RESUMEN
BACKGROUND AND AIMS: Variation in colorectal neoplasia detection limits the effectiveness of screening colonoscopy. By evaluating neoplasia detection rates of individual colonoscopists, we aimed to quantify the effects of pre-procedural knowledge of a positive (+) multi-target stool DNA (mt-sDNA) on colonoscopy quality metrics. METHODS: We retrospectively identified physicians who performed a high volume of + mt-sDNA colonoscopies; colorectal neoplasia at post-mt-sDNA colonoscopy was recorded. These colonoscopists were stratified into quartiles based on baseline adenoma detection rates. Baseline colonoscopy adenoma detection rates and sessile serrated lesion detection rates were compared to post-mt-sDNA colonoscopy neoplasia diagnosis rates among each quartile. Withdrawal times were measured from negative exams. RESULTS: During the study period (2014-17) the highest quartile of physicians by volume of post-mt-sDNA colonoscopies were evaluated. Among thirty-five gastroenterologists, their median screening colonoscopy adenoma detection rate was 32% (IQR, 28-39%) and serrated lesion detection rate was 13% (8-15%). After + mt-sDNA, adenoma diagnosis increased to 47% (36-56%) and serrated lesion diagnosis increased to 31% (17-42%) (both p < 0.0001). Median withdrawal time increased from 10 (7-13) to 12 (10-17) minutes (p < 0.0001) and was proportionate across quartiles. After + mt-sDNA, lower baseline detectors had disproportionately higher rates of adenoma diagnosis in female versus male patients (p = 0.048) and higher serrated neoplasia diagnosis rates among all patients (p = 0.0092). CONCLUSIONS: Knowledge of + mt-sDNA enriches neoplasia diagnosis compared to average risk screening exams. Adenomatous and serrated lesion diagnosis was magnified among those with lower adenoma detection rates. Awareness of the mt-sDNA result may increase physician attention during colonoscopy. Pre-procedure knowledge of a positive mt-sDNA test improves neoplasia diagnosis rates among colonoscopists with lower baseline adenoma detection rates, independent of withdrawal time.
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Adenoma , Neoplasias Colorrectales , Humanos , Masculino , Femenino , ADN de Neoplasias , Estudios Retrospectivos , Detección Precoz del Cáncer/métodos , Colonoscopía , Neoplasias Colorrectales/patología , Adenoma/patologíaRESUMEN
BACKGROUND & AIMS: Nonpedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure, and antithrombotic use. METHODS: An individual patient data meta-analysis was performed. Studies on prophylactic clipping in nonpedunculated colorectal polyps were selected from PubMed, Embase, Web of Science, and Cochrane database (last selection, April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders. RESULTS: Data of 5380 patients with 8948 resected polyps were included from 3 randomized controlled trials, 2 prospective, and 8 retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.44-0.88; number needed to treat = 32), especially with antithrombotics (OR, 0.59; 95% CI, 0.35-0.99; number needed to treat = 23; subgroup of anticoagulants/double platelet inhibitors: n = 226; OR, 0.40; 95% CI, 0.16-1.01; number needed to treat = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR, 1.41; 95% CI, 0.79-2.52). CONCLUSIONS: Prophylactic clipping reduces delayed bleeding after resection of nonpedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317.).
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Pólipos del Colon , Pólipos del Colon/etiología , Pólipos del Colon/cirugía , Colonoscopía/efectos adversos , Humanos , Hemorragia Posoperatoria/epidemiología , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/prevención & control , Estudios Prospectivos , Estudios Retrospectivos , Instrumentos QuirúrgicosRESUMEN
This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.
