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Recent advances in clinical practice
Effectiveness, training and quality assurance of colonoscopy screening for colorectal cancer
  1. Douglas J Robertson1,2,
  2. Michal F Kaminski3,4,5,
  3. Michael Bretthauer5,6
  1. 1VA Medical Center, White River Junction, Vermont, USA
  2. 2Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
  3. 3Department of Gastroenterology and Hepatology, Medical Center for Postgraduate Education, Warsaw, Poland
  4. 4Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
  5. 5Institute of Health and Society, University of Oslo, Oslo, Norway
  6. 6Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
  1. Correspondence to Dr Douglas J Robertson, Department of Gastroenterology, VA Medical Center, 215 M Main Street/Gastroenterology (111E), White River Junction, Vermont 05009, USA; douglas.robertson{at}va.gov

Abstract

Screening for colorectal cancer has been proven to be effective in reducing colorectal cancer incidence and mortality. While the precise benefit of screening exclusively by colonoscopy is not yet known, unarguably, the exam is central to the success of any screening programme. The test affords the opportunity to detect and resect neoplasia across the entire large bowel and is the definitive examination when other screening tests are positive. However, colonoscopy is invasive and often requires sedation as well as extensive bowel preparation, all of which puts the patient at risk. Furthermore, the test can technically be demanding and, unarguably, there is variation in how it is performed. This variation in performance has now been definitively linked to important outcome measures. For example, interval cancers are more common in low adenoma detectors as compared with high adenoma detectors. This review outlines the most current thinking regarding the effectiveness of colonoscopy as a screening tool. It also outlines key concepts to optimise its performance through robust quality assurance programmes and high-quality training.

  • SCREENING
  • CANCER PREVENTION
  • COLONOSCOPY
  • COLORECTAL CANCER

https://doi.org/10.1136/gutjnl-2014-308076

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    Key messages

    • The two main measures for effectiveness of colonoscopy screening are reduction of colorectal cancer incidence and reduction of colorectal cancer mortality, and should be measured using the whole target population rather than those compliant with colonoscopy.

    • Effectiveness depends on patient compliance, efficacy of colonoscopy in reducing cancer incidence and mortality, and quality of the colonoscopy service and individual endoscopist.

    • Quality assurance programmes for colonoscopy are incredibly important since small decrements in the safety or quality of colonoscopy would have significant impact on the net gains from any large-scale colorectal cancer screening programme.

    • Those performing colonoscopy should routinely monitor the global patient experience as well as key quality indicators in the preprocedural, intraprocedural and postprocedural periods. Quality improvement work is required if deficiencies are identified.

    • Good colonoscopy performance requires structured basic colonoscopy training, upskilling courses and ‘train the trainers’ courses.

    • Basic colonoscopy training should include knowledge teaching, technical skill training and non-technical skill training.

    Introduction

    Colonoscopy is the gold standard examination tool for the colon and rectum. It is capable of both detection and removal of neoplasia during a single examination. It aims at examining the entire colon, as opposed to flexible sigmoidoscopy which only covers the distal part. However, colonoscopy is difficult to learn, it is invasive and resource-demanding, uncomfortable and requires extensive bowel preparation for patients. There is large interendoscopist variability in quality of performance, and there is uncertainty with regard to the magnitude of the effect of colonoscopy screening on colorectal cancer (CRC) incidence and mortality.1 ,2 This review outlines the state-of-the-art of effectiveness, training and quality assurance of colonoscopy screening for CRC and highlights ongoing research and future perspectives.

    Effectiveness of colonoscopy screening

    Evaluation of the effectiveness of colonoscopy is of paramount importance when colonoscopy is considered as a CRC screening tool, for example, in a national screening programme. Further, cost effectiveness needs to be addressed when prioritising screening over other healthcare measures. A valid evaluation of cost effectiveness requires a valid estimate of effectiveness. There are two overarching measures for effectiveness of colonoscopy: reduction in incidence of CRC and reduction in mortality from CRC. In the following paragraphs, we explain the current status for effectiveness of colonoscopy screening with regard to CRC incidence and mortality, and give an overview of developments in this field.

    What is effectiveness?

    The effectiveness of colonoscopy screening is measured by the magnitude of the effect on CRC incidence and mortality on a population level (ie, in those offered the test or in those eligible for the test). Thus, these measures should be determined on the entire target population for screening, besides those undergoing colonoscopy. Therefore, one of the major determents of effectiveness is that individuals in the target population accept the test (ie, undergo the colonoscopy; see figure 1).

