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di Pietro M, Canto MI, Fitzgerald RC. Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus: Screening, Diagnosis, and Therapy. Gastroenterology 2018; 154:421-436. [PMID: 28778650 PMCID: PMC6104810 DOI: 10.1053/j.gastro.2017.07.041] [Citation(s) in RCA: 160] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022]
Abstract
Because the esophagus is easily accessible with endoscopy, early diagnosis and curative treatment of esophageal cancer is possible. However, diagnosis is often delayed because symptoms are not specific during early stages of tumor development. The onset of dysphagia is associated with advanced disease, which has a survival at 5 years lower than 15%. Population screening by endoscopy is not cost-effective, but a number of alternative imaging and cell analysis technologies are under investigation. The ideal screening test should be inexpensive, well tolerated, and applicable to primary care. Over the past 10 years, significant progress has been made in endoscopic diagnosis and treatment of dysplasia (squamous and Barrett's), and early esophageal cancer using resection and ablation technologies supported by evidence from randomized controlled trials. We review the state-of-the-art technologies for early diagnosis and minimally invasive treatment, which together could reduce the burden of disease.
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Affiliation(s)
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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A survey of credentialing for ERCP in the United States. Gastrointest Endosc 2017; 86:866-869. [PMID: 28366439 DOI: 10.1016/j.gie.2017.03.1530] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/18/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS There are limited data measuring the variability in standards used by hospitals for credentialing physicians to ERCP in the United States. METHODS We performed an electronic survey of U.S. gastroenterologists. RESULTS Among 1126 respondents, 21% reported that their hospitals had no written guidelines for initial credentialing, and 59% reported that their hospitals had no written guidelines for repeat credentialing. Among those with guidelines, less than half had any of the criteria recommended by the American Society for Gastrointestinal Endoscopy. CONCLUSIONS There is an urgent need to improve the credentialing process to enhance practice and to protect patients. An easy-to-use national system for recording and reporting ERCP quality data, like that of the GI Quality Improvement Consortium, is needed.
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Cassani LS, DiSario JA. Reporting progress in ERCP hospital credentialing and quality review: stagnant is an understatement. Gastrointest Endosc 2017; 86:870-871. [PMID: 29061258 DOI: 10.1016/j.gie.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 07/01/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Lisa S Cassani
- Atlanta Veterans Affairs Health Care System, Emory University School of Medicine, Atlanta, Georgia, USA
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Baumgardner JM, Sewell JL, Day LW. Assessment of quality indicators among nurse practitioners performing upper endoscopy. Endosc Int Open 2017; 5:E818-E824. [PMID: 28879227 PMCID: PMC5585072 DOI: 10.1055/s-0043-115384] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Limited international data have shown that non-physicians can safely perform upper endoscopy, but no such study has been performed in the United States. Our aim was to assess the quality of outpatient upper endoscopies performed by nurse practitioners (NPs). PATIENTS AND METHODS Retrospective chart review of upper endoscopies performed by 3 NPs between 2010 and 2013 was performed. Comparisons among all NPs performing upper endoscopy and assessment of individual NP performance over time with respect to quality indicators were performed. RESULTS Three NPs performed 333 upper endoscopies (distribution of 166, 44, and 123, respectively). Of the cases, 98.2 %s were successfully completed to the second portion of the duodenum. In most cases, photo-documentation of required anatomical landmarks was performed: GE junction (84.2 %), GE junction in retroflexed view (84.2 %), antrum (82.1 %) and duodenum (80.9 %). Photo-documentation improved with increasing experience. NPs appropriately performed biopsies for specific medical conditions: 10/11 (90.9 %) gastric ulcers were biopsied and 63/66 (95.5) of patients with iron deficiency had duodenal biopsies performed for celiac disease. A physician endoscopist was required during the procedure 22.5 % of the time. Important parameters such as documenting informed consent (100 %) and documenting a discharge plan (99.4 %) in the procedure reports were overwhelming present. There was a single adverse event during the study period. CONCLUSION In the first US study of NPs performing upper endoscopy, they were able to perform high-quality and safe upper endoscopies. These findings support incorporation of non-physicians alongside physicians to help meet the growing demand for endoscopic services across the United States.
