Endoscopy 2017; 49(08): 745-753
DOI: 10.1055/s-0043-105265
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Patient-reported adverse events after colonoscopy in Norway

Geir Hoff1, 2, 3, Thomas de Lange2, 4, Michael Bretthauer3, 5, 6, Magne Buset7, Stein Dahler8, Fred-Arne Halvorsen9, Jörg Michael Halwe10, Mathis Heibert11, Ole Høie12, Øystein Kjellevold13, Volker Moritz1, Per Sandvei14, Birgitte Seip15, Lars Aabakken16, 17, Øyvind Holme3, 5
  • 1Department of Medicine, Telemark Hospital, Skien, Norway
  • 2Cancer Registry of Norway, Oslo, Norway
  • 3Department of Health Management and Health Economics, Institute of Health and Society, University of Oslo, Oslo, Norway
  • 4Department of Medicine, Vestre Viken Hospital, Bærum, Norway
  • 5Department of Medicine, Sørlandet Hospital Kristiansand, Kristiansand, Norway
  • 6Department of Transplantation Medicine and KG Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
  • 7Department of Medicine, University Hospital of North Norway, Harstad, Norway
  • 8Department of Medicine, Telemark Hospital Notodden, Notodden, Norway
  • 9Department of Medicine, Vestre Viken Hospital Drammen, Drammen, Norway
  • 10Department of Medicine, Stord Hospital, Stord, Norway
  • 11Department of Medicine, Namsos Hospital, Namsos, Norway
  • 12Department of Medicine, Sørlandet Hospital Arendal, Arendal, Norway
  • 13Department of Medicine, Telemark Hospital Kragerø, Kragerø, Norway
  • 14Department of Medicine, Østfold Hospital, Kalnes, Norway
  • 15Department of Medicine, Vestfold Hospital, Tønsberg, Norway
  • 16Department of Medicine, Oslo University Hospital, Oslo, Norway
  • 17Faculty of Medicine, University of Oslo, Oslo, Norway
Further Information

Corresponding author

Geir Hoff, MD PhD
Department of Medicine
Telemark Hospital
3710 Skien
Norway   

Publication History

submitted 16 November 2016

accepted after revision 13 February 2017

Publication Date:
26 April 2017 (eFirst)

 

Abstract

Background and aims Patient-reported outcome measures are increasingly important in healthcare. European guidelines have recommended inclusion of patient feedback to capture adverse events due to colonoscopy, but this is rarely implemented.

Methods The Norwegian Quality Assurance network for endoscopy (Gastronet) collects patient-reported outcome for colonoscopies. Free-text comments on patient reports from January to December 2015 were characterized as positive or negative. All negative free-text comments were scrutinized for information that might suggest colonoscopy-related adverse events. We identified severe adverse events with and without admission to hospital.

Results We included 16 552 outpatient colonoscopies performed at 21 hospitals. A total of 11 248 procedures (68 %) were accompanied by a patient feedback report, of which 2628 (23 %) had free-text comments (2196 [20 %] characterized as positive and 432 [3.8 %] as negative). These negative free texts on patient reports revealed 15 post-colonoscopy hospital admissions due to adverse events that had not been registered in the colonoscopy report. This increased the number of hospital admissions caused by adverse events from 3 (0.03 %) to 18 (0.16 %). In addition, there were 14 patient reports of severe events without hospital admission. Therefore, a total of 29 severe adverse events reported by patients were missed by conventional documentation in the colonoscopy form.

Conclusion It is feasible to implement patient feedback as routine reporting to capture the full picture of colonoscopy-related adverse events. Some patients experience significant complications that are not recorded through any registries. Patient feedback forms should be tailored to capture adverse events after colonoscopy that are otherwise not easily disclosed.


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Introduction

Worldwide, there is great variation in the regulations and facilitation for quality assurance in gastrointestinal endoscopy. Implementation of colorectal cancer screening programs in many countries and the implications of poor adenoma detection rates for future cancer risk have highlighted the need for rigorous quality assurance of colonoscopy [1]. This includes registration of complications.

Patient-reported outcome measures are an emerging field in medicine and healthcare and are recommended by many organizations and policy makers [2]. To get a full picture of colonoscopy-related adverse events occurring after the patient has left the endoscopy department, the European Union (EU) guidelines for quality assurance in colorectal cancer screening and diagnosis from 2011 [3] recommend “contacting all patients within a defined time frame” and “it is essential to obtain patient feedback on a regular basis.” Still, many consider this unfeasible [4] [5] and continuous registration of adverse events is often restricted to events occurring before the patient has left the premises [6]. Retrospective reviews of hospital records and register linkage are likely to miss detection of many less severe adverse events [7].

