Colonoscopy in a CRC Screening Program With FOBT
Colonoscopy in a CRC Screening Program With FOBT
Overall, 44 programmes from eight regions of Northern and Central Italy took part in the study, with an overall target population of 403 646 950 69-year-old persons. All programmes used the OC-Hemodia latex agglutination test, developed with the OC-Sensor Diana or OC-Sensor Micro instrument (Eiken, Tokyo, Japan). These programmes provided individual data on 93 249 colonoscopies included in the CRC database in 2010. Of these, 75 569 (81%) were for positive FIT, the remaining being for postpolypectomy surveillance (n=12 902, 13.8%), completion of previously incomplete colonoscopies (n=2483, 2.7%) or other screening-related indications (n=2295, 2.5%). Thus, the final study population consisted of 75 569 patients (mean age: 61.3 years; men: 57%). The geographical distribution of the study population is provided in Table 2.
Overall, 43 430 (57.5%) positives were at the first FIT examination, and the remaining patients had one or more previous negative FIT exams (Table 2). Sedation was applied in 81.7% of the cases. When reported (n=25 760, 41.7%), it was conscious sedation in most cases (89.6%). Caecal intubation was achieved in 93.1% of the patients. Colon cleansing was rated adequate in 92.7% of the patients.
The endoscopist's characteristics were available for 73% of endoscopists (350/479), accounting for 85.6% of (64 686/75 569) colonoscopies. In the remaining cases, the endoscopist's identification code was recorded, but his/her characteristics were not provided. As shown in Table 3, 76.5% of the exams were performed by male endoscopists, and 42.9% by operators between 50 and 59 years of age. The majority of the colonoscopies (73.8%) were performed by gastroenterologists, with the remaining by surgeons or other specialties. Distribution of endoscopists/colonoscopies according to experience/volume of procedures is provided in Table 3. More than 63% endoscopists had over 10 years of experience.
EC information was available for 79 centres, accounting for 88% (66 539/75 569) of the study colonoscopies. In 81% of the 79 centres, colonoscopy for positive FITs was performed in dedicated sessions, accounting for 87.5% of the procedures (Table 4). Sedation was used in >66% of colonoscopies in 60 ECs (75%), accounting for 51 068 (82.4%) procedures. Sedation was performed in 33%–66% and <33% of colonoscopies in 11 (13.8%) and 9 (11.3%) centres, respectively. Distribution of centres according to the volume of yearly screening colonoscopies and endoscopist specialty is reported in Table 4.
At a per-patient analysis, at least one polyp/adenoma/advanced adenoma was in 59.3%, 44.8% and 29% of the procedures. ADR of single endoscopists was strongly correlated with both PDR and AADR (figure 1).
(Enlarge Image)
Figure 1.
Linear regression of the polyp detection rate and advanced adenoma detection rate with the adenoma detection rate of single endoscopists.
ADR ranged from 13.5% to 75% among endoscopists who performed at least 30 colonoscopies, the 10th and 90th percentile of ADR among endoscopists being 31.9% and 60%.
Regarding patient characteristics, ADR was higher in men, those examined in the first FIT screening round, those with adequate bowel preparation, and it showed a trend toward increasing with older age (Table 5).
ADR was associated with endoscopist specialty, but not with endoscopist years of experience or the volume of activity. ADR was higher in centres with dedicated sessions and in those that routinely used sedation.
In the multilevel analysis (Table 6), ADR was associated with the following factors: (1) Patient-related, male sex (OR of women: 0.58, 95% CI 0.56 to 0.60), age (OR: 1.02 per 1-year increase, 95% CI 1.02 to 1.03), 1st FIT round (OR: 0.78 per 1-round increase, 95% CI 0.75 to 0.81), complete colonoscopy (OR: 2.52, 95% CI 2.32 to 2.75) and an adequate preparation (OR: 1.53, 95% CI 1.42 to 1.65); (2) Endoscopist-related, gastroenterology specialty (OR of other specialties: 0.87, 95% CI 0.76 to 0.96); (3) EC-related, routine use of sedation (OR of occasional (<33%) use: 0.80, 95% CI 0.64 to 1.00) and screening-dedicated session (OR: 1.35, 95% CI 1.11 to 1.66).
The residual variation was 1.1% both at the endoscopist and EC levels; no residual variability was observed at the region level.
