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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality indicators for colonoscopy. Gastrointest Endosc 2024; 100:352-381. [PMID: 39177519 DOI: 10.1016/j.gie.2024.04.2905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/25/2024] [Indexed: 08/24/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Department of Medicine/Division of Gastroenterology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine/Division of Gastroenterology, White River Junction VAMC, White River Junction, Vermont, USA; University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco; Chief Medical Officer, University of California San Francisco Health System
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA; VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Rex DK, Anderson JC, Butterly LF, Day LW, Dominitz JA, Kaltenbach T, Ladabaum U, Levin TR, Shaukat A, Achkar JP, Farraye FA, Kane SV, Shaheen NJ. Quality Indicators for Colonoscopy. Am J Gastroenterol 2024:00000434-990000000-01296. [PMID: 39167112 DOI: 10.14309/ajg.0000000000002972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/19/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Douglas K Rex
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Department of Medicine, Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
- New Hampshire Colonoscopy Registry, Lebanon, New Hampshire, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
- Chief Medical Officer, University of California San Francisco Health System, San Francisco, California, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Tonya Kaltenbach
- Department of Medicine, University of California, San Francisco, California, USA
- Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Theodore R Levin
- Kaiser Permanente Division of Research, Pleasonton, California, USA
| | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York Harbor Veterans Affairs Health Care System, New York, New York, USA
| | - Jean-Paul Achkar
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Sunanda V Kane
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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Corley DA, Jensen CD, Lee JK, Levin TR, Zhao WK, Schottinger JE, Ghai NR, Doubeni CA, Halm EA, Sugg Skinner C, Udaltsova N, Contreras R, Fireman BH, Quesenberry CP. Impact of a scalable training program on the quality of colonoscopy performance and risk of postcolonoscopy colorectal cancer. Gastrointest Endosc 2023; 98:609-617. [PMID: 37094690 PMCID: PMC10523929 DOI: 10.1016/j.gie.2023.04.2073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/05/2023] [Accepted: 04/14/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND AIMS Endoscopist adenoma detection rates (ADRs) vary widely and are associated with patients' risk of postcolonoscopy colorectal cancers (PCCRCs). However, few scalable physician-directed interventions demonstrably both improve ADR and reduce PCCRC risk. METHODS Among patients undergoing colonoscopy, we evaluated the influence of a scalable online training on individual-level ADRs and PCCRC risk. The intervention was a 30-minute, interactive, online training, developed using behavior change theory, to address factors that potentially impede detection of adenomas. Analyses included interrupted time series analyses for pretraining versus posttraining individual-physician ADR changes (adjusted for temporal trends) and Cox regression for associations between ADR changes and patients' PCCRC risk. RESULTS Across 21 endoscopy centers and all 86 eligible endoscopists, ADRs increased immediately by an absolute 3.13% (95% confidence interval [CI], 1.31-4.94) in the 3-month quarter after training compared with .58% per quarter (95% CI, .40-.77) and 0.33% per quarter (95% CI, .16-.49) in the 3-year pretraining and posttraining periods, respectively. Posttraining ADR increases were higher among endoscopists with pretraining ADRs below the median. Among 146,786 posttraining colonoscopies (all indications), each 1% absolute increase in screening ADR posttraining was associated with a 4% decrease in their patients' PCCRC risk (hazard ratio, .96; 95% CI, .93-.99). An ADR increase of ≥10% versus <1% was associated with a 55% reduced risk of PCCRC (hazard ratio, .45; 95% CI, .24-.82). CONCLUSIONS A scalable, online behavior change training intervention focused on modifiable factors was associated with significant and sustained improvements in ADR, particularly among endoscopists with lower ADRs. These ADR changes were associated with substantial reductions in their patients' risk of PCCRC.
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Affiliation(s)
- Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
| | - Christopher D Jensen
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Theodore R Levin
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA; Kaiser Permanente Medical Center, Walnut Creek, California, USA
| | - Wei K Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Joanne E Schottinger
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | | | - Chyke A Doubeni
- Department of Family and Community Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA; The Ohio State University Comprehensive Cancer Center/The James Cancer Hospital, Wexner Medical Center, Columbus, Ohio, USA
| | - Ethan A Halm
- Rutgers Biological Health Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Richard Contreras
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Bruce H Fireman
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Charles P Quesenberry
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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Kiesslich R, Teubner D, Hoffman A, Rey JW. Retrospective comparison of G-EYE balloon-colonoscopy with standard colonoscopy for increased adenoma detection rate and reduced polyp removal time. Endosc Int Open 2023; 11:E920-E927. [PMID: 37810901 PMCID: PMC10558257 DOI: 10.1055/a-2005-6934] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 06/08/2022] [Indexed: 01/04/2023] Open
Abstract
Background and study aims The newly introduced G-EYE colonoscope (G-EYE) employs a balloon, installed at the bending section of a standard colonoscope (SC), for increasing adenoma detection and stabilizing the colonoscope tip during intervention. This retrospective work explores the effect of introducing G-EYE into an SC endoscopy room, in terms of adenoma detection and polyp removal time. Patients and methods This was a single-center, retrospective study. Historical data from patients who underwent colonoscopy prior to, and following, introduction of G-EYE into a particular endoscopy room were collected and analyzed to determine adenoma detection rate (ADR), adenoma per patient (APP), and polyp removal time (PRT), in each of the SC and G-EYE groups. Results Records of 1362 patients who underwent SC and 1433 subsequent patients who underwent G-EYE colonoscopy in the same endoscopy unit by the same endoscopists were analyzed. Following G-EYE introduction, overall ADR increased by 37.5 % ( P < 0.0001) from 39.2 % to 53.9 %, the serrated adenoma rate increased by 47.3 % from 27.9 % to 41.1 % ( P < 0.0001), and the APP increased by 50.6 % from 0.79 to 1.19 ( P < 0.0001). The number of advanced adenomas increased by 32.7 %, from 19.6 % to 26.0 % of all adenomas ( P < 0.0001). With G-EYE, average PRT was reduced overall by 29.5 % ( P < 0.0001), and particularly for endoscopic mucosal resection (EMR) by 37.5 % for polyps measuring ≥ 5 mm to ≤ 20 mm ( P < 0.0001) and by 29.4 % for large polyps > 20 mm ( P < 0.0001). Conclusions Introduction of G-EYE to an SC endoscopy room yielded considerable increase in ADR and notable reduction in PRT, particularly with the EMR technique. G-EYE balloon colonoscopy might increase the effectiveness of colorectal cancer screening and surveillance colonoscopy, and can shorten the time of endoscopic intervention.
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Affiliation(s)
- Ralf Kiesslich
- Helios Dr. Horst Schmidt Kliniken (HSK), Klinik für Innere Medizin II, Wiesbaden, Germany
| | - Daniel Teubner
- Helios Dr. Horst Schmidt Kliniken (HSK), Klinik für Innere Medizin II, Wiesbaden, Germany
| | - Arthur Hoffman
- Klinikum Aschaffenburg-Alzenau, Klinik für Innere Medizin III, Wiesbaden, Germany
| | - Johannes W. Rey
- Klinikum Osnabrück, Medizinische Klinik III, Wiesbaden, Germany
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Honing J, Keith Tan W, Dieninyte E, O’Donovan M, Brosens L, Weusten B, di Pietro M. Adequacy of endoscopic recognition and surveillance of gastric intestinal metaplasia and atrophic gastritis: A multicentre retrospective study in low incidence countries. PLoS One 2023; 18:e0287587. [PMID: 37352223 PMCID: PMC10289343 DOI: 10.1371/journal.pone.0287587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/08/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Gastric atrophy (GA) and gastric intestinal metaplasia (GIM) are precursor conditions to gastric adenocarcinoma (GAC) and should be monitored endoscopically in selected individuals. However, little is known about adherence to recommendations in clinical practice in low-risk countries. OBJECTIVE The aim of this study was to evaluate endoscopic recognition and adequacy of surveillance for GA and GIM in countries with low GAC prevalence. METHODS We retrospectively analysed patients diagnosed with GIM or GA in three centers in The Netherlands and UK between 2012 and 2019. Cases with GIM and/or GA diagnosis at index endoscopy were retrieved through systematic search of pathology databases using 'gastric' and 'intestinal metaplasia' or 'atrophy' keywords. Endoscopy reports were analysed to ascertain accuracy of endoscopic diagnoses. Adequacy of surveillance was assessed following histological diagnosis at the index endoscopy based on ESGE guidelines published in 2012. RESULTS We included 396 patients with a median follow-up of 57.2 months. Mean age was 66 years and the rates of antrum-predominant versus extensive GIM were comparable (37% vs 38%). Endoscopic recognition rates were 48.5% for GA and 16.3% for GIM. Surveillance was adequately carried out in 215 of 396 patients (54.3%). CONCLUSION In countries with a low incidence of GAC, the rate of endoscopic recognition of gastric pre-cancerous lesions and adherence to surveillance recommendation are low. Substantial improvement is required in endoscopic training and awareness of guidelines recommendation in order to optimise detection and management of pre-malignant gastric conditions.
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Affiliation(s)
- Judith Honing
- Early Cancer Institute, University of Cambridge, Cambridge, United Kingdom
| | - W. Keith Tan
- Early Cancer Institute, University of Cambridge, Cambridge, United Kingdom
| | | | - Maria O’Donovan
- Department of Pathology, University of Cambridge, Addenbrooke’s University Hospital, Cambridge, United Kingdom
| | - Lodewijk Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
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Rajivan R, Thayalasekaran S. Improving polyp detection at colonoscopy: Non-technological techniques. World J Gastrointest Endosc 2023; 15:354-367. [PMID: 37274557 PMCID: PMC10236979 DOI: 10.4253/wjge.v15.i5.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/03/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Colonoscopy and polypectomy remain the gold standard investigation for the detection and prevention of colorectal cancer. Halting the progression of colonic adenoma through adequate detection of pre-cancerous lesions interrupts the progression to carcinoma. The adenoma detection rate is a key performance indicator. Increasing adenoma detection rates are associated with reducing rates of interval colorectal cancer. Endoscopists with high baseline adenoma detection rate have a meticulous technique during colonoscopy withdrawal that improves their adenoma detection. This minireview article summarizes the evidence on the following simple operator techniques and their effects on the adenoma detection rate; minimum withdrawal times, dynamic patient position change and proximal colon retroflexion.
