Comparison of Colonoscopy Quality Measures Across Various Practice Settings and the Impact of Performance Scorecards

Impact of visualising healthcare quality performance: a systematic review

OBJECTIVE

Performance visualisation tools are increasingly being applied in healthcare to enhance decision-making and improve quality of care. However, there is a lack of comprehensive synthesis of their overall effectiveness and the contextual factors that influence their success in different clinical settings. This study aims to provide a broad synthesis of visualisation interventions not limited to a specific department.

DESIGN

Systematic review.

DATA SOURCES

MEDLINE and Embase were searched until December 2022.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and observational studies in English involving a visualisation intervention, either alone or as a core intervention, that reported quantitative outcomes including process and outcome indicators.

DATA EXTRACTION AND SYNTHESIS

Data on study characteristics, intervention characteristics, outcome measures and results were extracted. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach, and risk of bias was evaluated with Risk of Bias 2 for RCTs and Risk of Bias in Non-randomised Studies - of Interventions for non-randomised studies. RESULTS : Of the 12 studies included, 2 were RCTs and 10 were observational studies, including 1 before-after study and 1 interrupted time series study. Five studies (42%) were conducted in teaching hospital settings. Compared with the control group or baseline, 10 studies reported a statistically significant change in at least one of their outcome measures. A majority of the studies reported a positive impact, including prescription adherence (6/10), screening tests (3/10) and monitoring (3/10). Visualisation tool factors like type, clinical setting, workflow integration and clinician engagement, may have some influence on the effectiveness of the intervention, but no reliable evidence was identified.

CONCLUSION

Performance visualisation tools have the potential to improve clinical performance indicators. More studies with standardised outcome measures and integrating qualitative methods are needed to understand the contextual factors that influence the effectiveness of these interventions.

Quality of Surveillance Impacts the Colitis-Associated Advanced Neoplasia Risk: A Multicenter Case-Control Study

BACKGROUND AND AIMS

Although colorectal cancer (CRC) surveillance is embedded in clinical inflammatory bowel disease (IBD) practice, a subset of patients still develops advanced neoplasia (AN) (high-grade dysplasia [HGD] and/or CRC). We aimed to assess the impact of surveillance quality on AN risk in IBD.

METHODS

In this multicenter case-control study, we searched the Dutch nationwide pathology databank to identify IBD cases with AN and controls with indefinite or low-grade dysplasia. The surveillance colonoscopy preceding the index lesion (first indefinite for dysplasia [IND]/low-grade dysplasia [LGD] or AN) was used to assess the impact of surveillance quality. We assessed intervals, bowel preparation, cecal intubation, and absence of inflammation as primary quality indicators. In addition, we assessed chromoendoscopy, endoscopist expertise, hospital setting, and biopsy strategy. Associations of quality indicators with AN risk were determined with multivariable logistic regression analyses with Firth's correction.

RESULTS

We included 137 cases and 138 controls. Delayed intervals (58.2% vs 39.6%) and active inflammation (65.3% vs 41.8%) were frequently present in cases and controls and were associated with AN (delayed interval: adjusted odds ratio [aOR], 2.00; 95% confidence interval [CI], 1.07-3.81; P = .03; active inflammation: aOR, 2.46; 95% CI, 1.33-4.61; P < .01). Surveillance compliant with primary quality indicators was associated with a reduced AN risk (aOR, 0.43; 95% CI, 0.22-0.91; P = .03), similar to chromoendoscopy (OR, 0.11; 95% CI, 0.01-0.89; P = .01). Other indicators were not significantly associated with AN.

CONCLUSIONS

Surveillance compliant with primary quality indicators is associated with a reduced colitis-associated AN risk. Delayed surveillance intervals and active inflammation were associated with an increased AN risk. This underlines the importance of procedural quality, including endoscopic remission to optimize the effectiveness of endoscopic surveillance.

Endoscopy Unit Level Interventions to Improve Adenoma Detection Rate: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator.

RESULTS

From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11).

CONCLUSIONS

The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.

Regular feedback to individual endoscopists is associated with improved adenoma detection rate and other key performance indicators for colonoscopy

OBJECTIVE

Monitoring of key performance indicators (KPIs) is a vital element of endoscopy quality improvement. Adenoma detection rate (ADR) is considered the best marker for colonoscopic quality as it inversely correlates with subsequent colonic cancer incidence and mortality, while polyp detection rate (PDR) is an easier-to-calculate surrogate for ADR. This study assessed whether regular feedback to individual endoscopists about their KPIs improved departmental performance.

METHODS

Individual KPIs were calculated for a period of 8 years (January 2012-December 2019) and fed back to all endoscopists at 6 monthly intervals, alongside anonymised indicators for other endoscopists, aggregate departmental performance data and benchmarks. An automated natural language processing software (EndoMineR) was used to identify adenomas in pathology reports and calculate ADR. Linear regressions were calculated for departmental ADR, PDR and other KPIs at 6 monthly intervals.

