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Carbonell C, Adegbulugbe A, Cheung W, Ruff P. Barriers and Challenges to Implementing a Quality Improvement Program: Political and Administrative Challenges. JCO Glob Oncol 2024; 10:e2300455. [PMID: 38935883 DOI: 10.1200/go.23.00455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 03/17/2024] [Accepted: 04/30/2024] [Indexed: 06/29/2024] Open
Abstract
Quality improvement (QI) programs have rapidly grown in health care over recent years. Despite increasing evidence of successful QI initiatives resulting in improved outcomes, the adoption and implementation of QI programs remain a challenge worldwide. This paper briefly describes political and administrative barriers that impede the implementation of QI programs, including political and ideological factors, socioeconomic and educational barriers, and barriers related to data collection, privacy, and security. Key political and administrative barriers identified include resource limitations due to inadequate public funding, stringent laws, and change resistance. Potential solutions include support and commitment from regional and national authorities, consultation of all involved parties during QI program development, and financial incentives. The barrier of limited resources is starker among low- and middle-income countries (LMICs) compared with high-income countries (HICs) due to the absence of adequate infrastructure, personnel equipped with QI-oriented skills, and analytical technology. Solutions that have facilitated QI programs in some LMICs include outreach and collaboration with other health centers and established QI programs in HICs. The lack of QI-specific training and education in medical curricula challenges QI implementation but can be mitigated through the provision of QI promotion webinars, QI-specific project opportunities, and formalized QI training modules. Finally, barriers related to data collection, privacy, and security include laws hindering the availability of quality data, inefficient data collection and processes, and outdated clinical information systems. Access to high-quality data, organized record-keeping, and alignment of data collection processes will help alleviate these barriers to QI program implementation. The multidimensional nature of these barriers means that proposed solutions will require coordination from multiple stakeholders, government support, and leaders across multiple fields.
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Affiliation(s)
- Chantelle Carbonell
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Abisola Adegbulugbe
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Winson Cheung
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Paul Ruff
- Emeritus Professor, Division of Medical Oncology, University of Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
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Schult AL, Hoff G, Holme Ø, Botteri E, Seip B, Ranheim Randel K, Darre-Næss O, Owen T, Nilsen JA, Nguyen DH, Johansen K, de Lange T. Colonoscopy quality improvement after initial training: A cross-sectional study of intensive short-term training. Endosc Int Open 2023; 11:E117-E127. [PMID: 36712907 PMCID: PMC9879657 DOI: 10.1055/a-1994-6084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
Background and study aims High-quality is crucial for the effectiveness of colonoscopy and can be achieved by high-quality training and verified with assessment of key performance indicators (KPIs) for colonoscopy such as cecum intubation rate (CIR), adenoma detection rate (ADR) and adequate polyp resection. Typically, trainees achieve adequate CIR after 275 procedures, but little is known about learning curves for KPIs after initial training. Methods This cross-sectional study includes work-up colonoscopies after a positive screening test with fecal occult blood testing (FIT) or sigmoidoscopy, performed by either trainees after 300 training colonoscopies or by consultants. Outcome measures were KPIs. We assessed inter-endoscopist variation in trainees and learning curves for trainees as a group. We also compared KPIs for trainees and consultants as a group. Results Data from 6,655 colonoscopies performed by 21 trainees and 921 colonoscopies performed by 17 consultants were included. Most trainees achieved target standards for main KPIs. With time, trainees shortened cecum intubation time and withdrawal time without decreasing their ADR, reduced the proportion of painful colonoscopies, and increased the adequate polyp resection rate (all P < 0.01). Compared to consultants, trainees had higher CIR (97.7 % vs. 96.3 %, P = 0.02), ADR after positive FIT (57.6 % vs. 50.3 %, P < 0.01), and proximal ADR after sigmoidoscopy screening (41.1 % vs. 29.8 %; P < 0.01), higher adequate polyp resection rate (94.9 % vs. 93.1 %, P = 0.01) and fewer serious adverse events (0.65 % vs. 1.41 %, P = 0.02). Conclusions Trainees performed high-quality colonoscopies and achieved international target standards. Several KPIs continuously improved after initial training. Trainees outperformed consultants on several KPIs.
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Affiliation(s)
- Anna Lisa Schult
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway,Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Department of Research and Development, Telemark Hospital Trust, Skien, Norway
| | - Øyvind Holme
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway,Institute of Health and Society, University of Oslo, Oslo, Norway,Department of Medicine, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway,Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Birgitte Seip
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway,Department of Medicine, Vestfold Hospital, Tønsberg, Norway
| | | | - Ole Darre-Næss
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | - Tanja Owen
- Department of Medicine, Østfold Hospital Trust, Grålum, Norway
| | - Jens Aksel Nilsen
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | | | - Kristin Johansen
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Thomas de Lange
- Department of Medicine and Emergencies Sahlgrenska University Hospital-Mölndal, Region Västra Götaland, Sweden,Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden,Department of Medical Research, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
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Hoff G. Quality assurance in colonoscopy: is case mix a problem? Endoscopy 2022; 54:463-464. [PMID: 34905790 DOI: 10.1055/a-1690-6488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Geir Hoff
- Department of Research, Telemark Hospital, Skien, Norway.,Cancer Registry of Norway, Oslo, Norway
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Rosvall A, Annersten Gershater M, Kumlien C, Toth E, Axelsson M. Patient-Reported Experience Measures for Colonoscopy: A Systematic Review and Meta-Ethnography. Diagnostics (Basel) 2022; 12:242. [PMID: 35204332 PMCID: PMC8871001 DOI: 10.3390/diagnostics12020242] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 12/10/2022] Open
Abstract
Patient experience is defined as a major quality indicator that should be routinely measured during and after a colonoscopy, according to current ESGE guidelines. There is no standard approach measuring patient experience after the procedure and the comparative performance of the different colonoscopy-specific patient-reported experience measures (PREMs) is unclear. Therefore, the aim was to develop a conceptual model describing how patients experience a colonoscopy, and to compare the model against colonoscopy-specific PREMs. A systematic search for qualitative research published up to December 2021 in PubMed, Cochrane, CINAHL, and PsycINFO was conducted. After screening and quality assessment, data from 13 studies were synthesised using meta-ethnography. Similarities and differences between the model and colonoscopy-specific PREMs were identified. A model consisting of five concepts describes how patients experience undergoing a colonoscopy: health motivation, discomfort, information, a caring relationship, and understanding. These concepts were compared with existing PREMs and the result shows that there is agreement between the model and existing PREMs for colonoscopy in some parts, while partial agreement or no agreement is present in others. These findings suggest that new PREMs for colonoscopy should be developed, since none of the existing colonoscopy-specific PREMs fully cover patients' experiences.
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Affiliation(s)
- Annica Rosvall
- Department of Care Science, Faculty of Health and Society, Malmö University, 214 28 Malmö, Sweden; (M.A.G.); (C.K.); (M.A.)
| | - Magdalena Annersten Gershater
- Department of Care Science, Faculty of Health and Society, Malmö University, 214 28 Malmö, Sweden; (M.A.G.); (C.K.); (M.A.)
| | - Christine Kumlien
- Department of Care Science, Faculty of Health and Society, Malmö University, 214 28 Malmö, Sweden; (M.A.G.); (C.K.); (M.A.)
- Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, 205 02 Malmö, Sweden
| | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden;
| | - Malin Axelsson
- Department of Care Science, Faculty of Health and Society, Malmö University, 214 28 Malmö, Sweden; (M.A.G.); (C.K.); (M.A.)
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Almario CV, Shergill J, Oh J. Measuring and Improving Quality of Colonoscopy for Colorectal Cancer Screening. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 24:269-283. [PMID: 36778081 PMCID: PMC9910391 DOI: 10.1016/j.tige.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Colorectal cancer (CRC) is largely preventable, yet it remains a major public health issue as it is the third most common and deadly malignancy in the United States. While there are many ways to screen for CRC, colonoscopy remains the gold standard as it is the only test that is both cancer-detecting and cancer-preventing through removal of precancerous polyps. Through identifying and removing neoplastic lesions, colonoscopy reduces CRC incidence by 31%-91% and CRC mortality by 65%-88%. However, colonoscopy is not an infallible test-there is a chance for missed lesions during the exam and there is substantial variation in outcomes among endoscopists. To enhance the quality of colonoscopic exams, and ultimately to improve CRC outcomes, quality indicators have been developed for measuring endoscopists' performance. In this review, we describe the colonoscopic quality indicators and benchmarks recommended by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy for screening colonoscopies in average-risk individuals. Measuring and monitoring endoscopists' performance on these measures are critical first steps in striving toward conducting high quality exams. We also review the evidence for interventions that aim to improve critical measures including adenoma detection rate, withdrawal time, cecal intubation, and bowel preparation quality. Finally, we provide a preview of the forthcoming Advancing Care for Appropriate Colon Health Merit-Based Incentive Payment System Value Pathway by the Centers for Medicare & Medicaid Services and its potential impact on clinical practice.
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Affiliation(s)
- Christopher V. Almario
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California;,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California;,Division of Health Services Research, Cedars-Sinai Medical Center, Los Angeles, California;,Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), Los Angeles, California;,Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, California;,Cancer Prevention & Control Program, Cedars-Sinai Cancer, Los Angeles, California
| | - Jaspreet Shergill
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Janice Oh
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Schult AL, Botteri E, Hoff G, Holme Ø, Bretthauer M, Randel KR, Gulichsen EH, El-Safadi B, Barua I, Munck C, Nilsen LR, Svendsen HM, de Lange T. Women require routine opioids to prevent painful colonoscopies: a randomised controlled trial. Scand J Gastroenterol 2021; 56:1480-1489. [PMID: 34534048 DOI: 10.1080/00365521.2021.1969683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Women are at high risk for painful colonoscopy. Pain, but also sedation, are barriers to colorectal cancer (CRC) screening participation. In a randomised controlled trial, we compared on-demand with pre-colonoscopy opioid administration to control pain in women at CRC screening age. METHODS Women, aged 55-79 years, attending colonoscopy at two Norwegian endoscopy units were randomised 1:1:1 to (1) fentanyl on-demand, (2) fentanyl prior to colonoscopy, or (3) alfentanil on-demand. The primary endpoint was procedural pain reported by the patients on a validated four-point Likert scale and further dichotomized for the study into painful (moderate or severe pain) and non-painful (slight or no pain) colonoscopy. Secondary endpoints were: willingness to repeat colonoscopy, adverse events, cecal intubation time and rate, and post-procedure recovery time. RESULTS Between June 2017 and May 2020, 183 patients were included in intention-to-treat analyses in the fentanyl on-demand group, 177 in the fentanyl prior to colonoscopy group, and 179 in the alfentanil on-demand group. Fewer women receiving fentanyl prior to colonoscopy reported a painful colonoscopy compared to those who were given fentanyl on-demand (25.2% vs. 44.1%, p < .001). There was no difference in the proportion of painful colonoscopies between fentanyl on-demand and alfentanil on-demand (44.1% vs. 39.5%, p = .40). No differences were observed for adverse events or any of the other secondary endpoints between the three groups. CONCLUSIONS Fentanyl prior to colonoscopy provided better pain control than fentanyl or alfentanil on-demand. Fentanyl before colonoscopy should be recommended to all women at screening age. Trial registration: Clinicaltrials.gov (NCT01538550). Norwegian Medicines Agency (16/16266-13). EU Clinical Trials Register (EUDRACTNR. 2016-005090-13).
