Abstract
Background and Aims
Tremendous growth in research focused on quality metrics in colonoscopy has occurred since 2000. However, whether national performance in colonoscopy quality outcomes have significantly changed since this time is not as well known.
Methods
We examined colonoscopy data collected prospectively through the Clinical Outcomes Research Initiative, which included 84 gastrointestinal practice sites from 2000 to 2014 for patients undergoing colonoscopy for multiple indications. Colonoscopy outcomes by indication were compared across three 5-year periods (2000–2004; 2005–2009; 2010–2014) using the following metrics: bowel prep quality (percent good/excellent), polyp finding, 2 or more polyp finding, and polyp finding >9 mm. Multivariate logistic regression was used to generate odds ratios and 95% confidence intervals for each time period while controlling for age, gender, and race/ethnicity.
Results
A total of 1,541,837 adults were included in the study across all indication groups. The average risk screening group (390,741 adults) demonstrated statistically significant improvement across all 4 quality metrics when comparing baseline period to the final time period. Bowel prep quality improved across all indications when comparing the baseline period with the final time period. Polyp finding, 2 or more polyp findings, and polyp finding >9 mm improved in average-risk screening; surveillance; and diagnostic indication groups when comparing the baseline period with final time period. The Increased Risk Screening and Inflammatory Bowel Disease indication groups did not see improvements beyond bowel prep quality when comparing baseline with final time period.
Conclusion
Colonoscopy outcomes as measured by bowel prep quality, polyp finding, 2 or more polyp findings, and polyp finding >9 mm improved significantly over the 15-year period between 2000 and 2014 with the largest and most consistent impact in the Average-Risk Screening indication group.
Introduction
Since the landmark publication of the Institute of Medicine’s (IOM) To Err is Human1 in 1999, the concept of quality improvement and safety has emerged as a growing priority in healthcare. This focus not surprisingly extended to gastroenterology and specifically endoscopic procedures. Early and ongoing efforts have often focused on colonoscopy given its ubiquitous use in clinical practice and its prominent role in colorectal cancer screening.
In 2002 a U.S. Multi-Society Task Force on Colorectal Cancer proposed initial consensus based standards.2 This was followed by the publication of the American Gastroenterologic Association (AGA) Task Force on Quality in Practice in 2005 which specifically concluded that developing and implementing meaningful and quantifiable measures of quality needed to be a priority.3 This was shortly followed by the 2006 publication of the joint Taskforce on Quality Endoscopy from the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE), which described specific endoscopic quality measures in a systematic way4 and the 2007 publication of the Quality Assurance Task Force of the National Colorectal Cancer Roundtable which developed a standardized reporting and data system for colonoscopy.5 Most recently, the joint ACG/ASGE Taskforce on Quality updated its guidelines6 in 2015. During this 15-year period there has been tremendous progress in the research involving quality and colonoscopy. Notably Centers for Medicare and Medicaid Services (CMS) has also recognized the importance of quality in colonoscopy by incorporating measures into its quality reporting system.7 Consequently, quality is now more directly tied to physician reimbursement.
Given the significant evolution and growth of quality metrics in colonoscopy over time, we aimed to determine whether quality outcomes in colonoscopy have changed during the 15-year period between 2000 and 2014.
Methods
Colonoscopy data were collected prospectively at 84 gastrointestinal practice sites from 2000 to 2014, using an endoscopic report generator, from 1,541,837 adults who underwent colonoscopy. The practice sites include community practices and endoscopy centers (77.1%), academic centers (9%) and VA/military medical centers (13.8%). Indications for colonoscopy were used to divide this larger group into 5 broad categories including Average-Risk Screening; Increased Risk Screening; Surveillance; Inflammatory Bowel Disease; and Diagnostic. Increased Risk Screening included the indication groups “family history of colorectal cancer;” “family history of polyps;” “positive fecal occult blood test;” “screening in hereditary nonpolyposis colorectal cancer syndrome;” “screening in familial adenomatous polyposis;” “polyps seen on barium enema;” “polyps seen on flexible sigmoidoscopy;” “other increased risk screening;” and “other risk factors.” Surveillance included indication categories of “surveillance of adenomatous polyps;” surveillance of colorectal cancer;” and “polyps seen on prior colonoscopy.” Inflammatory Bowel Disease included “established or surveillance of Crohns;” “established or surveillance of ulcerative colitis;” and “other surveillance.” Diagnostic included all indications related to bleeding or any symptom as well as “other evaluation;” “other evaluation of suspected;” “abnormal studies/imaging (not including polyps);” “personal history of non-GI cancer;” and “therapeutic intervention.”
Demographic characteristics collected included: age; sex; race/ethnicity; and ASA class. Primary outcomes included bowel prep quality (percent good/excellent), polyp finding, 2 or more polyp findings (2+ polyp finding), and polyp finding >9 mm (polyp >9). Of note, histology was not available for specimens removed; these metrics were consequently intended to approximate histologic risk.
