Measuring the observer (Hawthorne) effect on adenoma detection rates

Abstract

Background and study aims An independent observer can improve procedural quality. We evaluated the impact of the observer (Hawthorne effect) on important quality metrics during colonoscopies.

Patients and Methods In a single-center comparative study, consecutive patients undergoing routine screening or diagnostic colonoscopy were prospectively enrolled. In the index group, all procedural steps and quality metrics were observed and documented, and the procedure was video recorded by an independent research assistant. In the reference group, colonoscopies were performed without independent observation. Colonoscopy quality metrics such as polyp, adenoma, serrated lesions, and advanced adenoma detection rates (PDR, ADR, SLDR, AADR) were compared. The probabilities of increased quality metrics were evaluated through regression analyses weighted by the inversed probability of observation during the procedure.

Results We included 327 index individuals and 360 referents in the final analyses. The index group had significantly higher PDRs (62.4% vs. 53.1%, P=0.02) and ADRs (39.4% vs. 28.3%, P=0.002) compared with the reference group. The SLDR and AADR were not significantly increased. After adjusting for potential confounders, the ADR and SLDR were 50% (relative risk [RR] 1.51; 95%, CI 1.05–2.17) and more than twofold (RR 2.17; 95%, CI 1.05–4.47) more likely to be higher in the index group than in the reference group.

Conclusions The presence of an independent observer documenting colonoscopy quality metrics and video recording the colonoscopy resulted in a significant increase in ADR and other quality metrics. The Hawthorne effect should be considered an alternative strategy to advanced devices to improve colonoscopy quality in practice.

Keywords

Polyps / adenomas / ... - Endoscopy Lower GI Tract - Colorectal cancer - CRC screening - Endoscopic resection (polypectomy, ESD, EMRc, ...)

