The Quality Improvement in Colonoscopy (QIC) Study: Improving Adenoma Detection Rates and Reducing Variation between Colonoscopists

Introduction Adenoma detection rate (ADR) is an established quality marker in colonoscopy. Significant variability in ADR exists. Withdrawal time of ≥ 6 minutes; Buscopan use; position change and rectal retroflexion have been shown to improve lesion detection. We evaluated the feasibility and clinical outcome of implementing these measures, as a ‘bundle’, into routine practice to improve ADR. Factors influencing uptake were evaluated in a qualitative study. Methodology Twelve units participated. All nominated a lead colonoscopist and nurse. Implementation combined central training, local leadership, feedback and continuous central support. The 3 months prior to implementation was compared to a 9 month period after. Colonoscopists performing ≥ 25 procedures during the baseline period were ranked in quartiles by ADR. Buscopan use was used as a surrogate marker for uptake. Changes were evaluated using a corrected Chi Squared test. For the qualitative study, units and individuals were purposively sampled to ensure a range of units were included. Semi-structured interviews were conducted until saturation was reached. Data were evaluated using thematic analysis. Results Global and quartile analyses comprised data from 118 and 68 colonoscopists performing 17, 508 and 14,193 procedures respectively. There was a significant increase in Buscopan use globally (15.8% vs. 54.4%, p<0.001) and in each quartile. The ADR also increased significantly globally (16.0% vs. 18.1%, p=0.002), with a significant reduction in variation. Interviews were conducted with 8 lead and 3 non-lead colonoscopists and 1 lead nurse. Increased emphasis on examination time, awareness of ADR as a quality marker and empowerment of endoscopy nurses to encourage the use of quality measures were positive outcomes of the intervention. Challenges included difficulty in arranging set up meetings and engaging certain speciality groups. Discussion This evidence based educational intervention resulted in a significant change in behaviour, evidenced by increased Buscopan use. A significant increase in the global ADR and reduction in variation between quartiles was observed. Other positive outcomes included increased awareness of colonoscopy quality and empowerment of endoscopy nurses to promote quality measures. This study demonstrates that simple interventions can significantly change practice and improve quality. The timing of meetings and strategies to engage speciality groups are important

Efficiency in colonoscopy

Global trends, including demographic changes, are significantly increasing the demand and cost of healthcare. Endoscopy services are no exception and, even before the Covid-19 pandemic, significant pressure resulted in many units failing to meet cancer wait targets. The need to improve efficiency has never been greater and particularly so for colonoscopy which significantly reduces morbidity and mortality from colorectal cancer. Today, advances in colonoscope technologies and emergence of artificial intelligence offer the potential for improved colonoscopy practice. The aim of this thesis is to explore how efficiency in colonoscopy can be enhanced throughout the patient pathway. Five major studies were performed evaluating bowel preparation (CLEANSE), polyp detection (AI-DETECT), optical diagnosis (DISCARD3), insertion technique (WAVE) and post-colonoscopy colorectal cancer (AI-DETECT). CLEANSE is an evaluation of a novel low-volume same-day bowel preparation regime (Plenvu) and showed this offers a more efficient bowel cleansing option than standard regimens. AI-DETECT is a randomised study evaluating a computer-aided detection (CADe) system (GI Genius) and showed a borderline significant improvement in polyp detection is achieved amongst high performing endoscopists. DISCARD3 is a major evaluation of optical diagnosis with a “resect and discard” strategy exploring the learning curve, quality assurance process, causes of error and economic impact. This study shows such a strategy is feasible and safe and could potentially be implemented with a quality assurance process in place within the English Bowel Cancer Screening Progamme (BCSP). WAVE is a randomised study evaluating colonoscopy insertion technique. This showed a ‘hybrid’ insertion technique is more efficient than a water-exchange colonoscopy technique. REFLECT is a retrospective evaluation of post-colonoscopy colorectal cancer cases identified at national level and showed after local root cause analysis a significant proportion were in fact detected cancers. These studies provide valuable insights that we hope will ultimately lead to more efficient colonoscopy whilst maintaining quality and enhancing patient care.Open Acces

Using audit and feedback to improve colonic polyp detection, qualitative studies within the national endoscopy database automated performance reports to improve quality outcomes trial (NED APRIQOT)