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Affiliation(s)
- Anna Lisa Schult
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Vestre Viken Hospital Trust Baerum, Gjettum, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Research, Cancer Registry of Norway, Oslo, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Research and Development, Telemark Hospital Trust, Skien, Norway
| | - Øyvind Holme
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medicine, Sørlandet Hospital Trust, Kristiansand, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Kristin Ranheim Randel
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
- Department of Research and Development, Telemark Hospital Trust, Skien, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Badboni El-Safadi
- Department of Medicine, Østfold Hospital Trust, Grålum, Norway
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Ishita Barua
- Department of Medicine, Vestre Viken Hospital Trust Baerum, Gjettum, Norway
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Carl Munck
- Department of Medicine, Vestre Viken Hospital Trust Baerum, Gjettum, Norway
| | - Linn Rosén Nilsen
- Department of Gastroenterology, Østfold Hospital Trust, Grålum, Norway
| | | | - Thomas de Lange
- Department of Medical Research, Vestre Viken Hospital Trust Baerum, Gjettum, Norway
- Department of Medicine, Sahlgrenska University Hospital-Mölndal, Mølndal, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Rosvall A, Axelsson M, Toth E, Kumlien C, Annersten Gershater M. Patients' Experiences Before, During, and After a Colonoscopy Procedure: A Qualitative Study. Gastroenterol Nurs 2021; 44:392-402. [PMID: 34860190 DOI: 10.1097/sga.0000000000000569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/14/2020] [Indexed: 12/20/2022] Open
Abstract
Although colonoscopy is a common examination, there is limited research focusing on how patients experience this procedure. It is important that a colonoscopy is tolerated, as it may lead to lifesaving diagnostics and treatment. This study aims to explore adult patients' experience of undergoing a colonoscopy regarding the time prior to, during, and after the procedure. This was a qualitative study with individual interviews (n = 24) and a purposeful sample that was analyzed using thematic analysis. The analysis revealed four themes. The first, "making up one's mind," describes how the participants gathered information and reflected emotionally about the forthcoming procedure. The hope of clarification motivated them to proceed. In the theme "getting ready," self-care was in focus while the participants struggled to follow the instructions and carry out the burdensome cleansing. The next theme, "going through," illuminates' experiences during the colonoscopy and highlights the importance of feeling involved and respected. The last theme, "finally over," is characterized by experiences of relief, tiredness, and a desire for clarity. The healthcare professionals' ability to meet the participants' needs is vital, given that the experiences are highly individual. These findings contribute to a variegated image of how patients experience the process of undergoing a colonoscopy.
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Affiliation(s)
- Annica Rosvall
- Annica Rosvall, MSc, RN, is Doctoral Student, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Malin Axelsson, PhD, RN, is Associate Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Ervin Toth, PhD, MD, is Associate Professor and Senior Consultant, Department of Gastroenterology, Skåne University Hospital, Malmö, and Lund University, Lund, Sweden
- Christine Kumlien, PhD, RN, is Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Magdalena Annersten Gershater, PhD, RN, is Senior Lecturer, Department of Care Science, Faculty of Health and Society, Malmö University, Sweden
| | - Malin Axelsson
- Annica Rosvall, MSc, RN, is Doctoral Student, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Malin Axelsson, PhD, RN, is Associate Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Ervin Toth, PhD, MD, is Associate Professor and Senior Consultant, Department of Gastroenterology, Skåne University Hospital, Malmö, and Lund University, Lund, Sweden
- Christine Kumlien, PhD, RN, is Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Magdalena Annersten Gershater, PhD, RN, is Senior Lecturer, Department of Care Science, Faculty of Health and Society, Malmö University, Sweden
| | - Ervin Toth
- Annica Rosvall, MSc, RN, is Doctoral Student, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Malin Axelsson, PhD, RN, is Associate Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Ervin Toth, PhD, MD, is Associate Professor and Senior Consultant, Department of Gastroenterology, Skåne University Hospital, Malmö, and Lund University, Lund, Sweden
- Christine Kumlien, PhD, RN, is Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Magdalena Annersten Gershater, PhD, RN, is Senior Lecturer, Department of Care Science, Faculty of Health and Society, Malmö University, Sweden
| | - Christine Kumlien
- Annica Rosvall, MSc, RN, is Doctoral Student, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Malin Axelsson, PhD, RN, is Associate Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Ervin Toth, PhD, MD, is Associate Professor and Senior Consultant, Department of Gastroenterology, Skåne University Hospital, Malmö, and Lund University, Lund, Sweden
- Christine Kumlien, PhD, RN, is Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Magdalena Annersten Gershater, PhD, RN, is Senior Lecturer, Department of Care Science, Faculty of Health and Society, Malmö University, Sweden
| | - Magdalena Annersten Gershater
- Annica Rosvall, MSc, RN, is Doctoral Student, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Malin Axelsson, PhD, RN, is Associate Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Ervin Toth, PhD, MD, is Associate Professor and Senior Consultant, Department of Gastroenterology, Skåne University Hospital, Malmö, and Lund University, Lund, Sweden
- Christine Kumlien, PhD, RN, is Professor, Department of Care Science, Faculty of Health and Society, Malmö University, Malmö, Sweden; Department of Cardio-Thoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
- Magdalena Annersten Gershater, PhD, RN, is Senior Lecturer, Department of Care Science, Faculty of Health and Society, Malmö University, Sweden
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Neilson LJ, Sharp L, Patterson JM, von Wagner C, Hewitson P, McGregor LM, Rees CJ. The Newcastle ENDOPREM™: a validated patient reported experience measure for gastrointestinal endoscopy. BMJ Open Gastroenterol 2021; 8:e000653. [PMID: 34697041 PMCID: PMC8547355 DOI: 10.1136/bmjgast-2021-000653] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/05/2021] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Measuring patient experience of gastrointestinal (GI) procedures is a key component of evaluation of quality of care. Current measures of patient experience within GI endoscopy are largely clinician derived and measured; however, these do not fully represent the experiences of patients themselves. It is important to measure the entirety of experience and not just experience directly during the procedure. We aimed to develop a patient-reported experience measure (PREM) for GI procedures. DESIGN Phase 1: semi-structured interviews were conducted in patients who had recently undergone GI endoscopy or CT colonography (CTC) (included as a comparator). Thematic analysis identified the aspects of experience important to patients. Phase 2: a question bank was developed from phase 1 findings, and iteratively refined through rounds of cognitive interviews with patients who had undergone GI procedures, resulting in a pilot PREM. Phase 3: patients who had attended for GI endoscopy or CTC were invited to complete the PREM. Psychometric properties were investigated. Phase 4 involved item reduction and refinement. RESULTS Phase 1: interviews with 35 patients identified six overarching themes: anxiety, expectations, information & communication, embarrassment & dignity, choice & control and comfort. Phase 2: cognitive interviews refined questionnaire items and response options. Phase 3: the PREM was distributed to 1650 patients with 799 completing (48%). Psychometric properties were found to be robust. Phase 4: final questionnaire refined including 54 questions assessing patient experience across five temporal procedural stages. CONCLUSION This manuscript gives an overview of the development and validation of the Newcastle ENDOPREM™, which assesses all aspects of the GI procedure experience from the patient perspective. It may be used to measure patient experience in clinical care and, in research, to compare patients' experiences of different endoscopic interventions.
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Affiliation(s)
- Laura J Neilson
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Paul Hewitson
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Colin J Rees
- Department of Gastroenterology, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, UK
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Forbes N, Chau M, Koury HF, Lethebe BC, Smith ZL, Wani S, Keswani RN, Elmunzer BJ, Anderson JT, Heitman SJ, Hilsden RJ. Development and validation of a patient-reported scale for tolerability of endoscopic procedures using conscious sedation. Gastrointest Endosc 2021; 94:103-110.e2. [PMID: 33385464 PMCID: PMC8761529 DOI: 10.1016/j.gie.2020.12.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patient-reported experience measures (PREMs) assessing the tolerability of endoscopic procedures are scarce. In this study, we designed and validated a PREM to assess tolerability of endoscopy using conscious sedation. METHODS The patient-reported scale for tolerability of endoscopic procedures (PRO-STEP) consists of questions within 2 domains and is administered to outpatients at discharge from the endoscopy unit. Domain 1 (intraprocedural) consists of 2 questions regarding discomfort/pain and awareness, whereas domain 2 (postprocedural) consists of 4 questions on pain, nausea, distention, and either throat or anal pain. All questions are scored on a Likert scale from 0 to 10. Cronbach's alpha was used to measure internal consistency of the questions. Multivariable logistic regression was performed to assess predictors of higher scores, reported using adjusted odds ratios and confidence intervals. RESULTS Two hundred fifty-five patients (91 colonoscopy, 73 gastroscopy, and 91 ERCP) were included. Colonoscopy was the least tolerable procedure by recall, with mean intraprocedural awareness and discomfort scores of 5.1 ± 3.8, and 2.6 ± 2.7, respectively. Consistency between intraprocedural awareness and discomfort/pain yielded an acceptable Cronbach's alpha of .71 (95% confidence interval, .62-.78). Higher use of midazolam during colonoscopy was inversely associated with an intraprocedural awareness score of 7 or higher (per additional mg: adjusted odds ratio, .23; 95% confidence interval, .09-.54). CONCLUSIONS PRO-STEP is a simple PREM that can be administered after multiple endoscopic procedures using conscious sedation. Future work should focus on its performance characteristics in adverse event prediction.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Millie Chau
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Hannah F. Koury
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - B. Cord Lethebe
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Zachary L. Smith
- Department of Medicine, Division of Gastroenterology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA
| | - Rajesh N. Keswani
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - B. Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John T. Anderson
- Department of Gastroenterology, Gloucestershire Hospitals NHSFT, Gloucester, UK
| | - Steven J. Heitman
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Robert J. Hilsden
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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10
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Randel KR, Schult AL, Botteri E, Hoff G, Bretthauer M, Ursin G, Natvig E, Berstad P, Jørgensen A, Sandvei PK, Olsen ME, Frigstad SO, Darre-Næss O, Norvard ER, Bolstad N, Kørner H, Wibe A, Wensaas KA, de Lange T, Holme Ø. Colorectal Cancer Screening With Repeated Fecal Immunochemical Test Versus Sigmoidoscopy: Baseline Results From a Randomized Trial. Gastroenterology 2021; 160:1085-1096.e5. [PMID: 33227280 DOI: 10.1053/j.gastro.2020.11.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/29/2020] [Accepted: 11/17/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS The comparative effectiveness of sigmoidoscopy and fecal immunochemical testing (FIT) for colorectal cancer (CRC) screening is unknown. METHODS Individuals aged 50-74 years living in Southeast Norway were randomly invited between 2012 and 2019 to either once-only flexible sigmoidoscopy or FIT screening every second year. Colonoscopy was recommended after sigmoidoscopy if any polyp of ≥10 mm, ≥3 adenomas, any advanced adenomas, or CRC was found or, subsequent to, FIT >15 μg hemoglobin/g feces. Data for this report were obtained after complete recruitment in both groups and included 2 full FIT rounds and part of the third round. Outcome measures were participation, neoplasia detection, and adverse events. Age-standardized detection rates and age-adjusted odds ratios (ORs) were calculated. RESULTS We included 139,291 individuals: 69,195 randomized to sigmoidoscopy and 70,096 to FIT. The participation rate was 52% for sigmoidoscopy, 58% in the first FIT round, and 68% for 3 cumulative FIT rounds. Compared to sigmoidoscopy, the detection rate for CRC was similar in the first FIT round (0.25% vs 0.27%; OR, 0.92; 95% confidence interval [CI], 0.75-1.13) but higher after 3 FIT rounds (0.49% vs 0.27%; OR, 1.87; 95% CI, 1.54-2.27). Advanced adenoma detection rate was lower in the first FIT round compared to sigmoidoscopy at 1.4% vs 2.4% (OR, 0.57; 95% CI, 0.53-0.62) but higher after 3 cumulative FIT rounds at 2.7% vs 2.4% (OR, 1.14; 95% CI, 1.05-1.23). There were 33 (0.05%) serious adverse events in the sigmoidoscopy group compared to 47 (0.07%) in the FIT group (P = .13). CONCLUSIONS Participation was higher and more CRC and advanced adenomas were detected with repeated FIT compared to sigmoidoscopy. The risk of perforation and bleeding was comparable. Clinicaltrials.gov, Number: NCT01538550.