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Affiliation(s)
- Ragul Rajivan
- Buckingham Medical School, Milton Keynes MK18 1EG, United Kingdom
| | - Sreedhari Thayalasekaran
- Department of Gastroenterology, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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Chang TL, Lewis B, Deutsch N, Nulsen B. Changes in Adenoma Detection Rate From Full-Spectrum Endoscopy to Standard Forward-Viewing Endoscopy. J Clin Gastroenterol 2023; 57:404-409. [PMID: 35470297 PMCID: PMC9983745 DOI: 10.1097/mcg.0000000000001706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/04/2022] [Indexed: 12/10/2022]
Abstract
GOALS The aim was to investigate the adenoma detection rate (ADR) of endoscopists who have used full-spectrum endoscopy (Fuse) for 3 years and revert back to traditional forward-viewing endoscopes (R-TFV) at an ambulatory surgical center. BACKGROUND Traditional forward viewing (TFV) endoscopes have 1 camera and provide an angle of view of 140 to 170 degrees, whereas Fuse provides a 330 degrees view through the addition of 2 side cameras. It has previously been reported that Fuse increased the ADR by 5.4% when compared with previous rates using TFV. Fuse is no longer commercially available. The ADR of endoscopists who revert back to TFV is unknown. STUDY We conducted a retrospective analysis of data examining the ADR from average risk screening colonoscopies at a 5-room ambulatory surgical center where endoscopists transitioned from TFV to Fuse in April 2014 and then reverted back to TFV in 2016. The primary outcome was ADR. Secondary outcomes were ADR for advanced and right-sided adenomas. RESULTS A total of 6110 procedures were reviewed. The ADR was 23.70% for TFV, 29.02% for Fuse and 28.88% for R-TFV. The ADR for advanced adenomas was 3.8% for TFV, 6.0% for Fuse and 7.3% for R-TFV. The ADR for right-sided adenomas was 13.0% for TFV, 16.7% for Fuse and 16.0% for R-TFV. The results for all 3 categories showed a statistical difference between TFV and Fuse as well as between TFV and R-TFV. There were no statistical differences between the ADR of Fuse compared with R-TFV. CONCLUSIONS During R-TFV, endoscopists are able to maintain their increased ability to detect adenomas. This would suggest that there was a change in behavior in endoscopists using Fuse that was durable.
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Melson J. Monitoring colonoscopy screening program quality at the provider level, the institution level, and beyond. Gastrointest Endosc 2023; 97:130-131. [PMID: 36371237 DOI: 10.1016/j.gie.2022.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/30/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Joshua Melson
- Division of Gastroenterology, Department of Internal Medicine, University of Arizona-Banner University Medical Center, Tucson, Arizona, USA
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Lam AY, Duloy AM, Keswani RN. Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them. Gastrointest Endosc Clin N Am 2022; 32:329-349. [PMID: 35361339 DOI: 10.1016/j.giec.2021.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.
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Affiliation(s)
- Angela Y Lam
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, 2350 Geary Boulevard, San Francisco, CA 94115, USA
| | - Anna M Duloy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635 Aurora Court, Aurora, CO 80045, USA
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, 676 North Street, Clair, Suite 1400, Chicago, IL 60611, USA.
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Parasa S, Wallace MB, Srinivasan S, Sundaram S, Kennedy KF, Williams LJ, Sharma P. Educational intervention to improve quality of care in Barrett's esophagus: the AQUIRE randomized controlled trial. Gastrointest Endosc 2022; 95:239-245.e2. [PMID: 34499903 DOI: 10.1016/j.gie.2021.08.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Despite quality measures in upper endoscopy (EGD) for Barrett's esophagus (BE), considerable variability remains in practice among gastroenterologists. This randomized controlled trial evaluated the role of structured intensive training on the quality of EGD in BE. METHODS In this multicenter study, 8 sites (from the GI Quality Consortium) were cluster randomized (1:1) to receive AQUIRE (A Quality Improvement program in cancer care during Endoscopy) training (intervention) or continue local standard practices (control). The primary outcome was compliance with the Seattle biopsy protocol. Secondary outcomes were change in knowledge of BE detection and sampling assessed by questionnaire and dysplasia detection rate (DDR) before and after completion of the 6-month study period. RESULTS The intervention sites (n = 4) had 31 gastroenterologists and the control sites (n = 4) had 34. There was a significant improvement in the compliance rates with the Seattle biopsy protocol from baseline to the end of the study in the intervention sites (64.8%-73.2%, P = .002) but not in the control sites (69.5%-69.4%, P = .953). The accurate response rate on the questionnaire at the intervention sites increased from 73% at baseline to 88% after AQUIRE training (difference, 14.8%; standard deviation, 18.7; P = .008). DDR did not change significantly from baseline to 6 months in either the control or intervention groups (P = .06). CONCLUSIONS This study confirms the capacity of a structured educational intervention to improve utilization of a standard biopsy protocol and knowledge of standards of care in BE but without significant change in DDR.
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Affiliation(s)
- Sravanthi Parasa
- Department of Gastroenterology, Swedish Medical Center, Seattle, Washington, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Sachin Srinivasan
- Department of Internal Medicine, University of Kansas School of Medicine, Wichita, Kansas, USA; Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Suneha Sundaram
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Department of Biostatistics, St Luke's Hospital, Kansas City, Missouri, USA
| | | | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
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11
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Hammami A, Elloumi H, Bouali R, Elloumi H. Clinical practice standards for colonoscopy. LA TUNISIE MEDICALE 2021; 99:952-960. [PMID: 35288895 PMCID: PMC8972176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Colonoscopy is considered as the most effective tool for preventing, screening, and diagnosing colorectal lesions. Effectiveness of colonoscopy was identified as a major priority, and it strictly depends on quality measures. Therefore, international guidelines were formulated on quality indicators for colonoscopy, aiming to reduce the rate of interval cancers related to missed lesions during colonoscopy. Quality indicators are divided into 3 time periods: preprocedure, intraprocedure, and postprocedure. The main pre-procedural indicators are the assessment of the appropriateness of indication of colonoscopy and the prescription of adequate bowel preparation during a consultation prior to colonoscopy. Per-procedural criteria include all technical aspects of the procedure, which are "endoscopist-dependent" factors, particularly cecal intubation, detection of adenomas and withdrawal time. The main post-procedure indicators are the rate of complications, patient experience and optimal surveillance intervals following removal of colorectal polyps. The implementation of key performance measures in endoscopy practice is increasingly important as it can help improving our care of patients and optimize outcomes. In this review, the "Club d'endoscopie digestive" (CED) presented a summary of the main colonoscopy quality indicators, and suggested recommendations that took into account the particularities of our local conditions.
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Affiliation(s)
- Aya Hammami
- 1-Hôpital SahloulSousse / Université de Sousse, Faculté de médecine de Sousse
| | - Hanen Elloumi
- 2-Hôpital Habib Bougatfa Bizerte / Université Tunis El Manar, Faculté de Médecine de Tunis, Tunisie
| | - Riadh Bouali
- 3-Hôpital militaire / Université Tunis El Manar, Faculté de Médecine de Tunis, Tunisie
| | - Hela Elloumi
- 4-Hôpital Habib Thameur / Université Tunis El Manar, Faculté de Médecine de Tunis, Tunisie
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12
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Shiha MG, Al-Rifaie A, Thoufeeq M. Impact of the National Endoscopy Database (NED) on colonoscopy withdrawal time: a tertiary centre experience. BMJ Open Gastroenterol 2021; 8:bmjgast-2021-000699. [PMID: 34215571 PMCID: PMC8256742 DOI: 10.1136/bmjgast-2021-000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/08/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Colonoscopy withdrawal time (CWT) is a key performance indicator affecting polyp detection rate (PDR) and adenoma detection rate (ADR). However, studies have shown wide variation in CWT and ADR between different endoscopists. The National Endoscopy Database (NED) was implemented to enable quality assurance in all endoscopy units across the UK and also to reduce variation in practice. We aimed to assess whether CWT changed since the introduction of NED and whether CWT affected PDR. METHODS We used NED to retrospectively collect data regarding CWT and PDR of 25 endoscopists who performed (n=4459 colonoscopies) in the four quarters of 2019. We then compared this data to their performance in 2016, before using NED (n=4324 colonoscopies). RESULTS Mean CWT increased from 7.66 min in 2016 to 9.25 min in 2019 (p=0.0001). Mean PDR in the two periods was 29.9% and 28.3% (p=0.64). 72% of endoscopists (18/25) had CWT>6 min in 2016 versus 100% (25/25) in 2019, the longer CWT in 2019 positively correlated with the PDR (r=0.50, p=0.01). Gastroenterology consultants and trainee endoscopists had longer CWT compared with colorectal surgeons both before and after using NED. CONCLUSION NED usage increased withdrawal times in colonoscopy. Longer withdrawal times were associated with higher PDR. A national colonoscopy audit using data from NED is required to evaluate whether wide variations in practice across endoscopy units in the UK still exist and to ensure minimum colonoscopy quality standards are achieved.
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Affiliation(s)
- Mohamed G Shiha
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ammar Al-Rifaie
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mo Thoufeeq
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Toyoshima O, Yoshida S, Nishizawa T, Yamakawa T, Arano T, Isomura Y, Kanazawa T, Ando H, Tsuji Y, Koike K. Simple feedback of colonoscopy performance improved the number of adenomas per colonoscopy and serrated polyp detection rate. Endosc Int Open 2021; 9:E1032-E1038. [PMID: 34222627 PMCID: PMC8211485 DOI: 10.1055/a-1393-5469] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/26/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims High-quality endoscopy requires improvement of not only the adenoma detection rate (ADR) but also the serrated polyp (SP) detection rate and the mean number of adenomas per positive procedure (MAP +). We evaluated whether a simple feedback of colonoscopy performance improves those quality indicators using propensity-score matching. Patients and methods Eleven endoscopists were evaluated regarding colonoscopy performance including ADRs, SP detection rates, mean numbers of adenomas per procedure (MAPs), and MAPs + with their ranking in the clinic. Endoscopic performance was compared before and after the feedback. Results Colonoscopies were performed for 874 patients before the feedback and 1,272 patients after the feedback. Using propensity-score matching, 803 patients before the feedback and 803 patients after the feedback were matched. ADR after the feedback was significantly higher than that before the feedback (50.8 % and 40.8 %, respectively). MAP after feedback was significantly larger than that before the feedback (0.92 and 0.69, respectively), as well as MAP + (1.96 and 1.69, respectively). Clinically significant SP detection rate was also improved from 10.0 % to 14.9 %. Conclusions Feedback including ADR, MAP, MAP +, and clinically significant SR detection rate could improve on those quality indicators. Further studies are needed to effectively prevent colorectal cancer in colonoscopy practice.
