Quality in Colonoscopy: Beyond the Adenoma Detection Rate Fever

Monitoring photographic proof of cecal intubation: A closed-loop audit of best practice colonoscopy

Gold standard colonoscopy in the UK demands a 90% cecal intubation (CI) rate. Endoscopists must provide photographic evidence of CI, which can include images of the terminal ileum, appendix orifice, anastomosis or ileocecal valve. Whilst photographic proof of intubation should be obtained for all complete colonoscopies, this is not routinely audited. Three hundred and ninety-six complete colonoscopies were analyzed, 200 in an initial audit, and 196 in a second audit. Photos taken during colonoscopy were reviewed for evidence of successful CI, as well as whether these photographs had been marked as "proof of intubation" (POI). Results were shared at departmental governance meetings in order to assess any improvement in practice. Initial audit revealed 70% of colonoscopies had provided sufficient proof of CI but only 50% provided photographs that were described as such. Twenty percent of colonoscopies provided sufficient images, but these were not identified as POI. Thirty percent of all colonoscopies provided insufficient proof of CI. Upon repeat audit, 71% of colonoscopies met best practice standards, with the remaining 29% showing insufficient evidence of CI. In the modern era of digital technology, lack of photographic evidence should be seen as unacceptable and may raise important clinical and medicolegal concerns. We recommend that audits such as this become standard practice to ensure best practice.

Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement

BACKGROUND AND AIMS

The importance of having quality assessment, assurance, and improvement tools in health care is increasingly recognized. However, the additional associated administration burden progressively interferes with the structural implementation and adoption of such tools, especially when it concerns high-volume procedures such as colonoscopies. The development of the Dutch Gastrointestinal Endoscopy Audit (DGEA), a registry with automated extraction of colonoscopy quality data, and its first results are described.

METHODS

In close cooperation with commercial endoscopy reporting systems and a national histopathology database, healthcare professionals performing colonoscopies initiated a quality registry that extracts data from its core hospital resource or histology database without manual interference of the healthcare providers. Data extracted consisted of patient age, gender, indication of the colonoscopy, American Society of Anesthesiologists score, Boston Bowel Preparation Score, and cecal intubation; for the colonoscopy after a positive fecal immunochemical test in the colorectal cancer screening program, other data were polyp detection rate, which was available for all 48 hospitals or endoscopy centers, and adenoma detection rate, which was available for 26 hospitals or endoscopy centers.

RESULTS

Between January 1, 2016 and March 31, 2019, 48 hospitals or endoscopy centers voluntarily participated in the DGEA, and 275,017 unique patients with 313,511 colonoscopies were registered. Overall missing values were limited to <1%.

CONCLUSIONS

The results of this study demonstrate that it is feasible to deploy a quality registry collecting uniform data without additional administration burden for healthcare professionals.

The impact of sedation on quality metrics of colonoscopy: a single-center experience of 48,838 procedures

PURPOSE

Investigation of the role of sedation during colonoscopy is meaningful as the advantages of colonoscopy performing with sedation are still controversial.

METHODS

Medical records of patients who underwent colonoscopy in our institution were retrospectively analyzed. The sedation rate, adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate (CIR), iatrogenic colonic perforation rate (ICP) were calculated.

RESULTS

A total of 48,838 colonoscopies (24,498 in males) dated from July 2007 to February 2017 were analyzed. The median age was 50 years (range 16-85 years). An overall sedation rate was 80.38%. The PDR was 26.77%, and was not statistically different between colonoscopy with or without sedation (26.67% vs 27.22, p = 0.474). ADR was 12.9% regardless of applying sedation or not (13.0% vs 12.44%, p = 0.337). The CIR was 87.42% in all examinations with an adjusted CIR of 90.34%, and was higher when performed with sedation than without sedation (88.92% vs 80.64%, p < 0.0001). Five cases (0.01%) of ICP were reported, all of which occurred in patients under sedation.

CONCLUSIONS

The use of sedation is associated with increased CIR, but ADR and PDR remain unchanged with or without sedation. However, perforation rate, albeit very low, is significantly higher in sedated patients.

Quality of Reporting in Upper Gastrointestinal Endoscopy: Effect of a Simple Audit Intervention

Background and Aim

In contrast to colonoscopy, there are few studies regarding upper gastrointestinal (UGI) endoscopy reporting its quality and ways of improving it. Quality audits are recommended, but their influence on the abovementioned quality is not well studied. Our aim was to evaluate the quality of UGI endoscopy reports and assess the effect of a simple audit intervention on UGI endoscopy reporting quality.

Methods

This was a prospective study in a tertiary referral center, including the evaluation of 1,000 consecutive reports of UGI endoscopies before an audit intervention and 250 after. The reports were analyzed according to performance measures defined by three experienced gastroenterologists.

Results

Before the intervention, 51.8% of the incomplete endoscopies did not present any justification for its incompleteness and 88.1% of lesions were correctly described. Overall, 64.1% of the reports were considered as being of high quality. After the audit intervention, follow-up recommendation (53.4 vs. 80.8%, p = 0.001), correct lesion description (88.1 vs. 95.8%, p = 0.001), and correct segment description (92.2 vs. 96.4%, p = 0.020) improved significantly. The rate of unjustified incomplete endoscopies decreased significantly (51.8 vs. 28.9%, p = 0.010). The high-quality endoscopy rate improved 13.9% after the intervention (p < 0.001). Both specialists and residents improved with the audit intervention with a similar percentage of improvement in the high-quality endoscopy rate (13.9 vs. 13.4%).

Conclusions

A simple audit intervention is a good way to improve the quality of reporting of UGI endoscopy, independently of degree and experience. Some of the performance measure accomplishments may depend on the software used by the endoscopy centers and it should be a priority to optimize it.