Incorporating quality measurement and improvement into a gastroenterology practice

The predictive value of small versus diminutive adenomas for subsequent advanced neoplasia

BACKGROUND AND AIMS

Patients with previous colorectal adenomas are at increased risk of colorectal cancer. Current guidelines for postpolypectomy surveillance intervals treat all tubular adenomas 1 to 9 mm in size with low-grade dysplasia as carrying the same level of risk. We evaluated whether 6 to 9 mm adenomas detected at colonoscopy are associated with greater risk of advanced neoplasia at follow-up compared with baseline 1 to 5 mm adenomas.

METHODS

We retrospectively evaluated a colonoscopy database at a single U.S. academic center. Patients with baseline examinations demonstrating tubular adenomas 1 to 9 mm in size with low-grade dysplasia and no advanced adenomas were included. Follow-up colonoscopies were performed at least 200 days later and were assessed for incident advanced neoplasia (cancer, high-grade dysplasia, adenoma ≥10 mm in size, or villous elements).

RESULTS

There were 2477 qualifying baseline colonoscopies. The absolute risk of metachronous advanced neoplasia increased from 3.6% in patients with 1 to 5 mm adenomas to 6.9% in patients with at least 1 adenoma of 6 to 9 mm (P = .001). Patients with 5 or more adenomas 1 of which was at least 6 to 9 mm had the highest risk of advanced neoplasia at follow-up (10.4%, P = .006). When only screening colonoscopies were considered, all baseline groups (1-2 adenomas, 3-4 adenomas, ≥5 adenomas) with adenomas 6 to 9 mm in size had an increased risk for metachronous advanced neoplasia (odds ratio [OR], 4.07; 95% confidence interval [CI], 1.50-11.04; OR, 4.91; 95% CI, 1.44-16.75; OR, 4.71; 95% CI, 1.30-17.05, respectively).

CONCLUSIONS

Patients with baseline small (6-9 mm) adenomas have an increased risk of advanced lesions on follow-up compared with patients with only diminutive (1-5 mm) adenomas. Postpolypectomy guidelines should consider risk stratification based on small versus diminutive adenomas.

Management patterns of gastric polyps in the United States

OBJECTIVE

Recent guidelines on endoscopic sampling recommend complete gastric polyp removal for solitary fundic polyps >10 mm, hyperplastic polyps >5 mm and all adenomatous polyps. We aim to describe endoscopic approach to polyps in the time period prior to the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and to identify opportunities for clinical practice improvements.

DESIGN

Retrospective review of the Clinical Outcome Research Initiative (CORI) database, including all oesophagogastroduodenoscopies (OGDs). Reviewers grouped interventions during procedures based on instruments used for polyp sampling by forceps or snare polypectomy. Logistic regression estimated the effect of variables of interest on method of polypectomy.

RESULTS

Of 783 037 OGDs reported in the CORI database, 25 670 (3.3%) described gastric polyps and met the inclusion criteria. Mean gastric polyp size was 6.5±4.9 mm, and 46.2% and 14.5% were located in the corpus and antrum, respectively. Polyps in the forceps group were smaller than polyps in the snare group (5.7±4.0 mm vs 9.3±6.4 mm, respectively, p<0.001). We identified 1056 polyps (41.3%) >10 mm that only underwent forceps biopsy. Forceps were used more frequently in the gastric fundus.

CONCLUSIONS

Snare polypectomy was underused in gastric polyps, per current ASGE guidelines. Anatomical location and endoscopic features of polyps were important predictors of the approach to gastric polypectomy.

Quality and competence in endoscopic retrograde cholangiopancreatography - Where are we 50 years later?

Training in endoscopic retrograde cholangiopancreatography (ERCP) requires the development of technical, cognitive, and integrative skills well beyond those needed for standard endoscopic procedures. So far, there are limited data regarding what constitutes competency in ERCP, including achievement and maintenance. Recent studies have highlighted overall procedural numbers are not enough to warrant competency, although more is better. We performed a comprehensive literature search until June 2017 using predetermined search terms to identify relevant articles and summarized their results as a narrative review. Selective native papilla deep cannulation should be used as a benchmark for assessing successful cannulation. Accurate and validated ERCP performance measures are needed to develop a curriculum that allows transition from numbers-based competency. However, available guidelines fail to state what degree of hands-on involvement is required by the trainee for the case to be counted in their overall procedural numbers. Qualitative assessment of competency should be done by trained raters using specially designed assessment tools. Competence continues to increase with practice following formal training in a fairly steady manner. The learning curve for overall common bile duct cannulation success may be a readily available surrogate for individual trainee progression and may correspond to learning curves for therapeutic interventions.