When restricting the analysis to subjects with complete colonoscopy (data not shown) the predictive role of the other variables did not show substantial changes.
Overall, the caecum was reached in 93.1% of colonoscopies. CIR was slightly lower in female patients and in those examined in their first FIT round, and it decreased with age (Table 5). CIR dropped to 71.3% in cases with inadequate bowel cleansing. CIR was higher for endoscopists with more than 5 years of experience, and in those performing a high volume of exams—both screening and overall. CIR ranged between 58.8% and 100% among endoscopists who had performed at least 30 colonoscopies (10th–90th percentile: 83.3% and 99.7%).
Among the organisational characteristics of ECs, CIR was higher when the exam was performed in dedicated sessions (94.3%) than in colonoscopies without dedicated sessions (90.6%), in centres with a higher proportion of sedated exams (94.5%) than in those performing sedation in <33% of colonoscopies and in those with a higher yearly volume of colonoscopies, compared with those with lower volumes.
At the multilevel analysis, CIR was lower in women (OR of women: 0.72, 95% CI 0.66 to 0.78), older age (OR per 1-year increase: 0.97, 95% CI 0.97 to 0.98), while it was higher in subjects at subsequent screening round (OR per 1-round increase: 1.42, 95% CI 1.27 to 1.58) (Table 7). Among endoscopist characteristics, caecal intubation was associated with the yearly number of screening colonoscopies performed (OR 1.38, 95% CI 1.04 to 1.82 and 1.51, 95% CI 1.11 to 2.04 for endoscopists with 301–600 and >600 colonoscopies, respectively). Screening-dedicated sessions were associated with a doubling of completion of colonoscopy too (OR: 2.18, 95% CI 1.24 to 3.83), while low rates of sedation reduced CIR by more than 50% (OR: 0.47, 95% CI 0.24 to 0.92). The residual unexplained variability for CIR was 2.4%, 8.5% and 7.1% for the region, EC and endoscopist levels, respectively.
When persons with inadequate bowel cleansing were included, the predictive role of the other variables did not show substantial changes (data not shown), while adequate cleansing was strongly associated with CIR (OR 9.94, 95% CI 9.07 to 10.9).
Results
Study Population
Overall, 44 programmes from eight regions of Northern and Central Italy took part in the study, with an overall target population of 403 646 950 69-year-old persons. All programmes used the OC-Hemodia latex agglutination test, developed with the OC-Sensor Diana or OC-Sensor Micro instrument (Eiken, Tokyo, Japan). These programmes provided individual data on 93 249 colonoscopies included in the CRC database in 2010. Of these, 75 569 (81%) were for positive FIT, the remaining being for postpolypectomy surveillance (n=12 902, 13.8%), completion of previously incomplete colonoscopies (n=2483, 2.7%) or other screening-related indications (n=2295, 2.5%). Thus, the final study population consisted of 75 569 patients (mean age: 61.3 years; men: 57%). The geographical distribution of the study population is provided in Table 2.
Patient Characteristics
Overall, 43 430 (57.5%) positives were at the first FIT examination, and the remaining patients had one or more previous negative FIT exams (Table 2). Sedation was applied in 81.7% of the cases. When reported (n=25 760, 41.7%), it was conscious sedation in most cases (89.6%). Caecal intubation was achieved in 93.1% of the patients. Colon cleansing was rated adequate in 92.7% of the patients.
Endoscopist Characteristics
The endoscopist's characteristics were available for 73% of endoscopists (350/479), accounting for 85.6% of (64 686/75 569) colonoscopies. In the remaining cases, the endoscopist's identification code was recorded, but his/her characteristics were not provided. As shown in Table 3, 76.5% of the exams were performed by male endoscopists, and 42.9% by operators between 50 and 59 years of age. The majority of the colonoscopies (73.8%) were performed by gastroenterologists, with the remaining by surgeons or other specialties. Distribution of endoscopists/colonoscopies according to experience/volume of procedures is provided in Table 3. More than 63% endoscopists had over 10 years of experience.
ECs' Characteristics
EC information was available for 79 centres, accounting for 88% (66 539/75 569) of the study colonoscopies. In 81% of the 79 centres, colonoscopy for positive FITs was performed in dedicated sessions, accounting for 87.5% of the procedures (Table 4). Sedation was used in >66% of colonoscopies in 60 ECs (75%), accounting for 51 068 (82.4%) procedures. Sedation was performed in 33%–66% and <33% of colonoscopies in 11 (13.8%) and 9 (11.3%) centres, respectively. Distribution of centres according to the volume of yearly screening colonoscopies and endoscopist specialty is reported in Table 4.