Patient feedback after colonoscopy has been a cornerstone of the Norwegian national quality register, Gastronet, although not specifically designed for the registration of post-colonoscopy adverse events beyond 24 hours [8].

The present study explores the potential for using patients’ free-text comments in Gastronet reports to extract information on adverse events after colonoscopy as this paper-based patients’ reporting form has been proven feasible to use in routine clinics in Norway. Free-text comments from patients were scrutinized to search for adverse events which were not captured in the colonoscopy form that was filled in by a nurse or doctor while the patient was still on the premises of the endoscopy center.


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Materials and methods

In the present study, 21 hospitals in Norway reporting at least 100 outpatient colonoscopies to Gastronet from January to December 2015 were included. Only outpatient colonoscopies are eligible for registration in Gastronet, except for in one hospital where both inpatient and outpatient colonoscopies were reported (981 colonoscopies performed) because most examinations were performed on inpatients in this particular hospital. During this period, 23 345 colonoscopies were eligible for Gastronet registration from these hospitals according to the National Patient Registry (NPR), of which 16 552 (71 %) were registered in Gastronet ([Fig. 1]). In Norway, reporting to the NPR is compulsory and it captures all colonoscopies performed at public hospitals. The NPR does not however contain clinical information on colonoscopy performance or patient-reported outcome/experience.

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Fig. 1 Flow chart of colonoscopies reported to Gastronet from 21 endoscopy centers in Norway. Reporting was restricted to outpatient colonoscopies with the exception of one hospital that also reported inpatient colonoscopies.

Gastronet is the quality assurance register for outpatient colonoscopies in Norway. Data are captured through two paper forms. One is completed by the endoscopist immediately after the colonoscopy and contains procedural data including adverse events that occur during the colonoscopy (e. g. bleeding and vasovagal reaction, among others). There are no mechanisms with this form to capture adverse events that occur after the patient has left the hospital premises. The patient is given another form ([Appendix 1]), together with a pre-paid return envelope, before leaving the endoscopy suite. This form is to be completed on the day after the procedure to assess the patient’s experience during and after the examination (satisfaction with service, pain during and after the examination, involuntary leakage post-colonoscopy). In addition, there is a box labeled “Other comments” for free-text elaboration, details, and suggestions for improvement. Online reporting is not an option in Gastronet.

When patient forms are received at the Gastronet secretariat, free-text comments are characterized as positive or negative by consensus of three secretaries. In the present study, all negative free-text comments were further categorized by one of the authors (G.H.) as “severe event with admission to hospital,” “severe event without text suggesting admission to hospital,” “adverse event with no free-text information suggesting it to be severe” (see definition of severe adverse event below), and “negative free-text with no suggestion of adverse event.” In addition to this categorization by one author (G.H.), the grading of adverse events into severe and non-severe was independently evaluated by G.H. and T.d.L.

Severe (major) adverse events of colonoscopy were defined as events requiring admission to hospital and/or some intervention beyond what could be done during the current colonoscopy [9]. We also included post-colonoscopy pain when this was combined with fever and poor general condition, in addition to loss of consciousness related to the colonoscopy itself or to the bowel-preparation procedures – all as defined by the patient. Abdominal pain for several days without fever was also accepted as a severe event if clearly stated to be a post-colonoscopy event. In addition, technical failure leading to a new appointment for colonoscopy was defined as a severe event.

The previous literature concerning patients’ experiences during colonoscopy was explored by conducting a PubMed search using the keywords “colonoscopy” and “patients’ experience.” Additional articles were found by manual examination of references in the initial articles and from personal experience in the field.

For statistical purposes, the package IBM SPSS 19.0 was used. The chi-squared test was used to assess differences in categorical data and statistical significance was defined as P < 0.05 using two-sided tests.


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Results

A total of 16 552 colonoscopies out of 23 345 (71 %) performed in 21 hospitals were registered by colonoscopy reports received at Gastronet. Of these, 11 248 (68 %) were accompanied by a patient report ([Fig. 1]). A negative comment was noted in 432 of the 11 248 procedures (3.8 %), a positive comment in 2196 (20 %), and no comments in 8620 (77 %).