Targeted Physician Education and Standardizing Documentation Improves Documented Reporting with Inflammatory Bowel Disease Quality Measures in a Large Academic and Private Practice

BACKGROUND

Prior studies have shown poor compliance with quality measures for IBD at academic and private practices. We sought to provide focused interventions to improve compliance and documentation with the IBD measures.

METHODS

Two centers, academic practice (AP) and private practice (PP), initially reviewed their compliance with eight established IBD quality measures in consecutive charts. A multi-faceted intervention was developed to improve awareness and documentation of these measures. The initial data and the quality measures were reviewed at a group meeting. Following this, a handout summarizing the measures was placed in each exam room. The AP added a new screen to the EHR that summarized the relevant IBD history, while the PP added a new template that was filled out and imported into the charts. Three months after this intervention, charts were reviewed for compliance with the measures.

RESULTS

The intervention cohort consisted of 768 patients (AP = 569/PP = 199) compared to the initial cohort of 566 patients (AP = 367/PP = 199). Improvement was seen throughout all measures compared to the initial cohort. The AP reported compliance with all relevant measures in 21% and the PP in 60% compared to 7 and 10% in the initial cohort. PP had ≥ 75% compliance with every measure, of which only assessment for bone loss and pneumococcal vaccination was under 80%. In contrast, the AP compliance ranged from 35 to 100% with assessment for bone loss, influenza, and pneumococcal vaccination scoring lowest.

CONCLUSION

Our study demonstrates that focused low-cost interventions can significantly improve compliance with IBD quality measures in different practice settings.

New York Citywide Colon Cancer Control Coalition: A public health effort to increase colon cancer screening and address health disparities

BACKGROUND

Although screening for colorectal cancer (CRC) is a widely accepted concept nationally and screening rates are increasing, there are differences in screening rates between states and within states.

METHODS

In an effort to increase screening rates and ensure equal access with respect to race/ethnicity, the New York City Department of Health and Mental Hygiene formed a coalition of stakeholders in 2003, with its primary focus on colonoscopy, to develop and implement strategies across the city to achieve this goal.

RESULTS

From a screening colonoscopy rate of only 42% in 2003, these concerted efforts contributed to achieving a screening rate of 62% by 2007 and a screening rate of almost 70% in 2014 with the elimination of racial and ethnic disparities.

CONCLUSIONS

This article provides details of how this program was successfully conceived, implemented, and sustained in the large urban population of New York City. The authors hope that by sharing the many elements involved and the lessons learned, they may help other communities to adapt these experiences to their own environments so that CRC screening rates can be maximized. Cancer 2016;122:269-277. © 2015 American Cancer Society.

Performance Feedback Improves Compliance With Quality Measures

Cirrhotic complications portend high morbidity and mortality and burden the health care system. Established quality measures in management of cirrhotics include screening for esophageal varices (EV), screening for hepatocellular carcinoma (HCC), and hepatitis A and B immunization. A retrospective review was conducted to identify adherence to cirrhosis. Baseline rates were shared with providers. Compliance with quality measures was measured prospectively at 1-month, 2-month, 1-year, and 3-year follow-up after provision of performance feedback. Baseline HCC rate was 60%, EV was 68%, and hepatitis A and B immunization was 51% and 47%, respectively. After performance feedback, HCC, EV, and hepatitis A and B vaccination rates improved to rates ranging from 92% to 100% and remained statistically significant after 3 years. Provider feedback, a simple intervention, achieved significant improvement in compliance with quality measures for management of cirrhotics. This improvement in adherence to quality measures was sustainable over a 3-year time period.