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Affiliation(s)
- Kristin R Randel
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Department of Research and Development, Telemark Hospital Trust, Skien, Norway; Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Anna L Schult
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Edoardo Botteri
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Geir Hoff
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Department of Research and Development, Telemark Hospital Trust, Skien, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo; Norway Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Giske Ursin
- Cancer Registry of Norway, Oslo, Norway; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway; Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | - Erik Natvig
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Paula Berstad
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | - Anita Jørgensen
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway
| | | | - Marie Ek Olsen
- Department of Pathology, Østfold Hospital Trust, Grålum, Norway
| | - Svein Oskar Frigstad
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ole Darre-Næss
- Department of Medicine, Vestre Viken Hospital Trust Bærum, Gjettum, Norway
| | - Espen R Norvard
- Department of Pathology, Vestre Viken Hospital Trust Drammen, Drammen, Norway
| | - Nils Bolstad
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Hartwig Kørner
- Department of Gastrointestinal Surgery, Stavanger University Hospital Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Arne Wibe
- Norwegian University of Science and Technology; Department of Surgery, St. Olav's hospital, Trondheim University Hospital, Trondheim, Norway
| | - Knut-Arne Wensaas
- Research Unit for General Practice, NORCE Norwegian Research Centre, Bergen, Norway
| | - Thomas de Lange
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Medical Research, Vestre Viken Hospital Trust Bærum, Gjettum, Norway; Department of Medicine, Sahlgrenska University Hospital-Mölndal, Sweden
| | - Øyvind Holme
- Section for Colorectal Cancer Screening, Cancer Registry of Norway, Oslo, Norway; Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo; Department of Medicine, Sorlandet Hospital Trust, Kristiansand, Norway
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11
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Rogers AC, Van De Hoef D, Sahebally SM, Winter DC. A meta-analysis of carbon dioxide versus room air insufflation on patient comfort and key performance indicators at colonoscopy. Int J Colorectal Dis 2020; 35:455-464. [PMID: 31900583 DOI: 10.1007/s00384-019-03470-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Carbon dioxide (CO2) has been used as an alternative to air insufflation at endoscopy with good results; however, uptake of the technique has been poor, possibly due to perceived lack of outcome equivalency. This meta-analysis evaluates the effectiveness of CO2 versus air in reducing pain post-colonoscopy and furthermore examines other key performance indicators (KPIs) such as sedative use, procedure times and polyp detection rates. METHODS This meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pubmed, Pubmed Central, Embase and Cochrane Library were searched for randomized studies from 2004 to 2019, reporting outcomes for patients undergoing colonoscopy with air or CO2 insufflation, who reported pain on a numerical or visual analogue scale (VAS). Results were reported as mean differences (MD) or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS Of 3586 citations, 23 studies comprising 3217 patients were analysed. Patients undergoing colonoscopy with air insufflation had 30% higher intraprocedural pain scores than those receiving CO2 (VAS 3.4 versus 2.6, MD -0.7, 95% CI - 1.4-0.0, p = 0.05), with a sustained beneficial effect amongst those in the CO2 group at 30 min, 1-2-h and 6-h post procedure (MD - 0.8, - 0.6 and - 0.2, respectively, p < 0.001 for all), as well as less distension, bloating and flatulence (p < 0.01 for all). There were no differences between the two groups in KPIs such as the sedation required, procedure time, caecal intubation or polyp detection rates. CONCLUSIONS CO2 insufflation improves patient comfort without compromising colonoscopic performance.
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Affiliation(s)
- Ailín C Rogers
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland. .,Centre for Colorectal Disease, University College Dublin, Dublin, Ireland.
| | - Dayna Van De Hoef
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, University College Dublin, Dublin, Ireland
| | - Shaheel M Sahebally
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, University College Dublin, Dublin, Ireland
| | - Des C Winter
- Department of Colorectal Surgery, St. Vincent's University Hospital, Dublin, Ireland.,Centre for Colorectal Disease, University College Dublin, Dublin, Ireland
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12
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Neilson LJ, Patterson J, von Wagner C, Hewitson P, McGregor LM, Sharp L, Rees CJ. Patient experience of gastrointestinal endoscopy: informing the development of the Newcastle ENDOPREM™. Frontline Gastroenterol 2020; 11:209-217. [PMID: 32419912 PMCID: PMC7223270 DOI: 10.1136/flgastro-2019-101321] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/12/2019] [Accepted: 12/13/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Measuring patient experience is important for evaluating the quality of patient care, identifying aspects requiring improvement and optimising patient outcomes. Patient Reported Experience Measures (PREMs) should, ideally, be patient derived, however no such PREMs for gastrointestinal (GI) endoscopy exist. This study explored the experiences of patients undergoing GI endoscopy and CT colonography (CTC) in order to: identify aspects of care important to them; determine whether the same themes are relevant across investigative modalities; develop the framework for a GI endoscopy PREM. METHODS Patients aged ≥18 years who had undergone oesophagogastroduodenoscopy (OGD), colonoscopy or CTC for symptoms or surveillance (but not within the national bowel cancer screening programme) in one hospital were invited to participate in semi-structured interviews. Recruitment continued until data saturation. Inductive thematic analysis was undertaken. RESULTS 35 patients were interviewed (15 OGD, 10 colonoscopy, 10 CTC). Most patients described their experience chronologically, and five 'procedural stages' were evident: before attending for the test; preparing for the test; at the hospital, before the test; during the test; after the test. Six themes were identified: anxiety; expectations; choice & control; communication & information; comfort; embarrassment & dignity. These were present for all three procedures but not all procedure stages. Some themes were inter-related (eg, expectations & anxiety; communication & anxiety). CONCLUSION We identified six key themes encapsulating patient experience of GI procedures and these themes were evident for all procedures and across multiple procedure stages. These findings will be used to inform the development of the Newcastle ENDOPREM™.
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Affiliation(s)
- Laura J Neilson
- Department of Gastroenterology, South Tyneside District Hospital, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Joanne Patterson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
- Speech and Language Therapy Department, Sunderland Royal Hospital, Sunderland, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Paul Hewitson
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Linda Sharp
- Population Health Sciences Institute & Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Colin J Rees
- Department of Gastroenterology, South Tyneside District Hospital, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Population Health Sciences Institute & Newcastle University Centre for Cancer, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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13
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Kaminski MF, Robertson DJ, Senore C, Rex DK. Optimizing the Quality of Colorectal Cancer Screening Worldwide. Gastroenterology 2020; 158:404-417. [PMID: 31759062 DOI: 10.1053/j.gastro.2019.11.026] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022]
Abstract
Screening, followed by colonoscopic polypectomy (or surgery for malignant lesions), prevents incident colorectal cancer and mortality. However, there are variations in effective application of nearly every aspect of the screening process. Screening is a multistep process, and failure in any single step could result in unnecessary morbidity and mortality. Awareness of variations in operator- and system-dependent performance has led to detailed, comprehensive recommendations in the United States and Europe on how colonoscopy screening should be performed and measured. Likewise, guidance has been provided on quality assurance for nonprimary colonoscopy-based screening programs, including strategies to maximize adherence. Quality improvement is now a validated science, and there is clear evidence that higher quality prevents incident cancer and cancer death. Quality must be addressed at the levels of the system, provider, and individuals, to maximize the benefits of screening for any population. We review the important aspects of measuring and improving the quality of colorectal cancer screening.
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Affiliation(s)
- Michael F Kaminski
- Department of Gastroenterological Oncology, the Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland; Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland; Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Douglas J Robertson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont; The Geisel School of Medicine at Dartmouth and The Dartmouth Institute, Hanover, New Hampshire
| | - Carlo Senore
- Epidemiology and Screening Unit-CPO, University Hospital Città della Salute e della Scienza, Turin, Italy
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.
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14
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Bugajski M, Wieszczy P, Pisera M, Rupinski M, Hoff G, Huppertz-Hauss G, Regula J, Bretthauer M, Kaminski MF. Effectiveness of digital feedback on patient experience and 30-day complications after screening colonoscopy: a randomized health services study. Endosc Int Open 2019; 7:E537-E544. [PMID: 31041371 PMCID: PMC6447395 DOI: 10.1055/a-0830-4648] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/26/2018] [Indexed: 11/03/2022] Open
Abstract
Background and study aims European guidelines (ESGE) recommend measuring patient experience and 30-day complication rate after colonoscopy. We compared digital and paper-based feedback on patients' experience and 30-day complications after screening colonoscopy. Patients and methods Screenees attending for primary screening colonoscopies in two centers from September 2015 to December 2016 were randomized (1:1) to an intervention arm (choice of feedback method) or control arm (routine paper-based feedback). Participants in the intervention arm could choose preferred feedback method (paper-based, automated telephone or online survey) and were contacted by automated telephone 30 days after colonoscopy to assess complications. Control group participants self-reported complications. Primary and secondary endpoints were response rates to feedback and complications questionnaire, respectively. Results There were 1,281 and 1,260 participants in the intervention and control arms, respectively. There was no significant difference in response rate between study groups (64.8 % vs 61.5 %; P = 0.08). Free choice of feedback improved response for participants identified as poor responders: younger than 60 years (60.8 % vs 54.7 %; P = 0.031), male (64.0 % vs 58.6 %; P = 0.045) and in small non-public center (56.2 % vs 42.5 %; P = 0.043). In the intervention arm, 1,168 participants (91.2 %) answered the phone call concerning complications. A total of 79 participants (6.2 %) reported complications, of which two (0.2 %) were verified by telephone as clinically relevant. No complications were self-reported in the control group. Conclusion The overall response rate was not significantly improved with digital feedback, yet the technology yielded significant improvement in participants defined as poor responders. Our study demonstrated feasibility and efficacy of digital patient feedback about complications after colonoscopy.
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Affiliation(s)
- M. Bugajski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - P. Wieszczy
- Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland,Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - M. Pisera
- Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - M. Rupinski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - G. Hoff
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway,Department of Research and Development, Telemark Hospital, Skien, Norway
| | | | - J. Regula
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - M. Bretthauer
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - M. F. Kaminski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Center for Postgraduate Education, Warsaw, Poland,Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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15
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Bugajski M, Wieszczy P, Hoff G, Rupinski M, Regula J, Kaminski MF. Modifiable factors associated with patient-reported pain during and after screening colonoscopy. Gut 2018; 67:1958-1964. [PMID: 28970289 DOI: 10.1136/gutjnl-2017-313905] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/31/2017] [Accepted: 09/07/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Pain associated with colonoscopy is a major burden for patients. We investigated modifiable factors associated with patient-reported pain during and after colonoscopy. DESIGN This cross-sectional analysis included database records from 23 centres participating in a population-based colonoscopy screening programme in Poland. Colonoscopies were performed under three sedation modalities: none, benzodiazepine-opioid sedation or propofol sedation. We used Gastronet (a validated tool) to assess patients' pain during and after colonoscopy; pain was scored on a four-point scale (no, little, moderate or severe pain), with moderate to severe defined as painful. We used multivariate logistic regression models to estimate ORs for painful colonoscopy and calculated risk-adjusted ratios of painful colonoscopies per endoscopist and compared it to the mean rate. RESULTS Of 35 216 screening colonoscopies in 2014 and 2015 included in our study, 22 725 (64.5%) patients returned valid Gastronet questionnaires. The proportion of examinations described as causing pain during (after) the procedure was 22.5% (14.2%) for unsedated, 19.9% (13.5%) for benzodiazepine-opioid sedation and 2.5% (7.5%) for propofol sedation. Propofol sedation, higher case volume of endoscopists, newest endoscope generation and adequate bowel preparation were significantly associated with lower odds of painful colonoscopy. Pain scores after colonoscopy showed similar associations. Adjusted pain rates during and after colonoscopy varied 11 and over 23-fold, respectively, between endoscopists. CONCLUSION We identified several independent, modifiable factors associated with pain during and after colonoscopy, of which individual endoscopist was the most important. Dedicated training should be considered to decrease variability among endoscopists.