Statistical Approach
Colonoscopy quality metrics were analyzed for patient groups based on indication, age, sex, and race/ethnicity and segmented into 5-year groupings: 2000 to 2004; 2005 to 2009; 2010 to 2014. Comparison of demographic data was performed by using chi-square tests and 1-way ANOVA. Cochran-Armitage test was used to measure trends in the data. Multivariate logistic regression was used to generate odds ratios and 95% confidence intervals for each time period while controlling for age, gender, and race/ethnicity. All analyses were performed with version 9.4 of SAS software (SAS Institute Inc, Cary, NC).
Results
Demographics
A complete breakdown of participants by indication, year period, age, sex, race/ethnicity, and ASA Class is provided in Table 1. A total of 1,541,837 adults were included in the study, with 390,741 in Average-Risk Screening; 199,226 in High-Risk Screening; 285,500 in Surveillance; 38,636 in Inflammatory Bowel Disease; and 627,734 in Diagnostic. Notably, there were statistical differences across nearly all demographic categories across all time periods across all indications (Table 1). As a result, the data was stratified by age and sex for each indication (Appendices 1–5) and further analyzed using multivariate logistic regression adjusting for differences in age, sex, and race/ethnicity (Table 2). The indication-specific, age and sex stratified results demonstrated significant heterogeneity across the various combination comparisons which are reported in Appendices 1 to 5. For a more global assessment of outcomes over time, the multivariate regression results are summarized below and in Table 2.
Table 1.
Patient Demographics By Indication and Time Period (Total N = 1,541,837)
| Patient Demographics | Screening (n = 390,741) | Increased Risk Screening (n = 199,226) | IBD (n = 38,636) | Surveillance of CRC/polyps (n = 285,500) | Diagnostic (n = 627,734) | |||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 82,000 | 197,704 | 111,037 | 79,708 | 80,340 | 39,178 | 11,648 | 16,949 | 10,039 | 82,474 | 122,318 | 80,708 | 235,834 | 269,374 | 122,526 | ||||||
| Age | ||||||||||||||||||||
| 139 (0.2) | 295 (0.2) | 225 (0.2) | <.0001 | 2577 (3.2) | 2560 (3.2) | 1305 (3.3) | <.0001 | 2105 (18.1) | 2659 (15.7) | 2292 (22.8) | <.0001 | 896 (1.1) | 1091 (0.9) | 680 (0.8) | <.0001 | 22237 (9.4) | 31647 (11.8) | 16663 (13.6) | <.0001 | |
| 1742 (2.1) | 3686 (1.9) | 2309 (2.1) | 11677 (14.7) | 12259 (15.3) | 5247 (13.4) | 2351 (20.2) | 2847 (16.8) | 1725 (17.2) | 4453 (5.4) | 5546 (4.5) | 2851 (3.5) | 37387 (15.9) | 46966 (17.4) | 21011 (17.2) | ||||||
| 35417 (43.2) | 103507 (52.4) | 56458 (50.9) | 29732 (37.3) | 32354 (40.3) | 15306 (39.1) | 3125 (26.8) | 4709 (27.8) | 2399 (23.9) | 17392 (21.1) | 29148 (23.8) | 18460 (22.9) | 65537 (27.8) | 71062 (26.4) | 29656 (24.2) | ||||||
| 26748 (32.6) | 61657 (31.2) | 39182 (35.3) | 20165 (25.3) | 21190 (26.4) | 12355 (31.5) | 2306 (19.8) | 4057 (23.9) | 2491 (24.8) | 26106 (31.7) | 42585 (34.8) | 34378 (42.6) | 50435 (21.4) | 57316 (21.3) | 29187 (23.8) | ||||||
