In the Journals

It’s not personal: Polyp detection better with higher volume, recent training

Carol Burke, MD
Carol A. Burke

Residual confounding, and not an endoscopist’s personal characteristics like surgical specialty training or sex, may be responsible for previously identified differences in adenoma detection rates and proximal sessile serrated polyp detection rates during colonoscopy, according to results of a single-center study published in JAMA Surgery.

“Other studies have suggested that specific features of the endoscopist doing colonoscopy are associated with an improved detection of precancerous colon polyps such as gastroenterologists vs. surgeons and female over male endoscopists,” Carol A. Burke, MD, vice chair of the Department of Gastroenterology, Hepatology & Nutrition at Cleveland Clinic, told Healio Gastroenterology and Liver Disease. “We believed that other important patient and endoscopist-related factors were never accounted for in those studies and may have impacted those results.”

Burke and colleagues assessed data from individuals undergoing screening colonoscopies between January 2015 and June 2017 across the Cleveland Clinic health system to determine if there was an association between endoscopist characteristics and polyp detection after adjusting for confounders that have been included in previous studies, as well as other factors.

They performed a multilevel mixed-effects logistic regression to examine seven endoscopist characteristics associated with adenoma detection rates (ADR) and proximal sessile serrated polyp detection rates (pSSPDR) after controlling for patient demographic, clinical, and colonoscopy-associated factors.

Provider characteristics considered in the study included endoscopist specialty, sex, location of medical school, years since fellowship, number of colonoscopies performed per year, practice setting and presence of trainee during colonoscopy.

Differences in ADRs and pSSPDRs served as the primary endpoint.

Fifty-six endoscopists, including gastroenterologists (n = 34), surgeons (n = 15) and advanced endoscopists (n = 7) performed 16,089 colonoscopies on the same number of individuals (51.8% men; median age, 59 years) during the 2-year study.

Approximately one-quarter (n = 14) of the endoscopists were women, and 14 of the endoscopists were graduates of international medical institutions.

The endoscopists included in the assessment had a median time from completion of training of 16.3 years (interquartile range [IQR], 6.4-26 years) and performed a median of 267 (IQR, 158.5-436.2) colonoscopies per year.

The results of the analysis from the Cleveland Clinic demonstrated that ADR was not significantly associated with any endoscopist characteristic. However, pSSPDR was lower with longer years in practice (OR = 0.86 [95%CI, 0.83-0.89] per increment of 10 years; P < .001) and increased with a greater number of annual colonoscopies performed (OR = 1.05 [95%CI, 1.01-1.09] per 50 colonoscopies/year; P = .02).

“Interestingly when we re-analyzed our data according to the methods used by researchers from previous studies which did not account for important patient confounders, we too demonstrated difference in polyp detection by endoscopist features,” Burke said. “We believe that the differences demonstrated in previous studies may not be valid by not adjusting for a variety of important factors which can increase or decrease polyp detection rates” she said.

Burke noted that the researchers were not surprised by the results involving pSSPDR, since the mean pSSPDR was 4.6% in men and women, which, according to Burke, involve lesions that are much less commonly encountered than adenomas.

“We suspect the ability to detect SSPs is higher in endoscopists doing more colonoscopies because they are exposed to these lesions more commonly,” she said. “Secondarily, endoscopists more recently [removed] from training have higher pSSPDR because SSPs are a more recently described colon cancer precursor lesion being firstly widely recognized in 2005,” Burke said in an email. “SSPs appear completely different than adenomas being flat, excessively subtle, the same color as the surrounding colon lining and often time covered in a glob of mucus.”

Burke mentioned that the researchers suggest endoscopists who have low PSSPDRs may need further training on the endoscopic appearance of these lesions.

“Currently the adenoma detection rate is a national colonoscopy quality metric. It is only adjusted for gender in average risk individuals undergoing first time screening colonoscopy. You can imagine there are more factors which may increase the prevalence of adenomas, like smoking, obesity, non-white ethnicity, comorbid diseases like diabetes, and factors which may decrease risk like use of aspirin or non-steroidal anti-inflammatory drugs or statins,” Burke said.

Additionally, Burke noted that patients should not be afraid to ask their clinicians pertinent questions regarding their ability to perform high quality colonoscopy.

“Patients should feel comfortable asking their endoscopist about their ADR and sessile serrated polyp detection rates and ensure they go to the physician that can provide high quality colonoscopy,” she said. “Many of these important measures are advertised on practices’ websites.” – by Ryan McDonald

Disclosures: The authors report no relevant financial disclosures.

