EAC and CAC in trainees.MethodsThis was a single-center, retrospective study involving 305 patients who underwent either EAC or CAC performed by three trainees between January and December 2018. We evaluated the ADR, mean number of adenomas detected per patient (MAP), cecal intubation rate, cecal intubation time, and occurrence of complications between the EAC and CAC groups.ResultsThe ADR was significantly higher in the EAC group than in the CAC group (54.3% vs. 37.3%, p=0.019), as was the MAP (1.36 vs. 0.74, p=0.003). No significant differences were found between the groups with respect to the cecal intubation rate or cecal intubation time. No major complications occurred in either group.ConclusionsOur results suggest that EAC exhibits increased ADR and MAP compared to CAC when performed by trainees.

Polyethylene glycol (PEG) is the standard agent for bowel preparation in colonoscopy. However, its combination with linaclotide may enhance bowel cleansing. This systematic review and meta-analysis compared the efficacy and safety of linaclotide combined with PEG versus PEG alone in patients undergoing colonoscopy. We searched PubMed, Embase, and Cochrane Library databases. We calculated pooled risk ratios (RRs) for dichotomous and mean differences (MDs) for continuous outcomes, with 95% confidence intervals (CIs). We included 8 RCTs (3591 patients). Linaclotide improved preparation quality (MD 0.31; 95% CI [0.08, 0.54]), willingness to repeat the preparation (RR 1.16; 95% CI [1.09, 1.23]), and reduced adverse events (AEs). Adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate, and withdrawal time were similar between the groups. Subgroup analyses showed consistent results, except for: (1) patients with constipation - linaclotide improved PDR and reduced withdrawal time; (2) studies using a lower volume of PEG in the intervention group - preparation quality was similar between groups; and (3) studies using the same volume of PEG in both groups- linaclotide improved PDR and ADR, but with similar willingness to repeat the preparation and risk of AEs. Linaclotide with PEG improved preparation quality, willingness to repeat the preparation, and reduced AEs compared to PEG alone. Subgroup analyses findings are particularly relevant for patients with a history of inadequate bowel preparation, especially those with low tolerance to high-volume PEG or difficulty achieving effective colonic cleansing. Future studies should further explore the cost-effectiveness and the applicability across diverse regimens and patient characteristics.

Purpose: Adequate bowel preparation is important for safe and effective colonoscopy. Quality of bowel preparation (prep) is commonly graded as excellent, good, fair and poor. Quality indicators (QI) for colonoscopy include achieving at least 95% completion rate and adenoma detection rate (ADR) of at least 25% in average risk men and 15% in average risk women over age 50. Aims of this study were to determine the influence of grades of prep on ADR and colonoscopy completion rates in average risk individuals over 50 years of age. Methods: Colonoscopy reports from a total of 66 endoscopists including 41 gastroenterologists, 15 colorectal surgeons, seven general surgeons and three other proceduralists during 2008-2009 were reviewed. Up to 120 procedures per endoscopist were randomly selected. Colonoscopic findings including indications, quality of prep, polyp size, location, morphology and pathology were retrieved. Patients with prior colon resection, and indications other than average risk screening were excluded. ADR was defined as percentage of colonoscopies with at least one adenoma detected. Complete colonoscopy was defined as reaching the cecum. Proximal colon consisted of cecum, ascending and transverse colon including splenic flexure while distal colon included descending, sigmoid and rectum. Prep was arbitrarily classified as excellent, good, fair and poor by the endoscopist at the time of the colonoscopy. Data is presented as mean ± sd, median (25th, 75th percentiles) or N (%). Analysis of variance (ANOVA), non-parametric Kruskal-Wallis test and Pearson's chisquare tests were used. A P value of <0.05 was considered significant. Results: A total of 2519 patients were included, of which 1030(41%) had excellent, 1145 (45%) had good, 240 (9.5%) fair and 104 (4%) poor prep. Patient demographics were similar in all groups except patients with fair and poor prep were slightly older than those with excellent or good prep. Colonoscopy completion rates were significantly lower in patients with poor and fair prep compared to those with good and excellent prep (72.1% vs 75.4%vs 99.7%vs 99.9% respectively, P<0.001). ADR (men and women combined) was similar in all four grades, excellent, good, fair and poor prep (24.2% vs 26.8% vs 32.1% vs 22.1%, P=0.055). Similarly proximal and distal colon ADR were similar in all the four grades of prep. The findings on ADR were similar when stratified by gender, men and women also. Conclusion: Patients with fair and poor prep have significantly lower colonoscopy completion rates compared to excellent and good prep. In this study, there was no difference in ADR between the different grades of prep. Quality of bowel preparation might influence the QI on colonoscopy completion rates but not the QI on ADR.