The ERCP quality network: a pilot study of benchmarking practice and performance

There is increasing interest in the quality of endoscopic practice and in documenting it. Endoscopic retrograde cholangiopancreatography (ERCP) is the most complex and risky procedure performed regularly by gastroenterologists. The goal was to test the acceptability and functioning of a voluntary system for individual endoscopists to report details of their ERCP cases and to compare them with unidentified peers. Participants were compared by site of practice, procedure complexity, volumes, durations, and selected technical success rates. There was no independent audit. A total of 63 endoscopists in the United States entered data on 18 182 procedures over 3 years. Results in academic and community practices were similar, but there were significant and expected differences in the complexity of practice and key quality metrics between endoscopists performing more than and fewer than 100 cases per year. The study provided useful data on variations in ERCP practice in the United States and will assist in planning the development of national projects in this field.

Development of quality measures for monitoring and improving care in gastroenterology

Over the past decade, most quality assurance (QA) efforts in gastroenterology have been aimed at endoscopy. Endoscopic quality improvement was the rational area to begin QA work in gastroenterology due to the relatively acute nature of complications and the high volume of procedures performed. While endoscopy is currently the focus of most quality assurance (QA) measures in gastroenterology, more recent efforts have begun to address clinical gastroenterology practices both in the outpatient and inpatient settings. Clinical outpatient and inpatient gastroenterology is laden with areas where standardization could benefit patient care. While data and experience in clinical gastroenterology QA is relatively limited, it is clear that inconsistent use of guidelines and practice variations in gastroenterology can lead to lower quality care. In this review, we review a variety of areas in clinical gastroenterology where existing guidelines and published data suggest both the need and practicality of active QA measures.

Quality endoscopists and quality endoscopy units

Endoscopy plays an important role in the diagnosis and treatment of digestive diseases. The benefits are maximized when procedures are performed at an optimal level of quality. Technical failures and adverse events are more likely to occur when procedures are performed by inexperienced endoscopists. Professional organizations and manufacturing industry which support and represent endoscopy, and their leaders, have increasingly embraced the quality improvement paradigm that is advancing through medicine. We all need to agree on the metrics of endoscopic performance, to develop the infrastructure to collect and analyze the data, and to use the resulting knowledge to stimulate improvements in practice and benefit the patients.

Polypectomy rate as a quality measure for colonoscopy

BACKGROUND

The adenoma detection rate (ADR) has been proposed as a robust quality indicator for colonoscopy, but it is cumbersome to calculate and not available at the time of colonoscopy.

OBJECTIVE

To determine whether endoscopists' polypectomy rates (PRs) correlate with their ADRs and to calculate benchmark PRs that correlate with benchmark ADRs.

DESIGN

Retrospective study.

SETTING

University and Veterans Affairs endoscopy units in Portland, Oregon.

SUBJECTS

Fifteen endoscopists and their patients.

MAIN OUTCOME MEASUREMENTS

Proportion of patients with any adenoma and any polyp removed; correlation between ADRs and PRs.

RESULTS

Fifteen endoscopists performed 2706 average-risk screening colonoscopies during the study. There was variation in the ADR for men (15.4%-44.7%) and women (6.1%-25.8%) and in the PRs for men (17.9%-66.0%) and women (11.3%-43.1%). Endoscopists' PRs correlated well with their ADRs (r(s) = 0.86, P < .001). To attain the established benchmark ADRs for men (25%) and women (15%), endoscopists needed PRs of 40% and 30%, respectively. Endoscopists attaining the benchmark PRs had a higher ADR among men (32.1% vs 18.4%, P < .001) and a higher ADR among women (21.0% vs 9.8%, P = .01) than those who did not.

LIMITATIONS

Study endoscopists' approach to polypectomy may differ from that of endoscopists in other settings.

CONCLUSIONS

The PR is a useful quality measure with a high degree of correlation with the ADR.

Improving colonoscopy quality through health-care payment reform

Problems with the quality of colonoscopy are well recognized. Variation in colonoscopist performance is compounded by payment structures that reward volume rather than quality. Payment reform has emerged as one strategy to address these and more systemic problems in the quality of health care. Various forms of value-based purchasing might encourage a realignment of incentives, and allow reimbursement to be directly linked with clinically important goals of colonoscopy. This paper proposes criteria for the selection of quality measures, and three candidate indicators to define quality for the purpose of payment reform in colonoscopy: cecal intubation rate, adenoma detection rate, and recommended post-polypectomy surveillance interval. These measures represent valid, credible, and reliable indicators of the quality of colonoscopy for colorectal cancer screening and surveillance. Payment reform should explicitly link public reporting and performance on these quality measures to payment for colonoscopy.