    Figure 1
    Figure 1

    Effectiveness of colonoscopy screening. The effectiveness of colonoscopy screening to reduce colorectal cancer incidence and mortality is determined by the four domains: compliance, efficacy, quality and treatment.

    Healthy-screenee bias

    Measuring the effect of colonoscopy only in those who actually undergo the test is appealing because it would, theoretically, give a better estimate of how good the test is in preventing cancer and cancer-related death. However, these analyses are subject to the so-called healthy-screenee bias and, thus, not trustworthy.3 Healthy-screenee bias is a form of selection bias and occurs frequently because individuals with a lower CRC risk (ie, the most healthy) are more prone to adhering to screening, while higher-risk individuals (ie, the unhealthy, such as smokers) do not attend the screening. Measurement of CRC incidence or mortality in those attending versus those not attending, or not offered screening in this setting, would result in an overestimate of colonoscopy's ability to reduce cancer, while the observed difference is rather due to different baseline risks.

    Determinants of effectiveness

    As figure 1 illustrates, in addition to patient compliance, the effectiveness of colonoscopy screening is determined by the efficacy of colonoscopy in reducing cancer incidence and mortality in those who underwent the colonoscopy; the quality of the colonoscopy service and individual endoscopist (determined by indicators such as adenoma detection rates (ADR), caecum intubation rates, quality of bowel preparation, and complication rates). Finally, the treatment of lesions detected at screening must result in better prognosis than treatment at a later (clinical) stage. This requires that the prognosis of CRC is related to the stage at diagnosis (early stages better prognosis than late stage) and that treatment of early (screening detected) stages is possible.4

    How effective is colonoscopy screening?

    Randomised trials

    Figure 2 shows an overview of the four large-scale randomised controlled trials comparing colonoscopy with no screening or faecal immunochemical testing (FIT) screening with regard to CRC incidence and mortality.5–8 Two of the trials (NordICC and SCREESCO) will provide data on the effectiveness of colonoscopy screening as compared with no screening, as they include a no-screening arm. The other two trials (CONFIRM and COLONPREV) are comparative effectiveness studies, comparing colonoscopy with FIT screening. They will provide the comparative effectiveness of colonoscopy as compared with either annual (CONFIRM) or biennial (COLONPREV) FIT screening. All trials are currently ongoing. Thus, the effectiveness of colonoscopy screening on CRC incidence and mortality is currently unknown. The Spanish COLONPREV trial and the Nordic-European (NordICC) trial have concluded colonoscopy enrolment and will presumably present results in about 10 years, while the Swedish SCREESCO and the US CONFIRM trials are currently recruiting patients and will need another decade or more before results become available.

    Figure 2
    Figure 2

    On overview of randomised colonoscopy screening effectiveness trials. All trials are in progress. FIT, faecal immunochemical test.

    Population statistics from the USA show a decline in CRC incidence since the mid-1970s. This has been attributed, in part, to faecal occult blood testing (FOBT) and colonoscopy screening.9 However, how large the contribution of screening is, remains uncertain.

    Observational studies

    Many case–control and cohort studies have tried to estimate the effectiveness of colonoscopy screening. The US National Polyp Study followed a cohort of patients with adenoma for 15.8 years and demonstrated a 53% lower CRC mortality among patients with adenoma compared with a reference group from the Surveillance, Epidemiology, and End Results (SEER) database (absolute risk, 0.8% vs 1.5%).10 Case–control studies from Germany,11 Canada12 and the USA13 indicate that colonoscopy may reduce CRC incidence and mortality by 30%–90%, with large variations between the studies. A recent meta-analysis of observational colonoscopy studies arrived at a pooled estimate of approximately 70% reduction of both CRC incidence and mortality with colonoscopy screening.14

    Intuitively, one would expect that colonoscopy prevents cancer and cancer-related death across the entire colon. However, there is some evidence that the protective effect of colonoscopy may be lower in the proximal as compared with the distal colon,12 although this difference has been less pronounced in the most recent studies.11 ,13 Quality issues may, at least partly, explain the difference. These issues will be explored in detail below.

