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Background and Aims: Endoscopists who encounter an interval colorectal cancer (I-CRC) may be concerned about the implications because I-CRCs may represent a lapse in colonoscopy quality and a missed opportunity for prevention. We wanted to determine the I-CRC rate per colonoscopy examination and to examine the effect of colonoscopy volume and adenoma detection rate (ADR) on the number of I-CRCs attributable to an endoscopist., Methods: We determined the rate of I-CRC diagnosis per outpatient colonoscopy examination by measuring the incidence of CRC diagnosis in practice and by assessing, via literature review, the percentage of cancers that are interval. We also estimated the number of attributable I-CRCs as a function of ADR and colonoscopy volume., Results: Among 93,562 colonoscopies performed in 2013 to 2015 by 120 physicians in 4 diverse U.S. medical centers, 526 CRCs were diagnosed (.6%). Of 149,556 CRCs in the published literature, 7958 were I-CRCs (5.25% ± .94%). With rates of .6% (CRC per colonoscopy) and 5.25% (I-CRC per CRC), the rate of I-CRC is 1 per 3174 colonoscopies (95% confidence interval, 1 per 2710 to 1 per 3875). An endoscopist at the median of outpatient colonoscopy volume (316/year) in the lowest ADR quintile of detection (7%-19%) would have an I-CRC attributed every 8.2 years, or 4.2 I-CRCs in a 35-year career, versus every 16.7 years, or 2.0 I-CRCs in a 35-year career, for an endoscopist in the highest ADR quintile (33%-52%)., Conclusions: An average-volume endoscopist will have 2 to 4 attributable I-CRCs in a 35-year career, but the frequency will vary depending on colonoscopy volume and ADR., (Copyright © 2018 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: The adenoma detection rate (ADR) is a validated and widely used measure of colonoscopy quality. There is uncertainty in the published literature as to which colonoscopy examinations should be excluded when measuring a physician's ADR., Objective: To examine the impact of varying the colonoscopy exclusion criteria on physician ADR., Design: We applied different exclusion criteria used in 30 previous studies to a dataset of endoscopy and pathology reports. Under each exclusion criterion, we calculated physician ADR., Setting: A private practice colonoscopy center affiliated with the University of Illinois College of Medicine., Patients: Data on 20,040 colonoscopy examinations performed by 11 gastroenterologists from July 2009 to May 2013 and associated pathology notes., Main Outcome Measurements: ADRs across all colonoscopy examinations, each physician's ADR, and ADR ranking., Results: There were 28 different exclusion criteria used when measuring the ADR. Each study used a different combination of these exclusion criteria. The proportion of all colonoscopy examinations in the dataset excluded under these combinations of exclusion criteria ranged from 0% to 92.2%. The mean ADR across all colonoscopy examinations was 39.1%. The change in mean ADR after applying the 28 exclusion criteria ranged from -5.5 to +3.0 percentage points. However, the exclusion criteria affected each physician's ADR relatively equally, and therefore physicians' rankings via the ADR were stable., Limitations: ADR assessment was limited to a single private endoscopy center., Conclusion: There is wide variation in the exclusion criteria used when measuring the ADR. Although these exclusion criteria can affect overall ADRs, the relative rankings of physicians by ADR were stable. A consensus definition of which exclusion criteria are applied when measuring ADR is needed., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Enteral access placement is performed among a variety of providers and specialties, yet there is a dearth of literature on trends and factors related to enteral access placement in the United States., Objective: To examine trends in the incidence of enteral access procedures performed by gastroenterologists in the United States., Design: Retrospective review of upper endoscopic procedures that involved PEG tube placement between 2000 and 2010., Setting: Endoscopy sites participating in the Clinical Outcomes Research Initiative (CORI)., Patients: Patients undergoing upper endoscopy., Interventions: PEG tube placement., Main Outcome Measurements: Number of PEG tubes placed., Results: Overall PEG tube placement by a provider from 2000 to 2010 was 1.7% (number of PEG tubes performed/number of upper endoscopies performed), with the majority of them being performed by gastroenterologists. Very young and very old, non-white racial background (Hispanic: odds ratio [OR] 1.21; 95% CI, 1.13-1.28; black: OR 2.24; 95% CI, 2.12-2.36), and men (OR 1.44; 95% CI, 1.39-1.50) were patient characteristics associated with greater PEG tube placement. In terms of practice setting, PEG tube placement occurred more frequently in community and/or health maintenance organization environments and on the East Coast. With respect to provider characteristics, male providers were less likely than female providers to perform a PEG tube insertion (OR 0.67; 95% CI, 0.64-0.71), and there was a trend that as providers were further out of medical school they were less likely to perform a PEG tube procedure. Interestingly, surgeons (OR 6.69; 95% CI, 6.18-7.24) and