How Often Did Poor Cooperation Leave a Screening Gastroscopy Incomplete?

Two findings in the same chart

A retrospective study examined 4,422 screening upper endoscopies performed by one experienced endoscopist. The operator rated cooperation as poor in 358 examinations, or 8.1%. Of those 358 examinations, 36 were judged incomplete. The two figures answer different questions. One reflects how the patient tolerated the examination, while the other addresses whether the intended examination was completed.

How sedation entered the analysis

The authors found an association between midazolam use and poor cooperation after adjustment for other recorded factors. The retrospective design leaves room for patient selection and other differences between patients who received sedation and those who did not. The same operator judged both cooperation and completion, so the result also depends on how that operator recorded each endpoint.

Which record answers the case question

If a chart describes poor tolerance, look separately for the documented extent of examination, areas the clinician could not inspect, images, specimens and any plan to repeat the procedure. A notation about cooperation does not identify which anatomical areas were examined. That distinction matters when a later review depends on whether the earlier examination could have assessed a specific site.

Source

Lee et al., Korean Journal of Internal Medicine (2017)