    Comparative effectiveness of colonoscopy and other screening tools

    Today, we have robust, randomised trial estimates of effectiveness for FOBT and flexible sigmoidoscopy screening in preventing death from CRC. A pooled analysis of the four large randomised trials on FOBT shows that modality reduced CRC mortality by 14%, but had no effect on CRC incidence.15 One of the four trials (the only one which employed annual screening; the other three used biennial screening) recently reported a significant reduction in CRC mortality after about 30 years of follow-up.16 Pooled estimates from four large randomised trials have shown that flexible sigmoidoscopy reduces colorectal cancer mortality by 28% and CRC incidence by 18%.15

    Importantly, the abovementioned effectiveness estimates for colonoscopy are derived from observational studies and, thus, cannot be directly translated into population-screening effectiveness. Therefore, they should not directly be compared with the effectiveness estimates for FOBT and flexible sigmoidoscopy. We may learn from mammography screening, where it has been shown that estimates from observational screening studies overinflated the effect of screening on cancer death. In a randomised mammography screening trial from Sweden, the observed relative risk for breast cancer mortality was 0.96 (95% CI 0.68 to 1.35), showing no effect of screening. However, when the investigators applied a case–control design analysing the same data, they found a large (but incorrect) 58% reduction in breast cancer mortality.17

    Castells and coworkers recently compared flexible sigmoidoscopy with colonoscopy screening, applying data from the four randomised sigmoidoscopy trials with yield data from the ongoing COLONPREV colonoscopy trial.18 Depending on the threshold for referral, flexible sigmoidoscopy detected between 57% and 65% of individuals with advanced proximal adenomas. The efficacy of these two tools may be assumed to be equal in the distal colon. Thus, one may assume that the efficacy of colonoscopy is about 20% higher compared with sigmoidoscopy, depending on the prevalence of distal and proximal adenomas in the screening population. This figure is, however, only a best guess and would certainly not qualify for evidence-based medical decision-making. Serrated polyps, recently recognised as CRC precursors, are best detected by colonoscopy and may add to the comparative effectiveness of this tool. As figure 1 illustrates, however, effectiveness is determined only partly by efficacy. Patient acceptance and quality of the service are other important factors that need to be considered, such as also for other screening tests like flexible sigmoidoscopy.

    Thus, while we are eagerly waiting for the randomised colonoscopy trials, we need to be transparent and inform the public and health caregivers that we do not know the precise magnitude of effectiveness and, thus, the cost effectiveness of colonoscopy screening (figure 2).

    Many countries are currently considering the implementation of CRC screening in national screening initiatives and population programmes. Until now, implementation of screening has traditionally been done in a rather static fashion, without the ability to generate knowledge about the risk-benefit profile of the screening programme. We lack evidence for comparative effectiveness and, thus, cost effectiveness of current screening tests (colonoscopy, flexible sigmoidoscopy, FIT, FOBT), less to speak emerging new tests such as CT colonography, faecal DNA testing or capsule endoscopy. We urge health policy makers to take advantage of innovative and investigative clinical trial methodology and design CRC screening programmes which can generate new, high-quality evidence-based knowledge. This can be best achieved by applying randomised trial methodology in new or existing screening programmes, along the principles of comparative effectiveness research.19

    Quality assurance in colonoscopy

    Screening programmes are ambitious, attempting to prevent disease in those that appear not to have any. Many will require evaluation to prevent disease in a few, and so most that submit to screening can never benefit.

    It is in this light, that quality assurance programmes for colonoscopy are incredibly important. First, small decrements in the safety or quality of colonoscopy programmes could have significant impact on the net gains from any large-scale CRC screening programme. For example, injuring just a small fraction of those undergoing the test will erode any benefits of the programme. Further, from the quality perspective, of the many exams performed, only a few could actually detect or prevent a cancer. Missing that opportunity because the caecum was not reached, or the prep was poor, directly impacts the small margin of success that most screening programmes operate under. Finally, quality assurance programmes need to maximise the patient experience. While a single colonoscopy exam may be quite technically adept, if good patient experience is lacking, important follow-up may be compromised. A positive experience from the patient perspective both enhances the likelihood that the individual will return for needed follow-up and, through word of mouth, that larger numbers of individuals will submit to screening.

