Table 3. GRADE summary of effects of feedback interventions on colonoscopy quality indicators 22 .
| Outcomes | Anticipated absolute effects 1 (95 % CI) | Relative effect (95 % CI) | № of participants (studies) | Certainty of the evidence (GRADE) | Comments | |
| Risk with control | Risk with Educational interventions | |||||
| Adenoma detection rate – all studies as observational (ADR – Obs) | 265 adenomas detected per 1,000 colonoscopies | 341 per 1,000 (323 to 362) | Rate ratio 1.29 (1.22 to 1.37) | 86008 (8 observational studies) | ⊕⊕○○ LOW | Educational interventions likely result in an increase in adenoma detection rate – all studies as observational. |
| Adenoma detection rate – only non-randomized studies (ADR) | 308 adenomas detected per 1,000 colonoscopies | 391 per 1,000 (357 to 431) | Rate ratio 1.27 (1.16 to 1.40) | 43854 (5 observational studies) | ⊕○○○ VERY LOW 2 | Educational interventions may result in an increase in adenoma detection rate. |
| Adenoma detection rate – only RCTs (ADR-RCTs) | 267 adenomas detected per 1,000 | 315 per 1,000 (283 to 350) | Rate ratio 1.18 (1.06 to 1.31) | 25791 (3 RCTs) | ⊕⊕⊕○ MODERATE | Educational interventions likely increase adenoma detection rate – only RCTs. |
| Polyp Detection Rate (PDR) | 494 polyps detected per 1,000 colonoscopies | 608 per 1,000 (593 to 628) | Rate ratio 1.23 (1.20 to 1.27) | 19237 (3 observational studies) | ⊕○○○ VERY LOW 2 | Educational interventions may increase polyp detection rate but the evidence is very uncertain. |
| Proximal adenoma detection rate (pADR) | 93 proximal adenomas detected per 1,000 colonoscopies | 130 per 1,000 (120 to 138) | Rate ratio 1.39 (1.29 to 1.48) | 26001 (2 observational studies) | ⊕○○○ VERY LOW 2 | Educational interventions may increase proximal adenoma detection rate but the evidence is very uncertain. |
| Withdrawal time (WT) | The mean withdrawal time was 10.5 minutes | MD 0.29 minutes higher (0.18 lower to 0.76 higher) | – | 48393 (4 observational studies) | ⊕○○○ VERY LOW | Educational interventions may increase withdrawal time but the evidence is very uncertain. |
| Cecal intubation rate (CIR) | 962 per 1,000 colonoscopies | 962 per 1,000 (962 to 971) | Rate ratio 1.00 (1.00 to 1.01) | 26562 (2 observational studies) | ⊕○○○ VERY LOW | Educational interventions may have little to no effect on cecal intubation rate but the evidence is very uncertain. |
ADR, adenoma detection rate; RR, rate ratio; CI, confidence interval; MD, mean difference; OBS, observational studies
GRADE Working Group grades of evidence:
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
The risk in the intervention group (and its 95 % confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95 % CI).
a. All the observational studies are quasi-experimental with before and after comparisons. b. The heterogeneity, both statistical and clinical, is substantial and cannot be fully explained. c. The overlap between the confidence intervals is very limited. d. The confidence in the estimate is low (the 95 % CI for the pooled estimate is wide and/or crosses the line of no effect).