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Affiliation(s)
- Marek Bugajski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Paulina Wieszczy
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland
| | - Geir Hoff
- Department of Research and Development, Telemark Hospital, Skien, Norway.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Maciej Rupinski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Jaroslaw Regula
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
| | - Michal Filip Kaminski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland.,Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland.,Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland.,Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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16
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Abstract
OPINION STATEMENT Colonoscopy is one of the most commonly performed endoscopic procedures. It is the gold standard examination for work-up of colonic symptoms, for follow-up of positive colorectal cancer screening tests and for detection and removal of neoplastic polyps. Colonoscopy is a complex and invasive procedure with a potential not only for colorectal cancer prevention, but also for serious complications. Numerous factors may affect the balance of benefit versus harm of colonoscopy, including the performance of the endoscopist. These factors are commonly called quality indicators. As an increasing number of countries are recommending the general population to undergo colorectal cancer screening, the quality of colonoscopy should be considered a public health concern. Key quality indicators have been identified, and several professional organizations have issued recommendation statements to promote high-quality colonoscopy. To achieve high quality, these key quality indicators must be monitored, results must be analysed, and measures must be undertaken to correct substandard performance. High-quality training in colonoscopy and polypectomy should be a quality assurance priority.
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17
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Lange TD, Randel KR, Schult AL, Knudsen MD, Kirkøen B, Botteri E, Berstad P, Jørgensen A, Ursin G, Bretthauer M, Hoff G. Sigmoidoscopy and faecal occult blood test - a comparative screening trial. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:727-730. [PMID: 28551972 DOI: 10.4045/tidsskr.16.1031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
| | | | | | | | | | - Edoardo Botteri
- Kreftregisteret og Nasjonal kompetansetjeneste for kvinnehelse
| | | | | | - Giske Ursin
- Kreftregisteret og Institutt for medisinske basalfag Universitetet i Oslo
| | - Michael Bretthauer
- Institutt for helse og samfunn Universitetet i Oslo og Oslo universitetssykehus
| | - Geir Hoff
- Sykehuset Telemark og Kreftregisteret og Universitetet i Oslo
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18
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Kaminski MF, Thomas-Gibson S, Bugajski M, Bretthauer M, Rees CJ, Dekker E, Hoff G, Jover R, Suchanek S, Ferlitsch M, Anderson J, Roesch T, Hultcranz R, Racz I, Kuipers EJ, Garborg K, East JE, Rupinski M, Seip B, Bennett C, Senore C, Minozzi S, Bisschops R, Domagk D, Valori R, Spada C, Hassan C, Dinis-Ribeiro M, Rutter MD. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. United European Gastroenterol J 2017; 5:309-334. [PMID: 28507745 PMCID: PMC5415221 DOI: 10.1177/2050640617700014] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 02/27/2017] [Indexed: 12/13/2022] Open
Abstract
The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for lower gastrointestinal endoscopy. We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 rate of adequate bowel preparation (minimum standard 90%); 2 cecal intubation rate (minimum standard 90%); 3 adenoma detection rate (minimum standard 25%); 4 appropriate polypectomy technique (minimum standard 80%); 5 complication rate (minimum standard not set); 6 patient experience (minimum standard not set); 7 appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.
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Affiliation(s)
- Michal F Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
- Departments of Gastroenterological Oncology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Siwan Thomas-Gibson
- Wolfson Unit for Endoscopy, St. Mark’s Hospital, Harrow, and Imperial College, London, UK
| | - Marek Bugajski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
- Departments of Gastroenterological Oncology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Michael Bretthauer
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Colin J Rees
- South Tyneside NHS Foundation Trust, South Tyneside, UK
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, University of Amsterdam, Amsterdam, The Netherlands
| | - Geir Hoff
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Department of Research and Development, Telemark Hospital, Skien, Norway
- Cancer Registry of Norway, Oslo, Norway
| | - Rodrigo Jover
- Unidad de Gastroenterologia, Hospital General Universitario de Alicante, Alicante, Spain
| | - Stepan Suchanek
- Department of Internal Medicine, Military University Hospital, Prague, Czech Republic
| | - Monika Ferlitsch
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - John Anderson
- Gloucestershire Hospitals NHS Foundation Trust, Cheltenham General Hospital, Cheltenham, UK
| | - Thomas Roesch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Hultcranz
- Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Istvan Racz
- Department of Internal Medicine and Gastroenterology, Petz Aladar County and Teaching Hospital, Györ, Hungary
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kjetil Garborg
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - James E East
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK
| | - Maciej Rupinski
- Department of Gastroenterology, Hepatology and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
- Departments of Gastroenterological Oncology and Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
| | - Birgitte Seip
- Department of Gastroenterology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Cathy Bennett
- Centre for Technology Enabled Research, Coventry University, Coventry, UK
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Silvia Minozzi
- CPO Piemonte, AOU Città della Salute e della Scienza, Turin, Italy
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven and KU Leuven, Leuven, Belgium
| | - Dirk Domagk
- Department of Internal Medicine, Joseph’s Hospital, Warendorf, Germany
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Cristiano Spada
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | | | - Mario Dinis-Ribeiro
- Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal
- Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
- School of Medicine, Durham University, Durham, UK
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Wåhlberg H, Valle PC, Malm S, Hovde Ø, Broderstad AR. The effect of referral templates on out-patient quality of care in a hospital setting: a cluster randomized controlled trial. BMC Health Serv Res 2017; 17:177. [PMID: 28270128 PMCID: PMC5341470 DOI: 10.1186/s12913-017-2127-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 03/01/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The assessment of quality of care is an integral part of modern medicine. The referral represents the handing over of care from the general practitioner to the specialist. This study aimed to assess whether an improved referral could lead to improved quality of care. METHODS A cluster randomized trial with the general practitioner surgery as the clustering unit was performed. Fourteen surgeries in the area surrounding the University Hospital of North Norway Harstad were randomized stratified by town versus countryside location. The intervention consisted of implementing referral templates for new referrals in four clinical areas: dyspepsia; suspected colorectal cancer; chest pain; and confirmed or suspected chronic obstructive pulmonary disease. The control group followed standard referral practice. Quality of treatment pathway as assessed by newly developed quality indicators was used as main outcome. Secondary outcomes included subjective quality assessment, positive predictive value of referral and adequacy of prioritization. Assessment of outcomes was done at the individual level. The patients, hospital doctors and outcome assessors were blinded to the intervention status. RESULTS A total of 500 patients were included, with 281 in the intervention and 219 in the control arm. From the multilevel regression model the effect of the intervention on the quality indicator score was insignificant at 1.80% (95% CI, -1.46 to 5.06, p = 0.280). No significant differences between the intervention and the control groups were seen in the secondary outcomes. Active use of the referral intervention was low, estimated at approximately 50%. There was also wide variation in outcome scoring between the different assessors. CONCLUSIONS In this study no measurable effect on quality of care or prioritization was revealed after implementation of referral templates at the general practitioner/hospital interface. The results were hindered by a limited uptake of the intervention at GP surgeries and inconsistencies in outcome assessment. TRIAL REGISTRATION The study was registered under registration number NCT01470963 on September 5th, 2011.
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Affiliation(s)
- Henrik Wåhlberg
- Department of Community Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Per Christian Valle
- University Hospital of North Norway Harstad, St. Olavsgate 70, 9480 Harstad, Norway
| | - Siri Malm
- University Hospital of North Norway Harstad, St. Olavsgate 70, 9480 Harstad, Norway
- Department of Clinical Medicine, UiT The Arctic University of Norway, 9037 Tromsø, Norway
| | - Øistein Hovde
- Department of Gastroenterology, Innlandet Hospital Trust, 2819 Gjøvik, Norway
- Institute for Clinical Medicine, University of Oslo, P.O. Box 1171, 0318 Oslo, Norway
| | - Ann Ragnhild Broderstad
- University Hospital of North Norway Harstad, St. Olavsgate 70, 9480 Harstad, Norway
- Centre for Sami Health Research, UiT The Arctic University of Norway, 9037 Tromsø, Norway
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Bretthauer M, Kaminski MF, Løberg M, Zauber AG, Regula J, Kuipers EJ, Hernán MA, McFadden E, Sunde A, Kalager M, Dekker E, Lansdorp-Vogelaar I, Garborg K, Rupinski M, Spaander MCW, Bugajski M, Høie O, Stefansson T, Hoff G, Adami HO. Population-Based Colonoscopy Screening for Colorectal Cancer: A Randomized Clinical Trial. JAMA Intern Med 2016; 176:894-902. [PMID: 27214731 PMCID: PMC5333856 DOI: 10.1001/jamainternmed.2016.0960] [Citation(s) in RCA: 236] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Although some countries have implemented widespread colonoscopy screening, most European countries have not introduced it because of uncertainty regarding participation rates, procedure-related pain and discomfort, endoscopist performance, and effectiveness. To our knowledge, no randomized trials on colonoscopy screening currently exist. OBJECTIVE To investigate participation rate, adenoma yield, performance, and adverse events of population-based colonoscopy screening in several European countries. DESIGN, SETTING, AND POPULATION A population-based randomized clinical trial was conducted among 94 959 men and women aged 55 to 64 years of average risk for colon cancer in Poland, Norway, the Netherlands, and Sweden from June 8, 2009, to June 23, 2014. INTERVENTIONS Colonoscopy screening or no screening. MAIN OUTCOMES AND MEASURES Participation in colonoscopy screening, cancer and adenoma yield, and participant experience. Study outcomes were compared by country and endoscopist. RESULTS Of 31 420 eligible participants randomized to the colonoscopy group, 12 574 (40.0%) underwent screening. Participation rates were 60.7% in Norway (5354 of 8816), 39.8% in Sweden (486 of 1222), 33.0% in Poland (6004 of 18 188), and 22.9% in the Netherlands (730 of 3194) (P < .001). The cecum intubation rate was 97.2% (12 217 of 12 574), with 9726 participants (77.4%) not receiving sedation. Of the 12 574 participants undergoing colonoscopy screening, we observed 1 perforation (0.01%), 2 postpolypectomy serosal burns (0.02%), and 18 cases of bleeding owing to polypectomy (0.14%). Sixty-two individuals (0.5%) were diagnosed with colorectal cancer and 3861 (30.7%) had adenomas, of which 1304 (10.4%) were high-risk adenomas. Detection rates were similar in the proximal and distal colon. Performance differed significantly between endoscopists; recommended benchmarks for cecal intubation (95%) and adenoma detection (25%) were not met by 6 (17.1%) and 10 of 35 endoscopists (28.6%), respectively. Moderate or severe abdominal pain after colonoscopy was reported by 601 of 3611 participants (16.7%) examined with standard air insufflation vs 214 of 5144 participants (4.2%) examined with carbon dioxide (CO2) insufflation (P < .001). CONCLUSIONS AND RELEVANCE Colonoscopy screening entails high detection rates in the proximal and distal colon. Participation rates and endoscopist performance vary significantly. Postprocedure abdominal pain is common with standard air insufflation and can be significantly reduced by using CO2. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00883792.
