Inflammatory Bowel Disease Is As Canadian As The Mounties

Endoscopist specialty is associated with colonoscopy quality

Crohn’s disease, which affects the large and small intestines, is even more common in Canada and affects about 234 per 100,000 people, with an incidence of 13.4 per 100,000 each year. By comparison, ulcerative colitis prevalence is 58 to 157 per 100,000 in Northern Europe and about 167 per 100,000 for an area of Minnesota. Crohn’s disease prevalence ranges from 27 to 48 per 100,000 in Northern Europe to 144 per 100,000 in an area of Minnesota. Some Third World nations and areas in tropical latitudes have still lower rates. Although the reasons for these differences remain unclear, the hygiene hypothesis may help explain the distribution in Canada, said Richard Fedorak, M.D., of the University of Alberta in Edmonton, a co-author. “If you live in an environment that’s too clean or too sterile as a child your intestines are not exposed to bacteria of the same types and numbers you would be exposed to in a tropical area,” he said. which is especially true for Canada because much of the country has cold winters with little bacterial activity in the soil. Then if the genetic triggers are present, “your intestine is not able to tolerate bacteria as you get older and starts to destroy itself,” he added. Supporting this speculation, the researchers discovered differences among provinces: Nova Scotia in the Maritimes consistently had the highest rates of ulcerative colitis (19.2 incidence and 247.9 prevalence per 100,000) and Crohn’s disease (20.2 incidence and 318.5 per 100,000), Following closely is Alberta, with ulcerative colitis incidence of 11.0 and prevalence of 185.0 per 100,000 and Crohn’s disease incidence of 16.5 and prevalence of 283.0 per 100,000, and Manitoba had likewise high rates of ulcerative colitis (15.4 incidence and 248.6 prevalence per 100,000) and Crohn’s disease (15.4 incidence and 271.4 prevalence per 100,000); Whereas British Columbia, on the west coast, consistently had much lower rates of both ulcerative colitis (9.9 incidence and 162.1 prevalence per 100,000) and Crohn’s disease (8.8 incidence and 160.7 prevalence per 100,000). British Columbia proved to be an outlier, particularly for Crohn’s disease perhaps because of its milder winters, more precipitation, and “because its population ethnic make-up is somewhat different from the rest of Canada,” the researchers wrote. Much of British Columbia’s immigration in the past 20 years has been from Asia, they said. “Asians are known to have less [inflammatory bowel disease] than Caucasians,” perhaps because of genetics, less sterile conditions during childhood, or other environmental factors. Males and females generally had similar rates of ulcerative colitis though significantly more females had Crohn’s disease (1.31 ratio, 95% CI 1.23-1.40). Notably, though, the prevalence of Crohn’s disease was significantly greater in boys than girls (prevalence 49.6 versus 43.8 per 100,000, P=0.0001).

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Gastroenterologists release new safety guidelines

In this Oct. 3, 2007, file photo released by the University of Wisconsin Medical School shows a virtual colonoscopy, a 3-D image that was computer-generated from a series of X-rays taken by a CT scanner. (AP Photo/ Courtesy of Dr. Perry J. Pickhardt/ University of Wisconsin Medical School, file)

– Canada’s gastroenterologists have new guidelines on safety and quality indicators to help with the more than 1.6 million procedures performed each year, their association announced Monday. Although the Canadian Association of Gastroenterology has guidelines around credentials and training, there was a void in other areas. “If one looks at the sort of totality of endoscopy service delivery, particularly from a patient point of view — which is access to services, rapid access, high quality services, feedback, and an ability to respond to how they perceive endoscopy service delivery — then there really was nothing in place,” said Dr. David Armstrong, chair of the endoscopy committee and the consensus guideline committee. Endoscopy is used to detect or screen for a number of diseases and involves examining the colon or digestive tract using a long, thin tube with a light and camera attached. Last October, about 6,800 Ottawa residents were sent letters from public health officials after it was found that a non-hospital clinic wasn’t following some procedures involving cleaning and infection prevention. The letters indicated the patients might have been exposed to hepatitis B, hepatitis C or HIV. Armstrong said he likes to think the presence of these guidelines would have made a difference in the Ottawa situation. “That’s really because one of the challenges for endoscopy — and it’s in and out of hospitals — has been that if there isn’t a framework to say how things should be monitored and how they should be delivered, it’s difficult to know how much or how closely to monitor things, and what actually are the standards,” Armstrong said in an interview from Hamilton, where he’s an associate professor of medicine at McMaster University. “So I think guidelines that say what should be monitored and what processes have to be in place really from a patient point of view and knowledge that there are tools available to monitor the way that services are delivered and to use as a basis for quality improvement programs would have made a big difference.” Armstrong indicated that it used to be felt that washing the scope and then doing a manual cleaning was sufficient. “And the trouble is there are times when that isn’t sufficient.

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Results from the Bowel Cancer Screening Programme in England show a significant increase in ADR among endoscopist with mean withdrawal time of 11 minutes or longer compared to those with mean withdrawal time of less than 7 minutes [ 27 ]. Investigators in Spain examined bowel cleansing, sedation, cecal intubation, and withdrawal time as potential predictors of ADR. Only withdrawal time longer than 8 minutes was independently associated with ADR [ 28 ]. However, a German study found neither annual case volume nor withdrawal time to be correlated with ADR [ 29 ]. The mixed findings regarding practice and technical factors that affect colonoscopy quality may be due to differences in training, accreditation, practice settings, and CRC screening delivery models between countries. A major strength of our study is primary data collection on patient level CRC risk factors that enabled adjustment for colonoscopy indication, family history of CRC and previous colonoscopy. This is important because polypectomy rate is a function of both patient risk and endoscopist performance. One study limitation is residual confounding. Although we adjusted for many important patient risk factors, it is possible that differences in the characteristics of patients referred to surgeons and gastroenterologists were not adequately captured by the patient-level covariates. A second limitation is potential misclassification, as data on polypectomy status were derived from provincial health administrative databases. To address this issue, we employed methods to adjust for the imperfect accuracy of health administrative data in both provinces. Using health administrative data whilst acknowledging and accounting for its limitations is good practice in clinical and health services research. However, our approach to misclassification adjustment for the Montreal data may have introduced bias if misclassification was differential between surgeons and gastroenterologists. Differences in administrative data quality between specialties may arise from differences in billing practices. Nevertheless, it is reassuring that the Calgary sample, where misclassification was reduced by combining two data sources, showed results in the same direction as the Montreal sample. Thirdly, hierarchical modeling was used to estimate the rates as it has the advantage of conservatively bringing unstable estimates closer to the overall mean so that they are less likely to affect the range of variation in polypectomy rates [ 30 ].

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