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Affiliation(s)
- Jeffrey M. Baumgardner
- Division of Gastroenterology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States,Corresponding author Jeffrey M. Baumgardner Zuckerberg San Francisco General Hospital and Trauma Center1001 Potrero AveSan Francisco CA 941101-415-206-5199
| | - Justin L. Sewell
- Division of Gastroenterology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States
| | - Lukejohn W. Day
- Division of Gastroenterology, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, United States
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Stephens M, Hourigan LF, Appleyard M, Ostapowicz G, Schoeman M, Desmond PV, Andrews JM, Bourke M, Hewitt D, Margolin DA, Holtmann GJ. Non-physician endoscopists: A systematic review. World J Gastroenterol 2015; 21:5056-5071. [PMID: 25945022 PMCID: PMC4408481 DOI: 10.3748/wjg.v21.i16.5056] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 12/22/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services.
METHODS: The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms. Studies were screened against eligibility criteria and for relevance. Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of non-physician endoscopists. These publications included a total of 28883 procedures performed by non-physician endoscopists.
RESULTS: The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter. 17/26 studies related to flexible sigmoidoscopies, 5 to upper GI endoscopy and 6 to colonoscopy. All studies were from metropolitan centres with nurses working under strict supervision and guidance by specialist gastroenterologists. Geographic distribution of publications showed the majority of research was conducted in the United States (43%), the United Kingdom (39%) and the Netherlands (7%). Most studies conclude that after appropriate training nurse endoscopists safely perform procedures. However, in relation to endoscopic competency, safety or patient satisfaction, all studies had major methodological limitations. Patients were often not randomized (21/26 studies) and not appropriately controlled. In relation to cost-efficiency, nurse endoscopists were less cost-effective per procedure at year 1 when compared to services provided by physicians, due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations.
CONCLUSION: Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite. Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.
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Current status of core and advanced adult gastrointestinal endoscopy training in Canada: Survey of existing accredited programs. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2014; 27:267-72. [PMID: 23712301 DOI: 10.1155/2013/186284] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the current status of core and advanced adult gastroenterology training in Canada. METHODS A survey consisting of 20 questions pertaining to core and advanced endoscopy training was circulated to 14 accredited adult gastroenterology residency program directors. For continuous variables, median and range were analyzed; for categorical variables, percentage and associated 95% CIs were analyzed. RESULTS All 14 programs responded to the survey. The median number of core trainees was six (range four to 16). The median (range) procedural volumes for gastroscopy, colonoscopy, percutaneous endoscopic gastrostomy and sigmoidoscopy, respectively, were 400 (150 to 1000), 325 (200 to 1500), 15 (zero to 250) and 60 (25 to 300). Eleven of 13 (84.6%) programs used endoscopy simulators in their curriculum. Eight of 14 programs (57%) provided a structured advanced endoscopy training fellowship. The majority (88%) offered training of combined endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography. The median number of positions offered yearly for advanced endoscopy fellowship was one (range one to three). The median (range) procedural volumes for ERCP, endoscopic ultrasonography and endoscopic mucosal resection, respectively, were 325 (200 to 750), 250 (80 to 400) and 20 (10 to 63). None of the current programs offered training in endoscopic submucosal dissection or natural orifice transluminal endoscopic surgery. CONCLUSION Most accredited adult Canadian gastroenterology programs met the minimal procedural requirements recommended by the Canadian Association of Gastroenterology during core training. However, a more heterogeneous experience has been observed for advanced training. Additional studies would be required to validate and standardize evaluation tools used during gastroenterology curricula.
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Ehrenfeld JM, Henneman JP, Peterfreund RA, Sheehan TD, Xue F, Spring S, Sandberg WS. Ongoing professional performance evaluation (OPPE) using automatically captured electronic anesthesia data. Jt Comm J Qual Patient Saf 2012; 38:73-80. [PMID: 22372254 DOI: 10.1016/s1553-7250(12)38010-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Massachusetts General Hospital (Boston), a large academic center providing anesthesia services for more than 49,000 procedures each year, created an Ongoing Professional Practice Evaluation (OPPE) process that could use readily available, automatically captured electronic information from its vendor-provided anesthesia information management system. METHODS The OPPE credentialing committee selected the following initial metrics: Blood pressure (BP) monitoring, end tidal CO2 monitoring, and timely documentation of compliance statements. Baseline data on the metrics were collected in an eight-month period (January 1, 2008-August 31, 2008). In February 2009 information on the metrics was provided to the department's staff members, and the ongoing evaluation process began. On the basis of three months of data, final reports for physicians being credentialed were distributed. Each report included a listing for each metric of the total number of compliant cases and noncompliant cases and a comparison by percentage to the baseline departmental evaluation. A summary statement indicated whether a physician's performance was within the group representing 95% of all department physicians. Noncompliant cases were listed by medical record number and case date so providers and reviewers could examine individual cases. CONCLUSION A novel, automated, and continuous reporting system for physician credentialing that uses the existing clinical information system infrastructure can serve as a key element of a comprehensive clinical performance evaluation that measures both technical and generalizable clinical skill sets. It is not intended to provide a complete system for measuring competence but rather to serve as a first-round warning mechanism and metric scoring tool to identify problems and potential performance noncompliance issues.