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Affiliation(s)
- Osamu Toyoshima
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuntaro Yoshida
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshihiro Nishizawa
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology and Hepatology, International University of Health and Welfare, Chiba, Japan
| | | | - Toru Arano
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Yoshihiro Isomura
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastroenterology, Kyoundo Hospital, Tokyo, Japan
| | - Takamitsu Kanazawa
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan
- Department of Gastrointestinal Surgery, JR Tokyo General Hospital, Tokyo, Japan
| | | | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Rubio CA. Two histologic compartments in nonpolypoid conventional colon adenomas. J Gastroenterol Hepatol 2021; 36:910-917. [PMID: 32757480 DOI: 10.1111/jgh.15210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 08/02/2020] [Indexed: 12/09/2022]
Abstract
Two intertwined compartments coexisting in nonpolypoid conventional (i.e. tubular or villous) adenomas are highlighted in this review: one built of dysplastic tissue on top and the other portraying crypts with irregular, corrupted shapes, albeit lined with normal epithelium, below. The latter compartment has remained unattended in the literature. Recently, however, the histologic characteristics of the nondysplastic compartment in nonpolypoid conventional adenomas were closely examined, and some of its biological attributes were unveiled. Studies with the proliferation marker ki67 showed that the crypts with irregular, corrupted shapes in the nondysplastic compartment displayed haphazardly distributed proliferating cell-domains. Given that the proliferating cells are generated by stem cells, the relocation of proliferating cell-domains in those crypts seems to be the result of a reorganization of the stem cells within the crypts. The abnormal distribution of proliferating cells, the finding of p53-upregulated cells, and of crypts in asymmetric fission suggest that the crypts in that compartment are histo-biologically altered, probably somatically mutated. This new information might contribute to unravel the riddle of crypto-histogenesis of nonpolypoid conventional adenomas of the colon. More research along these lines is necessary, before the biology of the crypts in the nondysplastic compartment can be fully translated into molecular terms.
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Affiliation(s)
- Carlos A Rubio
- Gastrointestinal Research Laboratory, Department of Pathology, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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15
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Bleijenberg AGC, van Leerdam ME, Bargeman M, Koornstra JJ, van Herwaarden YJ, Spaander MCW, Sanduleanu S, Bastiaansen BAJ, Schoon EJ, van Lelyveld N, Dekker E, IJspeert JEG. Substantial and sustained improvement of serrated polyp detection after a simple educational intervention: results from a prospective controlled trial. Gut 2020; 69:2150-2158. [PMID: 32139550 PMCID: PMC7677479 DOI: 10.1136/gutjnl-2019-319804] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Serrated polyps (SPs) are an important cause of postcolonoscopy colorectal cancers (PCCRCs), which is likely the result of suboptimal SP detection during colonoscopy. We assessed the long-term effect of a simple educational intervention focusing on optimising SP detection. DESIGN An educational intervention, consisting of two 45 min training sessions (held 3 years apart) on serrated polyp detection, was given to endoscopists from 9 Dutch hospitals. Hundred randomly selected and untrained endoscopists from other hospitals were selected as control group. Our primary outcome measure was the proximal SP detection rate (PSPDR) in trained versus untrained endoscopists who participated in our faecal immunochemical test (FIT)-based population screening programme. RESULTS Seventeen trained and 100 untrained endoscopists were included, who performed 11 305 and 51 039 colonoscopies, respectively. At baseline, PSPDR was equal between the groups (9.3% vs 9.3%). After training, the PSPDR of trained endoscopists gradually increased to 15.6% in 2018. This was significantly higher than the PSPDR of untrained endoscopists, which remained stable around 10% (p=0.018). All below-average (ie, PSPDR ≤6%) endoscopists at baseline improved their PSPDR after training session 1, as did 57% of endoscopists with average PSPDR (6%-12%) at baseline. The second training session further improved the PSPDR in 44% of endoscopists with average PSPDR after the first training. CONCLUSION A simple educational intervention was associated with substantial long-term improvement of PSPDR in a prospective controlled trial within FIT-based population screening. Widespread implementation of such interventions might be an easy way to improve SP detection, which may ultimately result in fewer PCCRCs. TRIAL REGISTRATION NUMBER NCT03902899.
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Affiliation(s)
- Arne G C Bleijenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Monique E van Leerdam
- Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Marloes Bargeman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
| | - Jan Jacob Koornstra
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yasmijn J van Herwaarden
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Manon CW Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Silvia Sanduleanu
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Barbara A J Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Niels van Lelyveld
- Department of Gastroenterology and Hepatology, Saint Antonius Hospital, Nieuwegein, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joep E G IJspeert
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Uche-Anya EN, Brown JJ, Asumeng C, Striplin J, Carlesimo M, Krauskopf M, Greenwald D, Bernstein B, Itzkowitz S, Schnoll-Sussman F, Lebwohl B. Impact of a Citywide Benchmarking Intervention on Colonoscopy Quality Performance. Dig Dis Sci 2020; 65:2534-2541. [PMID: 32036513 DOI: 10.1007/s10620-020-06067-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/09/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION There is marked variability in colonoscopy quality, limiting its effectiveness in colorectal cancer prevention. Multiple indicators have been established as markers for colonoscopy quality; however, there are conflicting data on the effects of quality reporting programs on endoscopist performance. In this study, we investigate the impact of a multicenter quarterly report card initiative on colonoscopy quality metric performance. METHODS Data were collected from 194 endoscopists at 10 participating sites throughout New York City using a Qualified Clinical Data Registry from January 2013 to December 2014. Adenoma detection rate (ADR), cecal intubation rate, withdrawal time, bowel preparation quality and appropriate interval recommendations were tracked. Report cards were distributed to each site on a quarterly basis and technical assistance was provided as needed. Performance trends were analyzed using the Cochran-Armitage trend and analysis of variance tests. RESULTS 37,258 screening colonoscopies were performed during the study period. There was a positive performance trend for ADR over time from the first quarter of 2013 to the last quarter of 2014 (15.6-25.7%; p < 0.001). There were also increases in cecal intubation rates (78.2-92.6%; p < 0.001), bowel preparation adequacy rates (77.5-92.8%; p < 0.001), and adherence to appropriate screening intervals (28.0-55.0%; p < 0.001). There was no clinically significant change in mean withdrawal time. CONCLUSIONS The implementation of a quarterly report card initiative resulted in statistically significant improvements in adenoma detection, cecal intubation, bowel preparation adequacy rates, and appropriate recommended screening intervals.
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Affiliation(s)
- Eugenia N Uche-Anya
- Department of Medicine, Columbia University Irving Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Jennifer J Brown
- New York City Department of Health and Mental Hygiene, New York, USA
| | - Charles Asumeng
- New York City Department of Health and Mental Hygiene, New York, USA
| | - Jared Striplin
- New York City Department of Health and Mental Hygiene, New York, USA
| | - Mari Carlesimo
- New York City Department of Health and Mental Hygiene, New York, USA
| | - Marian Krauskopf
- New York City Department of Health and Mental Hygiene, New York, USA
| | - David Greenwald
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Brett Bernstein
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Steven Itzkowitz
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Felice Schnoll-Sussman
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medical Center, New York, USA
| | - Benjamin Lebwohl
- Department of Medicine, Columbia University Irving Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, USA
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Connecting colonoscopy quality improvement initiatives with reduced rates of interval colorectal cancers. Gastrointest Endosc 2020; 92:365-367. [PMID: 32703370 DOI: 10.1016/j.gie.2020.03.3860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/29/2020] [Indexed: 12/11/2022]
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Abstract
Colonoscopy is a safe and effective tool, but operator dependent. Room for improvement in the quality of colonoscopy is the impetus for the development and measurement of colonoscopy quality indicators and the focus of many efforts to improve colonoscopy quality indicator prevention and control in provider practices and health systems. We present the preprocedural, intraprocedural, and postprocedural quality indicators and benchmarks for colonoscopy. Every provider and practice must make a commitment to performing high-quality colonoscopy and implement and monitor quality metrics. There are a variety of tools available to assist in improving quality indicators that range from distal attachment devices to education and feedback. Although technology can help, it is not a substitute for proper technique. The commitment also requires provider feedback through audits and report cards. The impact of these efforts on patient outcomes is an important area of further research.
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Fraser AG, Rose T, Wong P, Lane M, Frankish P. Improved detection of adenomas and sessile serrated polyps is maintained with continuous audit of colonoscopy. BMJ Open Gastroenterol 2020; 7:e000425. [PMID: 32675086 PMCID: PMC7368474 DOI: 10.1136/bmjgast-2020-000425] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/01/2020] [Accepted: 06/10/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The audit process may help improve performance indicators for colonoscopy quality but it is unclear whether this is sustained over several years. METHODS 44138 procedures for 28 endoscopists from 2004 to 2019 were analysed for polyp detection rate and withdrawal time. From 2012, 14 endoscopists were analysed with additional data on polyp histology and number of polyps removed. RESULTS Polyp detection increased from 40.7% in 2004 to 62.2% in 2019; removal of polyps>1 cm remained constant (11%). Adenoma detection rate was 25.8% in 2012 and 28.3% in 2019. Sessile serrated polyp (SSP) detection rate increased from 4.5% to 14.7%; most of the increase was in the first 2 years of the histology part of the audit. There was a significant correlation of adenoma detection rate with mean number of adenomas (r=0.72, p=0.004) and a significant correlation of SSP detection with mean number of SSPs (r=0.85, p=0.0001). CONCLUSION The audit process appears to encourage a higher rate of polyp detection. This was due to increased detection of smaller polyps and increased detection of SSPs.