Among the 11 248 colonoscopy reports that were accompanied by patients’ reports, 18 (0.16 %) were associated with a severe event leading to an admission to hospital ([Table 1]). Of these 18 events, 15 were reported only in the patient reply form (specified in [Table 2]). Events categorized as severe, but without stating hospital admission, were registered for 17 patients (0.15 %), with 14 of these being events stated in the patient report only (specified in [Table 3]). In the dichotomized grading of the severity of events, the reviewers (G.H. and T.d.L.) had diverging views on six out of 192 adverse events, five of which were when judging the patients’ free-text comments (cases marked with an asterisk in [Table 2] and [Table 3]). For these six events, the grading “severe” was chosen for the data analyses.

Table 1

Adverse events registered on the basis of the colonoscopy form (registered during the patients’ presence in the endoscopy premises) and of free text extracted from the patient reply forms.

Registered on colonoscopy report

Registered on patient form only

Total from both forms

Severe adverse event

Other adverse events[*]

Total on colonoscopy reports

Severe adverse event

Other adverse events[*]

Total on patient forms

Hospital admission

No admission

Hospital admission

No admission

Vasovagal without syncope

0

0

 22

 22

 0

 0

 0

 0

 22

Syncope

0

3

  0

  3

 0

 3

 0

 3

  6

Bleeding

0

0

 21

 21

 2

 0

 9

11

 32

Perforation

0

0

  0

  0

 1

 0

 0

 1

  1

Bradycardia

1

0

  2

  3

 1

 0

 0

 1

  4

Technical failure

0

0

  1

  1

 0

 1

 1

 2

  3

Abdominal pain with fever

1

0

  0

  1

 5

 4

 0

 9

 10

Abdominal pain without fever

0

0

  3

  3

 3

 5

19

27

 30

Nausea, unwell

0

0

  6

  6

 1

 1

11

13

 19

Hypoxia

1

0

  0

  1

 0

 0

 0

 0

  1

Soiling on way home after colonoscopy

0

0

  0

  0

 0

 0

 5

 5

  5

Stroke

0

0

  0

  0

 1

 0

 0

 1

  1

Other events

0

0

  0

  0

 1

 0

 2

 3

  3

Unspecified

0

0

 54

 54

 0

 0

 0

 0

 54

Total

3

3

109

115

15

14

47

76

191

* Including events with no grading of severity.


Table 2

Severe adverse events after colonoscopy that led to hospital admission, but were not registered on the colonoscopy report. Free-text comments on the patient reply forms suggested hospital admission because of the adverse event.

Free-text comments as expressed on patient reply forms

 1

Admitted to hospital 4 hours after the colonoscopy. Stayed for 2 days

 2

Eventually I had to contact emergency service and the hospital where I stayed overnight

 3

Terrible pains on the days after the examination which led to admission to the emergency department

 4

Removal of polyp in the uppermost parts of the large bowel caused leakage to the abdominal cavity, surgery, and closure of the leak. Five days in hospital and problems with digestion thereafter

 5

Saturday morning at 0630 hrs I got blood pressure drop after three rounds of bloody stools and fainted. My wife contacted the hospital, admitted at 0700 hrs and stayed till Sunday 1700 hrs. Received one unit of blood (I think it was). Still not in shape. Would not be surprised if I need a readmission to hospital

 6[*]

Itching rash after medication at colonoscopy. Tried allergy tablets, but attended emergency dept. the day after. Received i. v. allergy medication which worked

 7

The colonoscopy was surprisingly painful and drained my powers completely. Ended up in hospital a few hours after I returned home – with cardiac arrhythmia

 8

Had to return to the hospital after the examination due to much blood loss. Discharged after 2 days

 9

Much pain, distended abdomen, fever after the examination. Have now phoned the emergency and been accepted for examination

10

When several polyps were removed, I had to discontinue warfarin for 5 days. The result was cerebral stroke on day 6. Vision is injured. Some memory loss

11

It took very long to remove one polyp. My doctor diagnosed infection due to the colonoscopy. I am now on antibiotics. Don’t feel good

12

Fever and abdominal pain some hours after. Admitted to hospital X, emergency. Moved to hospital Y the same evening because I am on peritoneal dialysis for kidney failure. Test puncture showed bacteria in the peritoneal fluid. Treated with antibiotics. Discharged 1 week later

13

Terrible pains when I got home. Phoned – had to go to emergency. 39 °C. Stayed 2 nights in hospital. Had two polyps removed and a biopsy in the small bowel at the colonoscopy. Now on antibiotics

14

Severe abdominal pains after colonoscopy when I got home. Eventually I attended emergency. Have still abdominal pains the day after the examination

15

Very ill for several days. Prescribed Metronidazole – made me more ill and had to discontinue after 3 days

* Graded as not severe by one of the two reviewers.


