Stanford Colonoscopy Quality Assurance Program: Lessons From the Intersection of Quality Improvement and Clinical Research

Costs and benefits of a formal quality framework for colonoscopy: Economic evaluation

Background and study aims Reduction of colorectal cancer morbidity and mortality is one of the primary objectives of colonoscopy. Post-colonoscopy colorectal cancers (PCCRCs) are critical outcome parameters. Analysis of PCCRC rates can validate quality assurance measures in colonoscopy. We assessed the effectiveness of implementing a gastroenterologist-led quality framework that monitors key procedure quality indicators (i.e., bowel preparation quality, adenoma detection rates, or patient satisfaction) by comparing the PCCRC rate before and after implementation. Patients and methods Individuals who had a colonoscopy between 2010 and 2017 at a single tertiary center in Queensland, Australia, were included and divided into two groups: baseline (2010-2014) and redesign phase (2015-2017). Data linkage of the state-wide cancer registry and hospital records enabled identification of subjects who developed colorectal cancers within 5 years of a negative colonoscopy. Costs associated with quality improvement were assessed for effectiveness. Results A total of 19,383 individuals had a colonoscopy during the study period. Seventeen PCCRCs were detected. The PCCRC rate was 0.376 per 1,000 person-years and the average 5-year PCCRC risk ranged from 0.165% to 0.051%. The rate of PCCRCs was higher at the beginning (0.166%; 95% confidence interval [CI] 0.15%-0.17%) compared with the later period with full implementation of quality control measures (0.027%; 95% CI 0.023%-0.03%). The quality process determined an incremental cost-effectiveness ratio of -$5,670.53 per PCCRC avoided. Conclusions This large cohort study demonstrated that a formal gastroenterologist-led quality assurance framework embedded into the routine operations of a clinical department not only reduces interval cancers but is also cost-effective regarding life years gained and quality-adjusted life years.

Adenoma and Sessile Serrated Lesion Detection Rates at Screening Colonoscopy for Ages 45-49 Years vs Older Ages Since the Introduction of New Colorectal Cancer Screening Guidelines

BACKGROUND AND AIMS

All major U.S. guidelines now endorse average-risk colorectal cancer (CRC) screening at 45-49 years of age. Concerns exist that endoscopic capacity may be strained, that low-risk persons may self-select for screening, and that calculations of the adenoma detection rate may be diluted. We analyzed age-specific screening colonoscopy volumes and lesion detection rates before vs after the endorsement of CRC screening at 45-49 years of age.

METHODS

We compared colonoscopy volumes and lesion detection rates in our healthcare system during period 1 (October 2017 to December 2018), before the first change in guidelines, vs period 2 (January 2019 to August 2021), the era of new guidelines.

RESULTS

The proportion of first-time screening colonoscopies performed in 45- to 49-year-olds increased from 3.5% to 11.6% (relative risk, 3.36; 95% CI, 2.45-4.61). The period 2 detection rates for adenoma, advanced adenoma, sessile serrated lesion, advanced sessile serrated lesion, adenomas per colonoscopy, and lesions per colonoscopy were very similar for 45- to 49-year-olds (34.3%, 6.3%, 8.6%, 2.9%, 0.58, and 0.69, respectively) and 50- to 54-year-olds (38.2%, 5.8%, 9.4%, 3.0%, 0.63, and 0.76, respectively) at first-time screening, and for 60- to 64-year-olds at rescreening (33.4%, 6.1%, 7.2%, 2.3%, 0.61, and 0.70, respectively). All detection rates, adenomas per colonoscopy, and lesions per colonoscopy increased from period 1 to period 2 (eg, overall adenoma detection rate 35.1% vs 42.6%; P < .0001), without any decreases among 45- to 49-year-olds.

CONCLUSIONS

In our healthcare system, a lower CRC screening initiation age has modestly affected colonoscopy volume by age without compromising screening yield. Lesion detection rates, including for advanced adenomas, in average-risk 45- to 49-year-olds approximate those in 50- to 54-year-olds at first-time screening and 60- to 64-year-olds at rescreening. National monitoring is needed to assess fully the impact of lowering the CRC screening initiation age.