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Obstrucción de la Salida Gástrica , Stents Metálicos Autoexpandibles , Neoplasias Gástricas , Obstrucción de la Salida Gástrica/etiología , Obstrucción de la Salida Gástrica/cirugía , Humanos , Cuidados Paliativos , Estudios Retrospectivos , Stents , Neoplasias Gástricas/complicaciones , Resultado del TratamientoRESUMEN
BACKGROUND : Artificial intelligence (AI) research in colonoscopy is progressing rapidly but widespread clinical implementation is not yet a reality. We aimed to identify the top implementation research priorities. METHODS : An established modified Delphi approach for research priority setting was used. Fifteen international experts, including endoscopists and translational computer scientists/engineers, from nine countries participated in an online survey over 9 months. Questions related to AI implementation in colonoscopy were generated as a long-list in the first round, and then scored in two subsequent rounds to identify the top 10 research questions. RESULTS : The top 10 ranked questions were categorized into five themes. Theme 1: clinical trial design/end points (4 questions), related to optimum trial designs for polyp detection and characterization, determining the optimal end points for evaluation of AI, and demonstrating impact on interval cancer rates. Theme 2: technological developments (3 questions), including improving detection of more challenging and advanced lesions, reduction of false-positive rates, and minimizing latency. Theme 3: clinical adoption/integration (1 question), concerning the effective combination of detection and characterization into one workflow. Theme 4: data access/annotation (1 question), concerning more efficient or automated data annotation methods to reduce the burden on human experts. Theme 5: regulatory approval (1 question), related to making regulatory approval processes more efficient. CONCLUSIONS : This is the first reported international research priority setting exercise for AI in colonoscopy. The study findings should be used as a framework to guide future research with key stakeholders to accelerate the clinical implementation of AI in endoscopy.
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Inteligencia Artificial , Colonoscopía , Técnica Delphi , HumanosRESUMEN
OBJECTIVES: Multitarget stool DNA (MT-sDNA) testing has grown as a noninvasive screening modality for colorectal cancer (CRC), but real-world clinical data are limited in the post-FDA approval setting. The effect of previous colonoscopy on MT-sDNA performance is not known. We aimed to evaluate findings of colorectal neoplasia (CRN) at diagnostic colonoscopy in patients with positive MT-sDNA testing, stratified by patient exposure to previous colonoscopy. METHODS: We identified consecutive patients completing MT-sDNA testing over a 39-month period and reviewed the records of those with positive tests for neoplastic findings at diagnostic colonoscopy. MT-sDNA test positivity rate, adherence to diagnostic colonoscopy, and the positive predictive value (PPV) of MT-sDNA for any CRN and neoplastic subtypes were calculated. RESULTS: Of 16,469 MT-sDNA tests completed, testing returned positive in 2,326 (14.1%) patients. After exclusion of patients at increased risk for CRC, 1,801 patients remained, 1,558 (87%) of whom underwent diagnostic colonoscopy; 918 of 1,558 (59%) of these patients had undergone previous colonoscopy, whereas 640 (41%) had not. Any CRN was found in 1,046 of 1,558 patients (PPV = 67%). More neoplastic lesions were found in patients without previous colonoscopy (73%); however, the rates remained high among those who had undergone previous colonoscopy (63%, P < 0.0001). The large majority (79%) of patients had right-sided neoplasia. DISCUSSION: MT-sDNA has a high PPV for any CRN regardless of exposure to previous colonoscopy. Right-sided CRN was found at colonoscopy in most patients with positive MT-sDNA testing, representing a potential advantage over other currently available screening modalities for CRC.
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Colonoscopía , Neoplasias Colorrectales/diagnóstico , ADN de Neoplasias/análisis , Heces/química , Tamizaje Masivo/métodos , Anciano , Detección Precoz del Cáncer , Femenino , Humanos , Masculino , Persona de Mediana Edad , Lesiones Precancerosas/diagnóstico , Valor Predictivo de las Pruebas , Estudios RetrospectivosRESUMEN
Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.
