Quality of colonoscopy performed by medical or surgical specialists and trainees in five Australian hospitals

ARTICLE HIGHLIGHTS

Research background

There is increasing attention on the quality of colonoscopy performed in Australia due to its vital role in the prevention of colorectal cancer, and its relative under-utilisation among rural and lower socioeconomic communities. However, quality of colonoscopy in Australia has seldom been reported outside of single-centre studies. The largest database, the National Re-certification Program, attempts to address this but largely reflects the quality of work being performed in private hospital settings. Government funded procedures are not well represented in this data, yet accounts for 25% of colonoscopy work, and remains the main pathway for patients without private insurance and within the lowest socioeconomic strata to access this care. We sought to characterise the quality of colonoscopy in this sector, with the aim of informing quality improvement initiatives.

Research motivation

The key quality metrics for colonoscopy are bowel preparation quality, procedure completion rate, and lesion detection rates (cancer, adenomas, and clinically significant serrated lesions). Serrated lesions have also received increasing attention recently, resulting in their incorporation within current national re-certification guidelines. We hope to determine if there are deficiencies in these metrics according to national guidelines and by comparison between participating hospital sites. We also sought to determine if there are significant differences in the detection rates of lesions according to consultant specialty (medical vs surgical), training level (specialist vs trainee), hospital site, and trainee background (medical vs surgical). The outcomes of this research can drive further inquiry into understanding the reasons for these differences and potential solutions.

Research objectives

We aimed to determine the lesion (cancer, adenoma, clinically significant serrated lesion) detection rates, quality of bowel preparation, procedure completion rates among teaching hospitals in Australia. Additionally, we wished to compare the outcomes according to proceduralist specialty, hospital, involvement of trainees, and trainee specialty. We were able to realize all these outcomes, however the analysis of outcomes according to sites was limited by the small sample sizes at some of the participating hospitals. Further studies to explore the link between proceduralist specialty, gender, and adenoma detection rates in Australia are warranted. Additional research regarding methods to improve these outcomes is also indicated.

Research methods

This was a retrospective cohort study involving consecutive colonoscopies performed over five publicly-funded teaching hospitals in Australia. Currently available colonoscopy quality metrics in Australia are either self-reported and reflect privately funded procedural work or pertain to fewer procedures at single centres. To our knowledge, this is the first study to describe colonoscopy quality across multiple large teaching endoscopy units in the public sector of Australia.

Research results

The overall quality of colonoscopy performed in participating hospitals met all specified national benchmarks (adenoma detection rate/procedure completion rate/serrated lesion detection rate). Two hospitals did not meet all benchmarks, due to either a low procedure completion or serrated lesion detection rate, when assessed individually. However, these results were not significantly different when compared with their peers. Significant differences between hospitals were identified on the remaining outcomes of bowel preparation, and detection of cancers and adenomas. Medical specialists detected adenomas in significantly more procedures than their surgical counterparts. In procedures attended by trainees, the detection rate of clinically significant lesions (cancer, adenoma, serrated lesions) was no different to those only involving specialists. Trainee specialty similarly did not affect lesion detection rates. The difference in adenoma detection rate between medical and surgical specialists was confirmed on multivariate analysis. An additional unexpected finding on the multivariate analysis was an association between female gender and adenoma detection. The findings highlight the need for further research to understand the differences between the colonoscopy procedures performed by medical and surgical specialists, and the reasons why female gender in this cohort of patients was an independent risk factor for adenoma detection. Furthermore, it suggests the need for additional sampling in lower-volume endoscopy units for the assessment of quality in colonoscopy.

Research conclusions

Our study suggests that although the overall quality of colonoscopy in publicly funded Australian hospitals reach national standards, significant variations exist between hospitals, according to procedural specialty, as well as patient gender. Understanding the reasons for these differences can provide additional insights on how quality in colonoscopy can be further improved. Although comparison with peer hospitals may provide an acceptable alternative for the assessment of outcomes in low-volume centres, larger studies are ideally required to assess their quality independently.

Research perspectives

Further research is required to explain the disparity in adenoma detection rates between medical and surgical specialists performing colonoscopy, and to determine why female, rather than male gender, is an independent predictor for adenoma in Australia.