Quality and outcomes management in gastroenterology

Colonoscopy reports and current state of performance measures

Quality improvement of colonoscopy continues to be an important topic. This effort begins with creating detailed and accurate colonoscopy reports. Quality indicators are measurable endpoints that may be used in quality assurance and improvement plans. Key quality measures include cecal intubation rate, adenoma detection, withdrawal time, preparation quality, follow-up recommendations, and American Society of Anesthesiologists classification. Unresolved issues include establishing proper benchmarks, documenting the correlation between process measures and outcomes, aligning incentives to improved quality outcomes, and issues regarding access to quality data.

Using technology to promote gastrointestinal outcomes research: a case for electronic health records

Electronic health records (EHRs) have been shown to reduce medication errors, improve patient outcomes, and create administrative efficiencies. Numerous public and private efforts are currently underway to achieve universal EHR adoption in the United States by the year 2014. EHRs hold a great potential to integrate clinical care and research by allowing input of clinical data in a structured format, facilitating electronic data capture for clinical trials and providing linkage with genomic information. The goal of this article is to inform the academic gastrointestinal community about the research opportunities created by the widespread adoption of EHRs and present a systematic approach in utilizing EHR-derived data for observational, experimental, or translational studies.

Impact of day-case gastroscopy on children and their families

BACKGROUND AND AIM

Increasing numbers of endoscopies are being carried out in children. The purpose of our study was to evaluate the provision of information about the admission and procedure and the functional and economic impact of day-case gastroscopy on children and their families.

METHODS

We administered a structured questionnaire to families of children undergoing elective gastroscopy, with daily follow up by telephone over the next 3 days.

RESULTS

One-hundred-and-three children were recruited. All had seen a consultant gastroenterologist (usually the proceduralist) prior to the endoscopy, who had obtained signed consent; 89% of families remembered receiving an explanation from the doctor carrying out the procedure. Nearly all (94%) described the information they received as adequate. However, only one-third of families recalled receiving an explanatory brochure and very few had toured the Day Surgical Unit or seen the complimentary video. Thirty percent were unhappy with the time spent at the Day Surgical Unit and an apparent failure to warn of possible delays, 8% felt that they were not given adequate information prior to discharge, and 39% of children failed to attend school the day after the procedure. Although tiredness or sleepiness was common, no correlation was found between the presence of symptoms and school absence. Complaints about the admission included overcrowding, lack of privacy, excessive noise, and failure to cater for adolescents. Fifty percent of parents took leave from work, but most manipulated work rosters and holidays so that costs to them and to the workplace were minimal.

CONCLUSION

Information provision about the procedure and admission appears to be adequate in most families of children undergoing day-case gastroscopy, but may be improved in some areas. Failure to remember elements of the consent and explanatory process is common. Minor morbidity is also common after the procedure.

Satisfaction of the referring physician: a quality control study focusing on EUS

INTRODUCTION

Utilization of endoscopic ultrasonography (EUS) is becoming more widespread. Largely in control of use of EUS, as a primary consumer of EUS, are the physicians who refer patients. This quality control study aimed to uncover remedial impediments to ideal utilization of EUS.

METHODS

Two thousand patient EUS reports, all by one endoscopist, were screened. One hundred forty referring physicians were identified. One hundred of these physicians completed extensive feedback survey questionnaires.

RESULTS

Overall satisfaction with EUS procedures was generally high. The level of satisfaction was comparable to satisfaction with gastroscopy procedures, both being significantly higher than for endoscopic retrograde cholongio-pancreatography. Sixty-nine percent of the physicians indicated their desire for more information regarding EUS, this being significantly higher among residents (vs. specialists). The open access system in current practice was seen as acceptable by less than half of physicians, both from the community and from within the hospital. Waiting time for EUS procedures and for biopsy results were rated as acceptable within the hospital, but more often as too long for outpatients.

CONCLUSIONS

Overall satisfaction with EUS procedures is high. More information should be brought to the referring physicians, in print and lectures. Improving communication and interacting with endoscopist-initiated feedback led to improved feelings of teamwork, uncovered remedial weak points in the EUS service, and was thus found to be valuable.

