Setting up a quality assurance program in endoscopy

Open-access colonoscopy quality indicators and patient perception using split-dose bowel preparation

Background and Aim

Open-access (OA) colonoscopies are defined as those scheduled without a gastrointestinal (GI) office visit. Past research has not focused on split preparation use and patient perception within OA. We aim to identify differences in bowel preparation (BP) adequacy, adenoma detection rate (ADR), self-reported compliance, and patient perception between OA and GI providers using split prep.

Methods

This was a cross-sectional study using split BP for colonoscopies. Patients completed a survey, and demographics, BP adequacy, and ADR were recorded. BP compliance was self-reported. Patients were asked three questions qualifying the BP instructions. Data were analyzed using chi square and Mann-Whitney tests by SPSS.

Results

BP adequacy was reported for 56 of 60 patients. Twenty-one participants (38%) were scheduled on OA, and 35 participants (62%) were scheduled after a GI office visit. Adequate BP was more frequent in 86% (18/21) of OA patients compared to 60% (21/35) in the GI group (P = 0.043). OA patients reported better review and explanation of the BP instructions compared to GI patients. There was no statistical difference between the demographics of the OA and GI groups or self-reported compliance and patient understanding of instructions.

Conclusion

OA scheduled colonoscopies were associated with more adequate BP. This could be explained by patients' self-motivation or an explanation of the importance of completing BP. This study supports the use of OA procedures as a standard of care.

Barriers and facilitators to implementing continuous quality improvement programs in colonoscopy services: a mixed methods systematic review

BACKGROUND AND AIM

Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients.

METHODS

We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process.

RESULTS

We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists' perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources.

CONCLUSION

Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.

Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance

BACKGROUND

The American Society for Gastrointestinal Endoscopy Committee on Outcomes Research has recommended monitoring nine endoscopic retrograde cholangiopancreatography (ERCP)-specific quality indicators for quality assurance in ERCP. With the development of a self-assessment tool for ERCP (Rotterdam Assessment Form for ERCP-RAF-E), key indicators can easily be assessed.

OBJECTIVE

The aim of this study was to test in daily practice an easy-to-use form for assessment of procedural quality in ERCP and to determine ERCP quality outcomes in a tertiary referral hospital.

DESIGN

This was a prospective study carried out in a tertiary referral hospital. In January 2008, a quality self-assessment programme was started. Five qualified endoscopists participated in this study. All ERCPs were appraised using RAF-E. Primary parameters were common bile duct (CBD) cannulation rate and procedural success. The indication was classified and procedural difficulty was graded; success rates of therapeutic interventions were measured for all different difficulty degrees.

RESULTS

A total number of 1691 ERCPs were performed. 1515 (89.6%) of these were appraised using RAF-E. Median CBD cannulation success rate was 94.1%. Successful sphincterotomy was accomplished in almost all patients (median 100%; range 98.2-100%). Stent placement was successful in 97.8% and complete stone extraction, if indicated, was achieved in 86.8%.

CONCLUSIONS

Quality indicators for ERCP can be measured using the Rotterdam self-assessment programme for ERCP. Outcome data in ERCPs obtained with this RAF-E provide insight into the quality of individual as well as group performance and can be used to assess and set standards for quality control in ERCP.

Patient-reported outcome measures after endoscopic retrograde cholangiopancreatography: a prospective, multicentre study

OBJECTIVE

While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences.

METHODS

From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded.

RESULTS

Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure.

CONCLUSIONS

Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.

Patterns and predictive factors of complications after endoscopic retrograde cholangiopancreatography

BACKGROUND

With an increased use of magnetic resonance imaging, the indications for endoscopic retrograde cholangiopancreatography (ERCP) have changed. Consequently, the patterns and factors predictive of complications after ERCP performed during current routine clinical practice are not well known.

METHODS

A prospective multicentre cohort study was undertaken in 11 Norwegian hospitals. Complications and mortality within 30 days after ERCP were analysed by univariable and multivariable regression analysis.

RESULTS

There were 2808 ERCP procedures, of which 2573 (91·6 per cent) were therapeutic. More than half of the patients were aged 70 years or more. Common bile duct cannulation was achieved in 2557 procedures (91·1 per cent). Complications occurred in 327 (11·6 per cent) of the procedures, including cholangitis in 100 (3·6 per cent), pancreatitis in 88 (3·1 per cent), bleeding in 66 (2·4 per cent), perforation in 25 (0·9 per cent) and cardiovascular-respiratory events in 32 (1·1 per cent). In the multivariable regression analysis, older age, increasing American Society of Anesthesiologists fitness score, centre ERCP volumes of more than 150 procedures annually and precut sphincterotomy were predictive factors for severe complications. The overall 30-day mortality rate was 2·2 per cent (63 patients), with a procedure-related mortality rate of 1·4 per cent (39 patients). Malignancy was diagnosed in 46 (73 per cent) of the patients who died.