    CRC screening is organised differently in different parts of the world. The European Union recommends organised, national programmes instead of opportunistic screening, because publicly organised, population-based programmes provide an administrative structure for service delivery and facilitate quality assurance and evaluation of the effectiveness and side-effects of the programme.20 Whether quality assurance is implemented within the framework of a national programme or an opportunistic one, the processes to improve delivery of a healthcare service, like colonoscopy, require multiple steps.21 Practice needs to be observed and compared with recognised performance standards. When deficiencies are recognised, change needs to be implemented. Finally, follow-up work (‘closing the loop’) is needed to assess whether improvement has occurred.22 In the following paragraphs, we highlight the key opportunities for quality assurance with colonoscopy programmes during the preprocedural, intraprocedural and postprocedural period. Assessment of the patient experience is also reviewed.

    Preprocedure

    Assuring a safe patient experience with endoscopy begins with detailed attention to the environment and equipment used to perform the procedure. All practicing endoscopy units need to guarantee that general infection-control policies are in place and adhered to. The prevention of intravenous infection is particularly important in this regard. A recent high-profile case of documented Hepatitis C transmission to six individuals attending an endoscopy clinic related to improper use of multidose medication vials has been described.23

    Generally, when thinking of infection control in endoscopy, most would immediately consider issues related to endoscope reprocessing. Thankfully, transmission of infection through the endoscope is extraordinarily rare.24 However, a recent report of infectious transmission through a properly cleaned duodenoscope serves as an important reminder that risk is not zero and apparent outbreaks require prompt investigation. While the details of effective reprocessing fall outside the purview of this brief summary, excellent reviews can be found elsewhere.25 Guidelines for effective practice in this area have been widely published and need to be meticulously followed.26

    Beyond these environmental safety considerations are direct patient-level concerns that can impact procedural safety. There is good evidence that some persons undergoing screening may be too sick or frail to benefit from that intervention and would be at high risk for complications. A study based in Veterans Administration hospitals suggested that 40% of those undergoing screening in that system had a severe comorbid disease that would limit life expectancy to less than 5 years.27 Those hospitals or programmes offering direct access endoscopy are at the most risk in this area and need to have systems in place to be sure that those presenting for screening are generally appropriate for such testing. Also, medication review with particular attention to antiplatelet agents and anticoagulants is warranted. Again, both European and American guidelines exist to facilitate best practice.28–30 While guidelines can be used to inform practice, ultimately, decisions regarding continuation or interruption of such therapy need to be individualised. Systems should allow for such decision-making to be made well before the patient has initiated a bowel prep to avoid patient inconvenience and late cancellation of procedures. Likewise, the preprocedural assessment should include evaluation of such factors that influence the safe use of electrocautery (ie, pacemaker, Automated Implantable Cardioverter-Defibrillator, or previous joint replacement). An assessment of American Society of Anesthesiologists class has also been found to be helpful to better assess those most at risk for complications of sedation and, by extension, who would benefit from anaesthesia evaluation and support. Tools to make routine at the provider or practice level this type of evaluation so that it occurs uniformly are necessary. Once in place, audits of documentation are required to assure that guidance is being followed.

    Intraprocedure

    The performance and documentation of good quality colonoscopy is essential to any colonoscopy screening programme. The critical components of a quality colonoscopy include adequate preparation, caecal intubation and lesion detection and removal.

    Bowel preparation

    As described above, the effectiveness of colonoscopy in reducing CRC incidence and mortality is stronger in the distal colon relative to the proximal. This discrepancy is multifactorial, but colon preparation and caecal intubation are two factors that contribute to this issue. Recently, expert panels from both the UK and USA have released guidance on bowel preparation for colonoscopy. Both endorse split dose preparation (dividing the bowel prep into two parts; one taken the evening before the exam, the other in the morning of the exam) or same day bowel preparation in case of afternoon colonoscopy as a way to improve preparation quality and explicitly encourage documentation of preparation quality in all patients.31 ,32 The US multisociety task force (USMSTF) guideline sets a target for adequate preparation of 85%. The first step, then, for practices not routinely documenting preparation quality is to mandate and audit that item. In a recent study examining 12 Dutch practices and 4800 colonoscopy exams, only 62% of the reports mentioned the quality of the preparation.33 Once regular documentation is accomplished, assuring prep adequacy to the levels suggested in the USMSTF guideline is the next step, with implementation of a quality improvement exercise if that is not accomplished.