RESULTS

39 359 colonoscopies (average 2460 in every 6-month period, range 1799-3059) were performed by an average of 42 (range 34-50) endoscopists. A continuous improvement in collective performance including ADR (12.7%-21.0%, R² 0.92, p<0.001) and PDR (19.0%-29.6%, R² 0.77, p<0.001) was observed throughout the study. Other KPIs showed similar improvement. The detection of non-neoplastic polyps did not increase. When analysed separately, ADR and PDR appeared to improve for gastroenterologists and nurse endoscopists but not for surgeons.

CONCLUSION

Regular feedback with individual and departmental KPIs was associated with improved ADR and overall performance throughout the 8-year study period. Concomitant monitoring of ADR and PDR may prevent 'gaming' behaviour and ensure that genuine improvement is achieved.

Adenoma detection by Endocuff-assisted versus standard colonoscopy in an organized screening program: the "ItaVision" randomized controlled trial

BACKGROUND

The Endocuff Vision device (Arc Medical Design Ltd., Leeds, UK) has been shown to increase mucosal exposure, and consequently adenoma detection rate (ADR), during colonoscopy. This nationwide multicenter study assessed possible benefits and harms of using Endocuff Vision in a fecal immunochemical test (FIT)-based screening program.

METHODS

Patients undergoing colonoscopy after a FIT-positive test were randomized 1:1 to undergo Endocuff-assisted colonoscopy or standard colonoscopy, stratified by sex, age, and screening history. Primary outcome was ADR. Secondary outcomes were ADR stratified by endoscopists' ADR, advanced ADR (AADR), adenomas per colonoscopy (APC), withdrawal time, and adverse events.

RESULTS

1866 patients were enrolled across 13 centers. After exclusions, 1813 (mean age 60.1 years; male 53.8 %) were randomized (908 Endocuff Vision, 905 standard colonoscopy). ADR was significantly higher in the Endocuff Vision arm (47.8 % vs. 40.8 %; relative risk [RR] 1.17, 95 % confidence interval [CI] 1.06-1.30), with no differences between arms regarding size or morphology. When stratifying for endoscopists' ADR, only low detectors (ADR < 33.3 %) showed a statistically significant ADR increase (Endocuff Vision 41.1 % [95 %CI 35.7-46.7] vs. standard colonoscopy 26.0 % [95 %CI 21.3-31.4]). AADR (24.8 % vs. 20.5 %, RR 1.21, 95 %CI 1.02-1.43) and APC (0.94 vs. 0.77; P  = 0.001) were higher in the Endocuff Vision arm. Withdrawal time and adverse events were similar between arms.

CONCLUSION

Endocuff Vision increased ADR in a FIT-based screening program by improving examination of the whole colonic mucosa. Utility was highest among endoscopists with a low ADR.

Colonoscopy quality in community hospitals and nonhospital facilities in Korea

BACKGROUND/AIMS

High-quality colonoscopy is essential to reduce colorectal cancer-related deaths. Little is known about colonoscopy quality in non-academic practice settings. We aimed to evaluate the quality of colonoscopies performed in community hospitals and nonhospital facilities.

METHODS

Colonoscopy data were collected from patients referred to six tertiary care centers after receiving colonoscopies at community hospitals and nonhospital facilities. Based on their photographs, we measured quality indicators including cecal intubation rate, withdrawal time, adequacy of bowel preparation, and number of polyps.

RESULTS

Data from a total of 1,064 colonoscopies were analyzed. The overall cecal intubation rate was 93.1%. The median withdrawal time was 8.3 minutes, but 31.3% of colonoscopies were withdrawn within 6 minutes. Community hospitals had longer withdrawal time and more polyps than nonhospital facilities (median withdrawal time: 9.9 minutes vs. 7.5 minutes, p < 0.001; mean number of polyps: 3.1 vs. 2.3, p = 0.001). Board-certified endoscopists had a higher rate of cecal intubation than non-board-certified endoscopists (93.2% vs. 85.2%, p = 0.006). A total of 819 follow-up colonoscopies were performed at referral centers with a median interval of 28 days. In total, 2,546 polyps were detected at baseline, and 1,088 were newly identified (polyp miss rate, 29.9%). Multivariable analysis revealed that older age (odds ratio [OR], 1.032; 95% confidence interval [CI], 1.020 to 1.044) and male sex (OR, 1.719; 95% CI, 1.281 to 2.308) were associated with increased risk of missed polyps.

CONCLUSION

The quality of colonoscopies performed in community hospitals and nonhospital facilities was suboptimal. Systematic reporting, auditing, and feedback are needed for quality improvement.

Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis

BACKGROUND AND AIMS

Colonoscopy quality indicators such as adenoma detection rate (ADR) are surrogates for the effectiveness of screening-related colonoscopy. It is unclear whether endoscopist feedback on these indicators improves performance. We performed a meta-analysis to determine whether associations exist between endoscopist feedback and colonoscopy performance.

METHODS

We conducted a search through May 2019 for studies reporting on endoscopist feedback and associations with ADR or other colonoscopy quality indicators. Pooled rate ratios (RRs) and weighted mean differences were calculated using DerSimonian and Laird random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to assess for potential methodological or clinical factors associated with outcomes.

RESULTS

From 1326 initial studies, 12 studies were included in the meta-analysis for ADR, representing 33,184 colonoscopies. Endoscopist feedback was associated with an improvement in ADR (RR, 1.21; 95% confidence interval [CI], 1.09-1.34). Low performers derived a greater benefit from feedback (RR, 1.62; 95% CI, 1.18-2.23) compared with moderate performers (RR, 1.19; 95% CI, 1.11-1.29), whereas high performers did not derive a significant benefit (RR, 1.06; 95% CI, 0.99-1.13). Feedback was not associated with increases in withdrawal time (weighted mean difference, +0.43 minutes; 95% CI, -0.50 to +1.36 minutes) or improvements in cecal intubation rate (RR, 1.00; 95% CI, 0.99-1.01).

CONCLUSION

Endoscopist feedback is associated with modest improvements in ADR. The implementation of routine endoscopist audit and feedback should be considered alongside other quality improvement interventions in institutions dedicated to the provision of high-quality screening-related colonoscopy.

Impact of a Citywide Benchmarking Intervention on Colonoscopy Quality Performance

INTRODUCTION

There is marked variability in colonoscopy quality, limiting its effectiveness in colorectal cancer prevention. Multiple indicators have been established as markers for colonoscopy quality; however, there are conflicting data on the effects of quality reporting programs on endoscopist performance. In this study, we investigate the impact of a multicenter quarterly report card initiative on colonoscopy quality metric performance.

METHODS

Data were collected from 194 endoscopists at 10 participating sites throughout New York City using a Qualified Clinical Data Registry from January 2013 to December 2014. Adenoma detection rate (ADR), cecal intubation rate, withdrawal time, bowel preparation quality and appropriate interval recommendations were tracked. Report cards were distributed to each site on a quarterly basis and technical assistance was provided as needed. Performance trends were analyzed using the Cochran-Armitage trend and analysis of variance tests.

RESULTS

37,258 screening colonoscopies were performed during the study period. There was a positive performance trend for ADR over time from the first quarter of 2013 to the last quarter of 2014 (15.6-25.7%; p < 0.001). There were also increases in cecal intubation rates (78.2-92.6%; p < 0.001), bowel preparation adequacy rates (77.5-92.8%; p < 0.001), and adherence to appropriate screening intervals (28.0-55.0%; p < 0.001). There was no clinically significant change in mean withdrawal time.

CONCLUSIONS

The implementation of a quarterly report card initiative resulted in statistically significant improvements in adenoma detection, cecal intubation, bowel preparation adequacy rates, and appropriate recommended screening intervals.

Quality Improvement in Gastroenterology: A Systematic Review of Practical Interventions for Clinicians

BACKGROUND

Quality improvement (QI) identifies practical methods to improve patient care; however, it is not always widely known which QI methods are successful. We sought to create a primer of QI in gastroenterology for the practicing clinician.

METHODS

We performed a systematic review of QI literature in gastroenterology. We included search terms for inflammatory bowel disease, irritable bowel syndrome, celiac disease, gastroesophageal reflux disease, pancreatitis, liver disease, colorectal cancer screening, endoscopy, and gastrointestinal bleeding. We used general search terms for QI as well as specific terms to capture established quality metrics for each GI disease area.

RESULTS

We found 33 studies that met our definitions for QI. There were 17 studies of endoscopy including screening colonoscopy, six on liver disease, four on IBD, two on GERD, three on GI bleeding, and one on celiac disease. Education was the most common intervention, although most successful studies combined education with another intervention. Other effective interventions included retraining sessions to reach ADR goals in colonoscopy, nursing protocols to increase HCC screening, and EMR decision support tools to prompt reassessment of PPI therapy. Many studies showed improved compliance to metrics, but few were able to show differences in length of stay, readmissions, or mortality.

CONCLUSIONS

Our review of quality improvement literature in gastroenterology revealed common themes of successful programs: Education was frequently used but often insufficient, the EMR may be underutilized in guiding decision making, and patient-reported outcomes were infrequently assessed. Further research may be needed to compare QI strategies directly.