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Poliposis Adenomatosa del Colon , Neoplasias Colorrectales , Poliposis Adenomatosa del Colon/genética , Endoscopía Gastrointestinal , Pruebas Genéticas , Humanos , Guías de Práctica Clínica como Asunto , Estudios Retrospectivos , Sociedades Médicas , Estados UnidosRESUMEN
BACKGROUND AND AIMS: Capsule endoscopy (CE) is an established, noninvasive modality for examining the small bowel. Minimum training requirements are based primarily on guidelines and expert opinion. A validated tool to assess the competence of CE is lacking. In this prospective, multicenter study, we determined the minimum number of CE procedures required to achieve competence during gastroenterology fellowship; validated a capsule competency test (CapCT); and evaluated any correlation between CE competence and endoscopy experience. METHODS: We included second- and third-year gastroenterology fellows from 3 institutions between 2013 and 2018 in a structured CE training program with supervised CE interpretation. Fellows completed the CapCT with a maximal score of 100. For comparison, expert faculty completed the same CapCT. Trainee competence was defined as a score ≥90% compared with the mean expert score. Fellows were tested after 15, 25, and 35 supervised CE interpretations. CapCT was validated using expert consensus and item analysis. Data were collected on the number of previous endoscopies. RESULTS: A total of 68 trainees completed 102 CapCTs. Fourteen CE experts completed the CapCT with a mean score of 94. Mean scores for fellows after 15, 25, and 35 cases were 83, 86, and 87, respectively. Fellows with at least 25 interpretations achieved a mean score ≥84 in all 3 institutions. CapCT item analysis showed high interobserver agreement among expert faculty (k = 0.85). There was no correlation between the scores and the number of endoscopies performed. CONCLUSION: After a structured CE training program, gastroenterology fellows should complete a minimum of 25 supervised CE interpretations before assessing competence using the validated CapCT, regardless of endoscopy experience.
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Endoscopía Capsular , Competencia Clínica , Becas , Humanos , Estudios ProspectivosRESUMEN
Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.
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Inhibidores de la Liberación de Acetilcolina/uso terapéutico , Toxinas Botulínicas/uso terapéutico , Dilatación/métodos , Endoscopía del Sistema Digestivo/métodos , Acalasia del Esófago/terapia , Esfínter Esofágico Inferior/cirugía , Miotomía de Heller/métodos , Manejo de la Enfermedad , Acalasia del Esófago/diagnóstico , Humanos , Inyecciones Intramusculares , Manometría/métodos , Miotomía/métodos , Sociedades Médicas , Estados UnidosRESUMEN
Efforts to increase patient safety and satisfaction, a critical concern for health providers, require periodic evaluation of all factors involved in the provision of GI endoscopy services. We aimed to develop guidelines on minimum staffing requirements and scope of practice of available staff for the safe and efficient performance of GI endoscopy. The recommendations in this guideline were based on a systematic review of published literature, results from a nationwide survey of endoscopy directors, along with the expert guidance of the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee members, ASGE Practice Operation Committee members, and the ASGE Governing Board.
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Endoscopía Gastrointestinal , Humanos , Guías de Práctica Clínica como Asunto , Revisiones Sistemáticas como Asunto , Estados Unidos , Recursos HumanosRESUMEN
BACKGROUND AND AIMS: Adenoma detection rate (ADR), a validated quality indicator (QI) of colonoscopy, does not take into account risk stratification of adenomas. Low-risk adenomas are not associated with a significantly increased risk of future colorectal cancer (CRC). On the other hand, high-risk adenomas (HRA) are associated with up to six fold higher risk of future CRC. Therefore, HRA detection rate (HR-ADR) as a QI in addition to ADR may further enhance the efficacy of screening colonoscopy. Our aim was to calculate ADR and HR-ADR in a large cohort of average risk screening colonoscopy patients and propose HR-ADR which correlates with current threshold ADR. METHODS: This is a retrospective chart review of all colonoscopies performed in patients aged ≥ 50 years at our institution between 2012 and 2014. Average risk patients who had complete colonoscopy with good, excellent and adequate bowel preparation were included. Overall and gender-specific ADR and HR-ADR were calculated. HR-ADR was defined as proportion of colonoscopies with HRA. RESULTS: Among 4158 colonoscopies included, ADR was 26.4 ± 10.9% overall, 32.7 ± 14.5% in men, and 22.1 ± 12.6% in women. HR-ADR was 8.0 ± 5.7% overall, 10.2 ± 8.6% in men, and 6.1 ± 6% in women. There was only moderate correlation between ADR and HR-ADR [r = 0.57 (0.40-0.70)]. HR-ADR corresponding with minimum threshold ADR of 30% in men and 20% in women were calculated to be 7% in men and 4% in women. CONCLUSIONS: HR-ADR correlates only moderately with ADR. Based on the current threshold ADRs, we propose a benchmark HR-ADR of 7% in men and 4% in women as complementary QI to ADR.