    Caecal intubation

    Like bowel preparation, caecal intubation is another factor that lends itself to benchmarking. First, target rates have been issued by expert consensus panels. The target rates for caecal intubation differ for screening (95%) and surveillance (90%) indications.34 ,35 Second, the factor can be audited. While admittedly, there is not strong data to demonstrate the accuracy of images of the caecum to definitively document colonoscopy completion, that practice should be encouraged. Pictures of the ileum have been shown to be more definitive,36 however, routine ileal intubation for this purpose is not recommended.37 Explicit documentation examination extant in the postprocedure report should be required. The use of computerised databases for procedural documentation facilitate the development of numerator/denominator reports for each endoscopist which could be used both within practices and externally to the public if required.38

    Adenoma detection

    Colonoscopy's effectiveness as a cancer prevention tool is largely accomplished through adenoma detection and resection. Historically, targets for adenoma detection during routine adult screening colonoscopy have been established at ≥25% for men and ≥15% for women.35 However, most recently, two US-based gastroenterology organisations (American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy) have released revised guidance in this area.39 Specifically, the targets have been increased to an ADR ≥30% for men and ≥20% for women. The change in recommendation largely rests on improved data directly linking higher ADRs with lower subsequent interval cancer rates at the level of the endoscopist.2

    A number of specific comments with regards to ADR relative to other potential similar quality measures merit comment. While ADR lends itself to regular audit (ie, numerator/denominator measure) and quality improvement exercises, if suboptimal, there are challenges. In the absence of linkage between colonoscopy and pathology databases, it may be difficult to ascertain ADR. For this reason, polyp detection rate (PDR) has been proposed as a reasonable surrogate measure for ADR. Separating colonoscopy cases by indication may provide another challenge. Finally, ADR does not perfectly capture differences in absolute ADRs.40 However, there is outstanding evidence that subsequent cancer detection is less likely to occur when a previous colonoscopy was performed by a high adenoma detector relative to a low one.1 ,2 Based upon current evidence, ADR is likely the single most important procedural quality metric, and practices should work to develop mechanisms to reliably measure and follow it. Given the correlation between PDR and ADR,41 PDR can be employed until systems are in place to reliably measure ADR.

    While ADR measurement is the near-term standard for adequate neoplasia detection during colonoscopy, admittedly, it is a surrogate measure. The goal of CRC screening programmes is early detection and cancer prevention. The detection of interval cancer after colonoscopy is well described and often represents missed neoplastic lesions.42 ,43 For obvious reasons, most individual providers or small groups cannot reliably detect the frequency of such occurrences in their practice. However, for larger healthcare system providers (eg, Veterans Administration, Kaiser Permanente) or nations with robust electronic data capture and linkages to cancer registries, routine measurement of interval cancers at the level of the endoscopist may someday be possible.44

    Polyp resection

    Of course, adenoma detection does not prevent subsequent CRC. Adequate resection is required for that. The contribution of incomplete polyp resection to the problem of interval cancer likely approaches 20%.42 While historically, endoscopists have taken resection for granted, one recent study using research biopsies around the margins of polyps thought to be entirely resected, estimated incomplete resection at 10% and significantly higher than that for large and serrated lesions.45 Presently, there is no easy way to measure this factor. Some experts have recommended retrieval rates as one marker of resection technique.37 Perhaps in the future, the use of endoscopic techniques (eg, chromoendoscopy), pathological techniques (eg, margin assessment) or a limited sampling of biopsy margins (eg, in large polyps) may be recommended. Currently, the minimal requirement should be adequate documentation in the endoscopic record as to the technique of endoscopic resection (piecemeal, en bloc) and whether specimens were submitted for pathological analysis.

    Postprocedure

    Procedural complications are an important postprocedural quality metric.37 ,46 There is good evidence that complications from colonoscopy occurring in large screening programmes are likely more frequent than that described in those participating in well-characterised clinical trials.47 Early complications are much more easily tracked than those occurring days after the procedure. For this reason, careful tracking of adverse events related to sedation (eg, use of reversal agents) and unexpected admission immediately postprocedure are likely the most easily obtained surrogates for this measure. European guidelines37 do explicitly recommend a 30-day mortality review of all screened patients and an 8-day unplanned admission review although the guidelines recognise that such evaluation may not be feasible in all settings. An American Society for Gastrointestinal Endoscopy (ASGE) workgroup suggested routine follow-up at 14-days and developed a standard lexicon for describing and grading such occurrences.48 At minimum, endoscopy instructions should be explicit, encouraging those experiencing complications (such as abdominal pain and perforation) to call the endoscopy unit. Serious complications (ie, bleeding and perforation) identified either immediately or in delayed reporting needs regular tracking and rates of complications should be compared with expected rates for the procedure.49 ,50 Cases of severe complications should be audited and discussed.

