Review for 10.1186/s12876-025-04020-9 (2025)

Title: A Cooling Off Period: Decline in the Use of Hot Biopsy Forceps Technique in
Colonoscopy in the U.S. Medicare Population 2000-2019
Version: 3 Date: 05 Mar 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While the study includes data on providers who performed more than 10 procedures per year,
this might exclude certain smaller or less active practitioners, potentially skewing the results.
Additionally, there is no direct measure of provider age or clinical experience, which could be
important factors influencing the use of hot versus cold biopsy forceps.
-The study uses Medicare Part B data, which lacks patient-level identifiers. While this protects
patient privacy, it also means that factors such as patient age, comorbidities, or specific
indications for colonoscopy are not accounted for. These could potentially influence the choice
of biopsy technique.
-While the regional analysis adjusts for Medicare enrollment, there may still be unaccounted-
for factors influencing regional variations in practice patterns, such as differences in local
guidelines, training programs, or institutional preferences that aren't captured by the data.
-The study primarily focuses on provider characteristics, but there might be other factors
influencing the decision to use hot versus cold biopsy forceps, such as the availability of
equipment, patient preferences, or institutional guidelines that weren't explored in depth.
The study doesn't assess clinical outcomes or complications (e.g., bleeding, perforation, polyp
recurrence), which would provide more direct evidence on why hot biopsy forceps are being
abandoned. A more complete evaluation of patient outcomes would strengthen the conclusion
that the decline is driven by improved techniques and safety.
-While the study mentions updated guidelines, it does not directly assess the role that specific
training programs or institutional practices might play in the adoption of new techniques.
Including an exploration of how these guidelines and educational initiatives have influenced
practice could provide more context.
-While you speculate that surgeons may be more comfortable with electrosurgical tools due to
their surgical training, this remains a hypothesis that is not directly supported by data in the study.
Further exploration of how specific training or experience influences practice would strengthen
this explanation.
-While the study points to regional variations and differences based on rurality, there is not a
detailed exploration of the underlying reasons for these variations beyond training. For example,
institutional or practice setting differences, local guidelines, or available resources could further
explain these disparities.
-The concept of de-implementation is introduced but not fully developed. More specific
suggestions on how to reduce hot biopsy forceps use, such as through provider education,
targeted interventions in certain geographic areas, or system-level changes, could strengthen the
practical implications of your findings.
-While you address some limitations regarding the dataset, there may be additional confounders
(e.g., patient preference, institutional protocols, or economic factors) that could influence the
choice of biopsy technique. Acknowledging these and suggesting ways to control them in future
studies would be beneficial.