M.D ThesisColorectal cancer (CRC) arises from polyps, and polyp detection and resection at colonoscopy is pivotal in preventing CRC. Colonoscopists with a low polyp detection rate have a higher rate of CRC after colonoscopy. The National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial (NED-APRIQOT) is a randomised cluster control trial of electronic audit and feedback (A&F) in English endoscopy centres. This MD aimed to (1) assess the acceptability of colonoscopy key performance indicators (KPIs); (2) develop an evidence-based and theoretically informed behaviour change intervention (BCI), an A&F endoscopist performance report, for implementation in the trial; and (3) explore pre-trial experiences of endoscopy A&F. A narrative review of A&F and KPIs in the colonoscopy literature was undertaken. This informed selection of KPIs for a Delphi consensus, to determine the clinical acceptability of KPIs available through the NED. A panel of UK experts in colonoscopy, reflecting the varied professional backgrounds performing endoscopy, undertook three rounds rating statements and provided free-text comments. A case-mix adjusted mean number of polyps (MNP) was chosen for the trial. An A&F behavioural theory review informed the design of a draft BCI. Interviews were undertaken with 19 endoscopists from six English NHS endoscopy centres, purposively sampled for clinical background and professional experience. The BCI was iteratively refined through rounds of cognitive interviews in which participants interacted with and ‘talked aloud’ about the BCI. The finalised BCI was implemented in the NED-APRIQOT. These participants also undertook semi-structured interviews exploring current colonoscopy A&F practices. A framework thematic analysis mapped themes to Feedback Intervention Theory (FIT) and the Theory of Planned Behaviour. A FIT-based model described A&F’s intended and paradoxical effects on endoscopist behaviour. Detection and patient safety were dependent on coaching, team behaviours and unit-leads managing underperformance. Future endoscopy A&F interventions should consider targeting behaviours using theoretical models

Colonoscopy: Advanced and Emerging Techniques-A Review of Colonoscopic Approaches to Colorectal Conditions.

A complete colonoscopy is key in the diagnostic and therapeutic approaches to a variety of colorectal diseases. Major challenges are incomplete polyp removal and missed polyps, particularly in the setting of a difficult colonoscopy. There are a variety of both well-established and newer techniques that have been developed to optimize polyp detection, perform complete polypectomy, and endoscopically treat various complications and conditions such as strictures and perforations. The objective of this article is to familiarize the colorectal surgeon with techniques utilized by advanced endoscopists

Genetic, clinical and pathological factors in management and surveillance of patients with colorectal tumours

Numerous factors influence an individual’s risk of colorectal cancer, including pathological features such as polyp size and multiplicity, and family history of colorectal malignancy. In clinical practice polyp size can be measured at different time points, however adenoma surveillance guidelines do not define which measurement to utilise, due to variance in data source. The initial study compared the measurements of 107 polyps. Variation in surveillance intervals occurred less frequently with postfixation than in situ measurements (5.6 versus 9.5%), supporting the use of post-fixation polyp size. A further study considered the level of agreement amongst histopathologists in Wales in the reporting of colorectal polyps. Only fair agreement (k = 0.24) was observed in the reporting of the completeness of excision. A lesion with epithelial misplacement and high grade dysplasia was misclassified as adenocarcinoma by five pathologists, indicating the need for further training and potential introduction of a formal accreditation process. Individuals with a moderate family history risk of colorectal cancer are at increased risk of colorectal lesions. Pathways through the Welsh genetics service were studied. 63.4% referrals were received from primary care. The majority of patient’s were female (70.8%). 93.8% patients were advised to undergo 5-yearly surveillance. Existing referral pathways were found to be complex increasing the risk of over/under surveillance. Little is known about colonoscopic surveillance outcomes following genetic assessment. A study of 172 patients revealed an adenoma detection rate (ADR) of 11.1% and advanced ADR of 4.1% at the index procedure. Cancer was diagnosed in 0.6% cases. The majority of lesions identified were diminutive low grade adenomas. Several endoscopic modalities have been utilised to enhance polyp detection in patients with a propensity to colonic polyps. Narrow band imaging was studied in 37 high-moderate risk patients, but did not significantly increase polyp yield above high definition white light colonoscopy

A. Training Simulators for Gastrointestinal Endoscopy: Current and Future Perspectives

Over the last decades, visual endoscopy has become a gold standard for the detection and treatment of gastrointestinal cancers. However, mastering endoscopic procedures is complex and requires long hours of practice. In this context, simulation-based training represents a valuable opportunity for acquiring technical and cognitive skills, suiting the different trainees’ learning pace and limiting the risks for the patients. In this regard, the present contribution aims to present a critical and comprehensive review of the current technology for gastrointestinal (GI) endoscopy training, including both commercial products and platforms at a research stage. Not limited to it, the recent revolution played by the technological advancements in the fields of robotics, artificial intelligence, virtual/augmented reality, and computational tools on simulation-based learning is documented and discussed. Finally, considerations on the future trend of this application field are drawn, highlighting the impact of the most recent pandemic and the current demographic trends