Adenoma Detection Rates
At a per-patient analysis, at least one polyp/adenoma/advanced adenoma was in 59.3%, 44.8% and 29% of the procedures. ADR of single endoscopists was strongly correlated with both PDR and AADR (figure 1).
(Enlarge Image)
Figure 1.
Linear regression of the polyp detection rate and advanced adenoma detection rate with the adenoma detection rate of single endoscopists.
ADR ranged from 13.5% to 75% among endoscopists who performed at least 30 colonoscopies, the 10th and 90th percentile of ADR among endoscopists being 31.9% and 60%.
Regarding patient characteristics, ADR was higher in men, those examined in the first FIT screening round, those with adequate bowel preparation, and it showed a trend toward increasing with older age (Table 5).
ADR was associated with endoscopist specialty, but not with endoscopist years of experience or the volume of activity. ADR was higher in centres with dedicated sessions and in those that routinely used sedation.
In the multilevel analysis (Table 6), ADR was associated with the following factors: (1) Patient-related, male sex (OR of women: 0.58, 95% CI 0.56 to 0.60), age (OR: 1.02 per 1-year increase, 95% CI 1.02 to 1.03), 1st FIT round (OR: 0.78 per 1-round increase, 95% CI 0.75 to 0.81), complete colonoscopy (OR: 2.52, 95% CI 2.32 to 2.75) and an adequate preparation (OR: 1.53, 95% CI 1.42 to 1.65); (2) Endoscopist-related, gastroenterology specialty (OR of other specialties: 0.87, 95% CI 0.76 to 0.96); (3) EC-related, routine use of sedation (OR of occasional (<33%) use: 0.80, 95% CI 0.64 to 1.00) and screening-dedicated session (OR: 1.35, 95% CI 1.11 to 1.66).
The residual variation was 1.1% both at the endoscopist and EC levels; no residual variability was observed at the region level.
When restricting the analysis to subjects with complete colonoscopy (data not shown) the predictive role of the other variables did not show substantial changes.
Caecal Intubation Rate
Overall, the caecum was reached in 93.1% of colonoscopies. CIR was slightly lower in female patients and in those examined in their first FIT round, and it decreased with age (Table 5). CIR dropped to 71.3% in cases with inadequate bowel cleansing. CIR was higher for endoscopists with more than 5 years of experience, and in those performing a high volume of exams—both screening and overall. CIR ranged between 58.8% and 100% among endoscopists who had performed at least 30 colonoscopies (10th–90th percentile: 83.3% and 99.7%).
Among the organisational characteristics of ECs, CIR was higher when the exam was performed in dedicated sessions (94.3%) than in colonoscopies without dedicated sessions (90.6%), in centres with a higher proportion of sedated exams (94.5%) than in those performing sedation in <33% of colonoscopies and in those with a higher yearly volume of colonoscopies, compared with those with lower volumes.
At the multilevel analysis, CIR was lower in women (OR of women: 0.72, 95% CI 0.66 to 0.78), older age (OR per 1-year increase: 0.97, 95% CI 0.97 to 0.98), while it was higher in subjects at subsequent screening round (OR per 1-round increase: 1.42, 95% CI 1.27 to 1.58) (Table 7). Among endoscopist characteristics, caecal intubation was associated with the yearly number of screening colonoscopies performed (OR 1.38, 95% CI 1.04 to 1.82 and 1.51, 95% CI 1.11 to 2.04 for endoscopists with 301–600 and >600 colonoscopies, respectively). Screening-dedicated sessions were associated with a doubling of completion of colonoscopy too (OR: 2.18, 95% CI 1.24 to 3.83), while low rates of sedation reduced CIR by more than 50% (OR: 0.47, 95% CI 0.24 to 0.92). The residual unexplained variability for CIR was 2.4%, 8.5% and 7.1% for the region, EC and endoscopist levels, respectively.
When persons with inadequate bowel cleansing were included, the predictive role of the other variables did not show substantial changes (data not shown), while adequate cleansing was strongly associated with CIR (OR 9.94, 95% CI 9.07 to 10.9).
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