| 15379 (18.8) | 24731 (12.5) | 11604 (10.5) | 12391 (15.6) | 9474 (11.8) | 4112 (10.5) | 1442 (12.4) | 2161 (12.8) | 963 (9.6) | 25542 (31.0) | 33731 (27.6) | 20112 (24.9) | 42702 (18.1) | 41727 (15.5) | 18032 (14.7) | ||||||
| 2575 (3.1) | 3828 (1.9) | 1259 (1.1) | 3166 (4.0) | 2503 (3.1) | 853 (2.2) | 319 (2.7) | 516 (3.0) | 169 (1.7) | 8085 (9.8) | 10217 (8.4) | 4227 (5.2) | 17536 (7.4) | 20656 (7.7) | 7977 (6.5) | ||||||
| 61.9 (9.0) | 59.9 (8.4) | 59.5 (8.2) | <.0001 | 59.0 (11.4) | 58.0 (10.7) | 58.1 (10.4) | <.0001 | 53.5 (14.5) | 54.9 (14.3) | 52.2 (14.9) | <.0001 | 66.1 (10.7) | 65.4 (10.2) | 64.8 (9.3) | <.0001 | 58.7 (14.5) | 57.5 (15.0) | 56.9 (15.3) | <.0001 | |
| Sex | ||||||||||||||||||||
| 44437 (54.2) | 105850 (53.5) | 62815 (56.6) | <.0001 | 43068 (54.0) | 40958 (51.0) | 19688 (50.3) | <.0001 | 6721 (57.7) | 9657 (57.0) | 5880 (58.6) | 0.037 | 51132 (62.0) | 74918 (61.3) | 52467 (65.0) | <.0001 | 108442 (46.0) | 121422 (45.1) | 58110 (47.4) | <.0001 | |
| 37563 (45.8) | 91854 (46.5) | 48222 (43.4) | 36640 (46.0) | 40958 (49.0) | 19490 (49.8) | 4927 (42.3) | 7292 (43.0) | 4159 (41.4) | 31342 (38.0) | 47400 (38.8) | 28241 (35.0) | 127392 (54.0) | 147952 (54.9) | 64416 (52.6) | ||||||
| Race/Ethnicity | ||||||||||||||||||||
| 69763 (85.1) | 166589 (84.3) | 86319 (77.7) | <.0001 | 67520 (84.7) | 68918 (85.8) | 30996 (79.1) | <.0001 | 10334 (88.7) | 15086 (89.01) | 8495 (84.6) | <.0001 | 72058 (87.4) | 107657 (88.0) | 68383 (84.7) | <.0001 | 191129 (81.0) | 219521 (81.5) | 87882 (71.7) | <.0001 | |
| 5289 (6.5) | 10108 (5.1) | 8048 (7.3) | 5280 (6.6) | 3833 (4.8) | 2020 (5.2) | 604 (5.2) | 784 (4.6) | 491 (4.9) | 4192 (5.1) | 5444 (4.5) | 3885 (4.8) | 16666 (7.1) | 16486 (6.1) | 8547 (7.0) | ||||||
| 4517 (5.5) | 15730 (8.0) | 10876 (9.8) | 2386 (3.0) | 5530 (6.9) | 4051 (10.3) | 321 (2.8) | 779 (4.6) | 713 (7.1) | 2955 (3.6) | 6686 (4.5) | 5513 (6.8) | 14309 (6.1) | 25356 (9.4) | 19732 (16.1) | ||||||
| 1705 (2.1) | 5091 (2.6) | 5709 (5.1) | 2009 (2.5) | 1957 (2.4) | 2080 (5.3) | 180 (1.6) | 278 (1.6) | 333 (3.3) | 1354 (1.5) | 2345 (1.9) | 2881 (3.6) | 6674 (2.8) | 7667 (2.9) | 6297 (5.1) | ||||||
| 726 (0.9) | 186 (0.1) | 85 (0.1) | 2513 (3.2) | 102 (0.1) | 31 (0.1) | 209 (1.8) | 22 (0.1) | 7 (0.1) | 1915 (2.3) | 186 (0.2) | 46 (0.1) | 7056 (3.0) | 344 (0.1) | 68 (0.1) | ||||||
| ASA Class | ||||||||||||||||||||
| 28931 (35.3) | 53269 (26.9) | 22196 (20.0) | <.0001 | 30824 (38.7) | 22514 (28.0) | 7058 (18.0) | <.0001 | 3557 (30.5) | 3287 (19.4) | 869 (8.7) | <.0001 | 22963 (27.8) | 24700 (20.2) | 6796 (8.4) | <.0001 | 82626 (35.0) | 70456 (26.2) | 19166 (15.6) | <.0001 | |
| 49445 (60.3) | 136266 (68.9) | 80927 (72.9) | 44605 (56.0) | 53385 (66.5) | 28758 (73.4) | 7416 (63.7) | 12543 (74.0) | 8118 (80.9) | 53229 (64.5) | 88514 (72.4) | 63805 (79.1) | 130679 (55.4) | 172500 (64.0) | 82333 (67.2) | ||||||
| 3566 (4.4) | 8002 (4.1) | 7665 (6.9) | 4168 (5.2) | 4316 (5.4) | 3275 (8.4) | 652 (5.6) | 1093 (6.5) | 1034 (10.3) | 6170 (7.5) | 8912 (7.3) | 9936 (12.3) | 21434 (9.1) | 25332 (9.4) | 20010 (16.3) | ||||||
| 58 (0.1) | 167 (0.1) | 249 (0.2) | 111 (0.1) | 125 (0.2) | 87 (0.2) | 23 (0.2) | 26 (0.2) | 18 (0.2) | 112 (0.1) | 192 (0.2) | 171 (0.2) | 1095 (0.5) | 1086 (0.4) | 1017 (0.8) | ||||||
Table 2.