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Affiliation(s)
- Jesse M Ehrenfeld
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA.
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Haycock A. Moving from training to competency testing. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011. [DOI: 10.1016/j.tgie.2011.02.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rate and predictors of early/missed colorectal cancers after colonoscopy in Manitoba: a population-based study. Am J Gastroenterol 2010; 105:2588-96. [PMID: 20877348 DOI: 10.1038/ajg.2010.390] [Citation(s) in RCA: 207] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Many of the colorectal cancers (CRCs) diagnosed within 3 years after a colonoscopy are likely because of lesions missed on the initial colonoscopy. In this population-based study, we investigated the rate and predictors of CRCs diagnosed within 3 years of a colonoscopy. METHODS We identified individuals 50-80 years of age diagnosed with CRC between 1992 and 2008 from the provincewide Manitoba Cancer Registry. Performance of colonoscopy and history of co-morbidities was determined by linkage to the provincial universal health care insurance provider's physician billing claims and hospital discharges databases. CRCs diagnosed within 6 months of a colonoscopy were categorized as detected CRCs and those 6-36 months after a colonoscopy as early/missed CRCs. Logistic regression analysis was performed to identify the patient, endoscopist, colonoscopy, and CRC factors associated with early/missed CRCs. RESULTS Of the 4,883 CRCs included in the study, 388 (7.9%) were early/missed CRCs, with a range of 4.5% of rectum/rectosigmoid cancers in men to 14.4% of transverse colon/splenic flexure cancers in women. Independent risk factors associated with early/missed CRCs included prior colonoscopy, performance of index colonoscopy by family physicians, recent year of CRC diagnosis, and proximal site of CRC. CONCLUSIONS This study suggests that approximately 1 in 13 CRCs may be an early/missed CRC, diagnosed after an index colonoscopy in usual clinical practice. Women are more likely to have early/missed CRC. It is unclear if this relates to differences in procedure difficulty, bowel preparation issues, or tumor biology between men and women.
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Fletcher RH, Nadel MR, Allen JI, Dominitz JA, Faigel DO, Johnson DA, Lane DS, Lieberman D, Pope JB, Potter MB, Robin DP, Schroy PC, Smith RA. The quality of colonoscopy services--responsibilities of referring clinicians: a consensus statement of the Quality Assurance Task Group, National Colorectal Cancer Roundtable. J Gen Intern Med 2010; 25:1230-4. [PMID: 20703953 PMCID: PMC2947628 DOI: 10.1007/s11606-010-1446-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 06/09/2010] [Accepted: 06/18/2010] [Indexed: 02/07/2023]
Abstract
Primary care clinicians initiate and oversee colorectal screening for their patients, but colonoscopy, a central component of screening programs, is usually performed by consultants. The accuracy and safety of colonoscopy varies among endoscopists, even those with mainstream training and certification. Therefore, it is a primary care responsibility to choose the best available colonoscopy services. A working group of the National Colorectal Cancer Roundtable identified a set of indicators that primary care clinicians can use to assess the quality of colonoscopy services. Quality measures are of actual performance, not training, specialty, or experience alone. The main elements of quality are a complete report, technical competence, and a safe setting for the procedure. We provide explicit criteria that primary care physicians can use when choosing a colonoscopist. Information on quality indicators will be increasingly available with quality improvement efforts within the colonoscopy community and growth in the use of electronic medical records.
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Affiliation(s)
- Robert H Fletcher
- Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA.
