Original article
Clinical endoscopy
Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications

https://doi.org/10.1016/j.gie.2012.11.012Get rights and content

Background and Objective

Serious GI adverse events in the outpatient setting were examined by polypectomy technique, endoscopist volume, and facility type (ambulatory surgery center and hospital outpatient department).

Design

Retrospective follow-up study.

Setting

Ambulatory surgery and hospital discharge datasets from Florida (1997-2004) were used.

Patients

A total of 2,315,126 outpatient colonoscopies performed in patients of all ages and payers were examined.

Main Outcome

Thirty-day hospitalizations because of colonic perforations and GI bleeding, measured as cumulative and specific outcomes, were investigated.

Results

Compared with simple colonoscopy, the adjusted risks of cumulative adverse events were greater with the use of cold forceps (1.21 [95% CI, 1.01-1.44]), ablation (3.75 [95% CI, 2.97-4.72]), hot forceps (5.63 [95% CI, 4.97-6.39]), snares (7.75 [95% CI, 6.95-8.64]), or complex colonoscopy (8.83 [95% CI, 7.70-10.12]). Low-volume endoscopists had higher risks of adverse events (1.18 [95% CI, 1.07-1.30]). A higher risk of adverse events was associated with procedures performed in ambulatory surgery centers (1.27 [95% CI, 1.16-1.40]). Important findings were also reported for the analyses stratified by specific outcomes and procedures.

Limitation

The study was constrained by limitations inherent in administrative data pertaining to a single state.

Conclusions

As the complexity of polypectomy increases, a higher risk of adverse events is reported. Using lower risk procedures when clinically appropriate or referring patients to high-volume endoscopists can reduce the rates of perforations and GI bleeding. Given the large number of colonoscopies performed in the United States, it is critical that the rates of adverse events be considered when choosing procedures.

Section snippets

Data sources

Ambulatory surgery and inpatient hospital discharge datasets were obtained from the Florida Agency for Health Care Administration for 1997 through 2004. Both datasets were at the encounter level and included unique patient and physician identifiers, primary and secondary diagnoses as classified by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), primary and secondary procedure codes based on Current Procedural Terminology (CPT), payer types,

Descriptive analyses

Among the more than 2 million colonoscopies in the sample, 44.38% were simple colonoscopies, 12.64% involved the use of cold biopsy forceps, 2.25% were ablations, 14.95% involved the use of hot biopsy forceps, 17.41% involved the use of snaring, and 8.37% were complex colonoscopies (Table 1). Low-volume endoscopists provided, on average, 179 simple colonoscopies, 177 colonoscopies with cold biopsy forceps, 180 colonoscopies with ablation, 183 colonoscopies with hot biopsy forceps, 188

Discussion

Analyses of all-encounter, all-payer data covering the entire population of Florida for a 7-year period provide an important advancement over previous studies that examined a limited number of facilities or health systems,4, 16, 17 used restricted datasets such as Medicare7 or Medicaid-only data,18 or were non-U.S. based.8, 19 As the complexity of polypectomy increases, a higher risk of adverse events was found in this study.

Simple colonoscopy without cautery is associated with the fewest

Acknowledgments

The authors thank Dr Theodore R. Levin, research scientist at the Kaiser Permanente Northern California Division of Research, gastroenterologist at Kaiser Permanente Medical Center, Walnut Creek, and assistant clinical professor of medicine, University of California, San Francisco, and Dr Doumit BouHaidar, Associate Professor of Medicine, Director of Advanced Therapeutic Endoscopy, Division of Gastroenterology, Virginia Commonwealth University, for reviewing earlier drafts of the manuscript and

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    DISCLOSURE: The authors disclosed no financial relationships relevant to this publication. This study (Dr Chukmaitov) is supported by the Virginia Commonwealth University Massey Cancer Center pilot grant.

    If you would like to chat with an author of this article, you may contact Dr Chukmaitov at [email protected].

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