Assessing the financial health of the endoscopy center

Just as a trend of a patient's physiologic vital signs is more informative than a single assessment, the most reliable measure of EASC financial health is achieved over a continuum of time. The earliest estimate of prognosis is accomplished with a business plan that is based on an analysis of practice history, strategic planning, and carefully derived assumptions. Periodic assessments of financial performance with benchmarking data provide a current assessment of health and allow trending of performance improvements or decline. Assurance of future financial health is derived from focusing on customer needs, developing EASC core competence, and creating value through innovation. Following these guidelines helps to ensure a strong, productive, and long-lasting EASC.

Waiting lines in the endoscopy unit

BACKGROUND

The efficient management of the endoscopy unit involves issues of scheduling. The aim of this study was to assess efficient use of an endoscopy unit and its relationship to patient waiting.

METHODS

Formulas of queueing theory are applied to patient scheduling in endoscopy. The M/M/n queueing model assumes exponential (Markovian) distributions underlying both patient arrival and endoscopy times with n as the number of endoscopists, while the D/M/n model assumes a constant (deterministic) patient arrival rate.

RESULTS

As the use of the facility increases, so does the probability that patients will have to wait. It is impossible for an endoscopy facility to have a 100% rate of use without patients being forced to wait. Any increase in the use rate of an endoscopy unit results in a concomitant increase in waiting times. A facility with multiple endoscopists can reduce waiting probability at a higher rate of facility use. A table is included that physicians and administrators can use as a guide to estimate the use rate and waiting characteristics of different types of endoscopy facilities.

CONCLUSIONS

Endoscopy units must find a balance between patient waiting and underuse of their resources. Endoscopists will occasionally find themselves idle at the benefit of providing patients with tolerable waiting times. It needs to be explained to patients that even under the best of circumstances some waiting cannot be prevented.

Timing and scheduling of endoscopic procedures

BACKGROUND

The aim of the present analysis is to compare the costs associated with different schemes of scheduling tests and to develop recommendations concerning the most cost-effective means for timing individual endoscopic procedures.

METHODS

The diagnostic costs of three competing strategies to schedule various radiologic and endoscopic procedures in patients with jaundice or gastrointestinal hemorrhage are compared by computer models using a Monte Carlo simulation. In strategy 1, the evaluation is started with the most promising procedure and proceeds with the next most promising procedure in case of a normal finding. In strategy 2, physicians adhere to a rigid sequence of diagnostic tests that starts with the least expensive procedure and advances through progressively more expensive procedures. In strategy 3, all promising tests are scheduled at the onset without waiting for test results to decide in favor or against individual procedures. In the Monte Carlo simulation, two hypothetical populations of 5000 inpatients or outpatients are subjected to each strategy.

RESULTS

Unless one particular diagnosis is suspected with a high a priori probability, a rigid sequence of advancing from less to more expensive and invasive procedures provides the cheapest diagnostic strategy. In case of limited access to endoscopy and long waiting times, the cheapest work-up may include simultaneous scheduling of complementary procedures without waiting for intermediate test results. Strategy 1 of starting with the most promising test procedure becomes the least expensive option, if the prior probability assigned to the most likely diagnosis exceeds a threshold between 40% and 70%, depending on the type of test needed to make the diagnosis.

CONCLUSIONS

An expeditious diagnostic evaluation or an evaluation that is guided primarily by medical considerations is more likely to result in low healthcare costs.

Research fundamentals: selection and development of clinical outcome measures

Clinical outcomes measure patient health or well-being. The choice of an outcome measure for use in a clinical trial or study is complex. It is even more difficult when no appropriate outcome measure exists, necessitating the development of a novel one. The ideal clinical outcome should be credible, comprehensive, sensitive to change, accurate, biologically sensible, and feasible. This paper describes the attributes of clinical outcomes and illustrates how to develop novel outcomes, using as an example the authors' experience in developing a wound cosmesis outcome measure.