Supplementary Material for: Closing the Gap: A Critical Examination of Adherence, Inconsistency, and Improvements in Colonoscopy Reporting Practices

Introduction: Comprehensive and standardized colonoscopy reports are crucial in colorectal cancer prevention, monitoring, and research. This study investigates adherence to national and international guidelines by analyzing reporting practices among 21 endoscopists in 7 German centers, with a focus on polyp reporting. Methods: We identified and assessed German, European, American and World Health Organization provided statements to identify key elements in colonoscopy reporting. Board-certified gastroenterologists rated the relevance of each element and estimated their reporting frequency. Adherence to the identified report elements was evaluated for 874 polyps from 351 colonoscopy reports ranging from March 2021 to March 2022. Results: We identified numerous recommendations for colonoscopy reporting. We categorized the reasoning behind those recommendations into clinical relevance, justification, and quality control and research. Although all elements were considered relevant by the surveyed gastroenterologists, discrepancies were observed in the evaluated reports. Particularly diminutive polyps or attributes which are rarely abnormal (e.g., surface integrity) respectively rarely performed (e.g., injection) were sparsely documented. Furthermore, the white light morphology of polyps was inconsistently documented using either the Paris classification or free text. In summary, the analysis of 874 reported polyps revealed heterogeneous adherence to the recommendations, with reporting frequencies ranging from 3% to 89%. Conclusion: The inhomogeneous report practices may result from implicit reporting practices and recommendations with varying clinical relevance. Future recommendations should clearly differentiate between clinical relevance and research and quality control or explanatory purposes. Additionally, the role of computer assisted documentation should be further evaluated to increase report frequencies of non-pathological findings and diminutive polyps.

引言：全面且标准化的结肠镜检查报告，在结直肠癌预防、监测与研究中均具有至关重要的意义。本研究通过分析德国7家医学中心共21名内镜医师的报告书写实践，评估其对国内外指南的依从性，重点聚焦息肉报告环节。方法：本研究梳理并评估了德国、欧洲、美国及世界卫生组织（World Health Organization, WHO）发布的相关指南文件，以明确结肠镜检查报告的核心要素。经专科认证的胃肠病学家对每项核心要素的重要性进行评分，并估算其实际报告频率。针对2021年3月至2022年3月期间的351份结肠镜检查报告中的874枚息肉，本研究评估了其对已明确的报告要素的依从情况。结果：本研究明确了多项结肠镜检查报告相关推荐意见，并将这些推荐意见背后的依据分为三类：临床相关性、合理性说明，以及质量控制与研究需求。尽管受访胃肠病学家均认为所有报告要素均具有重要性，但评估的报告中仍存在多处不符之处。尤其是微小息肉，或是极少出现异常的特征（如表面完整性），抑或是极少操作的项目（如黏膜下注射），相关记录均较为匮乏。此外，息肉的白光形态学特征，部分医师采用巴黎分类（Paris classification）记录，部分则采用自由文本描述，记录方式并不统一。综上，对874枚已报告息肉的分析显示，对推荐意见的依从性存在异质性，报告率区间为3%至89%。结论：这种不一致的报告实践，可能源于隐性的报告习惯，以及临床相关性各不相同的推荐意见。未来的指南推荐意见应明确区分仅具备临床相关性的要求、用于研究与质量控制的要求，以及用于说明解释的要求。此外，应进一步评估计算机辅助记录系统的作用，以提升非病理性发现与微小息肉的报告率。