Publikationsverlauf

Eingereicht: 05. November 2022

Angenommen nach Revision: 13. Juli 2023

Accepted Manuscript online:
17. Juli 2023

Artikel online veröffentlicht:
06. Oktober 2023

• References

• 1 Zauber AG, Winawer SJ, OʼBrien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696 DOI: 10.1056/NEJMoa1100370. (PMID: 22356322)
• 2 Rex DK, Schoenfeld PS, Cohen J. et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31-53 DOI: 10.1016/j.gie.2014.07.058. (PMID: 25480100)
• 3 Cross AJ, Robbins EC, Saunders BP. et al. Higher adenoma detection rates at screening associated with lower long-term colorectal cancer incidence and mortality. Clinical Gastroenterology and Hepatology 2022; 20: e148-e167
• 4 Kahi CJ, Vemulapalli KC, Johnson CS. et al. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric. The indiana university experience 2014; 79: 448-454
• 5 Taghiakbari M, Mori Y, von Renteln D. Artificial intelligence-assisted colonoscopy: A review of current state of practice and research. World J Gastroenterol 2021; 27: 8103-8122 DOI: 10.3748/wjg.v27.i47.8103. (PMID: 35068857)
• 6 Aniwan S, Orkoonsawat P, Viriyautsahakul V. et al. The secondary quality indicator to improve prediction of adenoma miss rate apart from adenoma detection rate. Am J Gastroenterol 2016; 111: 723-729
• 7 Srigley JA, Furness CD, Baker GR. et al. Quantification of the hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: A retrospective cohort study. BMJ Qual Saf 2014; 23: 974-980 DOI: 10.1136/bmjqs-2014-003080. (PMID: 25002555)
• 8 Taghiakbari M, Hamidi Ghalehjegh S, Jehanno E. et al. Automated detection of anatomical landmarks during colonoscopy using a deep learning model. J Canadian Assoc Gastroenterol 2023; DOI: 10.1093/jcag/gwad017.
• 9 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions: Recommendations by the us multi-society task force on colorectal cancer. Am J Gastroenterol 2020; 115: 435-464 DOI: 10.14309/ajg.0000000000000555. (PMID: 32058340)
• 10 Jass JR, Sobin LH, Morson BC. Histological typing of intestinal tumours. 2nd ed. Berlin, New York: Springer-Verlag; 1989
• 11 Gupta S, Lieberman D, Anderson JC. et al. Recommendations for follow-up after colonoscopy and polypectomy: A consensus update by the us multi-society task force on colorectal cancer. Gastroenterology 2020; 158: 1131-1153 DOI: 10.14309/ajg.0000000000000544. (PMID: 32039982)
• 12 The paris endoscopic classification of superficial neoplastic lesions. Esophagus, stomach, and colon: November 30 to december 1, 2002. Gastrointest Endosc 2003; 58: S3-S43 DOI: 10.1016/s0016-5107(03)02159-x. (PMID: 14652541)
• 13 Wang H, Wang P, Liu X. et al. Factors predicting the colorectal adenoma detection rate in colonoscopic screening of a chinese population: A prospective study. Medicine (Baltimore) 2019; 98: e15103 DOI: 10.1097/MD.0000000000015103. (PMID: 30985664)
• 14 Bailie L, Loughrey MB, Coleman HGJG. Lifestyle risk factors for serrated colorectal polyps: A systematic review and meta-analysis. Gastroenterology 2017; 152: 92-104 DOI: 10.1053/j.gastro.2016.09.003. (PMID: 27639804)
• 15 Kolligs FT, Crispin A, Munte A. et al. Risk of advanced colorectal neoplasia according to age and gender. PLoS One 2011; 6: e20076 DOI: 10.1371/journal.pone.0020076. (PMID: 21629650)
• 16 Lin J, O’Connor E, Evans C. et al. Screening for Colorectal Cancer: An Evidence Update for the U.S. Preventive Services Task Force [Internet]. 2021 https://www.ncbi.nlm.nih.gov/books/NBK570913/
• 17 Rex DK, Johnson DA, Anderson JC. et al. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol 2009; 104: 739-750
• 18 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803 DOI: 10.1056/NEJMoa0907667. (PMID: 20463339)
• 19 Regula J, Rupinski M, Kraszewska E. et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N Engl J Med 2006; 355: 1863-1872 DOI: 10.1056/NEJMoa054967. (PMID: 17079760)
• 20 Brenner H, Altenhofen L, Hoffmeister MJA. Sex, age, and birth cohort effects in colorectal neoplasms: A cohort analysis. Ann Intern Med 2010; 152: 697-703 DOI: 10.7326/0003-4819-152-11-201006010-00002. (PMID: 20513827)
• 21 Ferlitsch M, Reinhart K, Pramhas S. et al. Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy. JAMA 2011; 306: 1352-1358 DOI: 10.1001/jama.2011.1362. (PMID: 21954479)
• 22 Ricci E, Hassan C, Petruzziello L. et al. Inter-centre variability of the adenoma detection rate: A prospective, multicentre study. Dig Liver Dis 2013; 45: 1022-1027 DOI: 10.1016/j.dld.2013.05.009. (PMID: 23816699)
• 23 Anderson JC, Butterly LF, Goodrich M. et al. Differences in detection rates of adenomas and serrated polyps in screening versus surveillance colonoscopies, based on the new hampshire colonoscopy registry. Clin Gastroenterol Hepatol 2013; 11: 1308-1312 DOI: 10.1016/j.cgh.2013.04.042. (PMID: 23660415)
• 24 Millan MS, Gross P, Manilich E. et al. Adenoma detection rate: The real indicator of quality in colonoscopy. Dis Colon Rectum 2008; 51: 1217-1220 DOI: 10.1007/s10350-008-9315-3. (PMID: 18500502)
• 25 Hassan C, Repici A, Rex DK. Fitting adr to colonoscopy indication. United European Gastroenterol J 2017; 5: 149-152 DOI: 10.1177/2050640616667171. (PMID: 28344785)
• 26 Rembacken B, Hassan C, Riemann JF. et al. Quality in screening colonoscopy: Position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012; 44: 957-968 DOI: 10.1055/s-0032-1325686. (PMID: 22987217)
• 27 Aziz M, Weissman S, Khan Z. et al. Use of 2 observers increases adenoma detection rate during colonoscopy: Systematic review and meta-analysis. Clin Gastroenterol Hepatol 2020; 18: 1240-1242
• 28 Oh YS, Collins CL, Virani S. et al. Lack of impact on polyp detection by fellow involvement during colonoscopy: A meta-analysis. Digest Dis Sci 2013; 58: 3413-3421
• 29 Anderson JC, Butterly LF, Weiss JE. et al. Providing data for serrated polyp detection rate benchmarks: An analysis of the new hampshire colonoscopy registry. Gastrointest Endosc 2017; 85: 1188-1194 DOI: 10.1016/j.gie.2017.01.020. (PMID: 28153571)
• 30 Hazewinkel Y, de Wijkerslooth TR, Stoop EM. et al. Prevalence of serrated polyps and association with synchronous advanced neoplasia in screening colonoscopy. Endoscopy 2014; 46: 219-224
• 31 Schramm C, Janhsen K, Hofer J-H. et al. Detection of clinically relevant serrated polyps during screening colonoscopy: Results from seven cooperating centers within the german colorectal screening program. Endoscopy 2018; 50: 993-1000
• 32 Cubiella J, Castells A, Andreu M. et al. Correlation between adenoma detection rate in colonoscopy- and fecal immunochemical testing-based colorectal cancer screening programs. United European Gastroenterol J 2017; 5: 255-260