    The other major postprocedural quality benchmark that bears regular audit is colonoscopy surveillance recommendations. Although explicit guidelines are available,51 ,52 there is good evidence that they are often not followed.53 ,54 There are potential harms to both the patient and healthcare system when surveillance colonoscopy is either repeated too soon or too late.55 Tracking the appropriateness of surveillance recommendations is made challenging by the delayed nature of that determination. Such guidance demonstrates that the pathology is available, and many times the explicit instructions to the patient will fall outside the report itself (eg, into a letter) which becomes difficult to audit. Natural language processing likely will become an important tool to assess this measure.56 In addition to being sure that appropriate follow-up recommendations for colonoscopy are being made, systems should also be in place to facilitate those subsequent surveillance exams in an appropriate time frame.

    Patient experience

    Finally, but perhaps most importantly, a robust colonoscopy quality assurance programme needs to directly assess the patient experience. The patient experience begins well before the procedural day, and includes items, such as ease of scheduling, choice of procedural day and waiting time. It also includes the experience and interactions within the unit on the day of procedure (eg, the process of obtaining informed consent) and adequacy of communication in the days that follow the exam. The global rating scale (GRS) was initially developed in the UK and has been studied both within the UK and outside for the purpose of gathering this important information.57 ,58 A GRS questionnaire was recently applied in a group of over 1500 individuals undergoing outpatient endoscopy across 12 endoscopy units. Significant variation across practices was identified. For example, when patients were asked whether they were adequately informed about what to do if problems arose after discharge, those responding affirmatively ranged from 43% to 98%.59 Practices not routinely gathering information on patient experience should consider such an approach to capture this metric so that quality improvement programmes can be developed should deficiencies be identified.

    Colonoscopy training

    Colonoscopy quality assurance programmes that we learned about in the previous section have revealed large variation in colonoscopy performance in terms of caecal intubation rate,60 ADR,1 complete polyp resection rate45 and patient experience.61 There is evidence that some of the observed variations in performance are explained by inadequate training in colonoscopy.60 There are several possible reasons for this.

    First, there has been no widely accepted colonoscopy training curriculum.62 Although some countries have recently implemented elements of structured basic colonoscopy training,63 ,64 most have not. Importantly, colonoscopy training has traditionally followed an apprenticeship model,65 ,66 rarely using principles of adult education67 ,68 or teaching aids69 ,70 to facilitate skills acquisition.

    Second, not all expert colonoscopists are good colonoscopy trainers. At least part of this gap between personal competence and ability to train others may be explained by the lack of formal ‘train the trainers’ courses.68 ,71

    Third, colonoscopists were rarely subject to external performance evaluation. Thus, critical self-appraisal was the only way to recognise underperformance. Also, even when underperformance was recognised, upskilling courses were infrequently available.

    Fourth, colonoscopy training has been perceived as burdensome in terms of time and cost72 and not worth the invested effort.

    In this part of the review, we use available evidence to propose a framework for a basic colonoscopy curriculum, and summarise the current status of upskilling and ‘train the trainers’ educational courses for colonoscopy.

    Basic colonoscopy training

    It is well known that training in both cognitive and technical skills is required to achieve clinical competence in colonoscopy.73 As the quality and quantity of knowledge surrounding exam performance increased, the frequently proposed minimum numbers of colonoscopies to achieve competence in intubation were shown to be insufficient,74 ,75 and awareness of appropriate withdrawal technique76 and non-technical skills were identified as equally or more important.77 Moreover, as patient population and colonoscopy services changed over time, the competence requirements for colonoscopists changed. To understand this, it is useful to recall levels of colonoscopy competence proposed in European screening guidelines (see table 1).37 Today, level 2 competence (removal of sessile and stalked lesions <25 mm) should be required for all colonoscopists, and level 3 competence (removal of flat lesions <20 mm and all sessile and stalked lesions) for colonoscopists working with FOBT-positive patients, whereas in the past, level 0 or 1 would generally be considered sufficient. The UK Joint Advisory Group (JAG) on GI Endoscopy, understanding that colonoscopy training was not keeping pace with changes in colonoscopy competence requirements, pioneered important changes in colonoscopy training.64

    View this table:
    Table 1

    Levels of colonoscopy competence according to European guidelines (modified).37

    In the next paragraphs, we propose a simple, modern, evidence-based framework for a basic colonoscopy curriculum that includes knowledge teaching, hand skills training and non-technical skills training, with specific emphasis on competence testing.