Comparison of Colonoscopy Metrics Over Time By Indication
| Outcome | 2000–2004 | 2005–2009 | 2010–2014 |
| Good/excellent bowel preparation | 1.0 (reference) | 1.01 (.99–1.04) | 1.64 (1.60 – 1.68) |
| Polyp Finding | 1.0 (reference) | 1.12 (1.10 – 1.14) | 1.33 (1.30 – 1.35) |
| 2 or more polyp finding | 1.0 (reference) | 1.08 (1.05 – 1.10) | 1.41 (1.38 – 1.45) |
| Polyp finding > 9mm | 1.0 (reference) | 1.09 (1.05 – 1.13) | 1.25 (1.21 – 1.30) |
| Outcome | 2000–2004 | 2005–2009 | 2010–2014 |
| Good/excellent bowel preparation | 1.0 (reference) | 1.06 (1.03 – 1.09) | 1.62 (1.57 – 1.68) |
| Polyp Finding | 1.0 (reference) | 0.83 (0.81 – 0.85) | 0.97 (0.95 – 1.00) |
| 2 or more polyp finding | 1.0 (reference) | 0.75 (0.73 – 0.77) | 0.95 (0.92 – 0.98) |
| Polyp finding > 9mm | 1.0 (reference) | 0.73 (0.70 – 0.75) | 0.88 (0.85 – 0.92) |
| Outcome | 2000–2004 | 2005–2009 | 2010–2014 |
| Good/excellent bowel preparation | 1.0 (reference) | 1.09 (1.07 – 1.12) | 1.69 (1.65 – 1.74) |
| Polyp Finding | 1.0 (reference) | 1.05 (1.03 – 1.07) | 1.28 (1.26 – 1.31) |
| 2 or more polyp finding | 1.0 (reference) | 1.01 (0.98 – 1.03) | 1.34 (1.31 – 1.37) |
| Polyp finding > 9mm | 1.0 (reference) | 0.96 (0.93 – 0.99) | 1.06 (1.02 – 1.10) |
| Outcome | 2000–2004 | 2005–2009 | 2010–2014 |
| Good/excellent bowel preparation | 1.0 (reference) | 0.94 (0.88 – 1.00) | 1.34 (1.25 – 1.45) |
| Polyp Finding | 1.0 (reference) | 1.16 (1.10 – 1.23) | 1.05 (0.98 – 1.12) |
| 2 or more polyp finding | 1.0 (reference) | 1.19 (1.09 – 1.31) | 1.03 (0.92 – 1.15) |
| Polyp finding > 9mm | 1.0 (reference) | 0.99 (0.88 – 1.12) | 0.77 (0.67 – 0.89) |
| Outcome | 2000–2004 | 2005–2009 | 2010–2014 |
| Good/excellent bowel preparation | 1.0 (reference) | 0.95 (0.94 – 0.97) | 1.43 (1.40 – 1.45) |
| Polyp Finding | 1.0 (reference) | 1.04 (1.03 – 1.06) | 1.24 (1.22 – 1.26) |
| 2 or more polyp finding | 1.0 (reference) | 1.00 (0.98 – 1.02) | 1.29 (1.27 – 1.32) |
| Polyp finding > 9mm | 1.0 (reference) | 0.92 (0.90 – 0.94) | 1.08 (1.05 – 1.11) |
models are controlled for gender, age and race/ethnicity
Average-Risk Screening Population
For the Average-Risk Screening group, there was a statistically significant improvement in all outcome measures (bowel prep quality, polyp finding, 2+ polyp finding, and polyp >9) over all 3 time periods when adjusted for age, sex, and race/ethnicity (Table 2).
Increased Risk Screening Population
For the Increased Risk Screening group, there was a statistically significant improvement in Bowel Prep Quality across all time periods. However, for the remainder of the metrics there was either no change (polyp finding) or a declining trend (2+ polyp finding, polyp>9) when comparing the final time period to the baseline (Table 2).
Surveillance Population
For the Surveillance group, bowel prep quality and polyp finding improved across all 3 time periods. Two+ polyp finding was unchanged in the middle time period but improved by the final time period. Polyp>9 was lower than baseline in the middle time period, but improved by the final time period. There was a statistically significant improvement across all outcome measures by the final time period (Table 2).
Inflammatory Bowel Disease Population
For the Inflammatory Bowel Disease group, there was no change in the Bowel Prep Quality during the middle time period, but improvement in the final period. Polyp finding and 2+ polyp finding were improved in the middle time period, but unchanged in the final time period. Polyp >9 was unchanged in the middle period and decreased in the final period. Results are presented in Table 2.
Diagnostic Population
For the Diagnostic group, bowel prep quality declined in the middle period but improved in the final time period. Polyp finding improved across all time periods. 2+ polyp finding was unchanged in the middle time period, but improved in the final time period. Polyp>9 declined in the middle period, but improved in the final time period. There was a statistically significant improvement across all outcome measures by the final time period (Table 2).
Discussion
Colonoscopy Quality Metrics
Colonoscopy outcomes as measured by bowel prep quality, polyp finding, 2+ polyp finding, and polyp>9 improved significantly over the 15-year period between 2000 and 2014. Notably, bowel prep quality improved across all indication groups when comparing the baseline period with the final time period. This positive trend across all indications was not uniformly distributed across all quality metrics for colonoscopy. However, the Average-Risk Screening population, arguably the benchmark setting for quality in colonoscopy, demonstrated the most convincing and consistent improvements in all quality parameters. In addition to Average Risk, the Surveillance and Diagnostic indication groups also saw significant improvements across all metrics in the final time period compared to baseline. Increased Risk Screening population did not demonstrate similar improvements. One hypothesis may be that clinicians completed these examinations with a higher index of suspicion that resulted in sustained vigilance consistent across all time periods. This would explain the unchanged polyp finding though does not fully explain the declines in 2+ polyp finding and polyp >9. The indication group of Inflammatory Bowel Disease in particular did not as consistently demonstrate global improvement. This indication group as well as diagnostic represent clinical contexts in which other priorities such as assessment of disease activity or detection of bleeding may complicate a primary goal of colorectal cancer prevention. This is relevant because the quality metrics measured were principally developed to address this end.