Carol Burke, MD
Carol A. Burke

Residual confounding, and not an endoscopist’s personal characteristics like surgical specialty training or sex, may be responsible for previously identified differences in adenoma detection rates and proximal sessile serrated polyp detection rates during colonoscopy, according to results of a single-center study published in JAMA Surgery.

“Other studies have suggested that specific features of the endoscopist doing colonoscopy are associated with an improved detection of precancerous colon polyps such as gastroenterologists vs. surgeons and female over male endoscopists,” Carol A. Burke, MD, vice chair of the Department of Gastroenterology, Hepatology & Nutrition at Cleveland Clinic, told Healio Gastroenterology and Liver Disease. “We believed that other important patient and endoscopist-related factors were never accounted for in those studies and may have impacted those results.”

Burke and colleagues assessed data from individuals undergoing screening colonoscopies between January 2015 and June 2017 across the Cleveland Clinic health system to determine if there was an association between endoscopist characteristics and polyp detection after adjusting for confounders that have been included in previous studies, as well as other factors.

They performed a multilevel mixed-effects logistic regression to examine seven endoscopist characteristics associated with adenoma detection rates (ADR) and proximal sessile serrated polyp detection rates (pSSPDR) after controlling for patient demographic, clinical, and colonoscopy-associated factors.

Provider characteristics considered in the study included endoscopist specialty, sex, location of medical school, years since fellowship, number of colonoscopies performed per year, practice setting and presence of trainee during colonoscopy.

Differences in ADRs and pSSPDRs served as the primary endpoint.

Fifty-six endoscopists, including gastroenterologists (n = 34), surgeons (n = 15) and advanced endoscopists (n = 7) performed 16,089 colonoscopies on the same number of individuals (51.8% men; median age, 59 years) during the 2-year study.

Approximately one-quarter (n = 14) of the endoscopists were women, and 14 of the endoscopists were graduates of international medical institutions.

The endoscopists included in the assessment had a median time from completion of training of 16.3 years (interquartile range [IQR], 6.4-26 years) and performed a median of 267 (IQR, 158.5-436.2) colonoscopies per year.

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The results of the analysis from the Cleveland Clinic demonstrated that ADR was not significantly associated with any endoscopist characteristic. However, pSSPDR was lower with longer years in practice (OR = 0.86 [95%CI, 0.83-0.89] per increment of 10 years; P < .001) and increased with a greater number of annual colonoscopies performed (OR = 1.05 [95%CI, 1.01-1.09] per 50 colonoscopies/year; P = .02).

“Interestingly when we re-analyzed our data according to the methods used by researchers from previous studies which did not account for important patient confounders, we too demonstrated difference in polyp detection by endoscopist features,” Burke said. “We believe that the differences demonstrated in previous studies may not be valid by not adjusting for a variety of important factors which can increase or decrease polyp detection rates” she said.

Burke noted that the researchers were not surprised by the results involving pSSPDR, since the mean pSSPDR was 4.6% in men and women, which, according to Burke, involve lesions that are much less commonly encountered than adenomas.

“We suspect the ability to detect SSPs is higher in endoscopists doing more colonoscopies because they are exposed to these lesions more commonly,” she said. “Secondarily, endoscopists more recently [removed] from training have higher pSSPDR because SSPs are a more recently described colon cancer precursor lesion being firstly widely recognized in 2005,” Burke said in an email. “SSPs appear completely different than adenomas being flat, excessively subtle, the same color as the surrounding colon lining and often time covered in a glob of mucus.”

Burke mentioned that the researchers suggest endoscopists who have low PSSPDRs may need further training on the endoscopic appearance of these lesions.

“Currently the adenoma detection rate is a national colonoscopy quality metric. It is only adjusted for gender in average risk individuals undergoing first time screening colonoscopy. You can imagine there are more factors which may increase the prevalence of adenomas, like smoking, obesity, non-white ethnicity, comorbid diseases like diabetes, and factors which may decrease risk like use of aspirin or non-steroidal anti-inflammatory drugs or statins,” Burke said.

Additionally, Burke noted that patients should not be afraid to ask their clinicians pertinent questions regarding their ability to perform high quality colonoscopy.

“Patients should feel comfortable asking their endoscopist about their ADR and sessile serrated polyp detection rates and ensure they go to the physician that can provide high quality colonoscopy,” she said. “Many of these important measures are advertised on practices’ websites.” – by Ryan McDonald

Disclosures: The authors report no relevant financial disclosures.