Performing a colonoscopy in a private office or clinic rather than a hospital triples the likelihood that the procedure will be incomplete, reported Dr. Hemant A. Shah and associates in an article in the June issue of Gastroenterology.
The University of Toronto researchers conducted a population-based study to assess the effects of patient, endoscopist, and treatment-setting factors on the risk for incomplete colonoscopy. Their sample comprised more than 331,000 index colonoscopies, and more than 43,000 (13%) were incomplete.
Older patient age, female sex, and a history of abdominal or pelvic surgery were the main patient factors that raised the risk of incomplete colonoscopy. Regarding endoscopist factors, performing a low volume of the procedures and practicing general medicine rather than specializing in gastroenterology both increase the risk of incomplete colonoscopy, they reported.
The authors combined information from four Canadian databases to identify all residents of Ontario who underwent screening colonoscopy between 1999 and 2003 when they were aged 50–74 years. The mean patient age was 61 years, and 47% of the subjects were men. Procedures in which the colonoscope was inserted to the cecum or the terminal ileum were considered complete; procedures that fell short of those landmarks were considered incomplete.
In physician specialties, general surgeons performed the largest number of procedures (47%) and gastroenterologists performed the smallest (24%). The physician category combining internists, family physicians, and general practitioners accounted for the remaining 29% of colonoscopies. Community hospitals were the most common setting (72%). Another 15% of the procedures were performed in private offices, and 13% were done in academic hospitals.
The rates of incomplete colonoscopy were highest in the office setting (24.6%), compared with the community hospital (10.8%) and academic hospital (12.6%), regardless of patient or endoscopist characteristics. This high rate is of concern because of the rapid growth of office-based colonoscopy in many areas. That growth is fueled by limited access to endoscopy resources in many hospitals, particularly in academic medical centers, they added.
The researchers did not examine the reasons for incomplete colonoscopy but suggested that less or no sedation is used in offices, so more procedures are abandoned because of patient discomfort.
Endoscopists who performed a high volume of the procedures were the most likely to achieve complete colonoscopies. Among physicians with a low volume of these procedures, generalist physicians had an incomplete colonoscopy rate of nearly 30%, whereas general surgeons and gastroenterologists had incompletion rates of about 17% and 14%, respectively.