Significance
This report is the largest and longest evaluation of colonoscopy quality outcomes to date. With its large and diverse sample size, there is higher confidence in the validity of the improvement demonstrated. This study also demonstrated the potential use of polyp >9 as a robust measurement of quality that has not been previously described. The progress in colonoscopy quality mirrors the growth in research and regulation around quality improvement more broadly as well as its increased importance within gastroenterology societies through publications and formal recommendations/guidelines. Other factors may have played role include: increased overall awareness by providers; improvements in colonoscope technology including image quality and processing; and improvements in bowel preparation agents as well as greater use of more effective protocols such as split-dosing. Although it is not possible to directly ascribe causation to these factors, these results do confirm that improvements in colonoscopy quality are taking place.
Limitations
There are several limitations to consider. First, the outcomes collected represent process or intermediary measures in the broader landscape of preventing colorectal cancer. To this end, adenoma detection rate (ADR) has been the current gold standard proxy for colorectal cancer prevention as demonstrated by two notable studies that showed that ADR performance was inversely associated with the risk of interval colorectal cancer.8,9 However, the data collection infrastructure during the 15-year study period did not regularly document histology to calculate this endpoint reliably. Nevertheless, the correlation between ADR and PDR is established10 and the latter has also been correlated with decreased incidence of CRC.11 To further address this limitation, we also examined 2+ polyp finding that may approximate a higher-quality examination because ADR could be theoretically gamed by the removal of a single adenomatous polyp. We also examined polyp >9, which was intended to capture higher risk lesions due to known association of polyp size and risk for advanced neoplasia,12 although these metrics are not as well established. In addition, although improvements in colonoscopy quality would be ideally tied to clinical outcomes for each of indication group, these data were not collected.
Summary
Colonoscopy quality broadly improved in the 15-year period between 2000 and 2014, most notably with the largest and most consistent gains in the Average-Risk Screening population. This suggests that multifactorial efforts over the past decade are improving colonoscopy quality.
Funding declaration:
This project was supported with funding from NIDDK U01DK57132. In addition, the practice network (Clinical Outcomes Research Initiative) has received support from the following entities to support the infrastructure of the practice-based network: AstraZeneca, Novartis, Bard International, Pentax USA, ProVation, Endosoft, GIVEN Imaging, and Ethicon. The commercial entities had no involvement in this research.
Acronyms and Abbreviations
- IOM
Institute of Medicine
- AGA
American Gastroenterologic Association
- ACG
American College of Gastroenterology
- ASGE
American Society for Gastrointestinal Endoscopy
- CMS
Centers for Medicare and Medicaid Services
- ASA
American Society of Anesthesiologists
- ANOVA
Analysis of Variance
- ADR
Adenoma Detection Rate
- PDR
Polyp Detection Rate
- CRC
Colorectal Cancer
Appendix A.
Screening Colonoscopy Quality Metrics Over Time
| Percent Good/Excellent Bowel Prep (when documented) | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 40–49 | 76.16 | 78.28 | 86 | <.0001 | 80.00 | 78.65 | 88.82 | <.0001 |
| 50–59 | 78.55% | 78.59% | 84.55% | <.0001 | 82.58% | 82.30% | 87.92% | <.0001 |
| 60–69 | 76.47% | 75.87% | 82.05% | <.0001 | 80.21% | 80.90% | 87.33% | <.0001 |
| 70–79 | 74.60% | 73.67% | 83.00% | <.0001 | 78.43% | 78.56% | 87.49% | <.0001 |
| >79 | 74.62% | 74.25% | 82.87% | 0.0007 | 78.61 | 78.69 | 87.28 | <.0001 |
| Colonoscopy Polyp Detection Rate | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 40–49 | 34.02 | 37.65 | 36.60 | 0.215 | 25.80 | 25.49 | 27.84 | 0.271 |
| 50–59 | 39.52 | 42.38 | 47.02 | <.0001 | 28.37% | 30.40% | 33.99% | <.0001 |
| 60–69 | 44.52 | 47.71 | 52.48 | <.0001 | 32.52% | 34.43% | 37.21% | <.0001 |
| 70–79 | 44.44 | 46.90 | 50.84 | <.0001 | 33.51 | 35.57 | 38.54 | <.0001 |
| >79 | 42.69 | 46.19 | 43.72 | 0.383 | 33.01 | 36.21 | 37.95 | 0.020 |
| Colonoscopy Polyp Detection Rate 2+ | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 40–49 | 10.59 | 11.52 | 14.82 | 0.002 | 6.69 | 7.26 | 6.33 | 0.658 |
| 50–59 | 14.86 | 15.99 | 19.76 | <.0001 | 8.24 | 8.37 | 11.19 | <.0001 |
| 60–69 | 18.52 | 20.12 | 25.26 | <.0001 | 10.52 | 10.70 | 13.19 | <.0001 |
| 70–79 | 18.97 | 19.65 | 22.81 | <.0001 | 11.29 | 12.06 | 13.72 | <.0001 |
| >79 | 17.67 | 19.70 | 19.84 | 0.177 | 11.56 | 12.64 | 11.07 | 0.98 |
| Colonoscopy Polyp Detection Rate > 9mm | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 40–49 | 5.12 | 5.24 | 4.29 | 0.342 | 3.18 | 3.60 | 3.35 | 0.928 |
| 50–59 | 6.08 | 6.56 | 7.81 | <.0001 | 3.65 | 4.23 | 5.37 | <.0001 |
| 60–69 | 8.55 | 9.08 | 9.92 | <.0001 | 5.11 | 5.54 | 6.10 | 0.000 |
| 70–79 | 9.52 | 9.91 | 10.36 | 0.093 | 6.25 | 7.07 | 7.11 | 0.040 |
| >79 | 10.79 | 11.23 | 8.53 | 0.233 | 7.25 | 7.05 | 10.26 | 0.061 |
Appendix B.