other providers (non-pediatric/non-general practice) (OR 3.22; 95% CI, 2.63-3.94) were more likely to perform PEG tube procedures than were gastroenterologists., Limitations: Participation in CORI is voluntary and may not capture data on non-gastroenterologist providers., Conclusion: Significant practice variation was noted in PEG tube placement in the United States with respect to patient and provider characteristics, geographic region, and endoscopy settings., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Background: Despite having one of the highest rates per capita for colonoscopy worldwide, colorectal cancer remains the second most commonly diagnosed malignancy in Australia., Objective: Our aim was to document colonoscopy/polypectomy practice nationwide and assess whether significant differences exist., Design: Observational study., Setting: Online survey conducted nationally in 2012., Participants: Medical practitioners registered with the Gastroenterological Society of Australia practicing colonoscopy., Main Outcome Measurements: Rates of polypectomy techniques for varying polyp sizes, postpolypectomy bleeding prophylaxis techniques, and adenoma detection practices. To assess whether variations exist according to practice location, specialty, and experience and comparison of practice with a previous American cohort., Results: Of the 846 members contacted, 244 (28.8%) responded. The cohort consisted primarily of consultant gastroenterologists (182/244, 74.6%). The cold-snare technique was preferred (165/244, 67.6%) for polyps 3 mm in size; however, this decreased rapidly with increasing polyp size (5 mm [120/244, 49.2%] and 7-9 mm [18/244, 7.4%]). EMR was the preferred method of resection for polyps 7 to 9 mm in size (148/244, 60.7%). The withdrawal technique predominantly consisted of double-passing high-risk areas and rectal retroflexion (134/244, 54.9%). Significant differences across specialty, location, and experience included polypectomy method for diminutive polyps, the use of EMR, and retroflexion., Limitations: Survey-based study and response rate., Conclusion: Although variations in colonoscopy and polypectomy practice exist, the majority of our cohort performs cold-snare polypectomy for diminutive polyps and pass high-risk, poorly visualized areas twice on withdrawal. This is a significant shift in practice from that of the U.S. cohort studied 10 years earlier., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. All rights reserved.)

Background: Despite the increasing number of patients undergoing endoscopic therapy for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal cancer (IMC), there are few data to guide clinical decision making and research initiatives in the area of posttreatment follow-up., Objectives: We aimed to define expert practice patterns regarding follow-up after endoscopic treatment of BE with HGD and IMC., Design: Electronic survey., Subjects: Forty-eight endoscopists in the United States with expertise in BE endotherapy based on high-impact publications and national reputation., Intervention: A 21-item Web-based survey inquiring about post-BE endotherapy follow-up practices., Results: Of 48 expert endoscopists, 42 completed the survey. After successful treatment of BE with HGD or IMC, all experts perform surveillance upper endoscopy, most commonly at 3-month intervals in the first posttreatment year, every 6 months during the second year, and annually thereafter. None of the experts perform surveillance EUS after treatment of HGD, and only 19% perform EUS after treatment of IMC. After cancer eradication, only 36% of experts refer patients for CT, and 24% refer patients for positron emission tomography. Thirty-eight percent of experts refer patients for a surgical opinion when IMC extends into the muscularis mucosa; 100% refer when IMC extends into submucosa., Limitations: Not a consensus document; only U.S. experts included., Conclusions: This study reports the follow-up practices of expert endoscopists after successful endotherapy for BE with HGD and IMC. Additional research is necessary to establish optimal surveillance intervals, the role of follow-up EUS, CT, and positron emission tomography, as well as the surgical implications of low-risk IMC extending into the muscularis mucosa., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Endoscopic management of Barrett's esophagus (BE) has evolved over the past decade; however, the practice patterns for managing BE among gastroenterologists remain unclear., Objective: To assess practice patterns for management of BE among gastroenterologists working in various practice settings., Design: A random questionnaire-based survey of practicing gastroenterologists in the United States. The questionnaire contained a total of 10 questions pertaining to practice setting, physician demographics, and strategies used for managing BE., Setting: Survey of gastroenterologists working in various practice settings., Intervention: Questionnaire., Main Outcome Measurements: Practice patterns for endoscopic imaging and management of BE., Results: The response rate was 45% (236/530). The majority (85%) were gastroenterologists in community practice, 72% were aged 41 to 60 years, 80% had >10 years of experience, and 81% had attended postgraduate courses and/or seminars on BE