Estimates indicate that incomplete polyp resection may cause up to 30% of all post-colonoscopy colorectal cancer. The use of cold forceps to remove nondiminutive (larger than 5 mm) polyps during colonoscopy can leave behind residual tissue.
However, researchers in UT Southwestern’s Division of Digestive and Liver Diseases and Department of Population and Data Scientists found that between 2017 and 2019 in two U.S. health systems, cold forceps were used to remove large polyps in more than 20% of colonoscopies – despite the fact that the risk of incomplete resection is 79% lower when using the cold snare technique.
Our researchers investigated why this was happening and whether provider education could encourage the use of the more effective cold snare technique.
About the Research
We found that several factors contributed to the use of forceps, including the gastroenterologist performing the procedure. This suggests that the quality of the polypectomy varies from provider to provider, as does adenoma detection, which is a separate technical skill.
We also found that higher numbers of polyps removed correlated with a lower likelihood of inappropriate forceps use. This could be related to equipment costs. Once a snare device is unpackaged, there may be a tendency to continue using it to remove all polyps rather than opening a forceps.
Technical challenges, polyp location, and inadequate bowel prep are also likely to contribute to inappropriate forceps use.
Intervention and Incentives
Our research included a mixed-effects logistic regression model to examine the efficacy of interventions to reduce the frequency of these inappropriate uses of forceps.
We used two simple interventions:
- Educational conversations via email and at faculty meetings and emails
- A modest group financial incentive tied to metrics
The result was a 53% decrease in inappropriate forceps use for polypectomy, indicating that higher-quality colonoscopies are within reach. Based on these findings, we believe that with additional education efforts and regular measurement and reporting, removal of nondiminutive polyps using forceps could become a future quality metric to achieve more thorough polyp removal and improved patient outcomes.
Email: David.Fudman@utsouthwestern.edu
Disclosure: These authors disclose the following: David I. Fudman reports consulting fees from Pfizer. Amit G. Singal has served as a consultant for Exact Sciences and GRAIL. Caitlin C. Murphy serves as a consultant for Freenome. The remaining authors disclose no conflicts.