Increased Risk Screening Colonoscopy Quality Metrics Over Time
| Percent Good/Excellent Bowel Prep (when documented) | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 80.5 | 83.76 | 87.22 | 0.000 | 80.81 | 84.79 | 90.19 | <.0001 |
| 40–49 | 80.61 | 82.36 | 86.72 | <.0001 | 82.17 | 84.21 | 90.12 | <.0001 |
| 50–59 | 78.03 | 77.41 | 83.68 | <.0001 | 81.36 | 82.34 | 86.60 | <.0001 |
| 60–69 | 76.09 | 75.71 | 81.74 | <.0001 | 80.00 | 82.52 | 87.84 | <.0001 |
| 70–79 | 73.52 | 74.56 | 82.65 | <.0001 | 78.03 | 80.06 | 85.95 | <.0001 |
| >79 | 73.92 | 71.43 | 77.38 | 0.598 | 74.04 | 79.26 | 83.48 | <.0001 |
| Colonoscopy Polyp Detection Rate | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 34.61 | 32.39 | 28.23 | 0.007 | 26.85 | 23.09 | 25.99 | 0.372 |
| 40–49 | 41.95 | 40.17 | 42.13 | 0.664 | 30.91 | 27.55 | 31.65 | 0.609 |
| 50–59 | 51.38 | 46.55 | 50.09 | <.0001 | 35.79 | 31.91 | 36.81 | 0.960 |
| 60–69 | 56.73 | 51.18 | 55.45 | 0.003 | 40.02 | 35.14 | 38.64 | 0.008 |
| 70–79 | 55.74 | 51.43 | 53.54 | 0.002 | 41.64 | 35.64 | 39.16 | 0.000 |
| >79 | 52.6 | 48.09 | 47.83 | 0.019 | 39.23 | 35.68 | 39.83 | 0.549 |
| Colonoscopy Polyp Detection Rate 2+ | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 11.75 | 10.00 | 10.00 | 0.1787 | 7.16 | 5.47 | 7.30 | 0.7548 |
| 40–49 | 15.74 | 14.26 | 16.28 | 0.9526 | 9.52 | 7.61 | 9.71 | 0.4441 |
| 50–59 | 24.73 | 20.06 | 23.64 | <.0001 | 12.46 | 9.59 | 12.67 | 0.2886 |
| 60–69 | 30.24 | 23.79 | 28.82 | 0.0001 | 16.06 | 11.59 | 13.75 | <.0001 |
| 70–79 | 29.51 | 25.31 | 26.70 | <.0001 | 16.75 | 11.59 | 14.01 | <.0001 |
| >79 | 25.93 | 22.31 | 25.06 | 0.2153 | 17.61 | 10.88 | 16.23 | 0.0087 |
| Colonoscopy Polyp Detection Rate > 9mm | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 7.51 | 5.64 | 5.81 | 0.0907 | 5.28 | 3.38 | 4.38 | 0.1644 |
| 40–49 | 7.91 | 6.27 | 7.06 | 0.0294 | 5.28 | 3.92 | 4.97 | 0.1254 |
| 50–59 | 11.75 | 9.6 | 11.35 | 0.0120 | 6.67 | 4.59 | 5.77 | <.0001 |
| 60–69 | 16.34 | 12.87 | 15.48 | 0.0065 | 9.27 | 5.83 | 6.60 | <.0001 |
| 70–79 | 19.76 | 14.78 | 16.23 | <.0001 | 11.91 | 7.21 | 8.74 | <.0001 |
| >79 | 20.79 | 18.23 | 17.14 | 0.0432 | 16.58 | 12.51 | 20.78 | 0.5934 |
Appendix C.
