Quality indicators for colonoscopy in a Tunisian endoscopy unit

Colonoscopy is a powerful tool for prevention and early diagnosis of colorectal cancer. However, the effectiveness of colonoscopy is dependent on the quality of the procedure, which is assessed by a number of key quality indicators. Among them, cecal intubation and adenoma detection rate are historically the most commonly used indicators of quality of colonoscopy. The aim of our study was to evaluate these two indicators of quality of colonoscopy in a Tunisian endoscopy center.

We conducted a retrospective study from January 2009 to March 2013. Data were collected from colonoscopies reports. Demographic data, indication of the procedure, and endoscopic diagnosis were collected. The quality of bowel preparation was subjectively classified at the time of the examination by each endoscopist as good, fair, or poor. Procedure related quality indicators considered for analysis were: cecal intubation rate (CIR) and polyp detection rate.

During the period of the study, 859 colonoscopies were performed without sedation. The average age was 54.76 ± 17.5 years. Males represented the majority of our population (50.2%). Colic preparation was judged good, fair and poor in respectively 24 %, 61% and 15% of cases. The cecal intubation rate was 61.1 %. Causes of incomplete colonoscopy were especially poor preparation (47.3%) and poor tolerance (34.4%). Univariate analysis disclosed 3 predictive factors of CIR : the quality of bowel preparation (good vs fair or poor( (67.2 % vs 31.3%, p = 0.0001,OR: 4.5, 95% CI: 3.3-6), the screening indication (72.9% vs 60.1% , p = 0.03, OR: 1.7, 95% CI: 1-3) and the presence of alarming signs (55% vs 43%, p=0.04; OR: 1.1, 95% CI:0.9-2.5). By multivariate analysis, the factors influencing independently the CIR were the quality of bowel preparation (p=10-3, OR=2.23, 95% CI: 1.47-3.3) and the screening indication (p=0.02, OR: 1.9, 95% CI: 1.1-3.4). The polyp detection rate was 21% and was correlated, in univariate analysis with: age over 47 years (p=10-3, OR:3.2, 95 % CI:2-4.9), male gender (25.1% vs 16.8%, p=0.001, OR:2.36, 95% CI: 1.4-4), the quality of the preparation (26.5% vs 19.1%, p=0.03 OR:1.4, 95% CI:0.9 -2), the presence of colorectal cancer (50.9% vs 18.2%, p=0.0001, OR:4.6, 95% CI: 2.6-8) and the screening indication (35.7% vs 19%, p=0.001 OR: 2.36, 95% CI: 1.4- 4). By multivariate analysis, 3 independent factors associated with polyp detection rate were identified: age over 47 years (p=10-3, OR: 3.5 95% CI:2-5.9), bowel preparation (p=10-3 OR=5, 95% IC:2.7-9.6) and the screening indication( p=0.01, OR 2.5, 95% IC 1.4-4.7).

In our cohort, the quality of bowel preparation, tolerance of the procedure, age and the indication of colonoscopy were significantly associated with the indicators of quality. Bowel preparation and tolerance are targets on which we should act to improve performance.