Improving Screening Colonoscopy Quality
Improving Screening Colonoscopy Quality
Objectives: Adenoma-detection rates (ADRs) are associated with decreased interval colorectal cancer (CRC) rates and CRC mortality; quality improvement strategies focus on improving physician ADRs. The objective of this study was to examine the sequential effect of physician report cards and implementing institutional standards of practice (SOP) on ADRs.
Methods: Colonoscopy metrics were prospectively evaluated at a single academic medical center over a 23-month period (November 2012 to October 2014). ADRs were evaluated over three time periods—Period 1: Before initial report card distribution or SOP (November 2012 to March 2013); Period 2: After individualized report card distribution detailing physician and institutional ADRs (April 2013 to March 2014); Period 3: After second report card and SOP implementation (April 2014 to October 2014). The SOP required physicians to have a minimum 5-min withdrawal time in normal colonoscopies (WT) and an ADR minimum of 20%; those who did not meet benchmarks would require further training or endoscopy block time alterations. Only endoscopists averaging >15 colonoscopies/month were included in this analysis.
Results: Twenty endoscopists met the inclusion criteria, performing 12,894 screening colonoscopies over the 23-month period. Following report card distribution, physician ADRs increased by 3% (P<0.001). SOP implementation resulted in a further significant increase in mean physician ADR of 8% (P<0.0001). Overall, mean ADR increased by 11% from Period 1 to Period 3 (P<0.0001). All physicians met the minimum 20% ADR benchmark during Period 3. Although ADRs significantly correlated with WT overall (r=0.45; 95% CI 0.01, 0.75; P=0.04), mean WT did not significantly increase from Period 1 to Period 3.
Conclusions: Our data suggest that distributing colonoscopy quality report cards resulted in a significant ADR improvement. Further, we report evidence that implementing SOP significantly improved ADRs beyond report card distribution and resulted in all endoscopists meeting minimum benchmarks. This suggests that report cards and SOPs may have an additive effect in improving colonoscopy quality, and their implementation in endoscopy labs should be encouraged.
Screening colonoscopy and removal of precancerous polyps, or adenomas, is associated with a reduction in fatal colorectal cancer (CRC), the second leading cause of cancer death in the United States. Endoscopist adenoma-detection rate (ADR), the proportion of screening colonoscopies in which an adenoma is removed, is used as a metric for colonoscopy quality, as increasing physician ADR is associated with a decrease in interval CRC (cancer not detected at initial colonoscopy but developing within 3–5 years) and CRC mortality.
In an initial large study from Poland, endoscopists with an ADR of >20% were found to have a decrease in interval CRC compared with endoscopists with an ADR of <20%. A more recent study from an integrated health services organization in California found that this progressive reduction in interval CRC persisted up to an ADR of at least 33.5%. Thus, quality improvement efforts in screening colonoscopy have increasingly focused on measuring and improving endoscopist ADR including a comprehensive educational program and a single published study of six endoscopists demonstrating the effect of a report card on endoscopist performance, both noting a positive impact. However, despite the importance of measuring ADRs, it remains challenging to measure in clinical practice, as pathology databases are generally not integrated with the endoscopy reporting system, requiring manual chart review for ADR calculation; this is both laborious and impractical for continuous quality monitoring. For this reason, colonoscopy withdrawal time (WT), referring to the time spent looking for neoplastic polyps on colonoscope withdrawal from the cecum, has been used as a surrogate marker of colonoscopy quality owing to ease of measurement; however, conclusions regarding WT from published studies are mixed, as WT does not consistently correlate with ADR. Electronic data warehouses represent a solution to measuring ADR, able to integrate the entire electronic health record (e.g., pathology and endoscopy systems) and generate automated reports to drive ADR improvements.
The objectives of this report are to: (i) describe the effects of distributing an ADR report card, generated by an electronic data warehouse, on institutional and individual endoscopist ADRs, and (ii) to examine the impact of implementing institutional standards of practice (SOP) on institutional and individual endoscopist ADRs.