Surveillance of CRC/polyps Colonoscopy Quality Metrics Over Time
| Percent Good/Excellent Bowel Prep (when documented) | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 20–39 | 76.2 | 77.5 | 86.3 | 0.001 | ||||
| 40–49 | 74.2 | 76.9 | 84.3 | <.0001 | 77.1 | 78.9 | 85.4 | <.0001 |
| 50–59 | 82.3 | <.0001 | 76.6 | 78.7 | 86.1 | <.0001 | ||
| 60–69 | 74.5 | 75.2 | 81.0 | <.0001 | 77.8 | 79.9 | 86.4 | <.0001 |
| 70–79 | 73.3 | 73.7 | 80.4 | <.0001 | 77.3 | 78.6 | 86.2 | <.0001 |
| >79 | 73.2 | 74.1 | 81.3 | <.0001 | 76.2 | 77.3 | 86.0 | <.0001 |
| Colonoscopy Polyp Detection Rate | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 20–39 | 43.4 | 39.7 | 38.6 | 0.161 | 29.9 | 32.3 | 36.2 | 0.058 |
| 40–49 | 46.3 | 46.0 | 47.3 | 0.584 | 37.5 | 36.4 | 40.1 | 0.187 |
| 50–59 | 58.4 | <.0001 | 42.6 | 42.5 | 46.4 | <.0001 | ||
| 60–69 | 54.4 | 55.6 | 61.1 | <.0001 | 44.5 | 45.5 | 49.6 | <.0001 |
| 70–79 | 54.0 | 55.6 | 60.8 | <.0001 | 43.5 | 46.5 | 51.4 | <.0001 |
| >79 | 51.8 | 54.8 | 57.5 | <.0001 | 44.3 | 46.9 | 50.9 | <.0001 |
| Colonoscopy Polyp Detection Rate 2+ | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 20–39 | 13.0 | 12.1 | 13.6 | 0.864 | 8.4 | 9.6 | 12.4 | 0.065 |
| 40–49 | 17.7 | 17.3 | 19.1 | 0.360 | 12.5 | 11.8 | 14.7 | 0.11 |
| 50–59 | 23.7 | 22.6 | 27.8 | <.0001 | 16.2 | 14.3 | 18.5 | 0.0001 |
| 60–69 | 25.5 | 25.6 | 32.2 | <.0001 | 17.1 | 16.7 | 20.0 | <.0001 |
| 70–79 | 25.4 | 26.1 | 31.8 | <.0001 | 16.2 | 17.5 | 22.0 | <.0001 |
| >79 | 23.0 | 24.3 | 29.1 | <.0001 | 16.8 | 17.7 | 21.4 | 0.0002 |
| Colonoscopy Polyp Detection Rate > 9mm | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p | 2000–2004 | 2005–2009 | 2010–2014 | trend p | |
| 20–39 | 5.5 | 7.5 | 5.3 | 0.983 | 4.5 | 4.8 | 4.5 | 0.999 |
| 40–49 | 6.3 | 5.9 | 7.5 | 0.120 | 5.0 | 5.2 | 6.3 | 0.151 |
| 50–59 | 8.1 | 7.8 | 8.8 | 0.040 | 6.7 | 6.0 | 6.9 | 0.684 |
| 60–69 | 9.4 | 8.9 | 10.4 | 0.000 | 8.1 | 7.5 | 7.9 | 0.588 |
| 70–79 | 10.8 | 10.4 | 11.3 | 0.257 | 8.8 | 9.1 | 9.4 | 0.177 |
| >79 | 12.6 | 12.4 | 11.9 | 0.390 | 10.7 | 10.7 | 11.2 | 0.646 |
Appendix D.
IBD Colonoscopy Quality Metrics Over Time
| Percent Good/Excellent Bowel Prep (when documented) | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | trend p-value | 2000–2004 | 2005–2009 | 2010–2014 | ||
| 20–39 | 82.5 | 80.8 | 84.6 | 0.160 | 82.3 | 83.5 | 83.7 | 0.428 |
| 40–49 | 82.4 | 79.4 | 86.0 | 0.053 | 82.7 | 85.3 | 86.7 | 0.018 |
| 50–59 | 80.3 | 75.5 | 84.6 | 0.018 | 83.0 | 82.7 | 86.2 | 0.053 |
| 60–69 | 76.8 | 77.7 | 81.0 | 0.004 | 80.2 | 80.8 | 85.4 | 0.006 |
| 70–79 | 75.5 | 72.8 | 81.8 | 0.013 | 81.8 | 80.4 | 88.4 | 0.030 |
| >79 | 76.1 | 75.9 | 83.5 | 0.226 | 84.7 | 78.4 | 88.4 | 0.764 |
| Colonoscopy Polyp Detection Rate | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 13.0 | 12.8 | 13.2 | 0.903 | 9.5 | 9.8 | 8.0 | 0.220 |
| 40–49 | 17.1 | 19.4 | 19.7 | 0.100 | 13.7 | 15.9 | 13.8 | 0.771 |
| 50–59 | 25.1 | 28.5 | 26.4 | 0.262 | 18.4 | 21.1 | 19.4 | 0.494 |
| 60–69 | 28.4 | 36.3 | 31.5 | 0.111 | 23.8 | 23.4 | 22.9 | 0.661 |
| 70–79 | 33.3 | 34.7 | 31.7 | 0.631 | 23.2 | 24.4 | 25.6 | 0.412 |
| >79 | 31.2 | 33.7 | 33.0 | 0.679 | 25.7 | 24.4 | 21.7 | 0.542 |
| Colonoscopy Polyp Detection Rate 2+ | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 3.5 | 2.7 | 2.5 | 0.179 | 2.4 | 2.0 | 1.7 | 0.287 |
| 40–49 | 3.6 | 5.2 | 4.6 | 0.216 | 3.3 | 3.1 | 3.0 | 0.700 |
| 50–59 | 8.3 | 10.1 | 8.7 | 0.519 | 5.1 | 5.9 | 5.5 | 0.663 |
| 60–69 | 10.7 | 15.1 | 12.7 | 0.137 | 6.3 | 7.4 | 6.7 | 0.779 |
| 70–79 | 13.4 | 13.8 | 11.8 | 0.440 | 7.2 | 8.3 | 6.6 | 0.897 |
| >79 | 13.7 | 9.9 | 13.0 | 0.653 | 7.4 | 8.0 | 5.8 | 0.778 |
| Colonoscopy Polyp Detection Rate > 9mm | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 2.8 | 3.1 | 1.4 | 0.028 | 1.7 | 1.6 | 0.9 | 0.123 |
| 40–49 | 3.9 | 3.1 | 2.7 | 0.113 | 2.7 | 2.1 | 1.9 | 0.220 |
| 50–59 | 4.4 | 3.8 | 3.7 | 0.357 | 3.0 | 3.2 | 2.9 | 0.941 |
| 60–69 | 5.0 | 6.8 | 4.7 | 0.652 | 4.8 | 4.4 | 3.0 | 0.076 |
| 70–79 | 7.0 | 6.6 | 6.5 | 0.691 | 5.6 | 4.2 | 3.3 | 0.089 |
| >79 | 9.3 | 8.6 | 7.0 | 0.526 | 5.9 | 5.2 | 0.0 | 0.088 |
Appendix E.
