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:
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Rate of adequate bowel preparation (minimum standard 90 %);
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Cecal intubation rate (minimum standard 90 %);
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Adenoma detection rate (minimum standard 25 %);
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Appropriate polypectomy technique (minimum standard 80 %);
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Complication rate (minimum standard not set);
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Patient experience (minimum standard not set);
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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.
In this large study of colorectal-cancer screening, the endoscopist's rate of adenoma detection was associated with the risk of interval colorectal cancer after screening colonoscopy. Colorectal ...cancers were less likely to be diagnosed between screening examinations when colonoscopies were performed by endoscopists with an adenoma detection rate of 20% or more.
In this large study of colorectal-cancer screening, the endoscopist's rate of adenoma detection was associated with the risk of interval colorectal cancer after screening colonoscopy.
Although colonoscopy is widely used for colorectal-cancer screening,
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its miss rate for cancers and adenomatous polyps (benign premalignant tumors or adenomas), which is low but not negligible, remains a concern.
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It has been suggested that a high-quality examination that ensures the detection and removal of all neoplastic lesions is key for screening efficacy.
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In response, professional societies have proposed the use of various quality-assessment indicators. Of such indicators, the rates of adenoma detection and cecal intubation are the most commonly used.
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However, these measurements have never been validated, and it is not known whether an improvement . . .
Current guidelines recommend a 10-year interval between screening colonoscopies, but evidence is limited.
To assess the long-term risk for colorectal cancer (CRC) and death from CRC after a high- and ...low-quality single negative screening colonoscopy.
Observational study.
Polish Colonoscopy Screening Program.
Average-risk individuals aged 50 to 66 years who had a single negative colonoscopy (no neoplastic findings).
Standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) of CRC after high- and low-quality single negative screening colonoscopy. High-quality colonoscopy included a complete examination, with adequate bowel preparation, performed by endoscopists with an adenoma detection rate of 20% or greater.
Among 165 887 individuals followed for up to 17.4 years, CRC incidence (0.28 95% CI, 0.25 to 0.30) and mortality (0.19 CI, 0.16 to 0.21) were 72% and 81% lower, respectively, than in the general population. High-quality examination resulted in 2-fold lower CRC incidence (SIR, 0.16 CI, 0.13 to 0.20) and mortality (SMR, 0.10 CI, 0.06 to 0.14) than low-quality examination (SIR, 0.32 CI, 0.29 to 0.35; SMR, 0.22 CI, 0.18 to 0.25). In multivariable analysis, the hazard ratios for CRC incidence after high-quality versus low-quality colonoscopy were 0.55 (CI, 0.35 to 0.86) for 0 to 5 years, 0.54 (CI, 0.38 to 0.77) for 5.1 to 10 years, and 0.46 (CI, 0.25 to 0.86) for 10 to 17.4 years. Only after high-quality colonoscopy did the SIR and SMR for 10.1 to 17.4 years of follow-up not differ compared with earlier observation periods.
The general population was used as the comparison group.
A single negative screening colonoscopy was associated with reduced CRC incidence and mortality for up to 17.4 years. Only high-quality colonoscopy yielded profound and stable reductions in CRC incidence and mortality throughout the entire follow-up.
Polish Ministry of Health.
Objective This study aimed to develop and validate a model to estimate the likelihood of detecting advanced colorectal neoplasia in Caucasian patients. Design We performed a cross-sectional analysis ...of database records for 40-year-old to 66-year-old patients who entered a national primary colonoscopy-based screening programme for colorectal cancer in 73 centres in Poland in the year 2007. We used multivariate logistic regression to investigate the associations between clinical variables and the presence of advanced neoplasia in a randomly selected test set, and confirmed the associations in a validation set. We used model coefficients to develop a risk score for detection of advanced colorectal neoplasia. Results Advanced colorectal neoplasia was detected in 2544 of the 35 918 included participants (7.1%). In the test set, a logistic-regression model showed that independent risk factors for advanced colorectal neoplasia were: age, sex, family history of colorectal cancer, cigarette smoking (p<0.001 for these four factors), and Body Mass Index (p=0.033). In the validation set, the model was well calibrated (ratio of expected to observed risk of advanced neoplasia: 1.00 (95% CI 0.95 to 1.06)) and had moderate discriminatory power (c-statistic 0.62). We developed a score that estimated the likelihood of detecting advanced neoplasia in the validation set, from 1.32% for patients scoring 0, to 19.12% for patients scoring 7–8. Conclusions Developed and internally validated score consisting of simple clinical factors successfully estimates the likelihood of detecting advanced colorectal neoplasia in asymptomatic Caucasian patients. Once externally validated, it may be useful for counselling or designing primary prevention studies.
In a large, national program of colorectal-cancer screening in Poland, men were about twice as likely as women to have advanced neoplasia detected on colonoscopy. The yield of colonoscopy among men ...40 to 49 years of age was similar to that among women 55 to 59 years of age (in these differing age groups, one advanced neoplasia detected for every 23 men and 22 women screened).
In a large program of colorectal-cancer screening, men were about twice as likely as women to have advanced neoplasia detected on colonoscopy. The yield of colonoscopy among men 40 to 49 years of age was similar to that among women 55 to 59 years of age.
Colorectal cancer is the most frequent cancer in Europe
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and the second leading cause of death related to cancer in the United States.
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Screening can lead to decreased incidences of colorectal cancer and death owing to the detection of both precancerous lesions and cancers at early stages, respectively.
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Fecal occult-blood testing and flexible sigmoidoscopy can miss a substantial fraction of important lesions.
