Gauging Quality in Colonoscopy
Gauging Quality in Colonoscopy
Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
It's early in 2015, and the American College of Gastroenterology (ACG) and the American Society of Gastrointestinal Endoscopy (ASGE) have just released new quality indicators for endoscopy.This is a comprehensive series of articles that update the initial versions from 2006 and speak to endoscopy in general, upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound.
Because of the complexity of what we do in colonoscopy, and the fact that we spend most of our time doing that procedure, I thought it would be helpful to give an overview of the colonoscopy quality indicators and invite you to review the other high-quality reviews that were published by experts in each of these other areas.
The colonoscopy quality indicators were led by Doug Rex. The performance characteristics were divided into pre-, intra-, and post-procedure quality indicators, with performance targets for each quality indicator.
The preprocedure category includes the indications for the colonoscopy and the informed consent for the procedure. The performance target for frequency with which the colonoscopy is performed for an appropriate indication is > 80%, and the performance target for informed consent, with documentation of a discussion with the patient of the risks and benefits, is > 98%.
The colonoscopy follow-up intervals are predicated on an adequate colonic preparation (prep). This applies to screening colonoscopies as well as post-polypectomy and post-cancer resection surveillance colonoscopies. The recommended performance target for following recommended intervals is ≥ 90% for all, which is a fairly low threshold.
The intraprocedural category includes the documentation of the quality of the colonoscopy prep. This is something that you may not be doing, and the performance target for this is ≥ 98%. Part of every exam report should be documentation of whether the prep was adequate or inadequate [with respect to the ability to clearly visualize a polyp that is > 5 mm in size (the definition of an adequate prep)].
The task force went a step further, mirroring the recommendations of the US Multi-Society Task Force (USMSTF) on Colorectal Cancer for colonoscopy prep that were published in October 2014. The USMSTF assigned to colonoscopists the responsibility of ensuring that the prep is adequate 85% of the time. Likewise, the ACG/ASGE specifies a performance target of 85% for the frequency with which the bowel prep should be adequate to allow the use of recommended surveillance or screening intervals.
There are a couple of other key intraprocedural points.
Split-dose preps. The ACG/ASGE reiterated that the split-dose prep is the standard of care, and that the second dose should be taken on the morning of the procedure, 4-5 hours before the procedure is scheduled to begin. The prep should be completed 2 hours before the procedure so that the patient is NPO for at least 2 hours. If patients refuse to get up in the early morning hours to take the second dose of the split prep, they should take the second dose in the evening, after 11:00 PM, for an exam that begins before 9:00 the next morning. This would still constitute a split-dose prep. It would not provide as good a prep as when the second dose is taken on the morning of the exam, but the ACG/ASGE allowed some latitude for early morning exams.
Cecal intubation. Cecal intubation is documented photographically with a performance target of ≥ 95% for screening exams and ≥ 90% for all colonoscopies.
Adenoma detection rate. For the adenoma detection rate for men and women combined, they set a performance target of 25%. This is slightly different from what the National Quality Forum accepts as a benchmark (20%) for a combined rate. The ACG/ASGE uses a target of 30% for men and 20% for women. Although they recognize that other risk factors, such as smoking and obesity, can influence adenoma prevalence, adjustment of the target adenoma detection rate for different prevalences of these factors is not currently recommended.
Withdrawal time. The performance target of an average withdrawal time of at least 6 minutes was reiterated, and this should be measured in at least 98% or more of colonoscopies. Withdrawal time is measured by stopping at the cecum and measuring the time to withdraw the colonoscope from the anus.
Biopsies. For patients who are undergoing a colonoscopy for chronic diarrhea, the performance target for obtaining a biopsy is 98%. It is recommended to take eight or more biopsies, including samples from the proximal colon. When performing colonoscopy in patients with ulcerative colitis or Crohn's colitis, the performance target for obtaining biopsies is ≥98%. Biopsies can be taken either with a protocol (four biopsies every 10 cm, for a total of 28-32 biopsies) or by chromoendoscopy, which is the evolving standard of care. [Editor's note: For more on chromoendoscopy, see Get Ready for Chromoendoscopic Surveillance in IBD.]
Referrals for surgery. Mucosa-based pedunculated and sessile polyps < 2 cm in size should not be referred without an attempt at endoscopic resection, and the performance target for first attempting their removal is > 98%. Lesions should be referred if the endoscopist is not comfortable or capable of removing them endoscopically.
With respect to the post-colonoscopy quality measures, the first is the complication rate. Performance targets for complications include the following:
• Perforations (for all colonoscopies): < 1 in 500
• Perforations (for screening colonoscopies): < 1 in 1000
• Post-polypectomy bleeding: < 1%
Ideally, for larger lesions you would like bleeding to occur at low rates also, but recognizing that these rates may be higher; in aggregate, the average incidence should still be < 1%.