Diagnostic Colonoscopy Quality Metrics Over Time
| Percent Good/Excellent Bowel Prep | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 79.8 | 78.8 | 85.2 | <.0001 | 81.8 | 82.0 | 86.7 | <.0001 |
| 40–49 | 77.0 | 76.8 | 83.1 | <.0001 | 79.3 | 79.2 | 83.9 | <.0001 |
| 50–59 | 75.8 | 73.4 | 78.6 | <.0001 | 79.3 | 77.3 | 81.1 | 0.016 |
| 60–69 | 72.0 | 70.6 | 76.5 | <.0001 | 77.4 | 76.5 | 81.6 | <.0001 |
| 70–79 | 70.1 | 68.0 | 75.5 | <.0001 | 75.6 | 73.9 | 80.6 | <.0001 |
| >79 | 67.3 | 66.1 | 73.7 | <.0001 | 70.5 | 70.4 | 79.2 | <.0001 |
| Colonoscopy Polyp Detection Rate | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 18.3 | 17.8 | 18..9 | 0.331 | 12.8 | 12.7 | 13.8 | 0.036 |
| 40–49 | 31.0 | 31.6 | 34.7 | <.0001 | 21.4 | 22.7 | 23.9 | <.0001 |
| 50–59 | 37.2 | 38.6 | 41.9 | <.0001 | 25.4 | 26.5 | 31.2 | <.0001 |
| 60–69 | 40.4 | 41.2 | 45.7 | <.0001 | 29.1 | 29.9 | 33.7 | <.0001 |
| 70–79 | 39.5 | 40.1 | 45.2 | <.0001 | 29.5 | 30.5 | 34.9 | <.0001 |
| >79 | 37.1 | 37.4 | 39.4 | 0.029 | 29.5 | 30.4 | 33.5 | <.0001 |
| Colonoscopy Polyp Detection Rate 2+ | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 4.4 | 3.9 | 4.4 | 0.912 | 2.3 | 2.2 | 2.7 | 0.136 |
| 40–49 | 10.1 | 9.9 | 11.9 | <.0001 | 5.6 | 5.5 | 6.3 | 0.014 |
| 50–59 | 14.3 | 14.7 | 17.5 | <.0001 | 7.4 | 7.3 | 9.5 | <.0001 |
| 60–69 | 16.6 | 16.6 | 20.9 | <.0001 | 9.2 | 9.0 | 11.1 | <.0001 |
| 70–79 | 16.9 | 16.8 | 20.5 | <.0001 | 9.7 | 9.7 | 12.1 | <.0001 |
| >79 | 15.0 | 14.6 | 16.0 | 0.329 | 9.7 | 10.3 | 11.9 | 0.000 |
| Colonoscopy Polyp Detection Rate > 9mm | ||||||||
| Male | Female | |||||||
| 2000–2004 | 2005–2009 | 2010–2014 | p-value | 2000–2004 | 2005–2009 | 2010–2014 | p-value | |
| 20–39 | 3.7 | 2.7 | 3.0 | 0.009 | 2.0 | 1.9 | 1.9 | 0.603 |
| 40–49 | 6.3 | 6.0 | 6.5 | 0.758 | 3.9 | 3.9 | 4.2 | 0.208 |
| 50–59 | 8.5 | 4.0 | 9.1 | 0.184 | 4.8 | 4.8 | 5.5 | 0.002 |
| 60–69 | 11.2 | 9.8 | 11.6 | 0.826 | 6.6 | 5.9 | 6.9 | 0.667 |
| 70–79 | 12.1 | 11.1 | 13.4 | 0.084 | 8.1 | 7.8 | 8.7 | 0.239 |
| >79 | 14.0 | 12.7 | 14.1 | 0.573 | 11.1 | 10.6 | 12.2 | 0.189 |
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Disclosure statement:
The authors (SCM; NZ; JLH; DL) have no conflicts of interest to declare. SCM receives research funding from Genentech. The commercial entity had no involvement in this research.
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