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A snapshot of colonoscopy practice in England: stimulus for improvement
  1. K Palmer1,
  2. A I Morris2
  1. 1British Society of Gastroenterology, London, UK
  2. 2Joint Advisory Group on Gastrointestinal Endoscopy, London, UK
  1. Correspondence to:
    Dr K R Palmer
    Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, UK; kpalmergolf5063.freeserve.co.uk

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Colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?

In the West, 5% of individuals will at some time in their life develop colon cancer, and after the age of 54 years the risk lies between 1 in 19 to 1 in 22.12 There is increasing pressure to develop colon screening programmes to identify early tumours and adenomatous polyps whose endoscopic removal has been shown to reduce cancer development.34 Colon cancer screening is likely to be funded in England and in Scotland, and whether this is based on faecal occult blood testing,56 flexible sigmoidoscopy,7 or colonoscopy alone,89 and whether or not programmes will be targeted towards high risk groups or to all comers over a specific age, it is obvious that referrals for colonoscopy will increase. At the same time, there is increasing awareness among the general population and in primary care that rectal bleeding and altered bowel habit need investigation, ideally by colonoscopy. Most endoscopy units in the UK have difficulty coping with their current workload, and strains on the colonoscopy waiting list will inevitably increase when screening programmes are instigated.

Series published from the USA have reported success rates in excess of 97% for achieving total colonoscopy, coupled with low complication rates, and detection of significant pathology in asymptomatic populations.810 Specialist centres in the UK report comparable data and have shown that it is possible to undertake safe diagnostic and therapeutic colonoscopy using minimal sedation, little patient discomfort, and low complication rates. The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) state that approved endoscopy units should achieve completion rates greater than 90%, without resort to excessive sedation. The current curriculum for higher medical training in gastroenterology suggests that trainees should demonstrate this level of expertise at the time of completion of specialist training.11

In the light of these observations, the snapshot of colonoscopy practice in 68 English units, reported in this use of Gut,12 is disturbing [see page 277]. Caecal intubation rates were 77%, falling to 57% when the strict criteria of appendiceal orifice identification or intubation of the ileocaecal valve were used. The perforation rate was 1:769, and it is likely that colonoscopy contributed to the death of six patients. There are several possible mitigating factors. It is not clear for example whether it was the intention in every case to achieve pancolonoscopy; it is possible to speculate that in some cases the intention was to identify a relatively distal abnormality and it was then deemed unnecessary to visualise the whole colon. Criteria for completion may not have been defined prior to the audit and, while it is now standard practice to identify the appropriate landmarks to confirm completion rather than to rely on transillumination or indentation, this was probably not universal at the time of data collection. Furthermore, the case mix of patients in this series is likely to have been different to that reported from some other sources; for example, colonoscopy done in relatively young asymptomatic individuals as part of colon cancer screening programmes is generally more straightforward than that in patients who present with colonic symptoms—as was the case in the audit. These are however relatively weak arguments; pancolonoscopy should be the aim in all patients, the credibility of transillumination and indentation are flawed, and good colonoscopists succeed in the great majority of patients. It is noteworthy that the common reasons cited for failure were excessive looping and patient discomfort, aspects of practice minimised by good technique. Lastly, were the units who took part in the study particularly incompetent, chosen because they were known for their modest expertise? Obviously this was not the case; institutions who are motivated enough to participate in clinical research tend to be the better ones and it is therefore very likely that the picture painted in the paper is a reasonable, perhaps even an optimistic, representation of colonoscopy practice in the UK.

What then should British endoscopists do to rectify the unsatisfactory situation, particularly with the prospect of colonoscopy screening around the corner? As it is, we are apparently in danger of causing net harm to the general population by undertaking colonoscopy programmes with a possible 0.1% perforation rate and 0.05% mortality. In response, medical and surgical endoscopists have, even since the audit data were collected, improved aspects of expertise and training in endoscopy and many of the issues highlighted in the audit are being actively addressed.

The improvements started with the formation of JAG in 1994 by the Conference of Royal Colleges, and its publication of a first document in 1999 entitled Recommendations for training in gastrointestinal endoscopy. Within three years a second document, entitled Guidelines for the training, appraisal and assessment of trainees in GI endoscopy, was published. This emphasised achievement of targets and competence, rather than simply completing set numbers of procedures. Laid down in this document was the requirement that trainee endoscopists, from whatever discipline (medicine, surgery, non-medical), were to be trained to the same standards and that they and their trainers were required to attend proscribed JAG courses.

JAG specified that all trainees should attend a basic skills (foundation) course, followed by other specific courses related to the particular endoscopic skill they were learning. The Raven Department of Education at the Royal College of Surgeons of England was commissioned to develop the courses for JAG. Thus far, in addition to the foundation course, which provides “hands on” gastroscopy training, a basic skills in colonoscopy, and flexible sigmoidoscopy courses (also “hands on” courses) have been developed. Therapeutic endoscopy, ERCP, and EUS courses (partly funded by the British Society of Gastroenterology) are soon to be commissioned. Trainers were also to attend specific training the trainers courses for endoscopy when these were available.

A total of 250 trainees have so far attended the colonoscopy courses that are currently delivered at three full time and seven part time centres. There is no doubt that these “hands on” learning experiences are effective as the colonoscopy completion rate of those individuals who have attended a course is well in excess of 90%. These courses have to date been supported to the sum of £2.4 million for the period 2001–2003 from the National Cancer Project.

This year marks four major initiatives concerned with training in endoscopy.

The first major undertaking will be publishing of the third JAG document with new sections devoted to the assessment of both trainees and training units.

The second major development has been a government allocation of £8.2 million, via the National Cancer Plan, to support endoscopy training in England over the years 2003–2006. This has funded three national training centres (based at the Royal Liverpool Hospital, St George’s Hospital, and St Mark’s Hospitals) and seven regional endoscopy training centres, and is administered by the NHS Modernisation Agency Endoscopy Project. Service improvements which aspire to improve efficiency, quality, and output are developed in parallel with endoscopy training.

The third development has been the revision of the endoscopy section of the specialist medical curriculum for higher medical training in gastroenterology, produced by the statutory Specialist Advisory Committees (SACs) on behalf of the Joint Committee on Higher Medical Training. This is now a competency based assessment devised by the JAG.

Fourthly, JAG has developed a system for accrediting new endoscopy units and re-accrediting established units. A programme of inspections, held in conjunction with the SAC in gastroenterology, is planned to start in April 2004. These visits will concentrate on the training environment and will include scrutiny of endoscopy standards and compliance with current national guidelines. In order to limit the number of visitations to units, it is intended to involve the endoscopy lead for each strategic health authority in the visits so that aspects of service delivery can be assessed.

It will take some time before all endoscopists are trained to appropriate standards and all units are optimally equipped and functioning. We anticipate that colonoscopy practice in the UK will improve but it is crucial for our credibility that this is confirmed by future surveys of practice. The Department of Health seems remarkably unenthusiastic to support large scale audits of gastrointestinal practice; there has been no success in obtaining government funding for our audit of ERCP and attempts to support further audits of upper gastrointestinal bleeding, acute pancreatitis, and management of inflammatory bowel disease seem futile at the time of writing. The results of the colonoscopy audit will undoubtedly stimulate adverse comment about British endoscopy performance, but the audit has already caused us—and the Department of Health—to address important issues of training, equipment, and facilities. Surely we must strive for more large scale properly supported audits in order to improve and justify our practice, not only in relation to endoscopy but for the full range of our activities within gastroenterology.

Colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?

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