Andrew F. Goddard

Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme

Objectives Colonoscopy is central to colorectal cancer (CRC) screening. Success of CRC screening is dependent on colonoscopy quality. The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood (FOB) testing to 60–74 year olds and colonoscopy to those with positive FOB tests. All colonoscopists in the screening programme are required to meet predetermined standards before starting screening and are subject to ongoing quality assurance. In this study, the authors examine the quality of colonoscopy in the NHS BCSP and describe new and established measures to assess and maintain quality. Design The NHS BCSP database collects detailed data on all screening colonoscopies. Prospectively collected data from the first 3 years of the programme (August 2006 to August 2009) were analysed. Colonoscopy quality indicators (adenoma detection rate (ADR), polyp detection rate, colonoscopy withdrawal time, caecal intubation rate, rectal retroversion rate, polyp retrieval rate, mean sedation doses, patient comfort scores, bowel preparation quality and adverse event incidence) were calculated along with measures of total adenoma detection. Results 2 269 983 individuals returned FOB tests leading to 36 460 colonoscopies. Mean unadjusted caecal intubation rate was 95.2%, and mean withdrawal time for normal procedures was 9.2 min. The mean ADR per colonoscopist was 46.5%. The mean number of adenomas per procedure (MAP) was 0.91; the mean number of adenomas per positive procedure (MAP+) was 1.94. Perforation occurred after 0.09% of procedures. There were no procedure-related deaths. Conclusions The NHS BCSP provides high-quality colonoscopy, as demonstrated by high caecal intubation rate, ADR and comfort scores, and low adverse event rates. Quality is achieved by ensuring BCSP colonoscopists meet a high standard before starting screening and through ongoing quality assurance. Measuring total adenoma detection (MAP and MAP+) as adjuncts to ADR may further enhance quality assurance.

Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England

BACKGROUND AND STUDY AIMS Increasing colonoscopy withdrawal time (CWT) is thought to be associated with increasing adenoma detection rate (ADR). Current English guidelines recommend a minimum CWT of 6 minutes. It is known that in the Bowel Cancer Screening Programme (BCSP) in England there is wide variation in CWT. The aim of this observational study was to examine the relationship between CWT and ADR. PATIENTS AND METHODS The study examined data from 31 088 colonoscopies by 147 screening program colonoscopists. Colonoscopists were grouped in four levels of mean CWT ( < 7, 7 - 8.9, 9 - 10.9, and ≥ 11 minutes). Univariable and multivariable analysis (binary logistic and negative binomial regression) were used to explore the relationship between CWT, ADR, mean number of adenomas and number of right-sided and advanced adenomas. RESULTS In colonoscopists with a mean CWT < 7 minutes, the mean ADR was 42.5 % compared with 47.1 % in the ≥ 11-minute group (P < 0.001). The mean number of adenomas detected per procedure increased from 0.77 to 0.94, respectively (P < 0.001). The increase in adenoma detection was mainly of subcentimeter or proximal adenomas; there was no increase in the detection of advanced adenomas. Regression models showed an increase in ADR from 43 % to 46.5 % for mean CWT times ranging from 6 to 10 minutes. CONCLUSIONS This study demonstrates that longer mean withdrawal times are associated with increasing adenoma detection, mainly of small or right-sided adenomas. However, beyond 10 minutes the increase in ADR is minimal. Mean withdrawal times longer than 6 minutes are not associated with increased detection of advanced adenomas. Withdrawal time remains an important quality metric of colonoscopy.

Risk factors for gastrointestinal malignancy in patients with iron-deficiency anaemia.