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Affiliation(s)
- Alan Gordon Fraser
- Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Multidirectional Colonoscopy Quality Improvement Increases Adenoma Detection Rate: Results of the Seoul National University Hospital Healthcare System Gangnam Center Colonoscopy Quality Upgrade Project (Gangnam-CUP). Dig Dis Sci 2020; 65:1806-1815. [PMID: 31732905 DOI: 10.1007/s10620-019-05944-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND To prevent colorectal cancer, high-quality colonoscopy is advocated, undertaken by endoscopists with high adenoma detection rates (ADRs). Despite reports that various factors may impact ADRs, the significance of such factors is still unclear. AIMS The analysis was aimed at quality-oriented interventions for boosting ADRs. METHODS Study enrollees were adults subjected to screening colonoscopy between September 2013 and August 2016 at the Gangnam Center of Seoul National University Hospital Healthcare System. The investigation entailed six periods (P1-6) of 6 months each, during which serial multidirectional quality improvement efforts were instituted. In particular, we sought to further educate endoscopists, provide feedback on individual ADRs, and introduce a split-dose regimen, gauging results via the Boston Bowel Preparation Score. Changes in polyp detection rates (PDRs) and ADRs were then analyzed. RESULTS A total of 13,430 colonoscopies were undertaken by 15 experienced endoscopists. Overall, the ADR increased from 45.6% (P1) to 48.2% (P6, p < 0.001). The PDR, ADR, and advanced adenoma detection rate (AdvADR) showed the greatest increases between P3 and P4 [PDR 67.8% → 71.2% (p < 0.001); ADR 44.1% → 47.7% (p = 0.001); AdvADR 2.3% → 3.3% (p = 0.028)] in keeping with the introduction of a split-dose regimen. The sessile serrated adenoma detection rate (SSADR) increased substantially from 2.1% (P1) to 7.9% (P6, p < 0.001), with the largest gain between P1 and P2, just after education (p = 0.023). CONCLUSIONS Successful quality improvement in colonoscopy was achieved through comprehensive multidirectional efforts in education, feedback, and enhanced bowel preparation. Achieving high-level bowel preparation was paramount in ADR improvement. The SSADR was improved through education.
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21
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Effect of an educational intervention on colonoscopy quality outcomes. Surg Endosc 2019; 34:5142-5147. [PMID: 31820159 DOI: 10.1007/s00464-019-07304-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 11/28/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND We aimed to assess the effect of a colonoscopy skills improvement (CSI) course on quality indicators at our institution. METHODS This retrospective cohort study included ten surgeons and nine gastroenterologists practicing in a tertiary referral center who had undergone CSI training between 2014 and 2015. Procedural data for 50 colonoscopies by each physician was collected immediately before and after CSI training, and again 8 months after training. The primary outcome was adenoma detection rate (ADR) and secondary outcomes included colonoscopy completion rate (CCR), and withdrawal time (WT). Univariate analysis followed by stepwise multivariable logistic regression was performed to assess for predictors of these outcomes. These variables included patient age, gender, indication for colonoscopy, quality of bowel preparation, and CSI training. RESULTS 2533 colonoscopies were included. There was no improvement in ADR for the entire group immediately after training and at 8 months (31.8% vs. 33.6% vs. 35.3%, p = 0.319). In subgroup analysis, the ADR of surgeons improved non-significantly immediately after completing the course and increased further at 8 months (30.9% vs. 31.6% vs. 37.6%, p = 0.065). The same changes were not observed for the gastroenterology subgroup (32.9% vs. 36.0% vs. 32.8%, p = 0.550). No change was noted in CCR or WT. In multivariate analysis of the surgical subgroup, increased patient age, male gender, and the 8-month time point following CSI training were associated with higher ADR. CONCLUSION CSI training is associated with an improvement in ADR for surgeons at our institution.
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Training interventions to improve adenoma detection rates during colonoscopy: a systematic review and meta-analysis. Surg Endosc 2019; 34:3870-3882. [PMID: 31595401 DOI: 10.1007/s00464-019-07153-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/24/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Colonoscopies are effective means of detecting and removing precancerous adenomatous polyps. The adenoma detection rate (ADR) is a marker of colonoscopy quality and an independent predictor of colorectal cancer incidence. Focused training interventions may improve an endoscopist's ADR, but the supporting research is limited. This systematic review and meta-analysis identified, critically appraised, and meta-analyzed data from randomized trials (RCTs) evaluating the effect of training interventions on ADRs. METHODS Ovid Medline, EMBASE, CENTRAL, Eric, CINAHL, Scopus, Web of Science, and ClinicalTrials.gov were searched for RCTs investigating the effect of an educational intervention on ADRs. Two reviewers independently screened, identified, and extracted trial-level data. Internal validity was assessed in duplicate using the Risk of Bias tool. Our primary outcome was the ADR. Secondary outcomes were advanced ADR, adenocarcinoma detection rate, polyp detection rate, and withdrawal times. Safety outcomes were post-polypectomy bleeding rate and colonoscopy-related perforation rate. RESULTS From 2837 screened citations, we identified 3 trials (119 endoscopists) meeting our inclusion criteria. Training interventions were associated with a trend toward increased ADRs (odds ratio 1.16, 95% confidence interval (CI) 1.00-1.34; I2 83%; 3 trials; 119 endoscopists). When limited to screening colonoscopies, the odds ratio for ADRs associated with training interventions was 1.17 (95% CI 1.00-1.36; I2 80%; 3 trials; 119 endoscopists). There was a high level of heterogeneity between the trials' training interventions. Training intervention improved the advanced ADR, adenocarcinoma detection rate, polyp detection rate, and withdrawal times. Safety outcomes were not reported. CONCLUSIONS A focused training intervention was associated with a strong trend toward increased ADRs among certified endoscopists. While the described training interventions definitely show promise, further efforts around continuing professional developments activities are needed to more consistently improve ADRS among certified endoscopists.
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Duloy A, Yadlapati RH, Benson M, Gawron AJ, Kahi CJ, Kaltenbach TR, McClure J, Gregory DL, Keswani RN. Video-Based Assessments of Colonoscopy Inspection Quality Correlate With Quality Metrics and Highlight Areas for Improvement. Clin Gastroenterol Hepatol 2019; 17:691-700. [PMID: 29908363 DOI: 10.1016/j.cgh.2018.05.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 05/17/2018] [Accepted: 05/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Adenoma detection rate (ADR) and serrated polyp detection rate (SDR) vary significantly among colonoscopists. Colonoscopy inspection quality (CIQ) is the quality with which a colonoscopist inspects for polyps and may explain some of this variation. We aimed to determine the relationship between CIQ and historical ADRs and SDRs in a cohort of colonoscopists and assess whether there is variation in CIQ components (fold examination, cleaning, and luminal distension) among colonoscopists with similar ADRs and SDRs. METHODS We conducted a prospective observational study to assess CIQ among 17 high-volume colonoscopists at an academic medical center. Over 6 weeks, we video-recorded >28 colonoscopies per colonoscopist and randomly selected 7 colonoscopies per colonoscopist for evaluation. Six raters graded CIQ using an established scale, with a maximum whole colon score of 75. RESULTS We evaluated 119 colonoscopies. The median whole-colon CIQ score was 50.1/75. Whole-colon CIQ score (r=0.71; P<.01) and component scores (fold examination r=0.74; cleaning r=0.67; distension r=0.77; all P<.01) correlated with ADR. Proximal colon CIQ score (r=0.67; P<.01) and component scores (fold examination r=0.71; cleaning r=0.62; distension r=0.65; all P<.05) correlated with SDR. CIQ component scores differed significantly between colonoscopists with similar ADRs and SDRs for most of the CIQ skills. CONCLUSION In a prospective observational study, we found CIQ and CIQ components to correlate with ADR and SDR. Colonoscopists with similar ADRs and SDRs differ in their performance of the 3 CIQ components-specific, actionable feedback might improve colonoscopy technique.
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Affiliation(s)
- Anna Duloy
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Rena H Yadlapati
- Department of Gastroenterology, University of Colorado, Aurora, Colorado
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andrew J Gawron
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah
| | - Charles J Kahi
- Department of Gastroenterology, Indiana University School of Medicine, Richard L Roudebush VA Medical Center, Indianapolis, Indiana
| | - Tonya R Kaltenbach
- Department of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Jessica McClure
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dyanna L Gregory
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Patel VD, Thompson WK, Lapin BR, Goldstein JL, Yen EF. Screening Colonoscopy Withdrawal Time Threshold for Adequate Proximal Serrated Polyp Detection Rate. Dig Dis Sci 2018; 63:3084-3090. [PMID: 29974376 DOI: 10.1007/s10620-018-5187-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 06/26/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION For adequate adenoma detection rate (ADR), guidelines recommend a mean withdrawal time (MWT) of ≥ 6 min. ADR has been shown to correlate strongly with proximal serrated polyp detection rate (PSP-DR), which is another suggested quality measure for screening colonoscopy. However, the impact of directly measured withdrawal time on PSP-DR has not been rigorously studied. We examined the relationship between MWT to ADR and PSP-DR, with the aim of identifying a functional threshold withdrawal time associated with both increased ADR and PSP-DR. METHODS This was a retrospective study of endoscopy and pathology data from average-risk screening colonoscopy examinations performed at a large system with six endoscopy laboratories. A natural language processing tool was used to determine polyp location and histology. ADR and PSP-DR were calculated for each endoscopist. MWT was calculated from colonoscopy examinations in which no polyps were resected. RESULTS In total, 31,558 colonoscopy examinations were performed, of which 10,196 were average-risk screening colonoscopy examinations with cecal intubation and adequate prep by 24 gastroenterologists. When assessing the statistical significance of increasing MWT by minute, the first significant time mark for PSP-DR was at 11 min at a rate of 14.2% (p = 0.01). There was a significant difference comparing aggregated MWT < 11 min compared to ≥ 11 min looking at the rates of adenomas [OR 1.65 (1.09-2.51)] and proximal serrated polyps [OR 1.81 (1.06-3.08)]. While ADR linearly correlated well with MWT (R = 0.76, p < 0.001), the linear relationship with PSP-DR was less robust (R = 0.42, p = 0.043). CONCLUSION In this large cohort of average-risk screening colonoscopy, a MWT of 11 min resulted in a statistically significant increase in both ADR and PSP-DR. Our data suggest that a longer withdrawal time may be required to meet both quality metrics.
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Affiliation(s)
- Viral D Patel
- Division of Gastroenterology, University of Chicago, Pritzker School of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - William K Thompson
- Center for Clinical Research Informatics, NorthShore University HealthSystem, Evanston, IL, USA
| | - Brittany R Lapin
- Center for Clinical Research Informatics, NorthShore University HealthSystem, Evanston, IL, USA
| | - Jay L Goldstein
- Division of Gastroenterology, University of Chicago, Pritzker School of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Eugene F Yen
- Division of Gastroenterology, University of Chicago, Pritzker School of Medicine, NorthShore University HealthSystem, Evanston, IL, USA.
