Rajasekhar Praveen T, Rees Colin J, Bramble Mike G, Wilson Douglas W, Rutter Matthew D, Saunders Brian P, Hungin A Pali S, East James E
South Tyneside District General Hospital, South Shields. UK.
Northern Region Endoscopy Group, South Shields. UK.
Endoscopy. 2015 Mar;47(3):217-24. doi: 10.1055/s-0034-1391563. Epub 2015 Feb 12.
Low adenoma detection rates (ADRs) at colonoscopy are linked to significantly higher interval cancer rates, and vary between colonoscopists. Studies demonstrate that lesion detection is improved by: withdrawal time of ≥ 6 minutes; use of hyoscine butylbromide; position change; and rectal retroflexion. We evaluated the feasibility of implementing the above "bundle" of interventions into colonoscopy practice, and the effect on ADR.
A longitudinal cohort design was used. Implementation combined central training, local promotion, and feedback. The uptake marker was change in hyoscine butylbromide use. Comparisons were between the 3 months before and the 9 months after the implementation phase, globally, by endoscopy unit and by quartile when colonoscopists were ranked according to baseline ADR. Chi-squared or Fisher's tests were used to evaluate significance.
12 units participated. Global and quartile analyses included data from 118 and 68 colonoscopists and 17 508 and 14 193 procedures respectively. A significant increase in hyoscine butylbromide use was observed globally (54.4 % vs. 15.8 %, P < 0.001), in all endoscopy units (P < 0.001) and quartiles (P < 0.001). A significant increase in ADR was observed globally (18.1 % vs. 16.0 %, P = 0.002) and in the lower two colonoscopist quartiles (P < 0.001), with a nonsignificant increase in the upper middle quartile and a significant fall to 21.5 %. in the upper quartile. The significant variations in ADR among the upper three quartiles disappeared.
In routine clinical practice, introduction of a simple, inexpensive, evidence-based "bundle" of measures is feasible and is associated with higher global ADR, driven by improvements amongst the poorest performing colonoscopists.
结肠镜检查时低腺瘤检出率（ADR）与间隔期癌症发生率显著升高相关，且不同结肠镜检查医师之间存在差异。研究表明，通过以下方法可提高病变检出率：退镜时间≥6分钟；使用丁溴东莨菪碱；改变体位；直肠反转。我们评估了在结肠镜检查实践中实施上述“综合”干预措施的可行性及其对ADR的影响。
采用纵向队列设计。实施过程包括集中培训、本地推广和反馈。采用丁溴东莨菪碱使用情况的变化作为吸收指标。比较实施阶段前3个月和实施后9个月的数据，整体、按内镜检查单位以及根据基线ADR对结肠镜检查医师进行四分位排名后按四分位进行比较。采用卡方检验或费舍尔检验评估显著性。
12个单位参与研究。整体和四分位分析分别纳入了118名和68名结肠镜检查医师的数据，以及17508例和14193例检查病例。整体、所有内镜检查单位（P<0.001）和四分位（P<0.001）的丁溴东莨菪碱使用量均显著增加。整体ADR显著增加（18.1%对16.0%，P=0.002），较低的两个结肠镜检查医师四分位组也显著增加（P<0.001），中上四分位组增加不显著，而上四分位组显著降至21.5%。上三个四分位组之间ADR的显著差异消失。
在常规临床实践中，引入一套简单、廉价、基于证据的“综合”措施是可行的，并且在表现最差的结肠镜检查医师的改善推动下，与更高的整体ADR相关。