management. A total of 78% did not use the Prague C & M classification, and about a third used advanced endoscopic imaging routinely (37%) or in selected cases (31%). For nondysplastic BE, 86% practiced surveillance, 12% performed ablation, and 3% did no intervention. For BE with low-grade dysplasia, 56% practiced surveillance, 26% performed endoscopic ablation in all low-grade dysplasia cases, and 18% performed endoscopic ablation in only selected patients with low-grade dysplasia. The majority of respondents (58%) referred their patients with high-grade dysplasia to centers with BE expertise, 13% performed endoscopic ablation in all patients with high-grade dysplasia, 25% performed endoscopic ablation in selected cases only, and 3% referred these patients for surgery. The most frequently used endoscopic eradication therapy was radiofrequency ablation (39%) followed by EMR (17%)., Limitations: The sample may be unrepresentative, participation in the study was voluntary, and responses may be skewed toward following the guidelines., Conclusion: Results from this survey show that the majority of practicing gastroenterologists in the United States practice surveillance endoscopy in patients with nondysplastic BE and provide endoscopic therapy for those with high-grade dysplasia. The Prague C & M classification and advanced imaging techniques are used by less than a third of gastroenterologists. Practice patterns did not appear to be affected by respondent age or duration of clinical practice., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: ERCP practice patterns in the United States are largely unknown., Objective: To characterize the ERCP practice of U.S. gastroenterologists, stratified by their annual case volume: high volume (HV, >200), moderate volume (MV, 50-200), and low volume (LV, <50)., Design: Anonymous electronic survey., Subjects: American Society for Gastrointestinal Endoscopy members who are practicing U.S. gastroenterologists., Results: Among all responders (N = 1006), 63% were derived from community practices. Physicians who performed ERCPs and provided data on annual volume (n = 669) were classified as LV (n = 254), MV (n = 284), and HV (n = 131). During training, 77% of LV physicians did not complete 180 ERCPs compared with 58% of MV and 34% of HV physicians (P < .0001). Only 58% of LV physicians enjoy performing ERCP compared with 88% of MV and 98% of HV physicians (P < .0001); 60% reported being "very comfortable" with ERCP compared with more than 90% of MV and HV physicians (P < .0001). LV physicians are less comfortable with pancreatic duct stenting (PDS) (57% vs 92% [MV] and 98% [HV], P ≤ .02) and using prophylactic PDS. Although HV physicians (42%) were least likely to use short-wire devices (P < .02), use of wire-guided cannulation was similar (74% LV, 72% MV, 66% HV, P = .13). Thirty-seven percent of LV physicians reported comfort with needle-knife sphincterotomy compared with 75% (MV) and 99% (HV) (P < .0001)., Limitations: Survey completion rate of 18.5%., Conclusions: Self-reported comfort and/or enjoyment with ERCP is lower among LV physicians. Wire-guided cannulation is used by the majority of all ERCP practitioners, but prophylactic PDS is less frequently used by LV physicians. Because many LV physicians perform ERCP for higher-grade indications and use advanced techniques (eg, needle-knife sphincterotomy), further LV physician ERCP outcomes data are needed., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Recently updated practice guidelines give specific recommendations on surveillance and management of dysplasia in patients with ulcerative colitis. Previous studies of gastroenterologists in the United States and the United Kingdom demonstrated inconsistent surveillance techniques and limited understanding of the implications of dysplasia., Objectives: To demonstrate current surveillance practices and management of dysplasia among U.S. gastroenterologists., Design: An 18-item questionnaire was mailed to 1000 gastroenterologists in the United States who were randomly selected from an American Gastroenterological Association mailing list., Setting: United States., Results: A total of 334 questionnaires were returned, and 312 were analyzed: 25% of respondents were in academic practice and 75% were in private practice. The majority were in practice more than 10 years. Nearly 80% begin surveillance colonoscopy at 8 to 10 years of disease duration for patients with pancolitis, and 54% report sending at least 31 biopsy specimens. Sixty percent of respondents did not recommend immediate colectomy for a confirmed finding of low-grade dysplasia, instead opting for repeat colonoscopy in 3 to 12 months. Physicians who took fewer biopsy specimens were more likely to recommend continued surveillance for low-grade dysplasia compared with those who took a greater number of biopsy specimens., Limitations: Limitations included the response rate of 33% and the potential for recall bias., Conclusions: Most U.S. gastroenterologists are practicing surveillance in patients with ulcerative colitis in accordance with published guidelines. There is widespread variation in the management of dysplasia and raised lesions, and the majority of U.S. gastroenterologists do not recommend immediate colectomy for a finding of low-grade dysplasia.