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Affiliation(s)
- Michael Bretthauer
- Department of Health Management and Health Economy, University of Oslo, Oslo, Norway2Department of Transplantation Medicine and KG Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway 3Department of Epidemiology, Harvard T
| | - Michal F Kaminski
- Department of Health Management and Health Economy, University of Oslo, Oslo, Norway4Department of Gastroenterological Oncology, The Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology and Medical Center for Postgraduate Education, War
| | - Magnus Løberg
- Department of Health Management and Health Economy, University of Oslo, Oslo, Norway2Department of Transplantation Medicine and KG Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jaroslaw Regula
- Department of Gastroenterological Oncology, The Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology and Medical Center for Postgraduate Education, Warsaw, Poland
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Miguel A Hernán
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA7Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA8Division of Health Sciences and Technology, Harvard-Massachusetts Institute of Technology
| | | | | | - Mette Kalager
- Department of Health Management and Health Economy, University of Oslo, Oslo, Norway2Department of Transplantation Medicine and KG Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway 3Department of Epidemiology, Harvard T
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Kjetil Garborg
- Department of Transplantation Medicine and KG Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
| | - Maciej Rupinski
- Department of Gastroenterological Oncology, The Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology and Medical Center for Postgraduate Education, Warsaw, Poland
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Marek Bugajski
- Department of Gastroenterological Oncology, The Maria Sklodowska Curie Memorial Cancer Center and Institute of Oncology and Medical Center for Postgraduate Education, Warsaw, Poland
| | - Ole Høie
- Department of Medicine, Sørlandet Hospital, Arendal, Norway
| | - Tryggvi Stefansson
- Department of Surgery, The National University Hospital of Iceland, Reykjavik, Iceland
| | - Geir Hoff
- Department of Health Management and Health Economy, University of Oslo, Oslo, Norway13Department of Research and Development, Telemark Hospital, Skien, Norway
| | - Hans-Olov Adami
- Department of Health Management and Health Economy, University of Oslo, Oslo, Norway2Department of Transplantation Medicine and KG Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway 3Department of Epidemiology, Harvard T
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Garborg K, Wiig H, Hasund A, Matre J, Holme Ø, Noraberg G, Løberg M, Kalager M, Adami HO, Bretthauer M. Gradual stiffness versus magnetic imaging-guided variable stiffness colonoscopes: A randomized noninferiority trial. United European Gastroenterol J 2016; 5:128-133. [PMID: 28405331 DOI: 10.1177/2050640616639162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/20/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Colonoscopes with gradual stiffness have recently been developed to enhance cecal intubation. OBJECTIVE We aimed to determine if the performance of gradual stiffness colonoscopes is noninferior to that of magnetic endoscopic imaging (MEI)-guided variable stiffness colonoscopes. METHODS Consecutive patients were randomized to screening colonoscopy with Fujifilm gradual stiffness or Olympus MEI-guided variable stiffness colonoscopes. The primary endpoint was cecal intubation rate (noninferiority limit 5%). Secondary endpoints included cecal intubation time. We estimated absolute risk differences with 95% confidence intervals (CIs). RESULTS We enrolled 475 patients: 222 randomized to the gradual stiffness instrument, and 253 to the MEI-guided variable stiffness instrument. Cecal intubation rate was 91.7% in the gradual stiffness group versus 95.6% in the variable stiffness group. The adjusted absolute risk for cecal intubation failure was 4.3% higher in the gradual stiffness group than in the variable stiffness group (upper CI border 8.1%). Median cecal intubation time was 13 minutes in the gradual stiffness group and 10 minutes in the variable stiffness group (p < 0.001). CONCLUSIONS The study is inconclusive with regard to noninferiority because the 95% CI for the difference in cecal intubation rate between the groups crosses the noninferiority margin. (ClinicalTrials.gov identifier: NCT01895504).
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Affiliation(s)
- Kjetil Garborg
- Department of Medicine, Sorlandet Hospital, Kristiansand, Norway; Department of Transplantation Medicine, Section of Gastroenterology, Oslo University Hospital, Norway; Department of Health Economy and Health Management and KG Jebsen Center of Colorectal Cancer Research, University of Oslo, Norway
| | - Håvard Wiig
- Department of Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Audun Hasund
- Department of Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Jon Matre
- Department of Medicine, Sorlandet Hospital, Kristiansand, Norway
| | - Øyvind Holme
- Department of Medicine, Sorlandet Hospital, Kristiansand, Norway; Department of Health Economy and Health Management and KG Jebsen Center of Colorectal Cancer Research, University of Oslo, Norway
| | - Geir Noraberg
- Department of Medicine, Sorlandet Hospital, Arendal, Norway
| | - Magnus Løberg
- Department of Transplantation Medicine, Section of Gastroenterology, Oslo University Hospital, Norway; Department of Health Economy and Health Management and KG Jebsen Center of Colorectal Cancer Research, University of Oslo, Norway
| | - Mette Kalager
- Department of Health Economy and Health Management and KG Jebsen Center of Colorectal Cancer Research, University of Oslo, Norway; Telemark Hospital, Skien, Norway
| | - Hans-Olov Adami
- Department of Health Economy and Health Management and KG Jebsen Center of Colorectal Cancer Research, University of Oslo, Norway; Harvard T. H. Chan School of Public Health, Boston, MA, USA; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Michael Bretthauer
- Department of Medicine, Sorlandet Hospital, Kristiansand, Norway; Department of Transplantation Medicine, Section of Gastroenterology, Oslo University Hospital, Norway; Department of Health Economy and Health Management and KG Jebsen Center of Colorectal Cancer Research, University of Oslo, Norway
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Moritz V, Holme O, Leblanc M, Hoff G. An explorative study from the Norwegian Quality Register Gastronet comparing self-estimated versus registered quality in colonoscopy performance. Endosc Int Open 2016; 4:E326-32. [PMID: 27004252 PMCID: PMC4798930 DOI: 10.1055/s-0042-100904] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 01/04/2016] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The value of a colonoscopy quality assurance (QA) register may be questioned if it brings no new information on which to act for quality improvement, e. g. if self-assessed quality of colonoscopy performance correlates perfectly with registered performance. PATIENTS AND METHODS In this explorative study, 39 (33 Norwegian and 6 Swedish) out of 99 new endoscopists joining the Norwegian QA register Gastronet from 2008 to 2013 responded to an invitation to fill in a questionnaire for self-assessment of cecal intubation rate, polyp detection rate for polyps ≥ 5 mm (PDR-5 mm), withdrawal time, total examination time, and rates for severely painful and pain-free colonoscopies before receiving their first-time feedback of actually registered results from Gastronet. A linear regression analysis was applied to explore the correlation between experience level and quality of estimation. RESULTS We included 2654 colonoscopies in our study. Endoscopists underestimated their cecal intubation rate (estimated 88.8 %, registered 93.1 %, P < 0.001), total procedure time (estimated 31.7 minutes, registered 37.2 minutes, P = 0.014), withdrawal time (estimated 9.8 minutes, registered 14.4 minutes, P = 0.006) and the rate of pain-free procedures (estimated 18.3 %, registered 24.5 %, P = 0.001). Pre-study colonoscopy experience was not correlated with estimated quality for any of the indicators. CONCLUSIONS Apart from overestimation of severely painful examinations, endoscopists most often underestimated their colonoscopy performance. Self-assessed quality of colonoscopy performance may not be a satisfactory substitute for systematic registration of quality and not sufficiently valid to be acted upon.
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Affiliation(s)
- Volker Moritz
- Telemark Hospital – Department of Medicine Skien, Norway
| | - Oyvind Holme
- Sørlandet Hospital Kristiansand – Department of Medicine Kristiansand, Norway and University of Oslo – Institute of Health and Society, Oslo, Norway
| | - Marissa Leblanc
- Oslo University Hospital – Oslo Centre for Biostatistics and Epidemiology, Research Support Services Oslo, Norway
| | - Geir Hoff
- Institute of Population-based Cancer Research – Clinical and registry-based research, Oslo, Norway
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Candas B, Jobin G, Dubé C, Tousignant M, Abdeljelil AB, Grenier S, Gagnon MP. Barriers and facilitators to implementing continuous quality improvement programs in colonoscopy services: a mixed methods systematic review. Endosc Int Open 2016; 4:E118-33. [PMID: 26878037 PMCID: PMC4751006 DOI: 10.1055/s-0041-107901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/05/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND AIM Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients. METHODS We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process. RESULTS We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists' perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources. CONCLUSION Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.
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Affiliation(s)
- Bernard Candas
- Institut d’excellence en santé et services sociaux du Québec, Quebec City, Quebec, Canada
- Université Laval – Department of Social and Preventive Medicine, Quebec City, Quebec, Canada
| | - Gilles Jobin
- Université de Montréal – Department of Medicine, Montreal, Quebec, Canada
- Maisonneuve-Rosemont Hospital – Gastroenterology, Montreal, Quebec, Canada
| | - Catherine Dubé
- University of Calgary – Department of Community Health Sciences, Calgary, Alberta, Canada
| | - Mario Tousignant
- CHU de Québec Research Center – Public Health and Practice-Changing Research, Quebec City, Quebec, Canada
| | - Anis Ben Abdeljelil
- CHU de Québec Research Center – Public Health and Practice-Changing Research, Quebec City, Quebec, Canada
| | - Sonya Grenier
- CHU de Québec Research Center – Public Health and Practice-Changing Research, Quebec City, Quebec, Canada
| | - Marie-Pierre Gagnon
- Université Laval – Faculty of Nursing, Quebec City, Quebec, Canada
- CHU de Québec Research Center – Population Health and Optimal Health Practices, Quebec City, Quebec, Canada
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Moritz V, Bretthauer M, Holme Ø, Wang Fagerland M, Løberg M, Glomsaker T, de Lange T, Seip B, Sandvei P, Hoff G. Time trends in quality indicators of colonoscopy. United European Gastroenterol J 2016; 4:110-120. [PMID: 26966531 PMCID: PMC4766538 DOI: 10.1177/2050640615570147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 01/05/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND There is considerable variation in the quality of colonoscopy performance. The Norwegian quality assurance programme Gastronet registers outpatient colonoscopies performed in Norwegian endoscopy centres. The aim of Gastronet is long-term improvement of endoscopist and centre performance by annual feedback of performance data. OBJECTIVE The objective of this article is to perform an analysis of trends of quality indicators for colonoscopy in Gastronet. METHODS This prospective cohort study included 73,522 outpatient colonoscopies from 73 endoscopists at 25 endoscopy centres from 2003 to 2012. We used multivariate logistic regression with adjustment for relevant variables to determine annual trends of three performance indicators: caecum intubation rate, pain during the procedure, and detection rate of polyps ≥5 mm. RESULTS The proportion of severely painful colonoscopies decreased from 14.8% to 9.2% (relative risk reduction of 38%; OR = 0.92 per year in Gastronet; 95% CI 0.86-1.00; p = 0.045). Caecal intubation (OR = 0.99; 95% CI 0.94-1.04; p = 0.6) and polyp detection (OR = 1.03; 95% CI 0.99-1.07; p = 0.15) remained unchanged during the study period. CONCLUSIONS Pain at colonoscopy showed a significant decrease during years of Gastronet participation while caecal intubation and polyp detection remained unchanged - independent of the use of sedation and/or analgesics and level of endoscopist experience. This may be due to the Gastronet audit, but effects of improved endoscopy technology cannot be excluded.