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Reynolds C, Esrailian E, Hommes D. Quality Improvement in Gastroenterology: A Systematic Review of Practical Interventions for Clinicians. Dig Dis Sci 2018; 63:2507-2518. [PMID: 30014225 DOI: 10.1007/s10620-018-5198-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/05/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Quality improvement (QI) identifies practical methods to improve patient care; however, it is not always widely known which QI methods are successful. We sought to create a primer of QI in gastroenterology for the practicing clinician. METHODS We performed a systematic review of QI literature in gastroenterology. We included search terms for inflammatory bowel disease, irritable bowel syndrome, celiac disease, gastroesophageal reflux disease, pancreatitis, liver disease, colorectal cancer screening, endoscopy, and gastrointestinal bleeding. We used general search terms for QI as well as specific terms to capture established quality metrics for each GI disease area. RESULTS We found 33 studies that met our definitions for QI. There were 17 studies of endoscopy including screening colonoscopy, six on liver disease, four on IBD, two on GERD, three on GI bleeding, and one on celiac disease. Education was the most common intervention, although most successful studies combined education with another intervention. Other effective interventions included retraining sessions to reach ADR goals in colonoscopy, nursing protocols to increase HCC screening, and EMR decision support tools to prompt reassessment of PPI therapy. Many studies showed improved compliance to metrics, but few were able to show differences in length of stay, readmissions, or mortality. CONCLUSIONS Our review of quality improvement literature in gastroenterology revealed common themes of successful programs: Education was frequently used but often insufficient, the EMR may be underutilized in guiding decision making, and patient-reported outcomes were infrequently assessed. Further research may be needed to compare QI strategies directly.
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Affiliation(s)
- Courtney Reynolds
- Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, 10945 Le Conte Ave, Suite 2338, Los Angeles, CA, 90095, USA.
| | - Eric Esrailian
- Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, 10945 Le Conte Ave, Suite 2338, Los Angeles, CA, 90095, USA.,Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, 200 Medical Plaza Driveway, Los Angeles, CA, 90024, USA
| | - Daniel Hommes
- Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, 10945 Le Conte Ave, Suite 2338, Los Angeles, CA, 90095, USA
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Yoon JY, Cha JM, Shin JE, Kim KO, Yang HJ, Kim HG, Cho YS, Boo SJ, Lee J, Jung Y, Lee HJ, Koo HS, Joo YE. An Adjusted Level of Adenoma Detection Rate is Necessary for Adults Below 50 Years Old. J Clin Gastroenterol 2018; 52:703-708. [PMID: 28787362 DOI: 10.1097/mcg.0000000000000901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although adenoma prevalence is lower in younger people compared with screening-aged adults 50 years old and above, there is no adjustment recommendation for the target adenoma detection rate (ADR) in young people. Herein, we estimated a different target ADR for adults below 50 years old based on screening colonoscopy findings. MATERIALS AND METHODS Asymptomatic, average-risk adults below 50 years old who underwent screening colonoscopy were enrolled at 12 endoscopy centers in Korea between February 2006 and March 2012. Screening colonoscopies were stratified into low or high ADR groups with ADR levels of 20% and 25%, respectively. RESULTS The ADRs from 12 endoscopy centers ranged from 12.1% to 43.8% (median ADR, 24.1%) based on 5272 young adults receiving screening colonoscopies. Using 20% as an ADR level, the risks for metachronous adenoma and advanced adenoma were significantly higher in the low ADR group than the high ADR group (35.4% vs. 25.7%, P<0.001; 8.3% vs. 3.7%, P=0.001, respectively). However, using ADR level of 25%, the risk for metachronous neoplasia was similar in the high and low ADR groups in young adults according to screening colonoscopy. In subgroup analysis, similar findings were found in males, but not in females. CONCLUSIONS Optimal target ADR may be different between younger and older populations, and the adoption of a 20% target ADR could be used as a performance indicator for young populations.
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Affiliation(s)
- Jin Young Yoon
- Department of Internal Medicine, Kyung Hee University School of Medicine
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University School of Medicine
| | - Jeong Eun Shin
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu
| | - Hyo-Joon Yang
- Department of Internal Medicine, Kangbuk Samsung Hospital
| | - Hyun Gun Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine
| | - Young-Seok Cho
- Department of Internal Medicine, Catholic University College of Medicine
| | - Sun-Jin Boo
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju
| | - Jun Lee
- Department of Internal Medicine, Chosun University College of Medicine
| | - Yunho Jung
- Department of Internal Medicine, Soonchunhyang University College of Medicine
| | - Hyun Jung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul
| | - Hoon Sup Koo
- Department of Internal Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Young-Eun Joo
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju
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Hsieh YH, Leung FW. Increase your adenoma detection rate without using fancy adjunct tools. Tzu Chi Med J 2018; 30:127-134. [PMID: 30069119 PMCID: PMC6047331 DOI: 10.4103/tcmj.tcmj_86_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/24/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023] Open
Abstract
The correlation between a low adenoma detection rate (ADR) and interval cancers (ICs) has made ADR one of the most important quality indicators for colonoscopy. Data from nation-wide colorectal cancer (CRC) screening programs showed that there is room for improvement in ADR in order to reduce ICs in Taiwan. Measures with and without adjunct tools have been shown to have the potential to increase ADR, with the latter being more convenient to apply without additional cost. Optimal withdrawal techniques coupled with sufficient withdrawal time, training endoscopists with emphasis on recognition of subtle characteristics of flat lesions, dynamic position changes during the withdrawal phase, removing small polyps found during insertion, and retroflexion in the right colon have all been associated with increased ADR. In particular, water exchange (WE), which is characterized using water in lieu of air and suction removal of infused water during insertion, appears to meet the needs of colonoscopy patients in Taiwan. Analyses of both primary and secondary outcome variables of recently published studies have consistently shown that WE yields higher ADR than traditional air insufflation, even in propofol-sedated patients. Colonoscopists participating in the nationwide CRC screening program in Taiwan should consider applying one or more of the above measures to improve ADR and hopefully reduce ICs.
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Affiliation(s)
- Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Felix W. Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill, CA, USA
- Division of Gastroenterology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Bronzwaer MES, Greuter MJE, Bleijenberg AGC, IJspeert JEG, Dekker E, Coupé VMH. Impact of differences in adenoma and proximal serrated polyp detection rate on the long-term effectiveness of FIT-based colorectal cancer screening. BMC Cancer 2018; 18:465. [PMID: 29695244 PMCID: PMC5918867 DOI: 10.1186/s12885-018-4375-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 04/16/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Both the adenoma detection rate (ADR) and proximal serrated polyp detection rate (PSPDR) vary among endoscopists. It is unclear how these variations influence colorectal cancer (CRC) screening effectiveness. We evaluated the effect of variation in these detection rates on the long-term impact of fecal immunochemical test (FIT) based screening. METHODS The Adenoma and Serrated pathway to Colorectal CAncer (ASCCA) model was set up to simulate the Dutch national biennial FIT-based CRC screening program between 2014 and 2044. Adherence to FIT and colonoscopy was 73 and 92%. Besides a 'no screening scenario', several screening scenarios varying in ADR and PSPDR were evaluated. Using the available literature on colonoscopy miss rates led to a base-case ADR of 59% and PSPDR of 11%, which were varied with intervals of 3 and 2%. RESULTS Compared to no screening, FIT-screening in the base-case scenario reduced long-term mortality with 51.8%. At a fixed PSPDR of 11%, an increase in ADR from 44 to 62% would result in a 10.7% difference in mortality reduction. Using a fixed ADR of 59%, changing the PSPDR from 3 to 15% did not substantially influence long-term mortality (51.0 to 52.3%). CONCLUSIONS An increase in ADR gradually reduces CRC burden in a FIT-based screening program, whereas an increase in PSPDR only minimally influences long-term outcomes at a population-level. The limited effect of the PSPDR can be explained by the limited sensitivity of FIT for serrated polyps (SPs). Other triage modalities aiming to detect relevant SPs should be explored.
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Affiliation(s)
- Maxime E. S. Bronzwaer
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Marjolein J. E. Greuter
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Arne G. C. Bleijenberg
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Joep E. G. IJspeert
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Veerle M. H. Coupé
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
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Murchie B, Tandon K, Zackria S, Wexner SD, O'Rourke C, Castro FJ. Can polyp detection rate be used prospectively as a marker of adenoma detection rate? Surg Endosc 2018; 32:1141-1148. [PMID: 28812147 DOI: 10.1007/s00464-017-5785-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 07/28/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Adenoma detection rate (ADR) is a quality indicator for screening colonoscopy, but its calculation is time-consuming. Polyp detection rate (PDR) has been found to correlate with ADR; however, its use as a quality indicator has been criticized out of concern for endoscopists artificially inflating the PDR. We aim to evaluate whether active monitoring affects PDR. METHODS In March 2015, 14 endoscopists were made aware that their personal PDRs would be tracked monthly as a quality improvement project. Endoscopists received a report of their individual monthly and cumulative PDR, departmental averages, and a benchmark PDR. Following the intervention, data were collected for consecutive patients undergoing average risk screening colonoscopy for six months. PDR, ADR, and adenoma to polyp detection ratio quotient (APDRQ) were compared to a six-month pre-intervention period. RESULTS 2203 patients were included in the study. There was no statistically significant difference in PDR when comparing pre- and post-intervention (44 vs. 45%, OR 1.04; 95% CI 0.77-1.36). No statistically significant difference in ADR was observed when comparing pre- and post-intervention (29 vs. 30%, OR 1.03; 95% CI 0.64-1.52). There was no statistically significant difference in APDRQ when comparing pre- and post-intervention (0.67 vs. 0.66, OR 0.99; 95% CI 0.69-1.33). CONCLUSIONS Monthly report cards did not result in a change in PDR or APDRQ. In some environments, PDR can be used as a surrogate marker of ADR, despite endoscopist awareness that PDR is being measured.