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Adenoma , Neoplasias del Colon , Colonoscopía/métodos , Neoplasias Colorrectales , Adenoma/diagnóstico , Adenoma/patología , Anciano , Estudios de Cohortes , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/patología , Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/patología , Detección Precoz del Cáncer/normas , Detección Precoz del Cáncer/estadística & datos numéricos , Femenino , Humanos , Masculino , Tamizaje Masivo/métodos , Persona de Mediana Edad , Estudios Retrospectivos , Medición de RiesgoRESUMEN
Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
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Colangiopancreatografia Retrógrada Endoscópica , Coledocolitiasis/diagnóstico , Coledocolitiasis/terapia , Esfinterotomía Endoscópica , Pancreatocolangiografía por Resonancia Magnética , Colecistectomía , Endosonografía , Humanos , Síndrome de Mirizzi/diagnóstico , Síndrome de Mirizzi/terapia , StentsRESUMEN
Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.
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Colonoscopía/efectos adversos , Complicaciones Posoperatorias/etiología , Colonoscopía/métodos , Humanos , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND AND AIM: Feedback has been shown to improve performance in colonoscopy including adenoma detection rate (ADR). The frequency at which feedback should be given is unknown. As part of a quality improvement program, we sought to measure the outcome of providing quarterly and monthly feedback on colonoscopy quality measures. METHODS: All screening colonoscopies performed at endoscopy unit at Mayo Clinic Arizona by gastroenterologists between October 2010 and December 2012 were reviewed. Quality indicators, including ADR, were extracted for each individual endoscopist, and feedback was provided. The study period was divided into four distinct groups: pre-intervention that served as baseline, quarterly feedback, monthly feedback, and post-intervention. Based on ADR, endoscopists were grouped into "low detectors" (≤ 25%), "average detectors" (26-35%), and "high detectors" (> 35%). RESULTS: A total of 3420 screening colonoscopies were performed during the study period (555 patients during pre-intervention, 1209 patients during quarterly feedback, 599 during monthly feedback, and 1057 during the post-intervention period) by 16 gastroenterologists. The overall ADR for the group improved from 30.5% to 37.7% (P = 0.003). Compared with the pre-interventional period, all quality indicators measured significantly improved during the monthly feedback and post-intervention periods but not in the quarterly feedback period. CONCLUSIONS: In our quality improvement program, monthly feedback significantly improved colonoscopy quality measures, including ADR, while quarterly feedback did not. The impact of the intervention was most prominent in the "low detectors" group. Results were durable up to 6 months following the intervention.