Abstract and Introduction
Abstract
Objectives: Adenoma-detection rates (ADRs) are associated with decreased interval colorectal cancer (CRC) rates and CRC mortality; quality improvement strategies focus on improving physician ADRs. The objective of this study was to examine the sequential effect of physician report cards and implementing institutional standards of practice (SOP) on ADRs.
Methods: Colonoscopy metrics were prospectively evaluated at a single academic medical center over a 23-month period (November 2012 to October 2014). ADRs were evaluated over three time periods—Period 1: Before initial report card distribution or SOP (November 2012 to March 2013); Period 2: After individualized report card distribution detailing physician and institutional ADRs (April 2013 to March 2014); Period 3: After second report card and SOP implementation (April 2014 to October 2014). The SOP required physicians to have a minimum 5-min withdrawal time in normal colonoscopies (WT) and an ADR minimum of 20%; those who did not meet benchmarks would require further training or endoscopy block time alterations. Only endoscopists averaging >15 colonoscopies/month were included in this analysis.
Results: Twenty endoscopists met the inclusion criteria, performing 12,894 screening colonoscopies over the 23-month period. Following report card distribution, physician ADRs increased by 3% (P<0.001). SOP implementation resulted in a further significant increase in mean physician ADR of 8% (P<0.0001). Overall, mean ADR increased by 11% from Period 1 to Period 3 (P<0.0001). All physicians met the minimum 20% ADR benchmark during Period 3. Although ADRs significantly correlated with WT overall (r=0.45; 95% CI 0.01, 0.75; P=0.04), mean WT did not significantly increase from Period 1 to Period 3.
Conclusions: Our data suggest that distributing colonoscopy quality report cards resulted in a significant ADR improvement. Further, we report evidence that implementing SOP significantly improved ADRs beyond report card distribution and resulted in all endoscopists meeting minimum benchmarks. This suggests that report cards and SOPs may have an additive effect in improving colonoscopy quality, and their implementation in endoscopy labs should be encouraged.
Introduction
Screening colonoscopy and removal of precancerous polyps, or adenomas, is associated with a reduction in fatal colorectal cancer (CRC), the second leading cause of cancer death in the United States. Endoscopist adenoma-detection rate (ADR), the proportion of screening colonoscopies in which an adenoma is removed, is used as a metric for colonoscopy quality, as increasing physician ADR is associated with a decrease in interval CRC (cancer not detected at initial colonoscopy but developing within 3–5 years) and CRC mortality.
In an initial large study from Poland, endoscopists with an ADR of >20% were found to have a decrease in interval CRC compared with endoscopists with an ADR of <20%. A more recent study from an integrated health services organization in California found that this progressive reduction in interval CRC persisted up to an ADR of at least 33.5%. Thus, quality improvement efforts in screening colonoscopy have increasingly focused on measuring and improving endoscopist ADR including a comprehensive educational program and a single published study of six endoscopists demonstrating the effect of a report card on endoscopist performance, both noting a positive impact. However, despite the importance of measuring ADRs, it remains challenging to measure in clinical practice, as pathology databases are generally not integrated with the endoscopy reporting system, requiring manual chart review for ADR calculation; this is both laborious and impractical for continuous quality monitoring. For this reason, colonoscopy withdrawal time (WT), referring to the time spent looking for neoplastic polyps on colonoscope withdrawal from the cecum, has been used as a surrogate marker of colonoscopy quality owing to ease of measurement; however, conclusions regarding WT from published studies are mixed, as WT does not consistently correlate with ADR. Electronic data warehouses represent a solution to measuring ADR, able to integrate the entire electronic health record (e.g., pathology and endoscopy systems) and generate automated reports to drive ADR improvements.
The objectives of this report are to: (i) describe the effects of distributing an ADR report card, generated by an electronic data warehouse, on institutional and individual endoscopist ADRs, and (ii) to examine the impact of implementing institutional standards of practice (SOP) on institutional and individual endoscopist ADRs.
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