Assessing colon polypectomy competency and its association with established quality metrics

BACKGROUND AND AIMS

Inadequate polypectomy leads to incomplete resection, interval colorectal cancer, and adverse events. However, polypectomy competency is rarely reported, and quality metrics are lacking. The primary aims of this study were to assess polypectomy competency among a cohort of gastroenterologists and to measure the correlation between polypectomy competency and established colonoscopy quality metrics (adenoma detection rate and withdrawal time).

METHODS

We conducted a prospective observational study to assess polypectomy competency among 13 high-volume screening colonoscopists at an academic medical center. Over 6 weeks, we made video recordings of ≥28 colonoscopies per colonoscopist and randomly selected 10 polypectomies per colonoscopist for evaluation. Two raters graded the polypectomies by using the Direct Observation of Polypectomy Skills, a polypectomy competency assessment tool, which assesses individual polypectomy skills and overall competency.

RESULTS

We evaluated 130 polypectomies. A total of 83 polypectomies (64%) were rated as competent, which was more likely for diminutive (70%) than small and/or large polyps (50%, P = .03). Overall Direct Observation of Polypectomy Skills competency scores varied significantly among colonoscopists (P = .001), with overall polypectomy competency rates ranging between 30% and 90%. Individual skills scores, such as accurately directing the snare over the lesion (P = .02) and trapping an appropriate amount of tissue within the snare (P = .001) varied significantly between colonoscopists. Polypectomy competency rates did not significantly correlate with the adenoma detection rate (r = 0.4; P = .2) or withdrawal time (r = 0.2; P = .5).

CONCLUSIONS

Polypectomy competency varies significantly among colonoscopists and does not sufficiently correlate with established quality metrics. Given the clinical implications of suboptimal polypectomy, efforts to educate colonoscopists in polypectomy techniques and develop a metric of polypectomy quality are needed.

Evaluation of a fecal immunochemistry test prior to colonoscopy for outpatients with various indications

BACKGROUND

Stool tests can predict advanced neoplasms prior to colonoscopy. Results of immunochemical stool tests to predict findings at colonoscopy for various indications are less often reported. We compared pre-colonoscopy stool tests with findings in patients undergoing colonoscopy for different indications.

PATIENTS AND METHODS

Charts of patients undergoing elective or semi-urgent colonoscopy were reviewed. Comparison of adenoma detection rates and pathological findings was made between prescreened and non-prescreened, and between stool-positive and stool-negative cases. Demographics, quality of colonoscopy, and pathological findings were recorded. Odds ratios (ORs) and 95% confidence intervals (CIs) were assessed. Statistical significance was accepted at p≤0.05.

RESULTS

Charts of 325 patients were reviewed. Among them, stool tests were done on 144 patients: 114 were negative and 30 were positive. Findings were similar in the pretest and non-pretest groups. Detection of advanced adenomas per patient was higher in the stool-positive group compared to the stool-negative group (23.4% vs 3.5%, p=0.0016, OR =7.6 [95% CI: 2-29.3]). Five advanced adenomas (without high-grade dysplasia or adenocarcinoma) and several cases of multiple adenomas were missed in the negative group. Sensitivity and specificity for advanced polyps was 63.6% and 82.7%, respectively. The negative predictive value was 96.5%. Male gender was independently predictive of any adenoma.

CONCLUSION

The stool immunochemical test best predicted advanced neoplasms and had a high negative predictive value in this small cohort. Whether this test can be applied to determine the need for colonoscopy in groups other than average risk would require more studies.

Quality measures in gastrointestinal endoscopy: the current state

PURPOSE OF REVIEW

The purpose of this review is to summarize the current state of endoscopic quality measurement and use of measures in enhancing the value of endoscopic services.

RECENT FINDINGS

Initially, quality measurement of endoscopic procedures was claims based or included small unit or practice-specific efforts. Now we have a mature national registry and large electronic medical or procedural records that are designed to yield valuable data relevant to quality measurement.

SUMMARY

With the advent of better measures, we are beginning to understand that initial process and surrogate outcome measures (adenoma detection rate) can be improved to provide a better reflection of endoscopic quality. Importantly, however, even measures currently in use relate to important patient outcomes such as missed colon cancers. At a federal level, older cumbersome pay-for-performance initiatives have been combined into a new overarching program named the quality payment program within the centers for medicare and medicaid services. This program is an additional step toward furthering the progress from volume-to-value-based reimbursement. The legislation mandating the movement toward outcomes-linked (value) reimbursement is the medicare access and children's health insurance program reauthorization act, which was passed with overwhelming bipartisan support and will not be walked back by alterations of the affordable care act. Increasing portions of medicare reimbursement (and likely commercial to follow) will be linked to quality metrics, so familiarity with the underlying process and rationale will be important for all proceduralists.