Assessment and improvement of access and quality in lower gastrointestinal endoscopy

Quality assurance in lower gastrointestinal endoscopy (LGE) is gaining increasing attention. Simultaneously, there is an increasing demand for LGE. The overall aims of this thesis were to identify methods of improving both the availability and the technical quality of LGE in the National Health Service, United Kingdom. This thesis attempts to bring some of these concepts together in a series of studies as listed below:Study 1: The aim of this study was to assess patient satisfaction with LGE, and to determine factors that affect patient satisfaction. A new patient satisfaction questionnaire was developed and internally validated. The most important factors affecting patient satisfaction in this study were the technical skills of the endoscopist and the degree of discomfort/ pain experienced by the patient. This study has also shown that there are no differences between medical, nurse and non-medical endoscopists in terms of patient satisfaction with lower gastrointestinal endoscopy. Based on this understanding of factors affecting patient satisfaction with LGE, we performed the following studies (2, 3, 4 and 5) to determine methods of assessing technical quality of LGE and the best sedative regimen to ensure higher patient satisfaction. Studies 2 and 3: The aims of these studies were to assess the technique of endoscopic clipping with follow up abdominal x-ray for objective validation of completion in colonoscopy and flexible sigmoidoscopy. Both studies have shown that this technique is useful not only for assessment of completion but also for validation of pathology miss rates in LGE. This is a proof of concept study and further validation against current standards would be required. Studies 4 and 5: These two randomised controlled trials were performed to determine the best sedative/analgesic regimen for colonoscopy. The first study has shown that Entonox is associated with better pain relief, faster recovery of psychomotor function and higher patient satisfaction, as compared to conventional intravenous sedation. The second study has shown that there is no difference between Entonox and Propofol sedation in terms of pain relief, recovery of function, and time to discharge and patient satisfaction. However, propofol sedation is more resource intensive and makes patient manoeuvring more difficult. A further conclusion from the subset analysis of these studies is that there is no difference between doctors, nurses and non-medical colonoscopists in terms of patient satisfaction, pain relief, time for procedure or discharge and recovery of function. Study 6: The aims of this study were to develop, train and validate artificial neural network (ANN) algorithms capable of accurately identifying individual patients attending routine colorectal clinics likely to have a positive diagnosis (cancer, polyp, or colitis) necessitating a lower gastrointestinal endoscopy. This study has shown that artificial neural networks offer the possibility of personal prediction of outcome for individual patients presenting in clinics with colorectal symptoms, making it possible to make more appropriate requests for lower gastrointestinal endoscopy.EThOS - Electronic Theses Online ServiceGBUnited Kingdo