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Despite its risk, inconvenience, and cost, colonoscopy is a valid primary screening tool for colorectal cancer when performed every 10 years, beginning at 50 years of age in people who are at average risk.
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Whatever method . . .
Background and study aims:
Colonoscopy screening for colorectal cancer has been implemented without evidence from randomized controlled trials quantifying its benefit and invariably as an ...opportunistic program, both of which are contrary to the European Union guideline recommendations. The aim of this paper is to describe the rationale and design of the first population-based colonoscopy screening program (PCSP), which was launched in Poland in 2012 as a randomized health services (RHS) study.
Methods:
The PCSP is a natural extension of opportunistic colonoscopy screening implemented in 2000. It uses colonoscopy capacity, a quality assurance program, and a network of 92 centers built up during the opportunistic screening phase to develop a countrywide PCSP. Within the PCSP, single screening colonoscopy is offered to a target population aged 55 – 64 years. The PCSP uses an RHS design, which means that eligible individuals drawn from population registries are randomly assigned to immediate or postponed invitation to screening. Individuals from birth cohorts that will reach the upper age limit for screening before full implementation of the PCSP are randomly assigned, in a 1:1:1 ratio, to “immediate” screening, “postponed” screening, or a “never invited” control group. The RHS design is a natural platform that will evaluate the effectiveness of screening, and compare different age ranges for screening, invitation procedures, and quality improvement interventions. Up to 2015, 24 centers have been developed, with 34.2 % geographic coverage and 851 535 individuals enrolled.
Conclusions:
The PCSP sets an example for implementation of population-based colonoscopy screening with experimental design to ensure proper evaluation of its effectiveness.
RHS registration number: 007_2015_1_RHS.
Colorectal cancer (CRC) is a serious health problem, and various screening programs to reduce CRC have been introduced worldwide. However, the cost‑effectiveness of a program based on ...once‑in‑a‑lifetime colonoscopy in Poland is unknown.
The main aim of this study was to assess the cost‑effectiveness of Polish Colonoscopy Screening Platform (PCSP), the colonoscopy screening program in Poland.
A Markov model was constructed to compare the strategy of colonoscopy screening as compared with no screening in 100 000 subjects. The model was based on data collected from the nationwide Polish CRC screening program whenever possible. The incremental cost‑effectiveness ratio (ICER) was calculated and compared with the willingness‑to‑pay thresholds. A sensitivity analysis was also performed using the Monte Carlo simulation.
Colonoscopy screening within PCSP resulted in a 18.9% reduction in CRC incidence and 19.8% reduction in CRC mortality. The strategy allowed a gain of 2317 life‑years saved (1959 after discount‑ ing). The cost of colonoscopy screening per participant examined was estimated at 267.70 USD (95% CI, 263.08-272.32 USD). The ICER was less than 6500 USD, which was much lower than the accepted willingness‑to‑pay thresholds, indicating that the screening was cost‑effective.
Colonoscopy screening within the PCSP is cost‑effective and may have a substantial impact on the Polish society due to life‑years saved. The results have good informative value not only for health policy makers and medical practitioners, but also for health technology assessment.
Background & Aims The quality of endoscopists' colonoscopy performance is measured by adenoma detection rate (ADR). Although ADR is associated inversely with interval colorectal cancer and colorectal ...cancer death, the effects of an increasing ADR have not been shown. We investigated whether increasing ADRs from individual endoscopists is associated with reduced risks of interval colorectal cancer and subsequent death. Methods We performed a prospective cohort study of individuals who underwent a screening colonoscopy within the National Colorectal Cancer Screening Program in Poland, from January 1, 2004, through December 31, 2008. We collected data from 146,860 colonoscopies performed by 294 endoscopists, with each endoscopist having participated at least twice in annual editions of primary colonoscopy screening. We used annual feedback and quality benchmark indicators to improve colonoscopy performance. We used ADR quintiles in the whole data set to categorize the annual ADRs for each endoscopist. An increased ADR was defined as an increase by at least 1 quintile category, or the maintenance of the highest category in subsequent screening years. Multivariate frailty models were used to evaluate the effects of increased ADR on the risk of interval colorectal cancer and death. Results Throughout the enrollment period, 219 endoscopists (74.5%) increased their annual ADR category. During 895,916 person-years of follow-up evaluation through the National Cancer Registry, we identified 168 interval colorectal cancers and 44 interval cancer deaths. An increased ADR was associated with an adjusted hazard ratio for interval colorectal cancer of 0.63 (95% confidence interval CI, 0.45–0.88; P = .006), and for cancer death of 0.50 (95% CI, 0.27–0.95; P = .035). Compared with no increase in ADR, reaching or maintaining the highest quintile ADR category (such as an ADR > 24.56%) decreased the adjusted hazard ratios for interval colorectal cancer to 0.27 (95% CI, 0.12–0.63; P = .003), and 0.18 (95% CI, 0.06–0.56; P = .003), respectively. Conclusions In a prospective study of individuals who underwent screening colonoscopy within a National Colorectal Cancer Screening Program, we associated increased ADR with a reduced risk of interval colorectal cancer and death.
In this randomized trial involving 84,585 participants in Poland, Norway, and Sweden, the risk of colorectal cancer at 10 years was lower among those invited to undergo screening colonoscopy than ...among those assigned to no screening.
ObjectivePain associated with colonoscopy is a major burden for patients. We investigated modifiable factors associated with patient-reported pain during and after colonoscopy.DesignThis ...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.ResultsOf 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.ConclusionWe 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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