Cold resection techniques, including cold snaring, can reduce the risk for post-polypectomy bleeding. The submucosal injection technique is suggested for reducing risk during endoscopic mucosa resection, as well as insufflation of CO2 (rather than air) and the use of clips to close perforations recognized during the procedure. Another recommendation is taking care when pushing through strictures caused by inflammatory bowel disease or ischemia. When strictures are present, the use of graded dilation is recommended, with assessment of the mucosal disruption, and perhaps even using a wire to guide the access of the endoscope to stay within the lumen of the stricture so that it doesn't deviate to the side and dissect the adjacent colon wall.
For the management of post-polypectomy bleeding, the performance target is ≥ 90%, emphasizing that it should be possible to manage bleeding endoscopically without the need for surgery. Hemostatic clips can be used. [Editor's note: Several techniques for managing immediate and delayed post-polypectomy bleeding are discussed in the ACG/ASGE document.]
The final postprocedure quality indicator is compliance with assessing the histology and relaying it back to the patient, and making an appropriate recommendation for timing of a repeat colonoscopy, all of which is documented in the chart. The appropriate interval depends on the adequacy of the exam prep, the histology, and the surveillance guidelines. The performance target is ≥ 90%.
This is the first time that performance targets have been established for quality indicators in colonoscopy. The key messages, if you are looking at what you absolutely should be doing today, are three, and the first is the adenoma detection rate. The performance target is 30% for men and 20% for women, with a combined performance target of 25%.
The second key quality indicator is compliance with the interval for repeating a screening colonoscopy and for repeating colonoscopy after polyp or cancer resection. The interval guidelines are the same as those recommended by the USMSTF.
The third key quality indicator is photographic documentation of cecal intubation. Compliance in reaching the cecum is important, and documentation of the ileocecal valve and the appendiceal orifice is the chief way to prove it. Many insurance companies are moving toward requiring this for payment.
We have come a long way in our efforts to improve quality. We are looking at an era when patients and insurance companies not only are going to expect but will demand this quality, and we need to be cognizant of this by documenting and lauding what we do. We need to monitor these indicators and be transparent with our performance targets to show that gastroenterologists provide the best colonoscopy quality and that we can make a meaningful difference.
Review this document. It is very helpful. Look at the others (the overall endoscopy, upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound). I think you will find them very helpful in your practice.
I am Dr David Johnson. Thanks for listening.
A New Focus on Quality Colonoscopy
Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.
It's early in 2015, and the American College of Gastroenterology (ACG) and the American Society of Gastrointestinal Endoscopy (ASGE) have just released new quality indicators for endoscopy.This is a comprehensive series of articles that update the initial versions from 2006 and speak to endoscopy in general, upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound.
Because of the complexity of what we do in colonoscopy, and the fact that we spend most of our time doing that procedure, I thought it would be helpful to give an overview of the colonoscopy quality indicators and invite you to review the other high-quality reviews that were published by experts in each of these other areas.
The colonoscopy quality indicators were led by Doug Rex. The performance characteristics were divided into pre-, intra-, and post-procedure quality indicators, with performance targets for each quality indicator.
Preprocedure Quality Indicators
The preprocedure category includes the indications for the colonoscopy and the informed consent for the procedure. The performance target for frequency with which the colonoscopy is performed for an appropriate indication is > 80%, and the performance target for informed consent, with documentation of a discussion with the patient of the risks and benefits, is > 98%.
The colonoscopy follow-up intervals are predicated on an adequate colonic preparation (prep). This applies to screening colonoscopies as well as post-polypectomy and post-cancer resection surveillance colonoscopies. The recommended performance target for following recommended intervals is ≥ 90% for all, which is a fairly low threshold.
Intraprocedural Quality Indicators
The intraprocedural category includes the documentation of the quality of the colonoscopy prep. This is something that you may not be doing, and the performance target for this is ≥ 98%. Part of every exam report should be documentation of whether the prep was adequate or inadequate [with respect to the ability to clearly visualize a polyp that is > 5 mm in size (the definition of an adequate prep)].
The task force went a step further, mirroring the recommendations of the US Multi-Society Task Force (USMSTF) on Colorectal Cancer for colonoscopy prep that were published in October 2014. The USMSTF assigned to colonoscopists the responsibility of ensuring that the prep is adequate 85% of the time. Likewise, the ACG/ASGE specifies a performance target of 85% for the frequency with which the bowel prep should be adequate to allow the use of recommended surveillance or screening intervals.
There are a couple of other key intraprocedural points.
Split-dose preps. The ACG/ASGE reiterated that the split-dose prep is the standard of care, and that the second dose should be taken on the morning of the procedure, 4-5 hours before the procedure is scheduled to begin. The prep should be completed 2 hours before the procedure so that the patient is NPO for at least 2 hours. If patients refuse to get up in the early morning hours to take the second dose of the split prep, they should take the second dose in the evening, after 11:00 PM, for an exam that begins before 9:00 the next morning. This would still constitute a split-dose prep. It would not provide as good a prep as when the second dose is taken on the morning of the exam, but the ACG/ASGE allowed some latitude for early morning exams.
