Assessment of an innovative colonoscopy protocol using a 2-person technique and propofol sedation in ensuring high quality screening colonoscopies by trained primary care physicians

Background Screening colonoscopy can provide high colorectal cancer (CRC) protection. Population-wide CRC prevention programs face the formidable hurdle of a 50% specialist shortage relative to the need, calling for innovative workforce solutions. This study investigates whether an innovative colonoscopy protocol enables primary care physicians (PCPs) to perform high-quality colonoscopies comparable to specialists.

Methods: We assess whether two specific, innovative colonoscopy protocol elements are associated with high performance quality by PCPs relative to specialists at one endoscopy center. This center trains PCPs in colonoscopy, and post-training, provides technical support with an innovative clinical protocol and onsite specialist support for rescue assistance. The study investigates colonoscopy quality indicators under: 1) a 2-person technique - the endoscopy technician advancing the colonoscope and the physician manipulating the scope tip for polyp search and removal (preempting physician's motor skill deterioration due to fatigue, and conferring the dexterity of two “right” hands for endoscope advancement, colon surface inspection, and polyp removal), and, 2) propofol sedation (relative to Demerol-Versed). Quality indicators studied are polyp detection rate (PDR), adenoma detection rate (ADR), mean number of adenomas per subject (MNA), procedure time, and polyp anatomic location. We compare PCP rates (all are required to use the 2-person technique), with those of specialists using, and not using the technique. To assess propofol sedation (implemented since April 2005) effectiveness, we will compare pre-propofol rates with post.

Results Data on 18,140 screening colonoscopies performed during 2001-2009 were analyzed, 17,613 with the 2-person technique (13,662 by 54 PCPs supported by onsite specialist available for rescue assistance, 3,951 by 3 specialists) and 527 colonoscopies with solo technique (2 specialists). Mean procedure time was shorter for the 1-person technique specialists vs. 2-person technique providers, specialist or PCP. Within 2-person technique performers, PCPs had longer mean procedure time. The PDR for solo technique specialists was significantly lower than for PCPs and for specialists using the 2-person technique (47.1% vs. 61.5% and 63.7% respectively; p<.0001). ADR differences mirrored the PDR pattern (23.9%, 30.4%, 31.2% respectively; p<.0001), as did MNA differences (0.36, 0.47, and 0.50 respectively; p<.0001). Multiple regression analyses using multilevel modeling are underway, controlling for demographics, number of polyps, and colonoscopy volume experience level of PCPs. Analyses regarding propofol sedation are underway.

Conclusions Our findings establish the evidence for utilizing PCPs for screening colonoscopy, albeit in a specialist-supported endoscopy center environment. The 2-person technique enables high rates of adenoma clearance, and potentially better cancer protection.