• COLONOSCOPY
• COLONIC ADENOMAS

To the Editor In their recent national randomised trial published in Gut, Kaminski et al 1 reported that a quality improvement intervention involving dedicated training of endoscopy centre leaders in colonoscopy provided superior improvement in adenoma detection rates (ADRs) in screening colonoscopy compared with those randomised to receive simple audit and feedback. While study results are subject to a possible Hawthorne effect given ADRs were higher during the period when study participants were aware of being monitored, the findings otherwise appeared robust with ADR improvement observed across all endoscopist specialties, colonoscopy experience and types of screening facilities. These are important findings given that ADR is a key quality indicator of colonoscopy because of its role as an independent predictor of the development interval colorectal cancer (CRC) after colonoscopy and association with CRC death.2–4

However, ADR is only one of many colonoscopy quality indicators integral to the success of colonoscopy screening programmes with caecal intubation rate, adequacy of bowel preparation, colonoscopy withdrawal times, adverse event rates (eg, perforation, bleeding) and annual number of colonoscopies performed also important.3–5 While several of these were assessed in the above study, no data were provided on colonoscopy withdrawal times nor on the impact of the training course on this parameter or on withdrawal technique. Such information would have furthered our understanding of the relationship and relative importance of withdrawal time and technique to improved ADR, and provided important insight as to what area(s) need preferential targeting in training programmes to improve colonoscopy performance as measured by ADR.

Also a key consideration from the study by Kaminksi et al is how widely applicable the results are to other countries that conduct national CRC screening programmes. The above study focused the training course on endoscopy ‘leaders’ of dedicated national CRC screening centres, half of which were private practice based. Notably, the training course improved the ADR of not just the leaders but also of screening centres, suggesting there was effective communication and translation of course training methods from leaders to the other centre colonoscopists. Such an intervention would, therefore, seem appropriate for countries like the UK that identify specific CRC screening centres for their national programme and require ongoing rigorous accreditation of both the colonoscopists and relevant endoscopy centres.3 However, it would seem more challenging to both implement and evaluate in other countries that conduct similar population-based, organised screening programmes such as Australia where there are no dedicated CRC screening centres or sessions and/or specific accreditation requirements based on ADR or other colonoscopy quality indicators for endoscopists to perform colonoscopy as part of the national screening programme. Indeed, much of the screening colonoscopy performed in Australia is delivered not via larger hospitals and by ‘leaders’ and ‘teams’, but in smaller private facilities containing one or more individual colonoscopists. In such circumstances, a significant expansion of the training course programme involving a wider group of endoscopists would be needed for it to have a significant impact on ADR and ultimately interval CRC development and mortality. This brings with it significant additional costs that must be balanced against the potential benefits achieved. Unfortunately no cost-effectiveness or cost–benefit analysis was provided in the study by Kaminski et al to support such an initiative.

Nevertheless, the study by Kaminksi et al highlights the potential benefit of introducing a formal training curriculum in colonoscopy that includes methods to improve key colonoscopy quality indicators such as ADR. In Australia such programmes have already begun on a smaller scale involving Train-the-Colonoscopist Trainer courses that target supervisors actively supervising endoscopists-in-training to emphasise the key components of what constitutes high-quality colonoscopy.6