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Affiliation(s)
- Volker Moritz
- Department of Medicine, Telemark Hospital, Skien, Norway
| | - Michael Bretthauer
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway
| | - Øyvind Holme
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Medicine, Sørlandet Hospital, Kristiansand, Norway
| | - Morten Wang Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Magnus Løberg
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
- Departments of Epidemiology and Biostatistics; Harvard School of Public Health; Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA
- Cancer Registry of Norway, Oslo, Norway
| | - Tom Glomsaker
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Thomas de Lange
- Department of Medicine, Bærum Hospital, Vestre Viken Hospital Trust, Bærum, Norway
| | - Birgitte Seip
- Department of Medicine, Vestfold Hospital Trust, Tønsberg, Norway
| | - Per Sandvei
- Department of Medicine, Østfold Hospital, Frederikstad, Norway
| | - Geir Hoff
- Department of Medicine, Telemark Hospital, Skien, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
- Cancer Registry of Norway, Oslo, Norway
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Kiriyama S, Naitoh H, Fukuchi M, Yuasa K, Horiuchi K, Fukasawa T, Tabe Y, Yamauchi H, Suzuki M, Yoshida T, Saito Y, Kuwano H. Evaluation of abdominal circumference and salivary amylase activities after unsedated colonoscopy using carbon dioxide and air insufflations. J Dig Dis 2015; 16:747-51. [PMID: 26639093 DOI: 10.1111/1751-2980.12302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 11/11/2015] [Accepted: 11/26/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess and compare abdominal distention and stress in unsedated colonoscopy using carbon dioxide (CO2 ) and air insufflations. METHODS Two hundred and five patients underwent colonoscopic examinations without sedation using either CO2 or air insufflation. Abdominal circumference and salivary amylase (sAMY) activities before and 0 and 15 min after colonoscopy were measured by a nurse who was blinded to the grouping of the patients. RESULTS In all, 102 and 103 patients were randomly recruited in the CO2 and air insufflation groups, respectively. sAMY activities before and 0 and 15 min after colonoscopy were not significantly different between the two groups. Abdominal circumference measured immediately and 15 min after colonoscopy was significantly smaller in CO2 insufflation group than in the air insufflation group (81.2 cm vs 84.0 cm, and 79.7 cm vs 83.6 cm, respectively; P <0.05). The increasing ratio of abdominal circumference immediately after colonoscopy was not significantly different between the two groups; however, the ratio at 15 min after colonoscopy using CO2 insufflation was significantly lower than that in the air insufflation group (1.007 vs 1.028, P <0.001). CONCLUSION sAMY activities after unsedated colonoscopy using CO2 insufflation were not improved; however, CO2 insufflation decreases abdominal circumference after colonoscopy compared with air insufflation.
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Affiliation(s)
| | | | | | - Kazuhisa Yuasa
- Department of Gastroenterology, Gunma Chuo Hospital, Gunma
| | | | | | - Yuichi Tabe
- Department of Surgery, Gunma Chuo Hospital, Gunma
| | | | | | | | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo
| | - Hiroyuki Kuwano
- Department of General Surgical Science, Graduate School of Medicine, Gunma University, Gunma, Japan
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Hoff G. Gastrointestinal cancer screening: screening may release new research funding to improve health service also in routine clinics. Scand J Gastroenterol 2015; 50:718-26. [PMID: 25857737 DOI: 10.3109/00365521.2015.1011225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We are far from having seen the ideal method of screening for colorectal cancer (CRC) and the downsides of screening have not been fully addressed. Funding of adequately sized screening trials with a 10-15-year perspective for endpoints CRC mortality and incidence is difficult to get. Also, with such time horizons, there will always be an ongoing study to be awaited before feeling obliged to invest in the next. New, promising screening methods may, however, emerge far more often than every 10th year, and the knowledge gap may easily widen unless research is made a key responsibility for any ongoing cancer screening program. Previous lost battles on screening research may be won if accepting that scientific evidence may be obtained within the framework of screening programs - provided that they are designed as platforms for Comparative Effectiveness Research (CER). Accepting that CER-based screening programs should be preferred to non-CER programs and seriously compete for their funding sources, then CER screening programs may not be considered so much as contenders for ordinary clinical research funds. Also, CER within a screening framework may benefit patients in routine clinics as shown by screening research in Nordic countries. The Nordic countries have been early contributors to research on CRC screening, but slow in implementing screening programs.
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Robertson DJ, Kaminski MF, Bretthauer M. Effectiveness, training and quality assurance of colonoscopy screening for colorectal cancer. Gut 2015; 64:982-90. [PMID: 25804631 DOI: 10.1136/gutjnl-2014-308076] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/07/2015] [Indexed: 12/14/2022]
Abstract
Screening for colorectal cancer has been proven to be effective in reducing colorectal cancer incidence and mortality. While the precise benefit of screening exclusively by colonoscopy is not yet known, unarguably, the exam is central to the success of any screening programme. The test affords the opportunity to detect and resect neoplasia across the entire large bowel and is the definitive examination when other screening tests are positive. However, colonoscopy is invasive and often requires sedation as well as extensive bowel preparation, all of which puts the patient at risk. Furthermore, the test can technically be demanding and, unarguably, there is variation in how it is performed. This variation in performance has now been definitively linked to important outcome measures. For example, interval cancers are more common in low adenoma detectors as compared with high adenoma detectors. This review outlines the most current thinking regarding the effectiveness of colonoscopy as a screening tool. It also outlines key concepts to optimise its performance through robust quality assurance programmes and high-quality training.
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Affiliation(s)
- Douglas J Robertson
- VA Medical Center, White River Junction, Vermont, USA Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Michal F Kaminski
- Department of Gastroenterology and Hepatology, Medical Center for Postgraduate Education, Warsaw, Poland Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Michael Bretthauer
- Institute of Health and Society, University of Oslo, Oslo, Norway Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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Hoff G. Different standards for healthy screenees than patients in routine clinics? World J Gastroenterol 2013; 19:8527-30. [PMID: 24379569 PMCID: PMC3870497 DOI: 10.3748/wjg.v19.i46.8527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/20/2013] [Accepted: 11/03/2013] [Indexed: 02/06/2023] Open
Abstract
Less than 5% of colorectal adenomas will become malignant, but we do not have sufficient knowledge about their natural course to target removal of these 5% only. Thus, 95% of polypectomies are a waste of time exposing patients to a small risk of complications. Recently, a new type of polyps, sessile serrated polyps, has attracted attention. Previously considered innocuous, they are now found to have molecular similarities to cancer and some guidelines recommend to have them removed. These lesions are often flat, covered by mucous, not easily seen and situated in the proximal colon where the bowel wall is thinner. Thus, polypectomy carries a higher risk of perforation than predominantly left-sided, stalked adenomas - and we do not know what is gained in terms of cancer prevention. Screening is a neat balance between harms and benefit for presumptively healthy participants not interested in risk exposure to obtain confirmation of being healthy. The situation is quite different for patient worried about symptom. Thus, the standards set for evidence-based practice may be higher for screening than for routine clinics - a mechanism which may benefit patients in the long run.
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[International status colorectal cancer screening and quality assurance of screening-colonoscopy]. Wien Med Wochenschr 2013; 163:409-19. [PMID: 24006047 DOI: 10.1007/s10354-013-0232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 07/18/2013] [Indexed: 10/26/2022]
Abstract
Bowel cancer is frequent, early stages have much better prognosis and drug treatment of late stages is increasingly very expensive. Screening for colorectal cancer has the potential for both early detection and prevention. For a screening intervention colonoscopy is very invasive and holds the small risk of serious complications. Colonoscopy plays a key role for further diagnosis and intervention in all programs. Current international screening activities are presented. The emerging evidence on effectiveness of screening suggests that all strategies may have similar effect sizes. Participation rates and quality assurance thus are of key importance for realizing potential net health gains. Participation rates are higher for stool tests than for sigmoidoscopy and colonoscopy. For quality assurance of screening-colonoscopy an established range of quality measures is available. The possibility of systematic quality assurance also in the context of opportunistic screening like in Austria is proven by Germany and Poland.
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Glomsaker TB, Hoff G, Kvaløy JT, Søreide K, Aabakken L, Søreide JA. Patient-reported outcome measures after endoscopic retrograde cholangiopancreatography: a prospective, multicentre study. Scand J Gastroenterol 2013; 48:868-76. [PMID: 23721162 DOI: 10.3109/00365521.2013.794470] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences. METHODS From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded. RESULTS Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure. CONCLUSIONS Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.
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Affiliation(s)
- Tom B Glomsaker
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
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Holme Ø, Moritz V, Bretthauer M, Seip B, Glomsaker T, de Lange T, Aabakken L, Stallemo A, Høie O, Dahler S, Sandvei PK, Stray N, Ystrøm CM, Hoff G. [Pain in connection with colonoscopy in Norway]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:1074-1078. [PMID: 23712171 DOI: 10.4045/tidsskr.12.1467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Colonoscopies are common examinations at Norwegian hospitals. In contrast to many other countries, the majority of colonoscopies in Norway are conducted without routine sedation or analgesia. We wanted to investigate whether current Norwegian practice offers adequate pain relief. MATERIAL AND METHOD The material consists of prospectively recorded outpatient colonoscopies in the period January 2003-December 2011 performed at Norwegian hospitals in the quality assurance network for gastrointestinal endoscopy (Gastronet). We analysed demographic patient data and data from colonoscopies. Patients' experience of pain (none, slight, moderate or severe pain) in connection with the examination was established with the aid of a validated questionnaire. RESULTS Data from 61,749 colonoscopies (55% on women) performed at 29 different hospitals were analysed. Colonoscopies were perceived as moderately or very painful by 33% of the patients (41% of the women, 24% of the men, p < 0.001). There were substantial differences between hospitals as to the percentage of colonoscopies that were perceived as moderately or very painful (from 9% to 43%, p < 0.001) and the use of sedatives and analgesics for the colonoscopies (from 1% to 92% of the examinations, p < 0.001). Only 23% of those who found the colonoscopy painful received analgesics. Pethidine was used in 95% of the cases in which analgesics were used during the examination. INTERPRETATION Many patients find colonoscopies painful. Pain relief practice varies substantially between hospitals. Pethidine is an analgesic with a slow onset of action, and should perhaps be replaced with more rapidly acting opiates.
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Affiliation(s)
- Øyvind Holme
- Medisinsk avdeling, Sørlandet sykehus, Kristiansand, Norway.
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Gyökeres T, Rusznyák K, Visnyei Z, Schäfer E, Szamosi T, Banai J. [Introduction of a quality index in a Hungarian endoscopy unit]. Orv Hetil 2012; 153:1142-52. [PMID: 22805040 DOI: 10.1556/oh.2012.29408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
UNLABELLED The quality of endoscopic examinations substantially determines their value. In developed countries, Continuous Quality Management is used to improve it permanently. In Hungary there is no example for measuring quality in the field of gastrointestinal endoscopy. AIM The measurement and improvement of quality of endoscopy applying completeness index (cecum intubation rate) during colonoscopy. PATIENTS AND METHODS The authors defined base values retrospectively from 841 colonoscopy reports, performed in the last quarter of the year, before starting the project. The next two years (3160 colonoscopy in 2009 and 3167 in 2010) every three months they calculated the cecum intubation rate for each endoscopist. RESULTS The cecum intubation rate was 81.6% in the base period. When the authors excluded examinations with poor preparations and those with a previously unknown stenosis that prevented the total colonoscopy, the adjusted cecal intubation rate was 90.9%. In the next 2 years, the cecum intubation rate was 84.2% and 85.7% (p = 0.0394), while adjusted cecum intubation rate proved to be 92.3% and 92.6% (p = 0.381 NS) for the whole endoscopy unit. Of the 14 endoscopists only 6 reached an adjusted cecum intubation rate of 90%, but in the second year of the project 10 of them reached this rate and only one endoscopist remained below 87%. The endoscopists performing more than 100 colonoscopies per year had better adjusted cecum intubation rate (base 91.2%; 92.7% and 93.1% during the 2 project years) compared to those with less than 100 colonoscopies per year (base, 86.7%; project period, 85.5 and 89%). CONCLUSIONS The evaluation and publicity of the cecal intubation rate resulted in an improvement of the quality of colonoscopy. The authors also presented that endoscopists performing more than 100 colonoscopies per year have better endoscopic quality.