Table 3

Severe adverse events after colonoscopy that were not registered on the colonoscopy report and had free-text comments not suggesting hospital admission.

Free-text comments as expressed on patient reply forms

 1[*]

Chills all evening and during the night. Like running a high temperature

 2[*]

After nearly 1½ weeks I still have severe bowel pains. Dilated abdomen, no appetite, lots of gas trying to get out. Feels like the bowel is inflamed

 3

Severe abdominal pain during the evening after the examination, nausea and chills. Stayed in bed for 20 hours before it eased off

 4

High fever in the evening after the examination

 5

Temperature 38.7 °C after the examination. Fever gone the next morning

 6

Severe pain in the anastomosis in the afternoon after blocking. The pain actually lasted for 6 days. Worst during the first 3 days, then easing off. OK now after 1 week

 7

Exhausted after bowel cleansing. In the waiting room before the examination, I had a transient episode with vomiting and I was unconscious for a moment

 8

I cried out in horror as I got an electrical shock when they removed the polyps. They said that I should not feel anything

 9[*]

Been very ill for nearly 7 days. Vomiting, feeling feverish the same evening and next day. Still unwell in my abdomen

10

Fainted after the examination, very uncomfortable

11

Terrible pains low in the abdomen, especially to the right. Also pains today

12

Still terrible pains in the abdomen, especially to the left

13

I became very sick after the recommended bowel prep. Severe abdominal pain and I fainted during the night before the examination. N.B. This should be reported as severe side-effect of the recommended preparation

14[*]

Very painful abdomen for weeks after the examination

* Graded as not severe by one of the two reviewers.


In nearly half of the colonoscopy reports where “adverse events” were ticked on the form (54 out of 115), no specification of the nature and severity of these events was provided ([Table 1]). The second and third most frequently registered adverse events in the colonoscopy reports were vasovagal reaction without loss of consciousness (n = 22) and bleeding (n = 21), although none of these were graded as severe. On the patient report forms, bleeding also constituted one of the top three adverse events (11 /76 events), only superseded by “abdominal pain without fever” (n = 27) and “nausea, unwell” (n = 13) ([Table 1]).

There was nothing in the colonoscopy reports to suggest forthcoming severe complications. In particular, there was no increased risk for patients undergoing therapeutic colonoscopy (8/1652 [0.5 %]) compared with those undergoing diagnostic colonoscopy (18 /5642 [0.3 %]), or unspecified colonoscopy (9/3954 [0.2 %]; P = 0.29).

Five adverse events registered on the colonoscopy form were also commented on by the patient: one patient with atrioventricular block was admitted to hospital (verified by the patient comment), one syncope occurred on site (supplemented by the patient comment of “syncope twice” without specifying when or what action was taken), one patient with nausea occurring on site (supplemented by the patient comment of “severe abdominal pain after the examination” without stating any action taken), one episode of bleeding (supplemented by the patient comment of “re-bleeding after discharge” without stating any action taken), and one unspecified adverse event (supplemented by the patient comment of “severe pain 3 days after the examination,” again without further information).

In the literature survey, 19 relevant articles were found for patient-reported experience after colonoscopy ([Table 4]), only one of which reported the use of patients’ feedback to improve estimates of adverse events [4].

Table 4

Publications on patient experience with colonoscopy.

Size and setting

Study type

Topic

Ghanouni A et al. [10]

50 858 screening colonoscopies

Prospective cohort

Satisfaction with service, pain/discomfort during and after colonoscopy

Hatoum HT et al. [11]

12 011 routine colonoscopies

Prospective cohort

Satisfaction with bowel cleansing procedures

Ball AJ et al. [12]

100 screening colonoscopies

Randomized controlled trial

Pain scores comparing Entonox continuously vs. on-demand

Martindale F et al. [13]

34 routine colonoscopies

Randomized controlled trial

Effect of music as sedative during colonoscopy

Nicolai, MP et al. [14]

1419 routine colonoscopies

Cohort

Pain at colonoscopy in relation to previous history of sexual abuse

Denters, MJ et al. [15]

797 routine colonoscopies

Prospective cohort

Patient satisfaction with colonoscopy in five different patient categories (IBD, polyp surveillance etc.)