Background: In the United States, colonoscopy completion and complication rates are rarely reported outside academic institutions. Increased transparency of quality measures and outcomes is being driven by professional societies, government agencies, and private enterprise., Objective: To collect and report the completion and complication rates of colonoscopy in a community gastroenterology practice., Design: Single-center study, prospective for completion, retrospective for complications., Setting: Community gastroenterology group practice, conducted from August 2002 through December 2004., Patients: A total of 12,407 consecutive patients referred for colonoscopy; mean age, 59.7 years; 5925 men., Interventions: Polypectomy and cautery were completed as indicated., Main Outcome Measures: Completion of colonoscopy to cecum or ileocolonic anastomosis. Complications of hemorrhage and perforation., Results: A colonoscopy was completed in 98.4% of patients. Polypectomy was accomplished in 5074 (40.9%). Polyps occurred more often in men (46.4% vs 35.8%, P < .001). Causes for failure included difficult anatomy (55.9%), inadequate preparation (20.8%), obstructing malignancy (8.6%), discomfort (8.1%), and severe inflammation (6.1%). Failure from difficult anatomy was more likely in women (1.19% vs 0.56%, P < .001). Hemorrhage requiring hospitalization occurred after 25 cases (0.20%). Twenty-three episodes of bleeding occurred after polypectomy (0.46%) and 2 after treatment of arteriovenous malformations. Two perforations occurred (0.016%). One patient developed a posterior circulation stroke. No deaths occurred., Limitations: Completion not independently verifiable. Complications were collected retrospectively., Conclusions: Colonoscopy completion and complication rates in this community gastroenterology practice compared favorably with U.S. academic centers. Endoscopic quality in community practices can meet published outcomes.

Background: The aim of this study was to assess the colorectal cancer surveillance practices of British gastroenterologists for patients with ulcerative colitis., Methods: A questionnaire that investigated aspects of surveillance in patients with ulcerative colitis was mailed to all consultant gastroenterologists in the U.K. (n = 413)., Results: Three hundred forty-one questionnaires were returned (response rate 83%). Ninety-four percent of consultants practice cancer surveillance in ulcerative colitis, with 35% maintaining a registry of patients in surveillance programs. All gastroenterologists perform surveillance in patients with pancolitis, 24% in those with left-sided colitis and 2% in patients with proctitis. The mean duration of disease before surveillance is commenced is 9.2 years for pancolitis and 12.4 years for left-sided colitis (p < 0.0001). Only 4% of gastroenterologists routinely offer patients with disease of more than 10 years' duration a prophylactic colectomy. Colonoscopies are conducted by an accredited gastroenterologist in 65% of cases and biopsies are reviewed by specialists in gastrointestinal pathology in 45%. When histology reveals low-grade dysplasia only 4% advise colectomy and when high-grade dysplasia is found 53% recommend colectomy. Sixteen percent of gastroenterologists were unaware of the significance of a dysplasia associated lesion or mass., Conclusion: The majority of gastroenterologists practice surveillance on a disorganized basis. There is inconsistency in the management of patients with dysplasia and education of gastroenterologists is needed.

A randomized clinical trial assessed the medical costs during 6 months after the evaluation of dyspepsia by gastroenterology consultation with esophagogastroduodenoscopy versus barium radiography. Primary care physicians entered patients whose dyspepsia responded incompletely to empiric therapy or recurred. The consultation/endoscopy group (N = 32) was similar (p greater than 0.23) to the radiography group (N = 34) regarding age, gender, physician visits, and costs of all dyspepsia drugs and H2 blockers during 6 months before evaluation. Most patients had non-ulcer dyspepsia. Costs during the succeeding 6 months (consultation/endoscopy versus radiography groups) were physician visits ($33.1 +/- 14.5 vs. $114.2 +/- 23.3, p less than 0.005); radiologic procedures ($70.5 +/- 37.3 vs. $67.6 +/- 22.5, p greater than 0.30); all dyspepsia drugs ($30.4 +/- 10.0 vs. $100.1 +/- 36.8, p = 0.08); H2 blockers ($25.4 +/- 9.5 vs. $96.0 +/- 34.7, p = 0.06); and total cost ($134.0 +/- 43.8 vs. $435.3 +/- 93.9, p = 0.006). The higher total cost in the radiography group was partly due to the referral of 7 patients (21%) for gastroenterology consultation due to persistent dyspepsia, 6 of whom had endoscopy versus the performance of radiography in 0 of the 32 consultation/endoscopy patients (p less than 0.025). Dyspepsia self-ratings were similar.