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Evaluating changes in gastrointestinal endoscopy training over 5 years: closing the audit loop. Eur J Gastroenterol Hepatol 2010; 22:368-73. [PMID: 19620875 DOI: 10.1097/meg.0b013e32832adfac] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND An audit in 2002 showed that colonoscopy training in a large London training region was poorly structured, with the quality of supervision below recommendations and high reported complication rates. In 2004, the UK National Endoscopy Training Programme introduced centrally funded, accredited courses and new assessment tools to standardize training and raise the quality of colonoscopy by improving the skills of practicing endoscopists. AIM To evaluate the changes in the standard of colonoscopy training over the last 5 years. METHODS Questionnaires used in the earlier study were updated and e-mailed to all gastroenterology trainees in the region and those who participated in the earlier study. Trainees completed and returned the forms electronically. RESULTS Twenty-six out of 37 gastroenterology trainees responded (70.3%). Significantly more trainees said that they had been formally taught the principles of colonoscopy (91 vs. 65%; P = 0.02), polypectomy (81 vs. 52%; P = 0.02) and extubation (88 vs. 56%; P = 0.01) than in 2002, and reported that complication rates were lower. Trainers displayed more appropriate teaching strategies and course attendance had significantly increased (84 vs. 48%, P = 0.003). Eighty-seven percent of the trainees thought that their training had been adequate or better than adequate, compared with 25% in 2002. CONCLUSION In the 2007 survey, trainees reported a significant improvement both in colonoscopy training at base hospitals and in access to specialist courses compared with those in the 2002 survey. The centrally funded training programme has made a significantly positive impact in this large training region that is likely to be reflected elsewhere in England. The loss of such investment may have a detrimental effect on future colonoscopy training and the quality of service provision.
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Canadian credentialing guidelines for esophagogastroduodenoscopy. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2008; 22:349-54. [PMID: 18414707 DOI: 10.1155/2008/987012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Dominitz JA, Ikenberry SO, Anderson MA, Banerjee S, Baron TH, Cash BD, Fanelli RD, Gan SI, Harrison ME, Lichtenstein D, Shen B, Van Guilder T, Lee KK. Renewal of and proctoring for endoscopic privileges. Gastrointest Endosc 2008; 67:10-6. [PMID: 18045594 DOI: 10.1016/j.gie.2007.06.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Accepted: 06/13/2007] [Indexed: 02/05/2023]
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Bittner JG, Marks JM, Dunkin BJ, Richards WO, Onders RP, Mellinger JD. Resident training in flexible gastrointestinal endoscopy: a review of current issues and options. JOURNAL OF SURGICAL EDUCATION 2007; 64:399-409. [PMID: 18063277 DOI: 10.1016/j.jsurg.2007.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Revised: 07/17/2007] [Accepted: 07/19/2007] [Indexed: 05/25/2023]
Affiliation(s)
- James G Bittner
- Department of Surgery, Medical College of Georgia School of Medicine, Augusta, Georgia 30912, USA
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Policy guidelines suggested for robot-assisted prostatectomy. J Robot Surg 2007; 1:173-6. [PMID: 25484957 PMCID: PMC4247434 DOI: 10.1007/s11701-007-0031-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2007] [Accepted: 06/15/2007] [Indexed: 12/01/2022]
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Aslinia F, Uradomo L, Steele A, Greenwald BD, Raufman JP. Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a university hospital. Am J Gastroenterol 2006; 101:721-31. [PMID: 16494586 DOI: 10.1111/j.1572-0241.2006.00494.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite increased emphasis on endoscopic performance indicators, e.g., cecal intubation rates, limited data from actual clinical practice have been published. OBJECTIVES Retrospective database review to determine the rate and documentation of cecal intubation during colonoscopy at the University of Maryland Medical Center. METHODS We reviewed 5,477 consecutive colonoscopies performed by 10 faculty gastroenterologists at a University hospital over a 6-yr period (March 1, 1999 to February 28, 2005). Unadjusted cecal intubation rates were analyzed as were rates that were adjusted based on the U.S. Multi-Society Task Force on Colorectal Cancer recommendations. We analyzed trends in overall and individual cecal intubation rates, circumstances that impact these rates, and the quality of documentation of cecal intubation. RESULTS The overall adjusted cecal intubation rate for the entire 6 yr was 90.3%, and increased over the study period with the highest adjusted rate (93.7%) in the most recent year studied. There was no correlation between cecal intubation rate and patient age, gastroenterology fellow involvement, or endoscopist experience and number of procedures/year. In contrast, colon cancer screening, male gender, outpatient colonoscopy, and adequate bowel preparation predicted a higher cecal intubation rate. Written and photographic documentation of cecal intubation improved significantly after 2002. CONCLUSIONS Our analysis revealed cecal intubation and documentation rates that meet current guidelines, and identified factors that may cause substantial variance in these rates depending on the nature of the practice. The present analysis confirms that computerized databases can be used to assess individual and group cecal intubation and documentation rates on an annual basis, and to make these data available to the public.
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Affiliation(s)
- Florence Aslinia
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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