From the Journals

Clinician fatigue not associated with adenoma detection rates in community-based setting

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A unique objective measure of endoscopist fatigue

The impact of endoscopist fatigue on colonoscopy quality is an understudied topic of great importance. The authors in this study have developed a unique objective measure of fatigue and found no association between fatigue and adenoma detection rates in a large community practice. The lack of an association may reflect the resilience of endoscopists, which is a trait to which we all aspire. One must also consider other explanations for the findings in this study: For one, the measures of fatigue used in this study have not previously been validated, although they have face validity.

Dr. Ziad F. Gellad

Additional studies linking these measures with other indicators of fatigue would be valuable. Second, because adenoma detection rate (ADR) is based on finding at least one adenoma, ADR may not have the discriminatory power to be impacted by fatigue. I would expect fatigue to first show up in the number of polyps detected during a colonoscopy and it would be very interesting to see how fatigue also impacts polyp detection rate and adenomas per colonoscopy. Third, the analysis in this study did not adjust for all important contributors to ADR, including prep quality. Finally, the average number of endoscopy procedures performed in this cohort is lower than in many practices. It is unclear how generalizable these findings would be to higher-volume practices or practices with different operating characteristics. For the reasons above, I think the jury is still out on the impact of fatigue on colonoscopy quality.

Ziad F. Gellad, MD, MPH , associate professor of medicine in the division of gastroenterology, Duke University Medical Center, Durham, N.C., and Associate Editor on the Board of GI & Hepatology News. He has no conflicts of interest.


 

FROM GASTROINTESTINAL ENDOSCOPY

Neither time of day, nor number of procedures performed by the clinician impacted adenoma detection rates in a large community-based setting, a study has shown.

Previously, mixed and scanty data on whether endoscopist fatigue correlates with colonoscopy quality in a community-based setting – where the majority of colonoscopies are performed – brought into question the link between a clinician’s detection rates and patient mortality rates due to interval cancers. Colorectal cancer is the second leading cause of cancer death in the U.S.


The most recent recommended adenoma detection rates – considered benchmarks of colonoscopic quality – are at or above 20% in men and at or above 30% in women, according to the American College of Gastroenterology.

A new study published online in Gastrointestinal Endoscopy, however, indicates that the endoscopists working in a large, integrated, community-based health care system exceeded those quality benchmarks.

Gastroenterologist Alexander T. Lee, MD, and his colleagues identified 126 gastroenterologists in the health system, Kaiser Permanente Northern California, who performed an average of six endoscopy procedures per day – 259,064 in all – between 2010 and 2013, including 76,445 screenings and surveillance colonoscopies. They found that per physician, adenoma detection rates for screening colonoscopy examinations averaged 28.9% and 45.4% for surveillance examinations. By patient gender, the average detection rates per screening were 34.8% for men and 24.0% for women; detection rates per surveillance, the rates were 51.1% for men and 37.8% for women.

After adjusting for confounders, the investigators analyzed each physician’s average adenoma detection rates in association with the time of day each GI procedure was performed, the number of GI procedures performed before each colonoscopy, and the level of complexity of any prior procedures performed at the time of the screening or surveillance colonoscopy. Dr. Lee and his coinvestigators also found that compared with morning examinations, afternoon colonoscopies were not associated with lower adenoma detection for screening examinations, surveillance examinations, or their combination (odds ratio for combination, 0.99; 95% confidence interval, 0.96-1.03). Additionally, neither the number of procedures performed before a given colonoscopy, nor a prior procedure’s complexity, was inversely associated with adenoma detection (OR for detection rates late in the day vs. first procedure of the day, 0.99; 95% CI, 0.94-1.04).

In systems where physicians have larger daily GI procedure loads, there could be an adverse impact on adenoma detection rates, wrote Dr. Lee and his coauthors, but they also noted that quality could similarly be diluted by a lower ratio of procedures to clinician, as well. Whether other demands on a physician’s time, such as other clinical procedures or office tasks, might adversely impact detection rates, Dr. Lee and his colleagues didn’t know because they measured only the colonoscopic screening and surveillance activities. “The reported lack of an association with time of day would argue against this being a substantial factor in [this] study,” they wrote.

“The fact that increased adenoma detection was found only for screening colonoscopy examinations raises the question of whether endoscopists were systematically more vigilant during screening procedures, although the higher observed adenoma detection rates for surveillance examinations suggest otherwise,” the investigators wrote.

None of the investigators listed had any relevant disclosures.

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