Table 4

Harmful effects—patient care subthemes and illustrative quotations

SubthemeQuotation (Participant (P))
1. FIT gaming—TPB normative belief: patient experience should limit colonoscopy ‘I’m not one who’s going to push through a very painful, uncomfortable, difficult colonoscopy, just to get caecal intubation, if that’s not right for the patient, then I’m not going to do it.’ (P8)
‘… [If] you’ve had a run of a few people who are uncomfortable, I don’t think that actually saying that you said, no I’m not going to torture you anymore and withdrew, I don’t think that’s an unreasonable situation to be in. Rather than when we have reasonable alternatives, in terms of CT colonography.’ (P11)
2. FIT gaming direct harm: perseverance despite patient comfort ‘I know sometimes people persevere with things that they shouldn’t be persevering with because they’re frightened of their figures, performance data. And I think that has become a bit of a danger.’ (P7)
‘If you’re going to have bad bowel prep, do you then fight your way through the bad bowel prep to get to caecum. So then you get your caecal intubation high or do you actually say, look this is unsafe, I’m going to miss loads of pathology here, let’s call it a day. But then obviously recently, because I’m going for bowel cancer screening, caecal intubation rates is very important to me. So I have been fighting against poor bowel prep, where normally I would just call it a day, rebook, give enhanced bowel prep.’ (P12)
‘If you’re looking at completion rates it’s different. Because people then drive on and cause people discomfort and pain.’ (P14)
3. FIT gaming direct harm: unnecessary polypectomy ‘I guess if you’re always slightly under you’d say, “Well do I need to start thinking about looking a bit harder or taking off something, rectal hyperplastic ones?”’ (P3)
‘The goalposts have moved. So, I think initially, it was just, as I say, when we first started, people were leaving the small stuff in the 74-year old whereas now you’re just accepting that you’re taking everything off.’ (P7)
‘Simply a polyp detection rate isn’t good enough because you can always find metaplastic polyps in an elderly population.’ (P19)
4. FIT gaming direct harm: unnecessary polypectomy risks harm ‘In a [frail elderly] patient where you find the diminutive polyp and are you really going to risk that patient having a perforation by taking off a small polyp which is not going to ever have any effect on their life span? … I think the [endoscopy] standards are potentially causing risk in those two areas. … the wrong incentive is there.’ (P5)
‘More senior gastroenterologists will be more pragmatic … if I actually take that [insignificant polyp] off and make a hash of it and they’re elderly and frail, I’m doing this [colonoscopy] to prove that they haven’t got a big cancer … taking something little off, that could cause them more harm, they’re not going to do it.’ (P7)
  • FIT, feedback intervention theory; TPB, theory of planned behaviour.