The Alberta Primary Care Endoscopy (APC-Endo) Study

• Percentage of Successful Cecal Intubations (Crude) [ Time Frame: At time of colonoscopy (DAY 1 of study) ] [ Designated as safety issue: No ]
  The percentage of successful cecal intubations (crude) = (total # of colonoscopies performed where cecal intubation was achieved / total # of colonoscopies attempted) x 100
  
  
• Percentage of Successful Cecal Intubations (Adjusted) [ Time Frame: At time of colonoscopy (DAY 1 of study) ] [ Designated as safety issue: No ]
  The percentage of successful cecal intubations (adjusted) = total number of colonoscopies performed where cecal intubation was achieved / (total number of colonoscopies attempted -incomplete colonoscopies due to poor bowel preparation, colonic stricture, equipment failure or severe endoscopic colitis)
  
  
• Adenoma Detection Ratio [ Time Frame: When pathology from colonoscopy available (on average 2-3 weeks after procedure) ] [ Designated as safety issue: No ]
  The adenoma detection ratio is the number of pathologically verified adenomas per number of colonoscopies performed. Adenoma detection ratio = total number of pathologically confirmed adenomas / number of colonoscopies attempted.
  
  
• Percentage of Males 50 Years and Older Undergoing First Time Colonoscopy With an Adenoma [ Time Frame: When pathology from colonoscopy available (on average 2-3 weeks after procedure) ] [ Designated as safety issue: No ]

  Percentage of patients with an adenoma = (number of patients who had at least one adenoma detected on colonoscopy / total number of colonoscopies attempted) x 100.

  For this specific outcome: we explored this outcome for males 50 years and older undergoing first time colonoscopy.

  
  
• Percentage of Females 50 Years and Older Undergoing First Time Colonoscopy With an Adenoma [ Time Frame: [When pathology from colonoscopy available (on average 2-3 weeks after procedure)] ] [ Designated as safety issue: No ]

  Percentage of patients with an adenoma = (number of patients who had at least one adenoma detected on colonoscopy / total number of colonoscopies attempted) x 100.

  For this specific outcome: we explored this outcome for females 50 years and older undergoing first time colonoscopy.

  
  

• Colonoscopy Complications: Bleeding, Perforation, Cardiopulmonary Complications Secondary to Conscious Sedation, and Death. [ Time Frame: Within four (4) weeks of colonoscopy ] [ Designated as safety issue: Yes ]

  Potential serious complications of colonoscopy include bleeding, perforation, cardiopulmonary complications secondary to conscious sedation and death.

  Potential serious complications will be determined from the case report form (physician reported) and at patient satisfaction phone survey (on average four weeks after colonoscopy).

  All potential serious complications of colonoscopy will be externally adjudicated.

  
  
• Colonoscopy Withdraw Time in Cases Where no Lesions Found [ Time Frame: At time of colonoscopy (DAY 1 of study) ] [ Designated as safety issue: No ]
  Withdrawal time will be defined as the time from leaving the cecum until the colonoscope exits the anus. This will be calculated for cases in which no lesions were found.
  
  
• Patient Comfort During Colonoscopy [ Time Frame: At time of colonoscopy (DAY 1 of study) ] [ Designated as safety issue: No ]

  To determine the patients' comfort level during the colonoscopy, a five-item question used by the Joint Advisory Group on Gastrointestinal Endoscopy in the United Kingdom will be used.

  Patient discomfort on the 5 point scale:

  0 is no discomfort;

  1. is one or two episodes of discomfort, well tolerated;
  2. is more than two episodes of discomfort adequately tolerated;
  3. is significant discomfort experienced several times during the procedure;
  4. is extreme discomfort experienced frequency throughout the procedure.

  Minimum value = 0, maximum value = 4 with 4 being worse.

  
  
• Patient Satisfaction With Endoscopy Wait Time [ Time Frame: At patient satisfaction phone survey (on average 4 weeks after colonoscopy) ] [ Designated as safety issue: No ]

  Patient satisfaction with endoscopy wait time will be recorded using a 7 point Likert scale at the time of the patient phone survey. 7 is extremely satisfied and 1 is extremely dissatisfied

  minimum score = 1 maximum score = 7

  
  
• Patient Satisfaction With Hospital Experience for Colonoscopy [ Time Frame: At patient satisfaction phone survey (on average 4 weeks after colonoscopy) ] [ Designated as safety issue: No ]

  Patient satisfaction with their hospital experience during their colonoscopy will be recorded by using a 7 point Likert scale at the time of the patient satisfaction phone survey.

  7 = extremely satisfied

  1 = extremely dissatisfied

  Minimum score = 1 Maximum score = 7

  
  
• Colonoscopy Procedure Time [ Time Frame: At time of colonoscopy (DAY 1 of study) ] [ Designated as safety issue: No ]
  Colonoscopic procedural time will be defined as the time from the first insertion of the colonoscope until it is removed from the anus.
  
  
• Percentage of Patients Referred to a Specialist. [ Time Frame: Within four (4) weeks of colonoscopy ] [ Designated as safety issue: No ]
  The percentage of patients who are anticipated to be referred to specialists, for the gastrointestinal complaint for which the colonoscopy was performed will be determined and the reason for referral will be tabulated. The referral percentage will be determined both from the time of colonoscopy (physician reported) and from the patient satisfaction phone survey (patient reported).
  
  

Discrepant data exists about the quality of colonoscopies performed by family physicians and general internists. Currently in Canada, gastroenterologists and general surgeons perform 97% of the colonoscopies, but excessive wait times highlight a shortage of colonoscopists in Canada. This shortage will invariably worsen as our population ages and more Canadians become screened for colorectal cancer.

One method of improving this relative shortage of colonoscopists is through training primary care physicians in GI medicine and endoscopy. In order these physicians to be a legitimate option in the provision of colonoscopies; however, it must be shown that, as a group, they are able to meet benchmarks in colonoscopy competency.

This multi-centre observational study will be the first study to prospectively analyze colonoscopic examinations performed by primary care physicians at a provincial level. Using primarily cecal intubation rates and adenoma detection rates, along with other quality parameters, this study will compare the results of Alberta primary care physicians to standard benchmarks in colonoscopy competency.

Data will be collected using case report forms completed at the time of the colonoscopy, reviewing the patients' colonoscopy pathology results and a post procedure telephone survey to examine patient satisfaction rates.

If this study demonstrates that quality benchmarks are indeed met, then future training of primary care physicians in gastrointestinal medicine and endoscopy would be encouraged to help address current and future colonoscopist shortages.