CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(10): E1456-E1462
DOI: 10.1055/a-1486-6729
Original article

Colonoscopy quality across Europe: a report of the European Colonoscopy Quality Investigation (ECQI) Group

Cristiano Spada
 1   Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, Brescia, Italy
 2   Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, Rome, Italy
 3   Pomeranian Medical University in Szczecin-Department of Social Medicine and Public Health, Faculty of Health Sciences, Szczecin, Zachodniopomorskie, Poland
 4   Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
Pedro Amaro
 5   Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
Anurag Agrawal
 6   Doncaster Royal Infirmary, Doncaster, UK
Lene Brink
 7   Herlev and Gentofte Hospital, Copenhagen University, Gastro Unit, Division of Endoscopy, Herlev, Denmark
Wolfgang Fischbach
 8   Gastroenterologie und Innere Medizin, Aschaffenburg, Germany
Matthias Hünger
 9   Private Practice for Internal Medicine, Würzburg, Germany
Rodrigo Jover
10   Hospital General Universitario de Alicante – Instituto de Investigación Sanitaria ISABIAL – Servicio de Medicina Digestiva, Alicante, Spain
Urpo Kinnunen
11   Tampere University Hospital-Gastroenterology, Tampere, Finland
Akiko Ono
12   Hospital Clínico Universitario Virgen de la Arrixaca-Gastroenterology, El Palmar, Murcia, Spain
Árpad Patai
13   Markusovszky University Teaching Hospital-Gastroenterology, Szombathely, Hungary
14   Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
Lucio Petruzziello
14   Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
Jürgen F. Riemann
15   LebensBlicke Foundation, Ludwigshafen, Germany
Bharat Amlani
16   Norgine Ltd-Medical Affairs, Harefield, UK
Harry Staines
17   Sigma Statistical Services Ltd, Saint Andrews, UK
Ann L. Stringer
18   ECQI Secretariat, Buckinghamshire, UK
19   Skåne University Hospital, Lund University, Department of Gastroenterology, Malmö, Sweden
Giulio Antonelli
 4   Digestive Endoscopy, Nuovo Regina Margherita Hospital, Rome, Italy
20   Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, “Sapienza” University of Rome, Rome, Italy
21   Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli Hospital, Ariccia, Rome, Italy
Lorenzo Fuccio
22   Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy
› Author Affiliations


Background and study aims The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires.

Methods The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites.

Results We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received.

Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively.

Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing.

Conclusions Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.

Supplementary material

Publication History

Received: 15 October 2020

Accepted: 10 March 2021

Article published online:
16 September 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012; 62: 10-29
  • 2 Edwards BK, Ward E, Kohler BA. et al. Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 2010; 116: 544-573
  • 3 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
  • 4 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
  • 5 Anderson JC, Butterly LF. Colonoscopy: quality indicators. Clin Transl Gastroenterol 2015; 6: e 77
  • 6 Allen JI. Quality measures for colonoscopy: where should we be in 2015?. Curr Gastroenterol Rep 2015; 17: 10
  • 7 Barclay RL, Vicari JJ, Doughty AS. et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006; 355: 2533-2541
  • 8 Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007; 102: 856-861
  • 9 Yabroff KR, Borowski L, Lipscomb J. Economic studies in colorectal cancer: challenges in measuring and comparing costs. J Natl Cancer Inst Monogr 2013; 2013: 62-78
  • 10 Van Cutsem E, Borràs JM, Castells A. et al. Improving outcomes in colorectal cancer: where do we go from here?. Eur J Cancer 2013; 49: 2476-2485
  • 11 von Karsa L, Patnick J, Segnan N. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication. Endoscopy 2013; 45: 51-59
  • 12 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397
  • 13 Valori R, Cortas G, de Lange T. et al. Performance measures for endoscopy services: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1186-1204
  • 14 Rembacken B, Hassan C, Riemann JF. et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012; 44: 957-968
  • 15 Riemann JF, Demedts I, Agrawal A. et al. ECQI Group: Improving standards in colonoscopy through a practice level audit tool [PO160]. United European Gastroenterol J 2015; 3 (Suppl. 05) A191
  • 16 Jover R, Agrawal A, Amaro P. et al. Pilot results of the ECQI self-assessment questionnaire to evaluate quality in colonoscopy in Europe [PO165]. United European Gastroenterol J 2016; 05 (Suppl. 05) A213-A214
  • 17 Calderwood AH, Jacobson BC. Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc 2010; 72: 686-692
  • 18 Pontone S, Hassan C, Maselli R. et al. Multiple, zonal and multi-zone adenoma detection rates according to quality of cleansing during colonoscopy. United European Gastroenterol J 2016; 4: 778-783
  • 19 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
  • 20 Wang L, Sprung BS, DeCross AJ. et al. Split-dose bowel preparation reduces the need for early repeat colonoscopy without improving adenoma detection rate. Dig Dis Sci 2018; 63: 1320-1326
  • 21 Murphy D, Jenks M, McCool R. et al. A systematic review and cost analysis of repeat colonoscopies due to inadequate bowel cleansing in five European countries. Expert Rev Pharmacoecon Outcomes Res 2019; 19: 701-709
  • 22 Kaminski MF, Anderson J, Valori R. et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomised trial. Gut 2016; 65: 616-624
  • 23 Coe SG, Crook JE, Diehl NN. et al. An endoscopic quality improvement program improves detection of colorectal adenomas. Am J Gastroenterol 2013; 108: 219-227
  • 24 Corley DA, Jensen CD, Marks AR. Can we improve adenoma detection rates? A systematic review of intervention studies. . Gastrointest Endosc 2011; 74: 656-665
  • 25 Brenner H, Altenhofen L, Kretschmann J. et al. Trends in adenoma detection rates during the first 10 years of the German screening colonoscopy program. Gastroenterology 2015; 149: 356-366
  • 26 Adler A, Lieberman D, Aminalai A. et al. Data quality of the German screening colonoscopy registry. Endoscopy 2013; 45: 813-818