Bjørkman I et al. [16]

120 routine colonoscopies

Randomized controlled trial

Music for sedation

McEntire J et al. [17]

224 routine colonoscopies

Prospective cohort

Patients’ ranking importance of different aspects of colonoscopy care

von Wagner T et al. [18]

547 routine colonoscopies

Randomized controlled trial

Patient satisfaction and 3-month psychological outcome after CT colonography vs. colonoscopy

McLachlan SA et al. [19]

 – 

Review

Patient views on barriers toward screening

Gavarnuzzi T et al. [20]

90 routine colonoscopies

Prospective cohort

Patient pain report before, during, and after colonoscopy to explore recall bias

Ylinen ER et al. [21]

130 routine colonoscopies

Prospective cohort

Patient pain and anxiety

Hayee B et al. [22]

300 routine colonoscopies

Randomized controlled trial

Patient pain experience comparing two regimens

Bechtold ML et al. [23]

 – 

Review

Effect of music on patient experience

Kinner S et al. [24]

284 MR colonography and colonoscopy

Prospective cohort

Patient preference for MR colonography or colonoscopy

Sewitch M et al. [25]

 – 

Review

Patients’ evaluation of colonoscopy services

Sewitch M et al. [26]

 – 

Focus groups

Patient-identified quality indicators

Adler A et al. [4]

12 134 screening colonoscopies

Prospective cohort

Patient reports to capture a more complete range of adverse events after colonoscopy

Thiis-Evensen E et al. [27]

429 screening colonoscopies + 447 controls

Prospective case/control

Psychological reactions to colonoscopy screening after 2 weeks, 3 months, and 17 months compared with controls

Bretthauer M et al. [28]

31 420 screening colonoscopies

Randomized controlled trial

Patient-reported pain during and after colonoscopy screening (n = 12 574) in three European countries

Holme Ø et al. [29]

1198 routine colonoscopies

Prospective cohort

Risk stratification to predict pain

IBD, inflammatory bowel disease; CT, computed tomography; MR, magnetic resonance.


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Discussion

This observational study from the Gastronet quality assurance register showed that the majority of complications occur after the patient has left the endoscopy suite and significant post-colonoscopy events may not be recognized by tracking hospital admissions or emergency outpatient visits. Accordingly, to capture the full spectrum of complications due to colonoscopy, more than just linkage to hospital or public registries is necessary. Patient-reported feedback should also be considered an important source of information, as has been proposed in EU guidelines [30].

With regard to adverse event registration, the present version of the Gastronet patient form contains only an open question asking if there has been abdominal pain or other discomfort after the colonoscopy, with encouragement given to the patient to use free text to provide details (an English translation of the form used is found in [Appendix 1]).

The free-text comments exposed in the present study suggest that questions should be specified more towards complications to better grade any events that require clinical follow-up. This should ideally be initiated by the endoscopist, rather than it being left to the discretion of the patient to decide whether to endure the problem with or without professional advice. When taken to this level, a feedback-initiated follow-up service may be considered unfeasible if healthcare resources are already strained. Implementing patient feedback itself is however feasible as shown by the Gastronet register. The clinical follow-up is an organizational issue and a question of patient information combined with detailed questionnaires and specified thresholds for action to be taken. With an increasing proportion of the healthy population being subjected to colonoscopy as part of screening, and the need now recognized to remove sessile serrated polyps also from the thin-walled proximal colon, we should be organized to capture the full picture of adverse events related to colonoscopy beyond on-site registration and intermittent linkage reviews.

Severe (major) adverse events of colonoscopy have been defined as events requiring admission to hospital or emergency services and/or some intervention beyond what can be done during the current colonoscopy [9]. In the present study, we included cases of post-colonoscopy pain when combined with fever and poor general condition, in addition to loss of consciousness ([Table 2] and [Table 3]). Other adverse events with low or no grading ([Table 1]) also included cases with pain for days after colonoscopy, but with no further information to suggest its severity.

Text comments on the reply forms in [Table 3] suggest that at least some patients have a high threshold for calling emergencies for clinical symptoms that may suggest, for example, threatened perforation and abscess formation. Some hospitals provide patients with written information stating explicitly how to react to defined symptoms, particularly after polypectomy and discharge from hospital. In view of the present patient free-text comments, this should be made standard procedure in all endoscopy units.