    Knowledge teaching

    The framework for knowledge content in colonoscopy training has remained unchanged for years63 ,73 and includes the following items: preprocedure, insertion, withdrawal and diagnosis, treatment, postprocedure and complications (see table 2). Nonetheless, the quality and quantity of knowledge have increased dramatically, especially in terms of bowel preparation methods, lesion recognition, lesion removal and surveillance.

    View this table:
    Table 2

    Proposed framework for basic colonoscopy curriculum

    It is uncertain how to best deliver this extensive new knowledge in a simple and effective way. Didactic lectures, core reading requirements and small group discussions were proposed63 ,78 and are widely used. Modern teaching tools, like educational DVDs (available from the European Society of Gastrointestinal Endoscopy and American Society for Gastrointestinal Endoscopy) and e-learning, may be more widely applied in the future.79 To assure the effectiveness of this training, acquired postparticipation knowledge should be tested using multiple-choice exams.80 Knowledge testing has two major goals here: to motivate trainees to learn and for accreditation purposes. However, minimum knowledge requirements for colonoscopy competence have not been defined.

    Hand skills training

    Hand skills training is another crucial element of colonoscopy education.73 Historically, the focus was predominantly on intubation skills, whereas today, equal emphasis is placed on colonoscope handling, appropriate position during colonoscopy, withdrawal technique and polypectomy (see table 2).22 ,68 ,73 ,79

    Traditional hand skills training using the apprenticeship model is often ineffective because colonoscopy procedures performed by trainees are not uniformly supervised appropriately.22 ,62 Additionally, given the complexity of colonoscopy, learning curves across trainees can be long and highly variable.64 ,74 It has been suggested that the threshold number of procedures should be replaced by learning curves compared with a group reference.64 Table 2 displays advances in training methodology which might be implemented to better facilitate skills acquisition. Virtual reality simulators have been proven effective supplements for early bed-side colonoscopy training69 and may also specifically help in polypectomy training.81 Adjunctive magnetic endoscope imaging was shown to improve colonoscopy completion rate by inexperienced endoscopists.70 A self-assessment form for colonoscopy might be a useful add-on to the apprenticeship model.64 The use of adult educational theories (cognitive load theory, performance-enhancing feedback, Peyton model67 ,68) by the JAG revolutionised colonoscopy training in the UK.22 Specifically, the use of performance-enhancing feedback is considered a cornerstone of any skills training event. A popular performance-enhancing feedback model, the Pendleton approach, relies on a four-step assessment (positives in trainee perception, positives in trainer perspective, areas for improvement in trainee perception followed by trainer perspective). This approach is believed to encourage trainee self-reflection and planning for future learning while also speeding up skill acquisition. Moreover, it has been suggested that the use of a semiobjective competence assessment tools, such as the Mayo Colonoscopy Skills Assessment Tool,82 the Direct Observation of Procedural Skills assessment tool,83 the Direct Observation of Polypectomy Skills,84 and the Global Assessment of Gastrointestinal Endoscopic Skills85 may help to provide performance-enhancing feedback to trainees and guide assessment of competence. In fact, some certification bodies (eg, the JAG) have already adopted minimum scores derived from competence assessment tools to certify trainees.

    Non-technical skills training

    Non-technical skills are defined as a set of social (eg, communication and team work) and cognitive (eg, analytical and personal behaviour) skills that support high quality, safe, effective and efficient interprofessional care within a complex healthcare system.86 Although the majority of healthcare errors can be attributed to failure in non-technical skills,77 ,87 this aspect of colonoscopy performance has neither been explicitly measured nor incorporated in training curricula. In other medical disciplines, especially anaesthesiology and surgery, dedicated tools for non-technical skills assessment were developed88 ,89 and used to assess success of training interventions.90 Recently, a generic framework of non-technical skills for health education was developed.86 This framework contains four major domains (communication, teamwork, analytical and personal behaviours), split into 16 competency items. We will use one example from each domain to give an overview on how these competency items may fit into colonoscopic polypectomy training.