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Affiliation(s)
- Brent Murchie
- Department of Gastroenterology, Digestive Diseases Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Kanwarpreet Tandon
- Department of Internal Medicine, Blake Medical Center, Bradenton, FL, USA
| | - Shamiq Zackria
- Department of Internal Medicine, Aultman Hospital, Canton, OH, USA
| | - Steven D Wexner
- Department of Gastroenterology, Digestive Diseases Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Colin O'Rourke
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Fernando J Castro
- Department of Gastroenterology, Digestive Diseases Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
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Chan BP, Hussey A, Rubinger N, Hookey LC. Patient comfort scores do not affect endoscopist behavior during colonoscopy, while trainee involvement has negative effects on patient comfort. Endosc Int Open 2017; 5:E1259-E1267. [PMID: 29218318 PMCID: PMC5718911 DOI: 10.1055/s-0043-120828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Accepted: 05/02/2017] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Patient comfort is an important part of endoscopy and reflects procedure quality and endoscopist technique. Using the validated, Nurse Assisted Patient Comfort Score (NAPCOMS), this study aimed to determine whether the introduction of NAPCOMS would affect sedation use by endoscopists. PATIENTS AND METHODS The study was conducted over 3 phases. Phase One and Two consisted of 8 weeks of endoscopist blinded and aware data collection, respectively. Data in Phase Three was collected over a 5-month period and scores fed back to individual endoscopists on a monthly basis. RESULTS NAPCOMS consists of 3 domains - pain, sedation, and global tolerability. Comparison of Phase One and Two, showed no significant differences in sedative use or NAPCOMS. Phase Three data showed a decline in fentanyl use between individual months ( P = 0.035), but no change in overall NAPCOMS. Procedures involving trainees were found to use more midazolam ( P = 0.01) and fentanyl ( P = 0.01), have worse NAPCOMS scores, and resulted in longer procedure duration ( P < 0.001). Data comparing gastroenterologists and general surgeons showed increased fentanyl use ( P = 0.037), decreased midazolam use ( P = 0.001), and more position changes ( P = 0.002) among gastroenterologists. CONCLUSIONS The introduction of a patient comfort scoring system resulted in a decrease in fentanyl use, although with minimal clinical significance. Additional studies are required to determine the role of patient comfort scores in quality control in endoscopy. Procedures completed with trainees used more sedation, were longer, and had worse NAPCOMS scores, the implications of which, for teaching hospitals and training programs, will need to be further considered.
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Affiliation(s)
- Brian P.H. Chan
- Queen's University, Department of Medicine, Kingston Ontario, Canada
| | - Amanda Hussey
- Queen's University, Department of Medicine, Kingston Ontario, Canada
| | - Natalie Rubinger
- Queen's University, Department of Medicine, Kingston Ontario, Canada
| | - Lawrence C. Hookey
- Queen’s University, Gastrointestinal Diseases Research Unit, GI Division Hotel Dieu Hospital, Kingston Ontario, Canada
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the current state of endoscopic quality measurement and use of measures in enhancing the value of endoscopic services. RECENT FINDINGS Initially, quality measurement of endoscopic procedures was claims based or included small unit or practice-specific efforts. Now we have a mature national registry and large electronic medical or procedural records that are designed to yield valuable data relevant to quality measurement. SUMMARY With the advent of better measures, we are beginning to understand that initial process and surrogate outcome measures (adenoma detection rate) can be improved to provide a better reflection of endoscopic quality. Importantly, however, even measures currently in use relate to important patient outcomes such as missed colon cancers. At a federal level, older cumbersome pay-for-performance initiatives have been combined into a new overarching program named the quality payment program within the centers for medicare and medicaid services. This program is an additional step toward furthering the progress from volume-to-value-based reimbursement. The legislation mandating the movement toward outcomes-linked (value) reimbursement is the medicare access and children's health insurance program reauthorization act, which was passed with overwhelming bipartisan support and will not be walked back by alterations of the affordable care act. Increasing portions of medicare reimbursement (and likely commercial to follow) will be linked to quality metrics, so familiarity with the underlying process and rationale will be important for all proceduralists.
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Abstract
OPINION STATEMENT Colonoscopy is one of the most commonly performed endoscopic procedures. It is the gold standard examination for work-up of colonic symptoms, for follow-up of positive colorectal cancer screening tests and for detection and removal of neoplastic polyps. Colonoscopy is a complex and invasive procedure with a potential not only for colorectal cancer prevention, but also for serious complications. Numerous factors may affect the balance of benefit versus harm of colonoscopy, including the performance of the endoscopist. These factors are commonly called quality indicators. As an increasing number of countries are recommending the general population to undergo colorectal cancer screening, the quality of colonoscopy should be considered a public health concern. Key quality indicators have been identified, and several professional organizations have issued recommendation statements to promote high-quality colonoscopy. To achieve high quality, these key quality indicators must be monitored, results must be analysed, and measures must be undertaken to correct substandard performance. High-quality training in colonoscopy and polypectomy should be a quality assurance priority.
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33
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Racho RG, Krishna M, Coe SG, Thomas CS, Crook JE, Diehl NN, Wallace MB. Impact of an Endoscopic Quality Improvement Program Focused on Adenoma Detection on Sessile Serrated Adenoma/Polyp Detection. Dig Dis Sci 2017; 62:1464-1471. [PMID: 28444509 DOI: 10.1007/s10620-017-4582-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/18/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Sessile serrated adenomas/polyps (SSA/P) are an under-recognized disease with a unique malignant pathway. Improved endoscopic recognition and pathological interpretation is needed. AIMS To determine whether an educational intervention that improved adenoma detection rate (ADR) could improve SSA/P detection rate after reclassification of previously termed "hyperplastic" polyps. METHODS We reanalyzed data from a prospective randomized trial of an educational intervention aimed at increasing ADR. All hyperplastic polyps ≥6 mm reported in a previously published study were rereviewed and reclassified using standardized criteria for serrated lesions. Detection rates of sessile serrated adenomas/polyps and other clinically relevant serrated polyps were calculated in the baseline and post-training phases of the original study. RESULTS Of 263 available for rereview, 33 (12.5%) were reclassified as SSA/P (N = 32) or traditional serrated adenoma (TSA) (N = 1). Reclassification was more common in the right colon (18 vs. 8%, p = 0.02). Baseline SSA/P detection rate was 0.7% in the untrained group and 1.3% in the trained group. Post-training, the SSA/P detection rate increased to 2.1 and 1.5%, respectively. The clinically relevant serrated polyp detection rate at baseline was 14.2% in the untrained group and 11.3% in the trained group. After the educational intervention, the clinically relevant serrated polyp detection rates increased to 16.5 and 14.8% in the untrained and trained groups, respectively. The estimated odds of an endoscopist detecting either a SSA/P or other clinically relevant serrated polyp during colonoscopy increased by only 3% with the educational intervention (OR 1.03, 95% CI 0.61-1.74, p = 0.91). CONCLUSIONS Pathological re-interpretation of larger serrated polyps resulted in the reclassification of 12.5% of lesions. Quality improvement methods focused on adenoma detection did not impact SSA/P detection, and thus specific methods for serrated polyp detection are needed.
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Affiliation(s)
- Ronald G Racho
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
- Department of Gastroenterology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Murli Krishna
- Department of Pathology, Mayo Clinic, Jacksonville, FL, USA
| | - Susan G Coe
- Atlanta Gastroenterology Associates, Snellville, GA, USA
| | - Colleen S Thomas
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Julia E Crook
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Michael B Wallace
- Division of Gastroenterology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Nayor J, Saltzman JR. Response. Gastrointest Endosc 2017; 85:1114-1115. [PMID: 28411759 DOI: 10.1016/j.gie.2017.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/20/2017] [Indexed: 02/08/2023]
Affiliation(s)
- Jennifer Nayor
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - John R Saltzman
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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Recent Advances in Diagnostic Colonoscopy for Colorectal Cancer Screening: An Update for Radiologists. AJR Am J Roentgenol 2017; 209:88-93. [PMID: 28379726 DOI: 10.2214/ajr.17.17863] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Colonoscopy accuracy in detecting colorectal neoplasia is critical for colorectal cancer prevention but has been shown to be operator- and technology-dependent. This article will discuss several recent improvements in the technique and technology of colonoscopy. CONCLUSION More rigorous training and retraining programs, active monitoring of endoscopist technique and outcomes, and exclusion of poorly performing endoscopists are urgently needed to improve the ultimate efficacy of colorectal cancer screening programs.
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Inra JA, Nayor J, Rosenblatt M, Mutinga M, Reddy SI, Syngal S, Kastrinos F. Comparison of Colonoscopy Quality Measures Across Various Practice Settings and the Impact of Performance Scorecards. Dig Dis Sci 2017; 62:894-902. [PMID: 27995405 DOI: 10.1007/s10620-016-4410-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 12/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Quality performance measures for screening colonoscopy vary among endoscopists. The impact of practice setting is unknown. AIMS We aimed to (1) compare screening colonoscopy performance measures among three different US practice settings; (2) evaluate factors associated with adenoma detection; and (3) assess a scorecard intervention on performance metrics. METHODS This multi-center prospective study compared patient, endoscopist, and colonoscopy characteristics performed at a tertiary care hospital (TCH), community-based hospital (CBH), and private practice group (PPG). Withdrawal times (WT), cecal intubation, and adenoma detection rates (ADR) were compared by site at baseline and 12 weeks following scorecard distribution. Generalized linear mixed models identified factors associated with adenoma detection. RESULTS Twenty-eight endoscopists performed colonoscopies on 1987 asymptomatic, average-risk individuals ≥50 years. Endoscopist and patient characteristics were similar across sites. The PPG screened more men (TCH: 42.8%, CBH: 45.0%, PPG: 54.2%; p < 0.0001). Preparation quality varied with good/excellent results in 70.6, 88.3, and 92% of TCH, CBH, and PPG cases, respectively (p < 0.0001). Male ADRs, cecal intubation, and WT exceeded recommended benchmarks despite variable results at each site; female ADRs were <15% at the PPG which screened the fewest females. Performance remained unchanged following scorecard distribution. Adenoma detection was associated with increasing patient age, male gender, WT, adequate preparation, but not practice setting. CONCLUSIONS Each practice performed high-quality screening colonoscopy. Scorecards did not improve performance metrics. Preparation quality varies among practice settings and can be modified to improve adenoma detection.
