Conversion of colonoscopy to flexible sigmoidoscopy: an unintended consequence of quality measurement in endoscopy.

OBJECTIVE: To quantify the proportion of requests for colonoscopy that are performed as flexible sigmoidoscopy and documented reasons for this in ordinary UK hospital practice. To determine the effect these requests have on colonoscopy completion rate if they are included in the denominator of the calculated rate by individual endoscopist. DESIGN: Retrospective study of 22 months flexible sigmoidoscopy practice at a major UK teaching hospital. All flexible sigmoidoscopies performed had their associated request form examined. SETTING: UK NHS University Hospital. PATIENTS: All patients receiving outpatient flexible sigmoidoscopy from January 2013 to October 2014 with no exclusions. INTERVENTION: Conversion of colonoscopy to flexible sigmoidoscopy. MAIN OUTCOME MEASURES: Conversion of colonoscopy to flexible sigmoidoscopy, reason for conversion and adjusted colonoscopy completion rate. RESULTS: 71 of the 3526 flexible sigmoidoscopies performed (2.0%), representing 71 of 5905 colonoscopy requests (1.2%). Conversion reason was noted only in 26 (37%) of converted cases. Adjustment of colonoscopy completion rate to include conversions pushed four of our unit's 22 endoscopists below the UK national 90% standard. CONCLUSIONS: Conversion to flexible sigmoidoscopy occurs in 1.2% of patients originally booked for colonoscopy. The reason for this conversion is often unqualified and may be inappropriate. Conversion can affect the colonoscopy completion rate, and therefore, should be included in endoscopists' overall performance statistics.

An analysis of the learning curve to achieve competency at colonoscopy using the JETS database.

OBJECTIVE: The number of colonoscopies required to reach competency is not well established. The primary aim of this study was to determine the number of colonoscopies trainees need to perform to attain competency, defined by a caecal intubation rate (CIR) ≥90%. As competency depends on completion, we also investigated trainee factors that were associated with colonoscopy completion. DESIGN: The Joint Advisory Group on GI Endoscopy in the UK has developed a trainee e-portfolio from which colonoscopy data were retrieved. Inclusion criteria were all trainees who had performed a total of ≥20 colonoscopies and had performed ≤50 colonoscopies prior to submission of data to the e-portfolio. The primary outcome measure was colonoscopy completion. The number of colonoscopies required to achieve CIR ≥90% was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine factors which determine colonoscopy completion, a mixed effect logistic regression model was developed which allowed for nesting of patients within trainees and nesting of patients within hospitals, with various patient, trainee and training factors entered as fixed effects. RESULTS: 297 trainees undertook 36 730 colonoscopies. By moving average analysis, the cohort of trainees reached a CIR of 90% at 233 procedures. By LC-Cusum analysis, 41% of trainees were competent after 200 procedures. Of the trainee factors, the number of colonoscopies, intensity of training and previous flexible sigmoidoscopy experience were significant factors associated with colonoscopy completion. CONCLUSIONS: This is the largest study to date investigating the number of procedures required to achieve competency in colonoscopy. The current training certification benchmark in the UK of 200 procedures does not appear to be an inappropriate minimum requirement. The LC-Cusum chart provides real time feedback on individual learning curves for trainees. The association of training intensity and flexible sigmoidoscopy experience with colonoscopy completion could be exploited in training programmes.

Understanding of chemoprophylaxis and concordance in inflammatory bowel disease.

AIM: To assess patients' understanding for the reasons for taking 5-aminosalicylic acid or ursodeoxycholic acid as chemoprophylaxis against colorectal carcinoma associated with inflammatory bowel disease (IBD). METHODS: A questionnaire-based study using a 5-point opinion scale was performed. One hundred and ninety-two patients with colitis only and 74 patients with primary sclerosing cholangitis and IBD were invited to take part. RESULTS: Overall response rate was 58%. Sixty-four percent of patients claimed full concordance with chemoprophylaxis for maintenance of remission. Eighty-four percent of patients considered daily concordance during remission to be very important. Seventy-five percent stated they understood the reasons for taking the drugs. However, only 50% of the patients were aware of any link of their condition to bowel cancer. Seventy-nine percent of patients felt their concordance and understanding would be improved if they were informed of the chemoprophylactic potential of the medication. CONCLUSION: Despite good self-reported concordance, half of the patients were unaware of an association between colitis and bowel cancer. Explaining the potential chemoprophylactic benefits may enhance patients' overall concordance to 5-aminosalicylic acid and ursodeoxycholic acid and help maintain remission.

UK acquired hepatitis E--An emerging problem?

Eight cases of hepatitis E acquired in the UK are reported. These cases presented to an inner city hospital in Birmingham, UK, over a 5-month period in 2005. HEV is considered unusual in the UK and generally occurs after travel to endemic regions. Only five cases of hepatitis E acquired in the UK have been reported in the literature. This series represents an increase in the local incidence of hepatitis E, particularly that of UK-acquired infection. HEV should be considered in all patients with acute hepatitis, irrespective of travel history.