    • Communication: uses language clearly. It is common practice that an endoscopy assistant closes a snare during polypectomy at the proper time and rate, while the endoscopist applies electrocautery; clear verbal instructions on how fast a snare should be closed may be critical for the safety of polypectomy.

    • Teamwork: exchanges relevant information within a team; detailed information on the number, size, morphology, location and method of polyp removal are of utmost importance to ensure adequate histopathological assessment and postprocedural recommendations.

    • Personal behaviour: identifies when stress may pose a risk; production pressure may jeopardise efficacy and safety of colonoscopy and polypectomy.91

    • Analytical behaviour: changes approach when significant risk is encountered; large polyps should be referred for removal at tertiary referral centres rather than an endoscopist with insufficient competence level attempting removal.

    Although very few training courses for non-technical skills in medicine have been developed and validated,90 approaches from those can be used to create curriculums for colonoscopy training (see table 2). Indeed, recently a one-day course for non-technical colonoscopy skills training was developed and was shown to improve patient safety knowledge and some patient safety attitudes.92

    Upskilling courses

    The need for specific upskilling courses for independent colonoscopists was first recognised with implementation of quality assurance programmes. These programmes identified important areas for improvement within an individual endoscopist's practice.

    In 2007, Thomas-Gibson et al79 reported on a hands-on colonoscopy training course with positive and sustained impact on colonoscopy performance. After 5 days of training, endoscopists with various levels of colonoscopy experience improved both their knowledge and technical skills (eg, colonoscopy insertion and withdrawal, polypectomy technique) and maintained the change through 9 months of follow-up. The success of the course likely resulted both from the use of modern methodology and high-quality educational training. Specific important features of this programme included the use of multimedia educational materials, virtual reality simulators, magnetic endoscope imaging, performance-enhancing feedback and trainers who attended ‘train the trainers’ course. One limitation to the course was the use of a semiobjective measure of colonoscopy performance (the Direct Observation of Procedural Skills assessment tool).83 Subsequent training courses improved this, but focused only on lesion recognition and withdrawal technique.93 ,94 The Endoscopic Quality Improvement Program (EQUIP) course93 was a simple, short-session training course using multimedia presentations, followed by monthly feedback on ADR, and resulted in a significant and sustained improvement in ADR among gastroenterologists from one academic institution in the USA. The Train the Colonoscopy Leaders (TCL) course94 was a two half-day hands-on training course with annual feedback on ADR that resulted in significant and sustained improvement in ADR among endoscopists with various specialties, colonoscopy experience and working in academic, non-academic and private institutions. The TCL course used techniques drawn from skills improvement, ‘train the trainer’ and leadership courses developed by the JAG (see below).

    ‘Train the trainers’ courses

    In the past, colonoscopy training was often rated unsatisfactory by trainees, because trainers often failed to appropriately supervise the procedures and quickly overtook the endoscope instead of instructing and discussing the challenge.22 ,62 ‘Train the trainers’ courses are important for delivering high-quality colonoscopy training.68 However, their current availability is limited to courses organised by the World Gastroenterology Organization64 and the JAG in the UK.71 The evidence directly supporting their efficacy in colonoscopy training is restricted to the TCL study mentioned above.94 The TCL course, apart from having a positive effect on ADR of leaders (trainers), also had a positive long-term effect on ADR for endoscopic centres and all endoscopists.

    In summary, based on currently available knowledge, we propose a framework for a universal basic colonoscopy curriculum including knowledge teaching, technical skills training and non-technical skills training. The training curriculum should use methods of adult teaching, training aids and semiobjective competency assessment tools to facilitate acquisition of skills. Upskilling courses and ‘train the trainers’ courses are important requirements for colonoscopy training and should be implemented in any colonoscopy screening programme.

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    Footnotes

    • Contributors All authors contributed equally to this manuscript.

    • Funding MFK received stipends from the Polish Ministry of Science and Higher Education (77/2012) and Foundation for Polish Science (TEAM/2012-9/5/styp6) during the study period. This material is the result of work supported in part by resources from The Veterans Health Administration. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

    • Competing interests MB: member of the European scientific advisory board of Exact Sciences and has received equipment for testing in scientific studies from Olympus, Fujifilm, Falk Pharma and CCS Healthcare. MFK: speaking and teaching for Olympus Polska. DJR: member of the advisory board for Covidien/Given Imaging.

    • Provenance and peer review Commissioned; externally peer reviewed.