Negative Effects of Endoscopists’ Fatigue on Colonoscopy Quality on 34,022 Screening Colonoscopies

Abstract

Background and Aims: There is still considerable controversy surrounding the relationship between fatigue of endoscopists and the quality of colonoscopy. The aim of this study is to comprehensively explore the association between fatigue and adenoma detection rate (ADR) and cecal intubation rate (CIR).
 Methods: The mixed effects logistic regression model was used to explore the relationship between fatigue- related factors including procedure order, session of procedures and the day of week and ADR as well as CIR.
 Results: When controlling for confounders, the day of week (Monday as reference, Friday, p=0.022; weekends, p=0.015) and session of procedures (P<0.001) were significantly associated with ADR while procedure order (<5 as reference, 6-10, p<0.001; >10, p=0.001) and session of procedures (p=0.004) were independent predictors for CIR. Additionally, there was a significant downward trend on ADR and CIR with the approaching of weekends (p=0.005) and increasing procedure orders (p<0.001), respectively. In the subgroup analysis stratified by gender, age and workload intensity, significant lower ADR was found in the afternoon in all subgroups (male, p<0.001; female, p=0.005; <40 years, p<0.001; ≥40 years, p=0.020; intensity<50 per month, p=0.017; intensity≥50 per month, p<0.001) but the downward trend on ADR as the week progressed was only found in endoscopists with male gender (p=0.011), age<40 (p=0.027) and high workload intensity (p=0.003). Moreover, a significant downward trend on CIR as the procedure order increased was found in all subgroups except endoscopists with age≥40 (male, p=0.005; female, p<0.001; <40 years, p<0.001; intensity<50 per month, p=0.001; intensity≥50 per month, p<0.001).
 Conclusions: Colonoscopies in the afternoon will affect ADR negatively while increasing procedure order will cause a lower CIR. Importantly, the significant negative influence of Friday and weekends on ADR was first discovered in this study. Moreover, endoscopists with female gender and advanced age (≥40) but not high workload intensity showed superiority in resistance of fatigue caused by the end of the week and increasing daily procedures.

Initiatives to increase colonoscopy capacity – is there an impact on polyp detection? A UK National Endoscopy Database analysis

“…Regarding procedure day, several quality markers (including withdrawal time for negative procedures, and use of hyoscine butylbromide) -were worse for weekend than weekday procedures. Moreover, mean number of points per list was also higher at weekends, consistent with other studies which indicate that greater (cumulative) workload may be associated with endoscopist fatigue, or pressure to save time by cutting corners, and hence lead to lower detection [28][29][30]. Many of these markers have been associated with ADR in UK endoscopy practice [31] and, unlike case-mix, they are, at least to some extent, under the control of the endoscopist or unit and, hence, potentially modifiable.…”

Negative effect of prolonged cecal intubation time on adenoma detection in female patients

“…Furthermore, it may disrupt the schedule of the endoscopist, resulting in a possible hastened withdrawal with a higher chance of overlooking polyps. [17][18][19][20] On the contrary, some previous studies have shown no direct relationship between cecal intubation time and the number of detected adenomas. 8,9 Instead, they have suggested that the cecal intubation time to withdrawal time ratio (IWTR) was a quality indicator of adenoma detection, as IWTR <1.0 was associated with the detection of more adenomas compared with IWTR ≥1.0.…”

“…Furthermore, it may disrupt the schedule of the endoscopist, resulting in a possible hastened withdrawal with a higher chance of overlooking polyps. 17 , 18 , 19 , 20 …”

“…Prolonged cecal intubation can exhaust the endoscopist, causing impaired concentration. Furthermore, it may disrupt the schedule of the endoscopist, resulting in a possible hastened withdrawal with a higher chance of overlooking polyps 17–20 …”

Comparing artificial intelligence to humans for endoscopic diagnosis of gastric neoplasia: An external validation study

“…Although other factors such as selection time and time taken to advance the images were not considered, it is unlikely that a human would be able to outperform AI in terms of speed. Furthermore, unlike the human endoscopist, 20 the AI system is not fatigable, the accuracy of AI would remain the same when evaluating the first picture to the 300th picture, however this may not be true for the endoscopist. The comparison between the AI and the endoscopist is summarized in figure 1.…”