In the German screening colonoscopy registry, which has covered the national colonoscopy screening program since 2002, it is assumed that documentation of complications is largely restricted to events occurring during or immediately after colonoscopy until the time of patient discharge [4], particularly in patients who have not undergone polypectomy when there is no obvious need to access the hospital records for documentation of polyp histology. In a study on register data quality comprising 12 134 colonoscopies, a separate case report form was added explicitly to address 30-day post-colonoscopy events. The total documented complication rate doubled when this was used compared with the standard register. When a patient questionnaire on 14-day complications was also added, the overall complication rate was tripled compared with standard reporting in the screening program – a complication rate increase from 0.15 % to 0.45 %. In line with this, complications leading to hospital admission increased from 0.07 % to 0.19 %, which is consistent with the increase from 0.03 % (3/11 248) to 0.16 % (18/11 248) in our study. Apart from this publication by Adler et al. [4], our literature survey revealed no other papers that had reported on the use of patient feedback to improve estimates of adverse events after colonoscopy ([Table 4]).

A previous literature survey in 2011 revealed only eight studies addressing aspects of colonoscopy and/or endoscopy that were evaluated by patients [25]. Patients did not however express concern with safety and complications, presumably because safety was assumed to be monitored, as was expressed in one patient interview: “And the doctors must have to show they are keeping their skills up to date; this does not worry me. It’s a major hospital; they have to have standards or they would be in trouble” [26].

Studies have shown that monitoring of safety (i. e. tracking adverse events) in routine clinics and screening often does not capture events occurring after discharge. In one study, the risk of hospital transfer was 0.03 % immediately after colonoscopy, increasing to a hospital-based acute encounter of 2.2 % within 14 days after colonoscopy [5]. Another large study showed that most adverse events (67 %) were recognized after discharge for the index colonoscopy [31]. Therefore, it seems patients are taking it for granted that we have systems running for safety monitoring, which we do not in fact have. The Gastronet patient report form will now be revised to allow for better registration of post-colonoscopy events. Intermittent review of hospital records is often used, but this does not capture the full range of adverse events. Register linkage permits may also be a problem in many countries because of national legislation.

In the present study, it is obvious from the texts themselves that many of the severe events would not have been brought to light if patients had strictly adhered to the protocol of mailing their replies on the day after the examination (e. g. patient #4 in [Table 2] – surgery with 5 days in hospital). This suggests that patients adhering to the protocol to return their form by mail on the day after the examination may have lost the opportunity to report severe events that occurred later. Therefore, the present results clearly underestimate the number of severe post-colonoscopy events. Because the patient reports were not dated, we could not estimate how many adhered to sending their reply form on the day after the examination. The texts describing fever and pain for days without contacting health services suggest that imminent perforation after polypectomies and even abscess formation may be grossly underdiagnosed.

In addition to underestimating adverse events owing to the “next-day reporting” protocol, the subjective character of free-text comments themselves may contribute both to over- and under-reporting of adverse events. To avoid at least over-reporting of severe events, abdominal pain (however strong) usually had to be accompanied by fever to be categorized as a severe adverse event. Also, for transparency, events accepted as severe are presented with translated free texts in [Table 2] and [Table 3]. Pre-colonoscopy symptoms, such as abdominal pain, may also influence patients’ reports. We did not however have permission from the Data Inspectorate to check against patients’ hospital medical records. Therefore, non-severe adverse events were more likely to have been over-reported in this study and severe events to have been under-reported.

In conclusion, the present study showed the value of patient reply forms to document and capture post-colonoscopy adverse events. The use of patient-reported outcome measures may be an important tool to capture even severe events that are otherwise not easily disclosed.

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Appendix 1

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Competing interests

None

Acknowledgments

We are greatly indebted to the dedication of doctors and nurses in the endoscopy units that provide data for Gastronet. Without their engagement, Gastronet would not be able to contribute toward moving the field of quality improvement forward.

Gastronet is funded as a national quality register by the South-Eastern Norway Regional Health Authority.


Corresponding author

Geir Hoff, MD PhD
Department of Medicine
Telemark Hospital
3710 Skien
Norway   


Zoom Image
Fig. 1 Flow chart of colonoscopies reported to Gastronet from 21 endoscopy centers in Norway. Reporting was restricted to outpatient colonoscopies with the exception of one hospital that also reported inpatient colonoscopies.
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Appendix 1