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Affiliation(s)
- Tibor Gyökeres
- MH Honvédkórház Gasztroenterológia Budapest Podmaniczky.
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Terruzzi V, Paggi S, Amato A, Radaelli F. Unsedated colonoscopy: A neverending story. World J Gastrointest Endosc 2012; 4:137-41. [PMID: 22523614 PMCID: PMC3329613 DOI: 10.4253/wjge.v4.i4.137] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/18/2011] [Accepted: 03/01/2012] [Indexed: 02/05/2023] Open
Abstract
Although sedation and analgesia for patients undergoing colonoscopy is the standard practice in Western countries, unsedated colonoscopy is still routinely provided in Europe and the Far East. This variation in sedation practice relies on the different cultural attitudes of both patients and endoscopists across these countries. Data from the literature consistently report that, in unsedated patients, the use of alternative techniques, such as warm water irrigation or carbon dioxide insufflation, can allow a high quality and well tolerated examination.
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Affiliation(s)
- Vittorio Terruzzi
- Vittorio Terruzzi, Silvia Paggi, Arnaldo Amato, Franco Radaelli, Division of Gastroenterology, Valduce Hospital, I-22100 Como, Italy
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Should There Be Gender Differences in the Guidelines for Colorectal Cancer Screening? CURRENT COLORECTAL CANCER REPORTS 2012. [DOI: 10.1007/s11888-011-0113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Carbon dioxide insufflation in routine colonoscopy is safe and more comfortable: results of a randomized controlled double-blinded trial. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2011; 2011:378906. [PMID: 21747649 PMCID: PMC3123829 DOI: 10.1155/2011/378906] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 04/08/2011] [Indexed: 12/13/2022]
Abstract
Many patients experience pain and discomfort after colonoscopy. Carbon dioxide (CO2) can reduce periprocedural pain although air insufflation remained the standard procedure. The objective of this double-blinded, randomized controlled trial was to evaluate whether CO2 insufflation does decrease pain and bloating during and after colonoscopy compared to room air. Methods. 219 consecutive patients undergoing colonoscopy were randomized to either CO2 or air insufflation. Propofol was used in all patients for sedation. Transcutaneous CO2 was continuously measured with a capnograph as a safety parameter. Pain, bloating, and overall satisfaction were assessed at regular intervals before and after the procedure. Results(data are mean ±SD). 110 patients were randomized to CO2 and 109 to room air. The baseline characteristics were similar in both groups. The mean propofol dose was not different between the treatments, as were the time to reach the ileum and the withdrawal time. pCO2 at the end of the procedure was 35.2 ± 4.3 mmHg (CO2 group) versus 35.6 ± 6.0 mmHg in the room air group (P > .05). No relevant complication occurred in either group. There was significantly less bloating for the CO2 group during the postprocedural recovery period (P < .001) and over the 24-hour period (P < .001). Also, patients with CO2 insufflation experienced significantly less pain (P = .014). Finally, a higher overall satisfaction (P = .04
) was found in the CO2 group. Conclusions. This trial provides compelling evidence that CO2 insufflation significantly reduces bloating and pain after routine colonoscopy in propofol-sedated patients. The procedure is safe with no significant differences in CO2 between the two groups.
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Hoff G, Volker M, Bretthauer M, Aabakken L, Høie O, Delange T, Berset I, Kjellevold Ø, Glomsaker T, Huppertz-Hauss G, Lange O, Sandvei P. Gastronet survey on the use of one- or two-person technique for colonoscopy insertion. BMC Gastroenterol 2011; 11:73. [PMID: 21672243 PMCID: PMC3142529 DOI: 10.1186/1471-230x-11-73] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 06/14/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Usually, colonoscopy insertion is performed by the colonoscopist (one-person technique). Quite common in the early days of endoscopy, the assisting nurse is now only rarely doing the insertion (two-person technique). Using the Norwegian national endoscopy quality assurance (QA) programme, Gastronet, we wanted to explore the extent of two-person technique practice and look into possible differences in performance and QA output measures. METHODS 100 colonoscopists in 18 colonoscopy centres having reported their colonoscopies to Gastronet between January and December 2009 were asked if they practiced one- or two-person technique during insertion of the colonoscope. They were categorized accordingly for comparative analyses of QA indicators. RESULTS 75 endoscopists responded to the survey (representing 9368 colonoscopies) - 62 of them (83%) applied one-person technique and 13 (17%) two-person technique. Patients age and sex distributions and indications for colonoscopy were also similar in the two groups. Caecal intubation was 96% in the two-person group compared to 92% in the one-person group (p < 0.001). Pain reports were similar in the groups, but time to the caecum was shorter and the use of sedation less in the two-person group. CONCLUSION Two-person technique for colonoscope insertion was practiced by a considerable minority of endoscopists (17%). QA indicators were either similar to or better than one-person technique. This suggests that there may be some beneficial elements to this technique worth exploring and try to import into the much preferred one-person insertion technique.
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Affiliation(s)
- Geir Hoff
- Dept of Medicine, Telemark Hospital, 3710 Skien, Norway
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Aabakken L, Enochsson L. Mechanics of quality assurance - now and in the future. Best Pract Res Clin Gastroenterol 2011; 25:419-25. [PMID: 21764009 DOI: 10.1016/j.bpg.2011.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 05/20/2011] [Accepted: 05/20/2011] [Indexed: 01/31/2023]
Abstract
Quality assurance work requires acquisition of valid data, as well as mechanisms for enforcing quality criteria, detecting (non-)adherence to these criteria, and for improving inadequate performance. This chapter deals primarily with the various tools available to acquire information at the various steps of the patient journey. Different challenges arise in the prehospital phase, in the endoscopy room, and in the follow-up phase. The endoscopy report is a vital tool for much of the quality work, but other adjoining systems may be equally important to ensure completeness of the dataset required to ensure the requested quality. Future development is discussed briefly, since many of the present challenges may be solved with improved mechanics.
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Affiliation(s)
- Lars Aabakken
- Dept of Medicine, Oslo University Hospital Rikshospitalet, Norway.
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Cohen LB, Ladas SD, Vargo JJ, Paspatis GA, Bjorkman DJ, Van der Linden P, Axon ATR, Axon AE, Bamias G, Despott E, Dinis-Ribeiro M, Fassoulaki A, Hofmann N, Karagiannis JA, Karamanolis D, Maurer W, O'Connor A, Paraskeva K, Schreiber F, Triantafyllou K, Viazis N, Vlachogiannakos J. Sedation in digestive endoscopy: the Athens international position statements. Aliment Pharmacol Ther 2010; 32:425-442. [PMID: 20456310 DOI: 10.1111/j.1365-2036.2010.04352.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field. AIM To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy. METHODS Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll. RESULTS The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures. CONCLUSIONS While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.
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Affiliation(s)
- L B Cohen
- Mount Sinai School of Medicine, New York, NY, USA.
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Regula J, Kaminski MF. Targeting risk groups for screening. Best Pract Res Clin Gastroenterol 2010; 24:407-16. [PMID: 20833345 DOI: 10.1016/j.bpg.2010.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2010] [Revised: 06/28/2010] [Accepted: 06/28/2010] [Indexed: 02/06/2023]
Abstract
Currently colorectal cancer (CRC) screening guidelines are based on age and to some extent on family history of screenees only. Potentially CRC screening could be also customised according to gender, race, ethnicity, smoking habits, presence of obesity, diabetes and metabolic syndrome. The factors that could be individually modified are: choice of screening test, age of initiation of screening and screening intervals. Gender is probably the easiest factor to be included. One of the professional societies has already included the race into guidelines in order to lower the age of starting screening in African-Americans. Targeting persons at higher than average-risk aims at optimising the use of available resources. However, an important drawback of such approach exists; it is the risk of making guidelines too complex and incomprehensible for both eligible screenees and physicians.
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Affiliation(s)
- Jaroslaw Regula
- Department of Gastroenterology and Hepatology, Medical Center for Postgraduate Education, Warsaw, Poland.
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Hoff G, Ottestad PM, Skafløtten SR, Bretthauer M, Moritz V. Quality assurance as an integrated part of the electronic medical record - a prototype applied for colonoscopy. Scand J Gastroenterol 2010; 44:1259-65. [PMID: 19658021 DOI: 10.1080/00365520903132021] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Electronic medical records (EMRs) have not developed much beyond the days of typewritten journals when it comes to facilitating extraction of data for quality assurance (QA) and improvement of health-care performance. MATERIAL AND METHODS Based on 5 years' experience from the Norwegian Gastronet QA programme, we have developed a highly QA-profiled EMR for colonoscopy. We used a three-tier solution (client, server and database) written in the Java programming language using a number of open-source libraries. QA principles from the Norwegian paper-based Gastronet QA programme formed the basis for development of the ColoReg software. ColoReg is developed primarily for colonoscopy reporting in a screening trial, but may be used in routine clinical work. The QA module in ColoReg is well suited for intervention towards suboptimal performance in both settings. RESULTS We have developed user-friendly software dominated by clickable boxes and curtain menus reducing free text to a minimum. The software gives warnings when illogical registrations are entered and reasons have to be given for divergence from software recommendations for work-up and surveillance. At any time, defined performance quality parameters are readily accessible in tabular form with the named, logged-in endoscopist being compared with all other anonymized endoscopists in the database. CONCLUSION The ColoReg software is developed for use in an international, multicentre trial on colonoscopy screening. It is user-friendly and secures continuous QA of the endoscopist's performance. The principles used are applicable to development of EMRs in general.
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Affiliation(s)
- Geir Hoff
- Cancer Registry of Norway, Oslo, Norway.
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Seip B, Bretthauer M, Dahler S, Friestad J, Huppertz-Hauss G, Høie O, Kittang E, Nyhus S, Pallenschat J, Sandvei P, Stallemo A, Svendsen MV, Hoff G. Sustaining the vitality of colonoscopy quality improvement programmes over time. Experience from the Norwegian Gastronet programme. Scand J Gastroenterol 2010; 45:362-9. [PMID: 20095874 DOI: 10.3109/00365520903497106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE An important challenge of any quality assurance (QA) programme is to maintain interest among participants to ensure high data quality over time. The primary aim of this study was to identify factors associated with endoscopist compliance with the Norwegian QA programme for colonoscopies (Gastronet). MATERIAL AND METHODS The Gastronet registration tools are an endoscopy report form to be filled in directly after the procedure by the endoscopist, and a satisfaction questionnaire to be filled in by the patient on the day after the examination. During the study period from 1 January 2004 to 31 December 2006, endoscopist compliance was measured by assessing patient report coverage, defined as the percentage of patient satisfaction questionnaires received by the Gastronet secretariat divided by the total number of colonoscopy reports registered by the individual endoscopists during the study period. Multivariate logistic regression models were applied to identify individual factors related to patient report coverage. RESULTS Eighty-eight endoscopists from 10 hospitals contributed a total of 16,149 colonoscopies. Overall patient report coverage decreased from 87% in 2004 to 80% in 2006. A low patient report coverage was associated with time since the registrations started [odds ratio (OR) 0.98, 95% confidence interval (CI) 0.97-0.98; P < 0.001], use of sedation (OR 0.7, 95% CI 0.61-0.76; P < 0.001), and incomplete colonoscopy (OR 0.6, 95% CI 0.54-0.76; P < 0.001). CONCLUSIONS Decreasing compliance with registration over time may compromise data quality and the validity of the results. Lower coverage of patient's reports (presumably for the most difficult examinations) may lead to erroneous conclusions regarding colonoscopy performance.