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Affiliation(s)
- Jennifer A Inra
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Jennifer Nayor
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA. .,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
| | - Margery Rosenblatt
- Division of Population Sciences, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA, 02115, USA
| | - Muthoka Mutinga
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Sarathchandra I Reddy
- Division of Gastroenterology, South Shore Hospital, 1681 Washington Street, Braintree, South Weymouth, MA, 02184, USA
| | - Sapna Syngal
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.,Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.,Division of Population Sciences, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA, 02115, USA
| | - Fay Kastrinos
- Division of Digestive and Liver Diseases, Columbia University Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.,Herbert Irving Comprehensive Cancer Center, New York, NY, USA
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37
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Wallace MB, Crook JE, Thomas CS, Staggs E, Parker L, Rex DK. Effect of an endoscopic quality improvement program on adenoma detection rates: a multicenter cluster-randomized controlled trial in a clinical practice setting (EQUIP-3). Gastrointest Endosc 2017; 85:538-545.e4. [PMID: 27473182 DOI: 10.1016/j.gie.2016.07.042] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/10/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colonoscopy is protective against colorectal cancer, but its quality and protective benefits can vary. Adenoma detection rate (ADR) is associated with quality and the degree of protection against colorectal cancer and death. In a previous, single academic center, randomized, controlled trial, we demonstrated that an endoscopic quality improvement program increased ADR (EQUIP-1) and that those increases were durable (EQUIP-2). We hypothesized that EQUIP training would increase ADR in a multicenter clinical practice setting. METHODS Nine large clinical practice sites were recruited. After a baseline period (phase I), 5 sites were randomized to receive supplemental in-person EQUIP training with active feedback. After follow-up (phase II), the changes in ADRs at these sites were compared with the changes at 4 control sites that did not receive training or feedback until after study completion. RESULTS Twenty-two thousand three hundred sixteen colonoscopies were included. There was a statistically significant increase in ADR at the training sites (odds ratio [OR], 1.28; P = .004) with a raw ADR of 31% in phase I and 42% in phase II after the intervention. However, raw ADRs also increased at the control sites (from 36% to 39%). As a result, there was limited evidence of a training effect (OR, 1.03; 95% confidence interval [CI], 0.84-1.25; P = .78). CONCLUSIONS ADRs increased at the sites participating in the endoscopic quality improvement program. However it is not clear to what extent the training program is responsible for the changes, because raw ADRs also increased at the control sites but to a lesser extent. (Clinical Trials Registration number: NCT02325635.).
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Affiliation(s)
- Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA.
| | - Julia E Crook
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Colleen S Thomas
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Estella Staggs
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Laurie Parker
- American College of Gastroenterology, Bethesda, Maryland, USA
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Antipova M, Burdyukov M, Bykov M, Domarev L, Fedorov E, Gabriel S, Glebov K, Kashin S, Knyazev M, Korotkevich A, Kotovsky A, Kruglova I, Krushelnitsky V, Mayat E, Merzlyakov M, Mtvralashvili D, Pyrkh A, Sannikov O, Shitikov E, Subbotin A, Taran A, Veselov V, Zavyalov D, Hassan C, Radaelli F, Ridola L, Repici A, Korolev M. Quality of colonoscopy in an emerging country: A prospective, multicentre study in Russia. United European Gastroenterol J 2017; 5:276-283. [PMID: 28344796 PMCID: PMC5349354 DOI: 10.1177/2050640616639160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/18/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The quality of colonoscopy has been related to a higher risk of interval cancer, and this issue has been addressed extensively in developed countries. The aim of our study was to explore the main quality indicators of colonoscopy in a large emerging country. METHODS Consecutive patients referred for colonoscopy in 14 centres were prospectively included between July and October 2014. Before colonoscopy, several clinical and demographic variables were collected. Main quality indicators (i.e. caecal intubation rate, (advanced) adenoma detection rate, rate of adequate cleansing and sedation) were collected. Data were analysed at per patient and per centre level (only for those with at least 100 cases). Factors associated with caecal intubation rate and adenoma detection rate were explored at multivariate analysis. RESULTS A total of 8829 (males: 35%; mean age: 57 + 14 years) patients were included, with 11 centres enrolling at least 100 patients. Screening (including non-alarm symptoms) accounted for 59% (5188/8829) of the indications. Sedation and split preparation were used in 26% (2294/8829) and 25% (2187/8829) of the patients. Caecal intubation was achieved in 7616 patients (86%), and it was ≥85% in 8/11 (73%) centres. Adenoma detection rate was 18% (1550/8829), and it was higher than 20% in five (45%) centres, whilst it was lower than 10% in four (33%) centres. At multivariate analysis, age (OR: 1.020, 95% CI: 1.015-1.024), male sex (OR: 1.2, 95% CI: 1.1-1.3), alarm symptoms (OR: 1.8, 95% CI: 1.7-2), split preparation (OR: 1.4, 95% CI: 1.2-1.6), caecal intubation rate (OR: 1.6, 95% CI: 1.3-1.9) and withdrawal time measurement (OR: 1.2, 95% CI: 1.6-2.1) were predictors of a higher adenoma detection rate, while adequate preparation (OR: 3.4: 95% CI: 2.9-3.9) and sedation (OR: 1.3; 95% CI: 1.1-1.6) were the strongest predictors of caecal intubation rate. CONCLUSIONS According to our study, there is a substantial intercentre variability in the main quality indicators. Overall, the caecal intubation rate appears to be acceptable in most centres, whilst the overall level of adenoma detection appears low, with less than half of the centres being higher than 20%. Educational and quality assurance programs, including higher rates of sedation and split regimen of preparation, may be necessary to increase the key quality indicators.
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Affiliation(s)
| | | | - Mikhail Bykov
- Clinical Regional Hospital after prof.
Ochapovsky, Krasnodar, Russia
| | | | | | | | - Konstantin Glebov
- Municipal Clinical Hospital n. 15, n.n.
O.M. Filatov, Moscow, Russia
| | - Sergey Kashin
- Yaroslavl Regional Cancer Hospital,
Yaroslavl, Russia
| | - Mikhail Knyazev
- Federal Medical Enterprise Polyclinic n.
2 of the Ministry of Economic Development, Moscow, Russia
| | | | - Andrey Kotovsky
- Municipal Clinical Hospital n. 15,
n.n. O.M. Filatov, Moscow, Russia
| | | | | | | | | | | | | | - Oleg Sannikov
- Medical Care Unit n. 41 of the Federal
Biomedical Agency, Glazov, Udmurtia, Russia
| | | | | | - Alexander Taran
- Clinical Regional Hospital after prof.
Ochapovsky, Krasnodar, Russia
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Abstract
OPINION STATEMENT The adenoma detection rate (ADR), i.e., the proportion of average risk patients with at least one adenoma detected during screening colonoscopy, is inversely associated with the development of interval colorectal cancer. Increasing the ADR is therefore an important proxy for increase in quality and efficacy of (screening) colonoscopy. Several potentially modifiable factors, such as, procedural and technological factors, and quality improvement programs, and their effect on the ADR will be reviewed. Procedural factors, such as, bowel preparation, withdrawal time, and position changes of the patient are associated with the ADR. While the relation of others, such as inspection during insertion, use of antispasmodic agents, and second inspection in the proximal colon, with the ADR is not completely clear. Many new colonoscopy technologies have been evaluated over recent years and are still under evaluation, but no unequivocal positive effect on the ADR has been observed in randomized trials that have mostly been performed by experienced endoscopists with high baseline ADRs. Several quality improvement programs have been evaluated and seem to have a positive effect on endoscopists' ADR. Increase in ADR is important for the protective benefit of colonoscopy. There are now extensive methods to measure, benchmark, and improve ADR but increased awareness of these is critical. We have provided an overview of potential factors that can be used to increase personal ADRs in every day practice.
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Affiliation(s)
- Eelco C Brand
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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40
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Affiliation(s)
- Amit Rastogi
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sachin Wani
- University of Colorado, Aurora, Colorado, USA
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41
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Razzak A, Smith D, Zahid M, Papachristou G, Khalid A. Effect of quality metric monitoring and colonoscopy performance. Endosc Int Open 2016; 4:E1023-E1027. [PMID: 27747273 PMCID: PMC5063644 DOI: 10.1055/s-0042-110787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 06/13/2016] [Indexed: 01/10/2023] Open
Abstract
Background and aims: Adenoma detection rate (ADR) and cecal withdrawal time (CWT) have been identified as measures of colonoscopy quality. This study evaluates the impact of monitoring these measures on provider performance. Methods: Six blinded gastroenterologists practicing at a Veterans Affairs Medical Center were prospectively monitored over 9 months. Data for screening, adenoma surveillance, and fecal occult blood test positive (FOBT +) indicated colonoscopies were obtained, including exam preparation quality, cecal intubation rate, CWT, ADR, adenomas per colonoscopy (APC), and adverse events. Metrics were continuously monitored after a period of informed CWT monitoring and informed CWT + ADR monitoring. The primary outcome was impact on ADR and APC. Results: A total of 1671 colonoscopies were performed during the study period with 540 before informed monitoring, 528 during informed CWT monitoring, and 603 during informed CWT + ADR monitoring. No statistically significant impact on ADR was noted across each study phase. Multivariate regression revealed a trend towards fewer adenomas removed during the CWT monitoring phase (OR = 0.79; 95 %CI 0.62 - 1.02, P = 0.065) and a trend towards more adenomas removed during the CWT + ADR monitoring phase when compared to baseline (OR = 1.26; 95 %CI 0.99 - 1.61, P = 0.062). Indication for examination and provider were significant predictors for higher APC. Provider-specific data demonstrated a direct relationship between high ADR performers and increased CWT. Conclusions: Monitoring quality metrics did not significantly alter colonoscopy performance across a small heterogeneous group of providers. Non-significant trends towards higher APC were noted with CWT + ADR monitoring. Providers with a longer CWT had a higher ADR. Further studies are needed to determine the impact of monitoring on colonoscopy performance.