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Adenoma/diagnóstico , Colonoscopía , Neoplasias Colorrectales/diagnóstico , Retroalimentación , Mejoramiento de la Calidad , Anciano , Detección Precoz del Cáncer , Femenino , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Indicadores de Calidad de la Atención de Salud , Factores de TiempoRESUMEN
BACKGROUND: Split dose bowel preparations (SDP) have superior outcomes for colonoscopy as compared to evening before regimens. However, the association of the actual volume of the SDP to colonoscopy outcome measures has not been well studied. AIMS: Compare adenoma detection rate (ADR), sessile serrated polyp detection rate (SDR), mean bowel cleanse score, and predictors of inadequate exams between small volume SDP and large volume SDP. METHODS: We have conducted a retrospective study in patients undergoing colonoscopy with small volume SDP versus large volume SDP between July 2014 and December 2014. Basic demographics (age, gender and BMI) along with clinical co-morbidities were recorded. Quality of the bowel preparation, ADR and SDR was compared between these groups. Univariate and multivariable logistic regressions were used to assess the determinants of inadequate exams in each group. RESULTS: 1573 patients with split dose preparation were included in this retrospective study. 58.4% (920/1573) patients took small volume SDP. There was no difference in ADR (37.9 vs. 38.8%, p = 0.2); however, SDR was higher for small volume SDP compared to large volume SDP (11.9 vs. 7.9% p = 0.005). There was no difference in the rate of inadequate exams between the two groups (p = 0.7). A history of diabetes and constipation was associated with inadequate exams only in the small volume SDP. CONCLUSIONS: SDR was higher in small volume SDP. There was no difference in rate of inadequate exams between the two groups. A history of diabetes and constipation was associated with inadequate exams only in patients with the small volume SDP.
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Colonoscopía/métodos , Colonoscopía/normas , Polietilenglicoles/administración & dosificación , Adenoma/diagnóstico por imagen , Anciano , Neoplasias del Colon/diagnóstico por imagen , Pólipos del Colon/diagnóstico por imagen , Neoplasias Colorrectales/diagnóstico por imagen , Esquema de Medicación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Since 1985, the American Society for Gastrointestinal Endoscopy (ASGE) has awarded grants for endoscopic-related research. The goals of this study were to examine trends in ASGE grant funding and to assess productivity of previous recipients of the ASGE grant awards. METHODS: This was a retrospective cohort analysis of all research grants awarded by the ASGE through 2009. Measures of academic productivity and self-assessment of the ASGE awards' impact on the recipients' careers were defined by using publicly available resources (eg, National Library of Medicine-PubMed) and administration of an electronic survey to award recipients. RESULTS: The ASGE awarded 304 grants totaling $12.5 million to 214 unique awardees. Funding increased 7.5-fold between 1985 and 1989 (mean $102,000/year) and between 2005 and 2009 (mean $771,000/year). The majority of awardees were men (83%), were at or below the level of assistant professor (82%), with a median of 3 years of postfellowship experience at the time of the award, and derived from a broad spectrum of institutions as measured by National Institutes of Health funding rank (median 26, interquartile range [IQR] 12-64). Nineteen percent had a master's degree in a research-related field. Awardees' median publications per year increased from 3.5 (IQR 1.2-9.0) before funding to 5.7 (IQR 1.8-9.5) since funding; P = .04, and median h-index scores increased from 3 (IQR 1-8) to 17 (IQR 8-26); P < .001. Multivariate analysis found that the presence of a second advanced degree (eg, masters or doctorate) was independently predictive of high productivity (odds ratio [OR] 2.92; 95% confidence interval [CI], 1.09-7.81). Among 212 unique grant recipients, 82 (40%) completed the online survey. Of the respondents, median peer-reviewed publications per year increased from 3.4 (IQR 1.9-5.5) to 4.5 (IQR 2.0-9.5); P = .17. Ninety-one percent reported that the ASGE grant had a positive or very positive impact on their careers, and 85% of respondents are currently practicing in an academic environment. Most of the grants resulted in at least 1 peer-reviewed publication (67% per Internet-based search and 81% per survey). CONCLUSIONS: The ASGE research program has grown considerably since 1985, with the majority of grants resulting in at least 1 grant-related publication. Overall academic productivity increased after the award, and the majority of awardees report a positive or very positive impact of the award on their careers. Medical professional societies are an important sponsor of clinical research.
