Endoscopist factors that influence serrated polyp detection: a multicenter study

Abstract

Background Serrated polyps are important colorectal cancer precursors that are variably detected during colonoscopy. We measured serrated polyp detection rate (SPDR) in a large, multicenter, cross-sectional study of colonoscopy quality to identify drivers of SPDR variation.

Methods Colonoscopy and pathology reports were collected for a 2-year period (10/2013-9/2015) from four sites across the United States. Data from reports, including size, location, and histology of polyps, were abstracted using a validated natural language processing algorithm. SPDR was defined as the proportion of colonoscopies with ≥ 1 serrated polyp (not including hyperplastic polyps). Multivariable logistic regression was performed to determine endoscopist characteristics associated with serrated polyp detection.

Results A total of 104 618 colonoscopies were performed by 201 endoscopists who varied with respect to specialty (86 % were gastroenterologists), sex (18 % female), years in practice (range 1 – 51), and number of colonoscopies performed during the study period (range 30 – 2654). The overall mean SPDR was 5.1 % (SD 3.8 %, range 0 – 18.8 %). In multivariable analysis, gastroenterology specialty training (odds ratio [OR] 1.89, 95 % confidence interval [CI] 1.33 – 2.70), fewer years in practice (≤ 9 years vs. ≥ 27 years: OR 1.52, 95 %CI 1.14 – 2.04)], and higher procedure volumes (highest vs. lowest quartile: OR 1.77, 95 %CI 1.27 – 2.46)] were independently associated with serrated polyp detection.

Conclusions Gastroenterology specialization, more recent completion of training, and greater procedure volume are associated with serrated polyp detection. These findings imply that both repetition and training are likely to be important contributors to adequate detection of these important cancer precursors. Additional efforts to improve SPDR are needed.

