Correspondence
Colonoscopic Withdrawal Times and Adenoma Detection
N Engl J Med 2007; 356:1174March 15, 2007
- Article
To the Editor:
Barclay and colleagues (Dec. 14 issue)1 report on their study demonstrating that endoscopists who withdraw the colonoscope rapidly appear to miss more lesions than do endoscopists who withdraw the colonoscope more slowly. An interesting question raised by this study is why withdrawal times are so fast for some endoscopists. Certainly, there are differences in skill levels. (Indeed, an analysis of the rate of detection of neoplasia in relation to insertion times, rather than withdrawal times, might shed some light on the importance of skill.) Though skill is one possible explanation for a rapid colonoscopy, another has to do with economics and the cold, hard fact that screening colonoscopy is potentially economically advantageous if it can be performed rapidly. That the screening-colonoscopy frenzy has hit the financial radar screen is implicit in the data from this study. Clearly, carefully performed colonoscopy is in the best interest of patients. If the return on colonoscopy in practice were determined per adenoma detected and removed, things might be a little different.
1 ReferencesSamir Gupta, M.D.
Don C. Rockey, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75390
don.rockey@utsouthwestern. edu 1
Barclay RL ,Vicari JJ ,Doughty AS ,Johanson JF ,Greenlaw RL . Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533-2541
Full Text | Web of Science | Medline
To the Editor:
Although the study by Barclay et al. suggests that longer withdrawal times lead to greater detection of adenomas, it is possible that a greater number of adenomas leads to a longer examination. Examining and measuring polyps take time. The observation may be influenced by reverse causality. The reverse causality would not be an issue if the patients of each physician were all the same, but that was not the case in this study. Withdrawal time is not the main concern; the carefulness of the physician is.
Bailey Shen
Dartmouth College, Hanover, NH 03755
bailey.shen@dartmouth. edu Author/Editor Response
As Gupta and Rockey suggest, the most obvious reason for faster colonoscopic withdrawal would be the financial incentive to perform additional procedures. However, our study design, facilitated by our practice structure, eliminated this possibility. We allocated standard 30-minute time slots for colonoscopies uniformly among all physicians, leaving no opportunity to schedule additional procedures. One of the cornerstones of our practice is the equal distribution of both work and income among all partners. Despite the minimization of individual economic incentive for more rapidly performed procedures, we nevertheless observed large differences in colonoscopic withdrawal times, which correlated strongly with the rates of adenoma detection.
Therefore, a search for underlying contributors to faster withdrawal times should include an analysis of remunerative and nonremunerative physician activities during the extra time made available by faster colonoscopies. Besides additional procedures, such activities include discussing the procedure and endoscopic findings with patients and their families, documenting endoscopic findings, doing follow-up with the patient after the procedure, directing the care of other patients, reading medical literature, and addressing day-to-day needs that arise in a busy clinical practice.
We did not attempt to analyze the activities of physicians between colonoscopies. However, our results suggest that even a relatively small amount of additional time devoted to careful inspection during withdrawal of the colonoscope is likely to result in a significant increase in the rate of adenoma detection for many endoscopists.
The concern of Shen about reverse causality would be valid except for the observation that withdrawal times for procedures in which no polyps were removed also correlated strongly with rates of adenoma detection. In screening colonoscopy, careful inspection and withdrawal time are inextricably related: the former is not possible without a sufficient amount of the latter.
Robert L. Barclay, M.D.
Joseph J. Vicari, M.D.
Roger L. Greenlaw, M.D.
Rockford Gastroenterology Associates, Rockford, IL 61107
drbarclay@rockfordgi.com - Citing Articles (1)
Citing Articles
1
B. K. Enestvedt, M. Brian Fennerty, A. Zaman, G. M. Eisen. (2011) MiraLAX vs. Golytely: is there a significant difference in the adenoma detection rate?. Alimentary Pharmacology & Therapeutics 34:7, 775-782
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