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Affiliation(s)
- Birgitte Seip
- Department of Medicine, Telemark Hospital, Skien, Norway.
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Considering Gender Differences When Planning a Screening Program. CURRENT COLORECTAL CANCER REPORTS 2010. [DOI: 10.1007/s11888-009-0035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sánchez Del Río A, Baudet JS, Naranjo Rodríguez A, Campo Fernández de Los Ríos R, Salces Franco I, Aparicio Tormo JR, Sánchez Muñoz D, Llach J, Hervás Molina A, Parra-Blanco A, Díaz Acosta JA. [Development and validation of quality standards for colonoscopy]. Med Clin (Barc) 2009; 134:49-56. [PMID: 19913837 DOI: 10.1016/j.medcli.2009.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 07/15/2009] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES Before starting programs for colorectal cancer screening it is necessary to evaluate the quality of colonoscopy. Our objectives were to develop a group of quality indicators of colonoscopy easily applicable and to determine the variability of their achievement. PATIENTS AND METHODS After reviewing the bibliography we prepared 21 potential indicators of quality that were submitted to a process of selection in which we measured their facial validity, content validity, reliability and viability of their measurement. We estimated the variability of their achievement by means of the coefficient of variability (CV) and the variability of the achievement of the standards by means of chi(2). RESULTS Six indicators overcome the selection process: informed consent, medication administered, completed colonoscopy, complications, every polyp removed and recovered, and adenoma detection rate in patients older than 50 years. 1928 colonoscopies were included from eight endoscopy units. Every unit included the same number of colonoscopies selected by means of simple random sampling with substitution. There was an important variability in the achievement of some indicators and standards: medication administered (CV 43%, p<0.01), complications registered (CV 37%, p<0.01), every polyp removed and recovered (CV 12%, p<0.01) and adenoma detection rate in older than fifty years (CV 2%, p<0.01). CONCLUSIONS We have validated six quality indicators for colonoscopy which are easily measurable. An important variability exists in the achievement of some indicators and standards. Our data highlight the importance of the development of continuous quality improvement programmes for colonoscopy before starting colorectal cancer screening.
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Sánchez Del Río A, Campo R, Llach J, Pons V, Mreish G, Panadés A, Parra-Blanco A. [Patient satisfaction in gastrointestinal endoscopy: results of a multicenter study]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:566-71. [PMID: 19091244 DOI: 10.1157/13128295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to determine the main quality problems perceived by patients in gastrointestinal endoscopy through a satisfaction survey. PATIENTS AND METHODS A total of 321 patients from five gastrointestinal endoscopy units were included. Telephone interviews using a previously validated questionnaire on several aspects related to the procedure were carried out. Pareto analyses were performed to pinpoint the most common aspects among the vital few causes at each medical center. Based on the questionnaire, the satisfaction indicators were calculated for each center: the overall satisfaction score (the sum of the responses to the eight questions) and the rate of perceived problems (number of questions with a negative response divided by the number of questions asked). RESULTS The most frequent aspects among the vital few were waiting time for an appointment and discomfort during the examination, since both factors were included in the vital few in four of the five medical centers. Significant differences were found among centers in the overall satisfaction score (questionnaire score) (p < 0.001) and for the rate of perceived problems (p < 0.001). CONCLUSION According to the patients, the most problematic aspects were waiting time until the day of the appointment and discomfort during the examination. Perceived quality differed among the participating centers.
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Seip B, Huppertz-Hauss G, Sauar J, Bretthauer M, Hoff G. Patients' satisfaction: an important factor in quality control of gastroscopies. Scand J Gastroenterol 2008; 43:1004-11. [PMID: 19086282 DOI: 10.1080/00365520801958592] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Although oesophagogastroduodenoscopies (OGDs) are associated with few medical complications, substantial pre-procedural anxiety and discomfort during the procedure have been reported. The aims of the present study were to evaluate OGD-related discomfort assessed by the patient and to identify the possibilities for improvement. MATERIAL AND METHODS All outpatients undergoing OGDs at a single centre during 2004 were eligible for the study. On site, the endoscopy team completed a questionnaire on age of patients, gender and the use of sedation/anaesthesia. After the examination, the patients were given a questionnaire focusing on discomfort during and after the examination. The questionnaire was to be completed at home the following day and returned in a prepaid envelope. RESULTS During the study period, 1283 examinations were registered, giving 92% coverage of OGDs. The patient response rate was 80%. Patients' mean age was 55 years, and 45% were men. The sedation rate was 7.3%. None or only slight discomfort was experienced by 68% of the patients and severe discomfort by 14%. In patients, the odds ratio (OR) for experiencing moderate or severe discomfort decreased with increasing age (OR 0.96, 95% CI 0.95-0.97, p < 0.001). There were significant differences in patient discomfort depending on the level of experience of the endoscopists. CONCLUSIONS The majority of patients reported no or only slight discomfort during the examination, but as many as 32% did not. Increased use of sedation in selected patients is recommended. Our quality assurance program included a limited number of variables for registration, with satisfactory compliance by endoscopists and patients.
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Affiliation(s)
- Birgitte Seip
- Department of Medicine, Telemark Hospital, Skien, Norway.
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Chen TM, Chang TM, Huang PT, Tsai MH, Lin LF, Liu CC, Ho KS, Siauw CP, Chao PL, Tung JN. Management and patient survival in hepatocellular carcinoma: does the physician's level of experience matter? J Gastroenterol Hepatol 2008; 23:e179-88. [PMID: 18466287 DOI: 10.1111/j.1440-1746.2008.05341.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The prognostic determinants of hepatocellular carcinoma (HCC) depend on tumor stage, liver function reserve, and treatments offered. The clinical impact of the physician's experience on HCC management and the survival outcome is unknown. METHODS A total of 103 patients were managed by one high-volume physician and 249 patients by seven low-volume physicians. The experience of high-volume physician in HCC management was five times more than that of low-volume physicians. Patient survival was the single end point for this study. RESULTS Compared to the low-volume physician group, more of the patients allocated to the high-volume physician had early stage HCC on the date of diagnosis (66/103, 64.1%; vs 119/249, 47.8%; P = 0.008), and they received curative therapies including radiofrequency ablation or liver resection (66/103, 64.1% vs 54/249, 21.7%, P < 0.001), and had significantly better survival outcome (median survival of 34 months, 95% confidence interval [CI], 17.6-50.4; vs 6 months, 95% CI, 4.3-7.7; P < 0.001) with a multivariable-adjusted hazard ratio (HR) for survival of 1.94 (95%, CI, 1.31-2.87, P < 0.001). A multivariate analysis of the pretreatment prognostic factors for these two groups identified alpha-fetoprotein (AFP) level (HR, 1.42; 95% CI, 1.01-1.99; P = 0.042), ascites (HR, 1.68; 95% CI, 1.15-2.46; P = 0.007), maximum tumor diameter (HR, 1.78; 95% CI, 1.16-2.74; P = 0.009), and portal vein thrombosis (PVT) (HR, 2.17; 95% CI, 1.49-3.17; P < 0.001) as independent factors for the low-volume physician group. However, only maximum tumor diameter (HR, 4.54; 95% CI, 1.77-11.67; P < 0.001) and PVT (HR, 5.73; 95% CI, 2.30-14.22; P = 0.002) were independent factors for the high-volume physician group. CONCLUSION The survival of HCC patients was dependent on the level of experience of the physicians who oversaw these patients.
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Affiliation(s)
- Tsung-Ming Chen
- Department of Internal Medicine, Division of Hepato-Gastroenterology, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
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Radaelli F, Meucci G, Sgroi G, Minoli G. Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol 2008; 103:1122-30. [PMID: 18445096 DOI: 10.1111/j.1572-0241.2007.01778.x] [Citation(s) in RCA: 154] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND It is essential to identify the factors in clinical practice that influence the technical performance of colonoscopy as a basis for quality improvement programs. AIMS To assess the factors linked to two key indicators of colonoscopy performance, i.e., cecal intubation and polyp diagnosis. DESIGN AND SETTING Consecutives colonoscopies performed over a 2-wk period in 278 unselected practice sites throughout Italy were prospectively evaluated. A multivariate model was developed to identify determinants of the performance indicators of colonoscopy. RESULTS In total, 12,835 patients (mean age 60.5 yr, standard deviation [SD] 15.1, 53% men) were studied. Sedation and/or analgesia was administered in 55.3% of procedures: 28.8% of patients received intravenous (IV) benzodiazepines, 15.4% received benzodiazepines in combination with narcotics, 3.1% received propofol, and 7.5% received other sedation regimens. Overall, cecal intubation was achieved in 80.7% of procedures, and the polyp detection rate was 27.3%. Multivariate analysis showed that the strongest predictors of cecal intubation were the quality of bowel preparation (inadequate vs excellent: odds ratio [OR] 0.013, 95% confidence interval [CI] 0.009-0.018; fair vs excellent: OR 0.246, 95% CI 0.209-0.290; and good vs excellent: OR 0.586, 95% CI 0.514-0.667) and the use of sedation (IV benzodiazepines vs no sedation: OR 1.460, 95% CI 1.282-1.663; IV benzodiazepines and narcotics vs no sedation: OR 2.128, 95% CI 1.776-2.565; and propofol vs no sedation: OR 2.355, 95% CI 1.590-3.488). The colonoscopy setting (workload and organizational complexity of the center) and the endoscopist colonoscopy volume were other factors independently correlated with completion of the procedure. Detection of polyps partially depended on the quality of bowel cleansing (inadequate vs excellent: OR 0.511, 95% CI 0.404-0.647) and use of sedation (OR 1.172, 95% CI 1.074-1.286). CONCLUSION In usual clinical practice, the use of sedation/analgesia, the colon-cleansing quality, the endoscopist experience, and some features related to the colonscopy setting decisively influence the quality of colonoscopy. These factors indicate the targets of future corrective measures to boost the quality of this examination.
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Affiliation(s)
- Franco Radaelli
- Department of Gastroenterology, Valduce Hospital, Como, Italy
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Abstract
The past decade has seen major advances internationally in the implementation of colorectal cancer screening, influenced in differing ways by the profession, the public and by government. Relatively unique to colorectal cancer screening is the availability of so many test alternatives, which have substantial variation in methodology. While perhaps spoilt for choice, discerning the key advantages and disadvantages of each test is often difficult, depending on the perspective from which screening is viewed. Accordingly, this article provides an evaluation of screening tests as might be perceived by governments, the patient and the profession. Aligned issues such as choosing a screening test and provision of informed consent are discussed. Finally, the article identifies current problems with various screening tests that, if attended to, might change the perception of a test's value to a particular interest group.
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Affiliation(s)
- Geoffrey M Forbes
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Box X2213 GPO, Perth, Western Australia 6000, Australia.
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Latreille MW, Anderson JC. Colonoscopy screening for detection of advanced neoplasia. N Engl J Med 2007; 356:632; author reply 633-4. [PMID: 17287485 DOI: 10.1056/nejmc063405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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