Colonoscopy quality up during video recording

When seven colonoscopists knew they were being video recorded, the quality of their exams improved significantly.

The study investigators placed video recorders in all rooms in the hospital outpatients department and ambulatory surgery center of one institution. They explained the study to nurses and technicians and told them not discuss the video recordings with attending physicians.

After recording seven attending physicians each performing 8-10 colonoscopies for patients without inflammatory bowel disease or polyposis syndromes, the colonoscopists were informed that they would be video recorded for the purpose of quality review but were not told about the previous recordings.

Recordings of 8-10 more colonoscopies performed by each of the seven physicians were then obtained. All the recordings were downloaded onto separate digital video discs, identified as “preawareness” or “postawareness” of video recording, and then scored for exam quality and “inspection time” by a single expert. The expert was blinded to the “pre” and “post” categories, reported at the annual meeting of the American College of Gastroenterology.

The expert graded 98 of the video recordings using a 5-point sale (higher scores being better) to assess fold examination, accurate destention, and cleanup effectiveness. Finally, the expert provided a subjective assessment of whether adequate time was taken to examine each of six segments of the colon (cecum, ascending, transverse, descending, sigmoid, and rectum).

Mean scores for overall quality improved from 2.9 in the “preawareness” period to 3.8 in the “postawareness” period, a highly significant difference, distinguished professor of medicine at Indiana University Hospital. Quality scores also improved significantly for fold examination (2.5 versus 3.5), distention quality (3.4 versus 4.2), cleanup (3.0 versus 3.9), and time taken (2.6 versus 3.7).

Mean inspection time during colonoscopy also increased significantly, from 4.9 minutes before physicians knew about the video recording to 7.3 minutes in the later exams.

The reviewer used a stopwatch to measure only the time spent actively searching the colon (inspection time), subtracting time spent on biopsy, polypectomy, cleanup or suction.

The individual colonoscopists each spent more time inspecting the colon once they knew they were being video recorded and this was especially true of the two physicians with the shortest inspection times in the “preawareness” period.

Quality scores increased for each of the seven physicians. The changes in inspection time and in quality scores were significant for four of the individual colonoscopists.

It’s unclear whether these changes might affect the adenoma detection rate, but the findings suggest that it would be worth investigating whether systematic video recording might improve quality and outcomes in colonoscopies.

It’s also unclear whether the changes in quality after knowing about the video recording would be a sustained effect or whether quality would return to baseline if colonoscopists thought no one would have time to look at all the recordings.

“Creating permanency in the record probably could have a positive impact on performance.”

“Our exams in general are really poorly documented by comparison, for example, to radiographic exams, where there is a permanent record of what has taken place. That probably has an impact on performance in a long-term fashion because if there is a subsequent problem, it’s then possible to review the record for the quality of the examination.”

The identities of the physicians in each of the colonoscopy videos were kept confidential from investigators and were known only to the division chief.