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Investigación Biomédica , Gastroenterología , Apoyo a la Investigación como Asunto , Estudios de Cohortes , Eficiencia , Endoscopía Gastrointestinal , Femenino , Humanos , Masculino , National Institutes of Health (U.S.) , Edición , Investigadores , Estudios Retrospectivos , Sociedades Médicas , Estados UnidosRESUMEN
BACKGROUND: The frequency of nonneoplastic polypectomy (NNP) and its impact on the polyp detection rate (PDR) is unknown. The correlation between NNP and adenoma detection rate (ADR) and its impact on the cost of colonoscopy has not been investigated. OBJECTIVE: To determine the rate of NNP in screening colonoscopy, the impact of NNP on the PDR, and the correlation of NNP with ADR. The increased cost of NNP during screening colonoscopy also was calculated. DESIGN: We reviewed all screening colonoscopies. PDR and ADR were calculated. We then calculated a nonneoplastic polyp detection rate (patients with ≥1 nonneoplastic polyp). SETTING: Tertiary-care referral center. PATIENTS: Patients who underwent screening colonoscopies from 2010 to 2011. INTERVENTIONS: Colonoscopy. MAIN OUTCOME MEASUREMENTS: ADR, PDR, NNP rate. RESULTS: A total of 1797 colonoscopies were reviewed. Mean (±standard deviation) PDR was 47.7%±12.0%, and mean ADR was 27.3%±6.9%. The overall NNP rate was 10.4%±7.1%, with a range of 2.4% to 28.4%. Among all polypectomies (n=2061), 276 were for nonneoplastic polyps (13.4%). Endoscopists with a higher rate of nonneoplastic polyp detection were more likely to detect an adenoma (odds ratio 1.58; 95% confidence interval, 1.1-1.2). With one outlier excluded, there was a strong correlation between ADR and NNP (r=0.825; P<.001). The increased cost of removal of nonneoplastic polyps was $32,963. LIMITATIONS: Retrospective study. CONCLUSION: There is a strong correlation between adenoma detection and nonneoplastic polyp detection. The etiology is unclear, but nonneoplastic polyp detection rate may inflate the PDR for some endoscopists. NNP also adds an increased cost. Increasing the awareness of endoscopic appearances through advanced imaging techniques of normal versus neoplastic tissue may be an area to improve cost containment in screening colonoscopy.
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Adenoma/diagnóstico , Pólipos del Colon/diagnóstico , Pólipos del Colon/cirugía , Colonoscopía/estadística & datos numéricos , Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer/estadística & datos numéricos , Anciano , Pólipos del Colon/patología , Colonoscopía/economía , Detección Precoz del Cáncer/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
The emerging changes in healthcare impose significant burdens on integrated outpatient specialty services with respect to setting patient expectations, handling outside medical records; and coordinating specialty appointments scheduling. Moreover, because of the evolution of the electronic health record and its widespread use, it is critical that patient and physician interaction is maintained and clerical tasks are minimized. In the context of increased government regulation, declining reimbursement, and the rise of new payment models, outpatient practices need to be reimagined so that they are more efficient for the patient and the provider. The redesign of integrated outpatient specialty services can be accomplished only through teamwork, innovation, and efficient use of technology. To address these challenges, the Department of Medicine at Mayo Clinic in Scottsdale, Arizona, implemented an ideal practice design initiative that leveraged a hybrid set of change strategies. The change strategy, which was initiated after examination of current practices and design options, engaged key stakeholders and patients. A number of enablers and barriers to adoption were identified as a result of the implementation experience.