Objectives Iron-deficiency anaemia (IDA) is common and may be caused by blood loss from gastrointestinal tumours. The aim of this study was to define risk factors for gastrointestinal malignancy in patients with IDA. Methods Patients with suspected IDA referred for gastrointestinal investigations were prospectively identified from two neighbouring UK hospitals (serving a population of 550 000 patients) between 1 January 1998 and 31 December 1999. Final diagnoses were determined after 2 years, and those patients with and without gastrointestinal cancer as a cause for their IDA were compared. Data collected included sex, age, haemoglobin, serum ferritin, mean cell volume and drug history. Results A total of 695 patients (236 men, mean age 68.5 years; 459 women, mean age 66.2 years) with IDA were investigated. Malignancy was diagnosed in 91/695 (13.1%) and gastrointestinal malignancy in 78/91 (11.2%). The most frequently diagnosed cancers were colonic (n=44, 6.3%), gastric (n=25, 3.6%) and renal tract (n=7, 1%). The adjusted odds ratio (±95% confidence interval) for gastrointestinal cancer as a cause of IDA was significantly higher for male sex [2.96 (1.80, 4.87)], age over 50 years [7.04 (1.69, 29.32)] and haemoglobin level at presentation (⩽⩽9.0 g/dl) [2.25 (1.29, 3.90)]. There was no significant difference in gastrointestinal malignancy in those taking aspirin (12/111, 10.8%), non-aspirin non-steroidal anti-inflammatory drugs (5/84, 6.0%) or warfarin (4/31, 12.9%) compared with those not taking these drugs (57/470, 12.1%). No cause for IDA was found in 53.7%. Conclusions Cancer was diagnosed in 13.1% and gastrointestinal cancer in 11.2% of patients with IDA. Significant risk factors for gastrointestinal malignancy in IDA patients are male sex, age over 50 years and haemoglobin at presentation ⩽⩽9.0 g/dl. IDA should not be attributed to aspirin, non-steroidal anti-inflammatory drugs or warfarin use.

Outcome of 12-month surveillance colonoscopy in high-risk patients in the National Health Service Bowel Cancer Screening Programme

Current British guidelines recommend surveillance colonoscopy at 12 months for individuals found to have five or more adenomas, or three or more adenomas of which at least one is ≥ 1 cm in size. This study describes the yield of surveillance colonoscopy in this group and explores patient and clinical factors that may be associated with the presence of advanced adenomas or cancer at surveillance.

Efficacy and safety of colonoscopy in the UK NHS bowel cancer screening programme

Introduction Colonoscopy is a central investigation in all colorectal cancer (CRC) screening strategies. Success of CRC screening is dependent on the quality of colonoscopy. The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood testing to adults aged 60–74 years. Colonoscopy is offered to individuals with a positive faecal occult blood (FOB) test. All colonoscopists practicing within the screening programme are required to meet predefined standards through summative assessment and are subject to ongoing quality assurance. In this study we examine the quality of colonoscopy in the NHS BCSP and describe the measures taken by the BCSP to achieve high quality colonoscopy. Comparison of current quality indicators with existing quality standards and evidence from the UK pilot study of FOB screening will be undertaken. Methods The NHS BCSP national database prospectively collects detailed data on all screening colonoscopies. Data from the first 3 years of the programme (August 2006 to August 2009) were analysed. Colonoscopy quality indicators (adenoma detection rate, polyp detection rate, colonoscopy withdrawal time, caecal intubation rate, rectal retroversion rate, polyp retrieval rate, mean sedation doses, patient comfort scores, bowel preparation quality and adverse event incidence) were calculated for this period. All screening centres were contacted directly to verify adverse event data. Results In the study period, 2,269,983 individuals returned FOB tests and 36,460 colonoscopies were performed. Mean caecal intubation rate was 95.2% and mean withdrawal time for normal procedures was 9.2 min. The mean adenoma detection rate (ADR) per colonoscopist was 46.5%. ADR did not differ between prevalent and incident rounds (p = 0.90). Patient comfort scores were high and adverse event rates low. Conclusion The NHS Bowel Cancer Screening Programme provides high quality colonoscopy as demonstrated by high caecal intubation rate, adenoma detection rate and comfort scores and low adverse event rate. This quality is achieved by ensuring that BCSP colonoscopists are trained to a high standard and that these standards are maintained through ongoing quality assurance measures.