Abstract and Introduction
Objectives: Quality indicators including cecal intubation rate (CIR) and adenoma detection rate (ADR) are established. Sex differences of quality indicators are observed, but the influence of sedation has not been investigated so far. The objective of this study is to assess the impact of sedation on quality indicators, including CIR and ADR, according to sex.
Methods: We analyzed data of 52,506 screening colonoscopies performed by 196 endoscopists between November 2007 and April 2011 according to the Austrian "quality management for colon cancer prevention" program.
Results: Sedation did not affect polyp detection rate (women P=0.7972, men P=0.3711) or ADR for both sexes (women P=0.2773, men P=0.8676). ADR was not significantly influenced by sedation (P=0.1272), but by age and sex (both P<0.0001), when the executing endoscopist was considered. Although women were more often sedated than men (90.70 vs. 81.83%; P<0.0001), CIR was slightly lower in women than in men (94.69 vs. 96.58%; P<0.0001). Sedation improved the CIR in women by 2.95% (94.96 vs. 92.01%; P<0.0001), whereas in men it was just by 1.28% (96.81 vs. 95.53%; P<0.0001). Sedated women only reached the CIR of unsedated men (94.96 vs. 95.53%; P=0.1005). Accounting for the intra-observer influence of the endoscopist, the overall CIR was influenced by the interaction of sex and age (P=0.0049), but not by sedation (P=0.1435).
Conclusions: Sedation does not increase adenoma or polyp detection, although it leads to an increase in CIR in men and women. This effect is more pronounced in women, yet CIR of men remains higher compared with women. Quality indicators are mainly influenced by the patient's age, sex, and the endoscopists' individual performance, rather than the endoscopists' subspeciality or procedural experience.
Cecal intubation rate (CIR), adenoma detection rate (ADR), and withdrawal time are established quality indicators for screening colonoscopy. For an adequate CIR in screening colonoscopy, the cecum should be reached in over 95% of patients. Sex differences were observed, indicating a lower CIR for women, but the question if sex differences are influenced by sedation remained unclear. The ADR, which is inversely associated with an increased risk for interval cancer, is best to be targeted on ≥25% for men and ≥15% for women over 50 years of age, and endoscope withdrawal time should exceed 6 min.
Although the risk–benefit ratio of sedation has been controversially discussed, it has become a common practice in endoscopic procedures in the past years. Sedation reduces patient discomfort and pain, and leads to increased operator satisfaction. Recently, it has been shown that sedation does not result in a significantly increased rate of cardiovascular or respiratory complications.
Findings from an Italian study imply that premedication may result in a higher probability to reach the cecum. Data analysis from 12,825 colonoscopies showed a CIR of 76.1% in unsedated procedures vs. 84.2% in procedures with sedation, with influence of the endoscopist's colonoscopy volume on the likelihood of reaching the cecum. Other studies provided higher rates of cecal intubation under sedation with values ranging from 93.33 to 100% within the recommended quality standard. Despite these known findings about CIRs, less is known about the impact of sedation on polyp detection rates (PDRs) and ADRs. Only the association of sedation with an increased probability to detect at least one polyp, where women are generally less likely to have a polyp than men, has been described.
Therefore, the aim of this study was to assess the sex-specific impact of sedation in screening colonoscopy on quality indicators, including ADR, PDR, CIR, and rate of complications, in consideration of the influence of observer-related issues.