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Instituciones de Atención Ambulatoria/normas , Satisfacción del Paciente , Mejoramiento de la Calidad/organización & administración , Especialización , Arizona , Humanos , Estudios de Casos Organizacionales , Encuestas y CuestionariosAsunto(s)
Adenocarcinoma/diagnóstico , Esófago de Barrett/diagnóstico , Neoplasias Esofágicas/diagnóstico , Adenocarcinoma/patología , Esófago de Barrett/patología , Detección Precoz del Cáncer , Endosonografía , Neoplasias Esofágicas/patología , Esofagoscopía , Humanos , Tamizaje Masivo , Microscopía Confocal , Estadificación de Neoplasias , Espera VigilanteRESUMEN
OBJECTIVES: Little is known about the correlation between the polyp detection rate (PDR) and the adenoma detection rate (ADR) in individual colonic segments. The adenoma-to-polyp detection rate quotient (APDRQ) has been utilized in retrospective study as a constant to estimate ADR from PDR. It has been previously stated that diminutive polyps in the rectum are more likely to be non-adenomatous, compared with more proximal segments, yet the APDRQ uses data from the entire colon. We sought to characterize and compare ADR and PDR in each colonic segment, estimate ADR using the conversion factor, APDRQ, and assess the correlation between estimated and actual ADR for each colonic segment. METHODS: As part of a quality improvement program, a retrospective chart review was conducted of all outpatient colonoscopies performed by 20 gastroenterologists between 1 October 2010 and 31 March 2011 at a single academic tertiary-care referral center. PDR, ADR, and the APDRQ were calculated for each gastroenterologist, using data from the entire colon and then for each colonic segment separately. Actual ADR was compared with estimated ADR based on the measured APDRQ. RESULTS: During 1,921 colonoscopies, 2,285 polyps were removed; 1,122 (49%) were adenomas. The mean (s.d.) PDR for the group was 49% (12.4%) (range, 16-64%). The mean (s.d.) ADR was 31% (7.4%) (range, 13-42%). PDR and ADR correlated well in segments proximal to the splenic flexure, but diverged in distal segments. ADR was significantly higher in the right colon (17.1%) than in the left (13.5%) (P=0.001). The correlation between estimated and actual ADR using the APDRQ was significantly higher in the right colon (r=0.95 (95% confidence interval (CI), 0.87-0.98)) than in the left (r=0.59 (95% CI, 0.17-0.83)) (P<0.05). CONCLUSIONS: Although PDR and ADR correlate well in segments proximal to the splenic flexure, they do not correlate well in the left colon. Caution should be exercised when using PDR as a surrogate for ADR if data from the rectum and sigmoid are included.
Asunto(s)
Adenoma/diagnóstico , Colon/patología , Neoplasias del Colon/diagnóstico , Pólipos del Colon/diagnóstico , Colonoscopía/normas , Neoplasias del Ciego/diagnóstico , Colon Ascendente/patología , Colon Descendente/patología , Colon Sigmoide/patología , Colon Transverso/patología , Intervalos de Confianza , Femenino , Humanos , Masculino , Persona de Mediana Edad , Indicadores de Calidad de la Atención de Salud , Neoplasias del Recto/diagnóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: The adenoma detection rate (ADR) is a main quality indicator in colonoscopy but has many challenges for calculating. The polypectomy rate (PR) may be calculable from administrative claims data, but this has not been validated against the ADR. OBJECTIVE: To determine whether a PR calculated from United States billing claims data is an accurate surrogate for the ADR. DESIGN: A PR was calculated by using billing claims data from Current Procedural Terminology codes. The ADR was calculated for each endoscopist by using an endoscopy report database to which the pathology report data had been added. The relationship between PR and ADR was evaluated with the Pearson correlation coefficient. The ADR was plotted against the PR by individual endoscopist, and a least-squares regression line was created. A t test was used to analyze the differences in lesion detection between endoscopists with a PR above and below the benchmark PR. SETTING: Tertiary-care, outpatient endoscopy center. PATIENTS: All ages undergoing colonoscopy. MAIN OUTCOME MEASUREMENTS: PR and ADR. RESULTS: A total of 5382 colonoscopies were reviewed. A significant relationship between endoscopists' calculated PRs and ADRs was seen (r = 0.85; P < .001). Endoscopists needed a PR of 35% to achieve the recommended benchmark ADR of 20%. Endoscopists with PRs of 35% or greater had an ADR of 27% (6.2 standard deviation [SD]) as compared with 19% (1.9 SD) for those with PRs less than 35% (P = .0029). LIMITATIONS: Study population. CONCLUSION: Calculated PR from billing claims data is an accurate surrogate for ADR and may become an important quality measure for external and internal use.