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Impact of fellowship training level on colonoscopy quality and efficiency metrics

  • Hussein Bitar
    Correspondence
    Reprint requests: Hussein Bitar, MD, University of Oklahoma, 800 SL. Young Blvd. Suite 7400, Oklahoma City, OK 73104.
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • Hassaan Zia
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • Muhammad Bashir
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • Pratyusha Parava
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • Muhammad Hanafi
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • William Tierney
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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  • Mohammad Madhoun
    Affiliations
    Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA

    Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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Published:April 18, 2018DOI:https://doi.org/10.1016/j.gie.2018.04.2338

      Background and Aims

      Previous studies have described variable effects of fellow involvement on the adenoma detection rate (ADR), but few have stratified this effect by level of training. We aimed to evaluate the “fellow effect” on multiple procedural metrics including a newly defined adenoma management efficiency index, which may have a role in documenting colonoscopy proficiency for trainees. We also describe the impact of level of training on moderate sedation use.

      Methods

      We performed a retrospective review of 2024 patients (mean age, 60.9 ± 10 years; 94% men) who underwent outpatient colonoscopy between June 2012 and December 2014 at our Veterans Affairs Medical Center. Colonoscopies were divided into 5 groups. The first 2 groups were first-year fellows in the first 6 months and last 6 months of the training year. Second- and third-year fellows and attending-only procedures accounted for 1 group each. We collected data on doses of sedatives used, frequency of adjunctive agent use, procedural times, and location, size, and histology of polyps. We defined the adenoma management efficiency index as average time required per adenoma resected during withdrawal.

      Results

      Of the colonoscopies performed, 1675 involved a fellow and 349 were performed by the attending alone. There was no difference in ADR between fellows according to level of training (P = .8) or between fellows compared with attending-only procedures (P = .67). Procedural times decreased consistently during training and declined further for attending-only procedures. This translated into improvement in the adenoma management efficiency index (fellow groups by ascending level of training: 23.5 minutes vs 18.3 minutes vs 13.7 minutes vs 13.4 minutes vs attending group 11.7 minutes; P < .001). There was no difference in the average doses of midazolam and fentanyl used among fellow groups (P = .16 and P = .1, respectively). Compared with attending-only procedures, fellow involvement was associated with higher doses of fentanyl and midazolam and more frequent use of diphenhydramine and glucagon (P < .0001, P = .0002, P < .0001, and P = .01, respectively).

      Conclusions

      ADR was similar at different stages of fellowship training and comparable with the attending group. Efficiency of detecting and resecting polyps improved throughout training without reaching the attending level. Fellow involvement led to a greater use of moderate sedation, which may relate to a longer procedure duration and an evolving experience in endoscopic technique.

      Abbreviations:

      ADR (adenoma detection rate), CRC (colorectal cancer), IQR (interquartile range)
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      Linked Article

      • Oldie but goodie? Do attending endoscopists really need their fellows?
        Gastrointestinal EndoscopyVol. 89Issue 2
        • Preview
          In their retrospective study of more than 2000 colonoscopies, Bitar et al1 showed that adenoma detection rate (ADR) was not increased by the participation of fellows during colonoscopy. This finding prompted us to review our past 2 consecutive years of colonoscopy data of 2241 screening, surveillance, and diagnostic examinations (1580; 70.5% fellow-involved), inflammatory bowel disease evaluation and obstruction cases excluded. ADR, mean adenoma per colonoscopy, and examination completion rate were not different between the fellow-involved and the attending endoscopist-only groups (27.8% vs 26.1%, 0.45 ± 0.93 vs 0.44 ± 0.98 and 95.3% vs 94.6% [P = .51], respectively).
        • Full-Text
        • PDF
      • Impact of fellowship training level on colonoscopy quality and efficiency metrics: a United Kingdom perspective
        Gastrointestinal EndoscopyVol. 89Issue 2
        • Preview
          Performance metrics during colonoscopy training can be used to indicate readiness for independent practice. The study by Bitar et al1 is therefore a welcome addition to the colonoscopy training literature. The distinguishing feature of fellow seniority (and presumably competence) was the “efficiency” or speed with which the colon was intubated and adenomas detected and removed. However, speed does not necessarily imply proficiency.
        • Full-Text
        • PDF