Colorectal Surgery Resident Participation in Screening Colonoscopies: How Does It Impact Quality?

Abstract

BACKGROUND: Performing colonoscopies is an integral component of colorectal surgery residency training. There exists a paucity of literature regarding colonoscopy quality metrics with colorectal trainee involvement. OBJECTIVE: This study aimed to investigate the effect of colorectal surgery resident participation on quality metrics in screening colonoscopy. DESIGN: Screening colonoscopies performed between August 1, 2016, and July 31, 2018, were queried from a prospectively maintained institutional database. Data were cross-checked with resident case logs to verify colonoscopies with resident participation. SETTING: This study was conducted by the colorectal surgery department at a tertiary level hospital in the United States. PATIENTS Consecutive, asymptomatic patients aged ≥45 years, undergoing screening colonoscopy, were selected. MAIN OUTCOME MEASURES: The quality parameters measured included overall, male, and female adenoma detection rates; total examination time; withdrawal time; cecal intubation rate; quality of bowel preparation; complications; and medication dosage. RESULTS: A total of 4594 patients were included in the study with a mean age of 60.5 ± 8.4 years (range, 45–91); 51.7% were women. Overall, 4186 of the colonoscopies were performed without resident participation, and 408 were performed with resident participation. Scope insertion, withdrawal, and total examination times were longer in the resident group. Cecal intubation rate, polypectomy rate, sex-specific and overall adenoma detection rates, and complication rates were similar between the groups. In the multivariate model, trainee involvement had no significant impact on adenoma detection rate. In addition, the trainee group utilized a higher mean dose of fentanyl. LIMITATIONS: The retrospective nature of the data with possible coding errors of the database and the inability to quantify the amount of resident participation and to clarify the degree of attending surgeon assistance and oversight were limitations of the study. CONCLUSIONS: Colorectal surgery resident participation in screening colonoscopy takes longer and appears safe, while achieving all national quality metrics without compromising adenoma detection rates. Changes in colonoscopy scheduling in regard to length of time may prove beneficial when there is resident participation. See Video Abstract at http://links.lww.com/DCR/B43. PARTICIPACIÓN DE LOS RESIDENTES DE CIRUGÍA COLORRECTAL EN COLONOSCOPIAS DE CRIBADO: ¿CÓMO AFECTA LA CALIDAD? ANTECEDENTES: La realización de colonoscopias es un componente integral del entrenamiento de residencia en cirugía colorrectal. Existe una escasez de literatura con respecto a las medidas de calidad de la colonoscopia con la participación de los aprendices colorrectales. OBJETIVO: Investigar el efecto de la participación de residentes de cirugía colorrectal en las medidas de calidad en la colonoscopia de cribado. DISEÑO: Las colonoscopias de cribado realizadas entre el 1 de agosto de 2016 y el 31 de julio de 2018 se consultaron desde una base de datos institucional mantenida prospectivamente. Los datos se cotejaron con registros de casos de residentes para verificar las colonoscopias con participación de residentes. AJUSTE: Departamento de cirugía colorrectal en un hospital de tercer nivel de los Estados Unidos. PACIENTES: Pacientes consecutivos, asintomáticos, edad ≥45 años, sometidos a colonoscopia de detección. PRINCIPALES MEDIDAS DE RESULTADO: Parámetros de calidad que incluyen tasas generales de detección de adenoma en hombres y mujeres, tiempo total de examen, tiempo de retiro, tasa de intubación cecal, calidad de la preparación intestinal, complicaciones y dosis de medicamentos. RESULTADOS: Se incluyeron un total de 4.594 pacientes en el estudio con una edad media de 60,5 ± 8,4 años (rango, 45-91) y 51,7% mujeres. En total 4,186 de las colonoscopias se realizaron sin participación de los residentes y 408 se realizaron con la participación de los residentes. Los tiempos de inserción, retiro y examen total del alcance fueron más largos en el grupo residentes. La tasa de intubación cecal, la tasa de polipectomía, las tasas de detección de adenoma específicos de género y generales, y las tasas de complicaciones fueron similares entre los grupos. En el modelo multivariado, la participación de los aprendices no tuvo un impacto significativo en la tasa de detección de adenoma. Además, el grupo de aprendices utilizó una dosis media más alta de fentanilo. LIMITACIONES: Carácter retrospectivo de los datos con posibles errores de codificación de la base de datos. Incapacidad para cuantificar la cantidad de participación de los residentes y para aclarar el grado de asistencia y supervisión del cirujano. CONCLUSIONES: La participación de los residentes de cirugía colorrectal en la colonoscopia de cribado lleva más tiempo y parece segura, mientras se logran todas las medidas de calidad nacionales sin comprometer las tasas de detección de adenoma. Los cambios en la programación de la colonoscopia con respecto al período de tiempo pueden ser beneficiosos cuando hay participación de residentes. Vea el resumen del video en http://links.lww.com/DCR/B43.

Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics

“…The ADR, which is directly correlated with the risk of postcolonoscopy colon cancer, and the PDR were not significantly different when trainees were involved and after adjusting for potential confounders. Similarly, prior studies have not found a negative association between trainee participation and the ADR, with the exception of 2 studies that failed to adjust for confounders, 1 small study consisting of only 309 colonoscopies and 1 study involving an unknown number of gastroenterologists and trainees . No prior studies examined the ssPDR as an outcome, which is of particular relevance given the difficulty in detecting sessile serrated polyps.…”

“…The lack of association with CIR was congruent with 2 prior studies that also reported no difference in the CIR when trainees were involved. 23,29 To our knowledge, no studies prior to ours examined the association between trainee participation and the perforation rate. Although perforation rates were too low in our study for multivariable regression, the crude analysis failed to reveal a difference in this risk when trainees were involved.…”

“…Association of Trainee Participation in Colonoscopy Procedures With Quality Metrics between trainee participation and the ADR, [22][23][24][25][26] with the exception of 2 studies that failed to adjust for confounders, 27,28 1 small study consisting of only 309 colonoscopies 29 and 1 study involving an unknown number of gastroenterologists and trainees. 30 No prior studies examined the ssPDR as an outcome, which is of particular relevance given the difficulty in detecting sessile serrated polyps.…”

“…Prior studies in the field were on a much smaller scale, with our sample size more than 4 times greater than the next largest study. [22][23][24][25][26][27][28][29][30] Furthermore, prior studies were conducted at single centers, [22][23][24][25][26][27][28][29][30] involved a small number of trainees and endoscopists, [22][23][24][25][26][27][28][29] or were restricted to screening colonoscopies. 22,23,27,30 The end result of these methodological limitations is poor external validity due to the lack of diversity in endoscopy centers, trainees and trainers, and colonoscopy indications.…”

“…[22][23][24][25][26][27][28][29][30] Furthermore, prior studies were conducted at single centers, [22][23][24][25][26][27][28][29][30] involved a small number of trainees and endoscopists, [22][23][24][25][26][27][28][29] or were restricted to screening colonoscopies. 22,23,27,30 The end result of these methodological limitations is poor external validity due to the lack of diversity in endoscopy centers, trainees and trainers, and colonoscopy indications. In contrast, our large population-based study involved 71 endoscopists and 55 trainees from both gastroenterology and general surgery, 21 hospital sites inclusive of both academic and community centers, and 35 499 colonoscopies to encompass a wide variety of indications and practice patterns.…”