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Affiliation(s)
- Anthony Razzak
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dineen Smith
- VA Pittsburgh Health Care System, Pittsburgh, PA, USA
| | | | | | - Asif Khalid
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Corresponding author Asif Khalid, MD M2C-wingPUH200 Lothrop StreetPittsburghPA 15213USA+1-412-383-8992
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Shah BJ, de Melo SW, Falk GW. Four Approaches to Reinvigorate Learning for the 21st Century Gastroenterologist. Gastroenterology 2016; 151:218-21. [PMID: 27373515 DOI: 10.1053/j.gastro.2016.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Brijen J Shah
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Silvio W de Melo
- Deparment of Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Gary W Falk
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Bartel MJ, Robertson DJ, Pohl H. Colonoscopy practice for veterans within and outside the Veterans Affairs setting: a matched cohort study. Gastrointest Endosc 2016; 84:272-8. [PMID: 26784365 DOI: 10.1016/j.gie.2016.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 01/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS To minimize delays for colonoscopy within Veterans Affairs (VA) facilities, veterans may receive care at non-VA facilities based on fee-for-service contracts, and more recently, through the Veterans Access, Choice, and Accountability Act. The impact of diverting care from VA to non-VA facilities on quality of colonoscopy practice is unknown. METHODS We identified all veterans aged 50 to 85 years who received a fee-basis colonoscopy for colorectal cancer screening or surveillance at non-VA facilities in 2007 to 2010. These patients were matched for sex, age, and year of procedure to veterans who underwent colonoscopies at VA medical centers. The outcomes of interest were the adenoma detection rates (ADR) and compliance with surveillance guidelines. RESULTS During the observation period, 409 veterans (mean age 64 years; 94% men) underwent a fee-basis colonoscopy at 30 nonacademic (54%) and 2 academic (46%) facilities. Compared with colonoscopies performed at VA facilities, fee-basis colonoscopy patients had lower ADRs (38% vs 52%; P < .001), lower mean number of adenomas per procedure (0.72 vs 1.41; P < .001), and lower number of advanced ADRs (13% vs 22%; P < .001). Colonoscopies done at non-VA facilities were associated with lower ADRs in multivariate regression analysis (odds ratio 0.64; 95% CI, 0.44-0.92), whereas colonoscopies done in nonacademic settings or by colonoscopists who were not gastroenterologists were not. Compliance with surveillance guidelines was lower for colonoscopies performed outside VA facilities (80% vs 87%; P = .03). CONCLUSIONS In this regional study (Northern New England), compliance with colonoscopy surveillance guidelines was high in both VA and non-VA settings; however, lower ADRs raise concern that referring veterans outside the VA system may impact colonoscopy quality.
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Affiliation(s)
- Michael J Bartel
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Douglas J Robertson
- Department of Gastroenterology, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Heiko Pohl
- Department of Gastroenterology, White River Junction VA Medical Center, White River Junction, Vermont, USA; Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
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Keswani RN, Gawron AJ, Cooper A, Liss DT. Procedure Delays and Time of Day Are Not Associated With Reductions in Quality of Screening Colonoscopies. Clin Gastroenterol Hepatol 2016; 14:723-8.e2. [PMID: 26538206 DOI: 10.1016/j.cgh.2015.10.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 10/10/2015] [Accepted: 10/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been conflicting results from studies to determine whether factors unrelated to endoscopist skill, such as fatigue, affect the quality of screening colonoscopy. We studied the effects of human and system factors on screening colonoscopy withdrawal time and likelihood of detecting an adenoma in a large cohort of patients. METHODS We performed a retrospective analysis of operation and quality improvement data in colonoscopies performed at single academic medical center from November 2012 through February 2014. We collected data from the Northwestern Medicine Enterprise Data Warehouse on endoscopy procedure reports, patient demographics, and pathology reports of all patients undergoing endoscopy. We identified all screening colonoscopies during the study period and determined whether an adenoma was identified in each screening colonoscopy procedure. Our study included data from 7004 screening colonoscopies of patients 50-75 years old performed by endoscopists who performed at least 100 screening colonoscopies during the study period (n = 18). RESULTS Approximately 27% of procedures began on time; the median colonoscope insertion time was 5.9 minutes (interquartile range, 4.0-8.6). In multivariable logistic regression analysis adjusting for covariates and endoscopist-level clustering, adenoma detection was not associated with procedure delay (P = .48), hour of day (P = .40), or performing the second of 2 colonoscopy blocks in 1 day (P = .88). Adenoma detection was associated with insertion time overall (P = .006), but there was no consistent directional relationship across insertion quintiles. CONCLUSIONS Procedure delays and measured factors associated with fatigue, including time of day and multiple procedure blocks, do not reduce the odds of detecting an adenoma. Adenoma detection varies widely among providers, so efforts to improve adenoma detection should focus mainly on optimizing physician skill.
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Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Andrew J Gawron
- Division of Gastroenterology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Andrew Cooper
- Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - David T Liss
- Department of General Internal Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Atkins L, Hunkeler EM, Jensen CD, Michie S, Lee JK, Doubeni CA, Zauber AG, Levin TR, Quinn VP, Corley DA. Factors influencing variation in physician adenoma detection rates: a theory-based approach for performance improvement. Gastrointest Endosc 2016; 83:617-26.e2. [PMID: 26366787 PMCID: PMC4762744 DOI: 10.1016/j.gie.2015.08.075] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 08/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Interventions to improve physician adenoma detection rates for colonoscopy have generally not been successful, and there are little data on the factors contributing to variation that may be appropriate targets for intervention. We sought to identify factors that may influence variation in detection rates by using theory-based tools for understanding behavior. METHODS We separately studied gastroenterologists and endoscopy nurses at 3 Kaiser Permanente Northern California medical centers to identify potentially modifiable factors relevant to physician adenoma detection rate variability by using structured group interviews (focus groups) and theory-based tools for understanding behavior and eliciting behavior change: the Capability, Opportunity, and Motivation behavior model; the Theoretical Domains Framework; and the Behavior Change Wheel. RESULTS Nine factors potentially associated with adenoma detection rate variability were identified, including 6 related to capability (uncertainty about which types of polyps to remove, style of endoscopy team leadership, compromised ability to focus during an examination due to distractions, examination technique during withdrawal, difficulty detecting certain types of adenomas, and examiner fatigue and pain), 2 related to opportunity (perceived pressure due to the number of examinations expected per shift and social pressure to finish examinations before scheduled breaks or the end of a shift), and 1 related to motivation (valuing a meticulous examination as the top priority). Examples of potential intervention strategies are provided. CONCLUSIONS By using theory-based tools, this study identified several novel and potentially modifiable factors relating to capability, opportunity, and motivation that may contribute to adenoma detection rate variability and be appropriate targets for future intervention trials.
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Affiliation(s)
- Louise Atkins
- Centre for Behaviour Change, University College London, London, England
| | | | | | - Susan Michie
- Centre for Behaviour Change, University College London, London, England
| | | | - Chyke A. Doubeni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann G. Zauber
- Department of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Virginia P. Quinn
- Kaiser Permanente Southern California, Research and Evaluation, Pasadena, CA
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What makes a "good" colonoscopy quality indicator? Gastrointest Endosc 2016; 83:179-81. [PMID: 26706304 PMCID: PMC5627762 DOI: 10.1016/j.gie.2015.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 06/25/2015] [Indexed: 12/11/2022]
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Kim DJ, Kim HW, Park SB, Kang DH, Choi CW, Hong JB, Ji BH, Lee CS. Efficacy of cap-assisted colonoscopy according to lesion location and endoscopist training level. World J Gastroenterol 2015; 21:6261-6270. [PMID: 26034361 PMCID: PMC4445103 DOI: 10.3748/wjg.v21.i20.6261] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/27/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of cap-assisted colonoscopy (CAC) for detection of colorectal polyps and adenomas according to the lesion location and endoscopist training level.
METHODS: Patients 20 years or older, who underwent their first screening colonoscopy in a single tertiary center from May 2011 to December 2012 were enrolled in this study. All patients underwent either CAC or standard colonoscopy (SC), and all of the procedures were performed by 11 endoscopists (8 trainees and 3 experts). All procedures were performed with high-definition colonoscopes and narrow band imaging. The eight trainees had experiences of performing 150 to 500 colonoscopies, and the three experts had experiences of performing more than 3000 colonoscopies. A 4-mm-long transparent cap was attached to the end of a colonoscope in the CAC group. We retrospectively evaluated the number of polyps and adenomas, polyp detection rate (PDR), and the number of adenomas and adenoma detection rate (ADR) according to the lesion location and endoscopist training level between CAC and SC. We also evaluated the number of polyps and adenomas according to their size between CAC and SC.
RESULTS: Overall, PDR and ADR using CAC were significantly higher than those using SC for both whole colon (48.5% vs 40.7%, P = 0.012; 35.7% vs 28.3%, P = 0.012) and right-side colon (35.3% vs 26.6%, P = 0.002; 27.0% vs 16.9%, P < 0.001). The number of polyps and adenomas per patient using CAC was significantly higher than that using SC for both the whole colon (1.07 ± 1.59 vs 0.82 ± 1.31, P = 0.008; 0.72 ± 1.32 vs 0.50 ± 1.01, P = 0.003) and right-side colon (0.66 ± 1.18 vs 0.41 ± 0.83, P < 0.001; 0.46 ± 0.97 vs 0.25 ± 0.67, P < 0.001). In the trainee group, the PDR and ADR using CAC were significantly higher than those using SC for both the whole colon (46.7% vs 39.7%, P = 0.040; 33.9% vs 26.0%, P =0.012) and right-side colon (34.2% vs 26.5%, P = 0.015; 25.3% vs 15.9%, P = 0.001). In the expert group, the PDR and ADR using CAC were significantly higher than those using SC only for the right-side colon (42.1% vs 27.0%, P =0.035; 36.8% vs 21.0%, P = 0.020).
CONCLUSION: CAC is more effective than SC for detection of colorectal polyps and adenomas, especially when performed by trainees and when the lesions are located in the right-side colon.
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Anderson JC, Butterly LF. Colonoscopy: quality indicators. Clin Transl Gastroenterol 2015; 6:e77. [PMID: 25716302 PMCID: PMC4418496 DOI: 10.1038/ctg.2015.5] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/26/2015] [Indexed: 02/06/2023] Open
Abstract
Effective endoscopic screening for colorectal cancer (CRC), one of the few preventable cancers, is dependent on the adequate detection and removal of potentially precancerous lesions. However, observed variation in colonoscopy performance in practice and outcomes has highlighted the need for consistent quality measures. Quality indicators or measures are tools that help to quantify health-care processes and can aid in providing high-quality health care. The primary colonoscopy quality indicator is the adenoma detection rate (ADR), which is defined as the proportion of an endoscopist's screening colonoscopies in which one or more adenomas have been detected. The risk of post-colonoscopy CRC is inversely correlated with an endoscopist's ADR. However, ADR is dependent on other quality measures, including cecal intubation rates, withdrawal times, and quality of bowel preparation. Achieving suggested benchmarks for these other quality measures will aid the endoscopist in achieving the recently updated ADR benchmark of 25% in their practice. In addition, beyond ensuring adequate ADRs, endoscopists should have high compliance rates with guideline-recommended and evidence-based screening and surveillance intervals. Compliance with quality measures will ensure effective and safe CRC prevention and better patient outcomes.
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Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, White River Junction, VT and The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Lynn F Butterly
- 1] Section of Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA [2] The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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