Purpose: There is an increased interest in endoscopic performance indicators. Currently cecal intubation rates along with adenoma detection rates and colonoscope withdrawal time are being viewed as such performance indictors. A number of studies have been done to assess factors that could potentially affect these indicators. Factors such as inpatient status, female sex, and immobility, among others, have been associated with decreased cecal intubation rates. Trainee involvement could be another factor affecting quality indicators. There are very few studies that evaluated performance indicators in relation to trainee involvement. AIM: To determine whether trainee involvement affect cecal intubationand polyp detection rates. Methods: We retrospectively reviewed 6,027 consecutive colonoscopies that were performed on adults by six full-time gastroenterologists between mid-2003 and 2007 at a high-volume endoscopy unit in a large urban hospital. All colonoscopies by trainees were supervised by teaching attendings. For each colonoscopic procedure, trainee involvement, polyp findings, extent of the exam, type of anesthesia, patients age, sex, inpatient or outpatient status, were summarized and analyzed using Student t-test and Fischer's exact tests as indicated. P < 0.05 was considered to be significant. Results: Overallcecal intubation rate was 93%. Trainees participated in 28% of all colonoscopies. Colonoscopies with trainees' involvement had 94% cecal intubation rate compared with colonoscopies performed by attending gastroenterologists alone, 93%. The difference was statistically insignificant, P= 0.4. Trainees had 42% polyp detection rate compared with attending gastroenterologists, who had 41% detection rate, P= 0.5. Mean age of the patients undergoing colonoscopy with trainee involvement was older as compared to colonoscopies done by attending gastroenterologists alone, 60 (SD 13) and 58 (SD 14) respectively, P= 0.0005. Female patients constituted 63% of both groups. The percentage of outpatient colonoscopies was the same for trainees and attendings (88%). Conclusion: Results of this study do not suggest a significant effect of trainees' participation on cecal intubation andpolyp detection rates.

The safety and diagnostic accuracy of colonoscopy depend on the quality of colon cleansing. The adenoma detection rate is usually used as a quality measurement score. We aimed to introduce and evaluate three new parameters to determine polyps and adenomas segmental localization and their distribution in association with different bowel preparation levels during colonoscopy. We introduce the multiple adenoma detection rate (the percentage of patients with >2 adenomas diagnosed during colonoscopy), the zonal adenoma detection rate (the percentage of patients with >2 adenomas diagnosed during colonoscopy in different colon areas (rectum, sigmoid, descending, transverse, ascending and cecum colon)), and multi-zone adenoma detection rate (the percentage of patients with >2 adenomas diagnosed during colonoscopy in different colon areas with at least a segment between them with or without lesions (i.e. rectum and descending colon with or without lesions in the sigmoid)). We prospectively enrolled outpatients who underwent colonoscopy from January 2013 to October 2014. The bowel preparation quality, according to the Aronchick modified scale, number and location of lesions, Paris classification and histology, were recorded. The multiple adenoma/polyp detection rate, zonal adenoma/polyp detection rate, and multi-zone adenoma/polyp detection rate were determined. In total, 519 consecutive patients (266/253 M/F; mean age 55.3 ± 12.8 years) were enrolled. The adenoma and polyp detection rates were 21% and 35%, respectively. Multiple adenomas were detected in 28 patients. Adenoma and polyp detection rate and new parameters were statistically significantly higher in the optimal as compared with the adequate bowel preparation. An optimal level of bowel preparation was strongly associated not only with a higher adenoma detection rate, but also with a higher chance of detecting multiple clinically relevant lesions in adjacent or discrete segments of the colon.

<h3>Introduction</h3> Studies have determined that a high Body Mass Index (BMI) is associated with an increased risk of colonic adenoma. There is a paucity of data on the impact of weight loss in morbidly obese populations and its effects on colonic adenoma detection rate (ADR). This study aimed to determine the impact of weight loss after bariatric surgery on the adenoma detection rate on colonoscopy. <h3>Method</h3> After IRB approval a retrospective review of prospectively collected data was performed for patients who underwent bariatric surgery between 2004–2012. Patients who had a colonoscopy after bariatric surgery were identified as cases. Controls included a random sample of patients who had a colonoscopy during the same timeperiod. They were matched by age and gender in 1:4 ratio of case to controls. Patients with poor bowel preparation or Ottawa score &gt;11 were excluded. Patient demographics, baseline BMI and BMI at colonoscopy, weight change, co-morbidities, type of bariatric surgery and presence/absence of adenoma or advanced adenoma (AA) were collected. Adenoma and AA detection rates were analysed by age (&lt;40; 40–49; 50–59; &gt;60 years) and compared between the two groups. AA was defined as tubular adenoma or serrated polyp ≥10 mm in diameter, villous features, high-grade dysplasia. Hyperplastic polyps ≥10 mm were classified as advanced adenoma. <h3>Results</h3> 194 cases and 797 controls were included (females 68%). The mean age of patients was 51.5 years. 62.3% of the patients underwent gastric bypass, 28.5% sleeve gastrectomy and 9.2% gastric band. Average decrease in BMI after bariatric surgery was 13 ± 5.5 kg/m². The median follow-up was 31.6 (2–107) months. The average BMI at the time of colonoscopy of the cases and controls was 32 ± 6 kg/m²and 27.4 ± 5.5 kg/m²respectively. There was no significant difference in adenoma and AA detection rate between groups analysed by age. Among those who underwent bariatric surgery, there was no relation between the occurrence of adenomas and BMI reduction; however the effect of BMI reduction on the occurrence of AA did approach significance. (P = 0.05). The time interval between bariatric surgery and colonoscopy was not related to the incidence of adenoma nor AA. <h3>Conclusion</h3> Despite the differences in BMI between the patients and controls we found no difference in adenoma or advanced adenoma detection. BMI reduction after bariatric surgery did not affect the presence of adenomas but may be associated with a significant decrease in the risk of developing AA. Further studies with large population data might be required to validate these findings. <h3>Disclosure of interest</h3> None Declared.