Cecal intubation. Cecal intubation is documented photographically with a performance target of ≥ 95% for screening exams and ≥ 90% for all colonoscopies.
Adenoma detection rate. For the adenoma detection rate for men and women combined, they set a performance target of 25%. This is slightly different from what the National Quality Forum accepts as a benchmark (20%) for a combined rate. The ACG/ASGE uses a target of 30% for men and 20% for women. Although they recognize that other risk factors, such as smoking and obesity, can influence adenoma prevalence, adjustment of the target adenoma detection rate for different prevalences of these factors is not currently recommended.
Withdrawal time. The performance target of an average withdrawal time of at least 6 minutes was reiterated, and this should be measured in at least 98% or more of colonoscopies. Withdrawal time is measured by stopping at the cecum and measuring the time to withdraw the colonoscope from the anus.
Biopsies. For patients who are undergoing a colonoscopy for chronic diarrhea, the performance target for obtaining a biopsy is 98%. It is recommended to take eight or more biopsies, including samples from the proximal colon. When performing colonoscopy in patients with ulcerative colitis or Crohn's colitis, the performance target for obtaining biopsies is ≥98%. Biopsies can be taken either with a protocol (four biopsies every 10 cm, for a total of 28-32 biopsies) or by chromoendoscopy, which is the evolving standard of care. [Editor's note: For more on chromoendoscopy, see Get Ready for Chromoendoscopic Surveillance in IBD.]
Referrals for surgery. Mucosa-based pedunculated and sessile polyps < 2 cm in size should not be referred without an attempt at endoscopic resection, and the performance target for first attempting their removal is > 98%. Lesions should be referred if the endoscopist is not comfortable or capable of removing them endoscopically.
Postprocedure Quality Indicators
With respect to the post-colonoscopy quality measures, the first is the complication rate. Performance targets for complications include the following:
• Perforations (for all colonoscopies): < 1 in 500
• Perforations (for screening colonoscopies): < 1 in 1000
• Post-polypectomy bleeding: < 1%
Ideally, for larger lesions you would like bleeding to occur at low rates also, but recognizing that these rates may be higher; in aggregate, the average incidence should still be < 1%.
Cold resection techniques, including cold snaring, can reduce the risk for post-polypectomy bleeding. The submucosal injection technique is suggested for reducing risk during endoscopic mucosa resection, as well as insufflation of CO2 (rather than air) and the use of clips to close perforations recognized during the procedure. Another recommendation is taking care when pushing through strictures caused by inflammatory bowel disease or ischemia. When strictures are present, the use of graded dilation is recommended, with assessment of the mucosal disruption, and perhaps even using a wire to guide the access of the endoscope to stay within the lumen of the stricture so that it doesn't deviate to the side and dissect the adjacent colon wall.
For the management of post-polypectomy bleeding, the performance target is ≥ 90%, emphasizing that it should be possible to manage bleeding endoscopically without the need for surgery. Hemostatic clips can be used. [Editor's note: Several techniques for managing immediate and delayed post-polypectomy bleeding are discussed in the ACG/ASGE document.]
The final postprocedure quality indicator is compliance with assessing the histology and relaying it back to the patient, and making an appropriate recommendation for timing of a repeat colonoscopy, all of which is documented in the chart. The appropriate interval depends on the adequacy of the exam prep, the histology, and the surveillance guidelines. The performance target is ≥ 90%.
The Top Three
This is the first time that performance targets have been established for quality indicators in colonoscopy. The key messages, if you are looking at what you absolutely should be doing today, are three, and the first is the adenoma detection rate. The performance target is 30% for men and 20% for women, with a combined performance target of 25%.
The second key quality indicator is compliance with the interval for repeating a screening colonoscopy and for repeating colonoscopy after polyp or cancer resection. The interval guidelines are the same as those recommended by the USMSTF.
The third key quality indicator is photographic documentation of cecal intubation. Compliance in reaching the cecum is important, and documentation of the ileocecal valve and the appendiceal orifice is the chief way to prove it. Many insurance companies are moving toward requiring this for payment.
We have come a long way in our efforts to improve quality. We are looking at an era when patients and insurance companies not only are going to expect but will demand this quality, and we need to be cognizant of this by documenting and lauding what we do. We need to monitor these indicators and be transparent with our performance targets to show that gastroenterologists provide the best colonoscopy quality and that we can make a meaningful difference.
Review this document. It is very helpful. Look at the others (the overall endoscopy, upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound). I think you will find them very helpful in your practice.
I am Dr David Johnson. Thanks for listening.