• References

• 1 Snover DC. Update on the serrated pathway to colorectal carcinoma. Hum Pathol 2011; 42: 1-10
• 2 Crockett SD, Snover DC, Ahnen DJ. et al. Sessile serrated adenomas: an evidence-based guide to management. Clin Gastroenterol Hepatol 2015; 13: 11-26.e11
• 3 Crockett SD. Sessile serrated polyps and colorectal cancer. JAMA 2017; 317: 975-976
• 4 Hetzel JT, Huang CS, Coukos JA. et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol 2010; 105: 2656-2664
• 5 Arain MA, Sawhney M, Sheikh S. et al. CIMP status of interval colon cancers: another piece to the puzzle. Am J Gastroenterol 2010; 105: 1189-1195
• 6 Sawhney MS, Farrar WD, Gudiseva S. et al. Microsatellite instability in interval colon cancers. Gastroenterology 2006; 131: 1700-1705
• 7 Stoffel EM, Erichsen R, Froslev T. et al. Clinical and molecular characteristics of post-colonoscopy colorectal cancer: a population-based study. Gastroenterology 2016; 151: 870-878
• 8 Nishihara R, Wu K, Lochhead P. et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013; 369: 1095-1105
• 9 Lash RH, Genta RM, Schuler CM. Sessile serrated adenomas: prevalence of dysplasia and carcinoma in 2139 patients. J Clin Pathol 2010; 63: 681-686
• 10 Hazewinkel Y, Lopez-Ceron M, East JE. et al. Endoscopic features of sessile serrated adenomas: validation by international experts using high-resolution white-light endoscopy and narrow-band imaging. Gastrointest Endosc 2013; 77: 916-924
• 11 Kahi CJ, Hewett DG, Norton DL. et al. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 2011; 9: 42-46
• 12 de Wijkerslooth TR, Stoop EM, Bossuyt PM. et al. Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time. Gastrointest Endosc 2013; 77: 617-623
• 13 Payne SR, Church TR, Wandell M. et al. Endoscopic detection of proximal serrated lesions and pathologic identification of sessile serrated adenomas/polyps vary on the basis of center. Clin Gastroenterol Hepatol 2014; 12: 1119-1126
• 14 Clark BT, Laine L. High-quality bowel preparation is required for detection of sessile serrated polyps. Clin Gastroenterol Hepatol 2016; 14: 1155-1162
• 15 Harkema H, Chapman WW, Saul M. et al. Developing a natural language processing application for measuring the quality of colonoscopy procedures. J Am Med Informatics Assoc 2011; 18 (Suppl. 01) i150-156
• 16 Mehrotra A, Dellon ES, Schoen RE. et al. Applying a natural language processing tool to electronic health records to assess performance on colonoscopy quality measures. Gastrointest Endosc 2012; 75: 1233-1239
• 17 Carrell DS, Schoen RE, Leffler DA. et al. Challenges in adapting existing clinical natural language processing systems to multiple, diverse health care settings. J Am Med Inform Assoc 2017; 24: 986-991
• 18 Mehrotra A, Morris M, Gourevitch RA. et al. Physician characteristics associated with higher adenoma detection rate. Gastrointest Endosc 2018; 87: 778-786.e5
• 19 IJspeert JE, de Wit K, van der Vlugt M. et al. Prevalence, distribution and risk of sessile serrated adenomas/polyps at a center with a high adenoma detection rate and experienced pathologists. Endoscopy 2016; 48: 740-746
• 20 Blumenthal DM, Olenski AR, Yeh RW. et al. Sex differences in faculty rank among academic cardiologists in the United States. Circulation 2017; 135: 506-517
• 21 Goldstein MJ, Lunn MR, Peng L. What makes a top research medical school? A call for a new model to evaluate academic physicians and medical school performance. Acad Med 2015; 90: 603-608
• 22 Jena AB, Khullar D, Ho O. et al. Sex differences in academic rank in US medical schools in 2014. JAMA 2015; 314: 1149-1158
• 23 Rios-Diaz AJ, Metcalfe D, Singh M. et al. Inequalities in specialist hand surgeon distribution across the United States. Plast Reconstr Surg 2016; 137: 1516-1522
• 24 DesRoches CM, Barrett KA, Harvey BE. et al. The results are only as good as the sample: assessing three national physician sampling frames. J Gen Intern Med 2015; 30 (Suppl. 03) S595-S601
• 25 Rex DK, Bond JH, Winawer S. et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002; 97: 1296-1308
• 26 Johnson DA, Barkun AN, Cohen LB. et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US multi-society task force on colorectal cancer. Gastroenterology 2014; 147: 903-924
• 27 Rondagh EJ, Bouwens MW, Riedl RG. et al. Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention. Gastrointest Endosc 2012; 75: 1218-1225
• 28 Radaelli F, Paggi S, Hassan C. et al. Split-dose preparation for colonoscopy increases adenoma detection rate: a randomised controlled trial in an organised screening programme. Gut 2017; 66: 270-277
• 29 Horton N, Garber A, Hasson H. et al. Impact of single- vs. split-dose low-volume bowel preparations on bowel movement kinetics, patient inconvenience, and polyp detection: a prospective trial. Am J Gastroenterol 2016; 111: 1330-1337
• 30 Kahi CJ, Li X, Eckert GJ. et al. High colonoscopic prevalence of proximal colon serrated polyps in average-risk men and women. Gastrointest Endosc 2012; 75: 515-520
• 31 Anderson JC, Rangasamy P, Rustagi T. et al. Risk factors for sessile serrated adenomas. J Clin Gastroenterol 2011; 45: 694-699
• 32 Burnett-Hartman AN, Passarelli MN, Adams SV. et al. Differences in epidemiologic risk factors for colorectal adenomas and serrated polyps by lesion severity and anatomical site. Am J Epidemiol 2013; 177: 625-637
• 33 Sanaka MR, Gohel T, Podugu A. et al. Adenoma and sessile serrated polyp detection rates: variation by patient sex and colonic segment but not specialty of the endoscopist. Dis Colon Rectum 2014; 57: 1113-1119
• 34 O’Connell BM, Crockett SD. The clinical impact of serrated colorectal polyps. Clin Epidemiol 2017; 9: 113-125
• 35 Snover DC, Ahnen D, Burt R, Odze RD. Serrated polyps of the colon and rectum and serrated polyposis. In: Bosman FT, Carneiro F, Hruban RH. et al. eds. WHO classification of tumours of the digestive system. 4th. edn. Lyon: IARC; 2010
• 36 Gill P, Wang LM, Bailey A. et al. Reporting trends of right-sided hyperplastic and sessile serrated polyps in a large teaching hospital over a 4-year period (2009–2012). J Clin Pathol 2013; 66: 655-658
• 37 Alvarez C, Andreu M, Castells A. et al. Relationship of colonoscopy-detected serrated polyps with synchronous advanced neoplasia in average-risk individuals. Gastrointest Endosc 2013; 78: 333-341
• 38 Gao Q, Tsoi KK, Hirai HW. et al. Serrated polyps and the risk of synchronous colorectal advanced neoplasia: a systematic review and meta-analysis. Am J Gastroenterol 2015; 110: 501-509
• 39 Hazewinkel Y, de Wijkerslooth TR, Stoop EM. et al. Prevalence of serrated polyps and association with synchronous advanced neoplasia in screening colonoscopy. Endoscopy 2014; 46: 219-224
• 40 O’Connell B, Hafiz N, Crockett S. The serrated polyp pathway: is it time to alter surveillance guidelines?. Curr Gastroenterol Rep 2017; 19: 52