CONCLUSION

ERCP is a procedure with considerable risk for complications. Morbidity and mortality are related to patient age and co-morbidity, as well as hospital volume of ERCP procedures and the type of intervention.

Quality assessment of endoscopic retrograde cholangiopancreatography: results of a running nationwide Austrian benchmarking project after 5 years of implementation

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) has a high risk of various complications. The aim of this study is to report the main ERCP outcome, that means complications and success rates, on the basis of the pooled data of a national continuous quality assessment program.

METHODS

This study is an uncontrolled prospective survey and provides data from both academic and community-based endoscopy centers with varying case volumes and expertise. Data were collected within a nationwide voluntary ERCP benchmarking project that was initiated by the Austrian Society of Gastroenterology and Hepatology.

RESULTS

In total, 42 sites participated in this program for varying periods (1 month up to 5 years) and reported 13 513 procedures within 5 years. The overall complication rate in nonselected patients was 10.1%. Post-ERCP pancreatitis occurred in 4.2%, bleeding in 3.6% (0.4% clinically relevant), cholangitis in 1.4%, cardiopulmonary complications in 1.2%, perforation in 0.6%, and procedure-related deaths in 0.1% of procedures. The overall therapeutic and diagnostic target was achieved in 80.3% (2009-2011) to 84.8% (2006/2007) of procedures. The desired duct was visualized in 90.7% and cannulated in 88.8% of procedures.

CONCLUSION

The aim of the running benchmarking project in ERCP is to improve patient care in Austria. The survey reflects the general effectiveness and safety of ERCP. The overall complication and success rates are consistent with the available literature data. It sets an example as a benchmarking program that might result in international or even pan-European projects in high-risk endoscopic procedures.

[Introduction of a quality index in a Hungarian endoscopy unit]

The quality of endoscopic examinations substantially determines their value. In developed countries, Continuous Quality Management is used to improve it permanently. In Hungary there is no example for measuring quality in the field of gastrointestinal endoscopy.

AIM

The measurement and improvement of quality of endoscopy applying completeness index (cecum intubation rate) during colonoscopy.

PATIENTS AND METHODS

The authors defined base values retrospectively from 841 colonoscopy reports, performed in the last quarter of the year, before starting the project. The next two years (3160 colonoscopy in 2009 and 3167 in 2010) every three months they calculated the cecum intubation rate for each endoscopist.

RESULTS

The cecum intubation rate was 81.6% in the base period. When the authors excluded examinations with poor preparations and those with a previously unknown stenosis that prevented the total colonoscopy, the adjusted cecal intubation rate was 90.9%. In the next 2 years, the cecum intubation rate was 84.2% and 85.7% (p = 0.0394), while adjusted cecum intubation rate proved to be 92.3% and 92.6% (p = 0.381 NS) for the whole endoscopy unit. Of the 14 endoscopists only 6 reached an adjusted cecum intubation rate of 90%, but in the second year of the project 10 of them reached this rate and only one endoscopist remained below 87%. The endoscopists performing more than 100 colonoscopies per year had better adjusted cecum intubation rate (base 91.2%; 92.7% and 93.1% during the 2 project years) compared to those with less than 100 colonoscopies per year (base, 86.7%; project period, 85.5 and 89%).

CONCLUSIONS

The evaluation and publicity of the cecal intubation rate resulted in an improvement of the quality of colonoscopy. The authors also presented that endoscopists performing more than 100 colonoscopies per year have better endoscopic quality.

Endoscopic electronic record: A new approach for improving management of colorectal cancer prevention

Digestive endoscopy is currently the main diagnostic procedure for investigation of the digestive tract when a digestive disease is suspected. The use of computers and electronic medical records for the management of endoscopic data are an important key to improving endoscopy unit efficiency and productivity. This technology supports optimal program operation, monitoring and evaluation colorectal cancer screening. This article is a comprehensive survey of endoscopic electronic medical records and information systems. Computerized clinical records have the capability of identifying patients due for screening and to calculate baseline rates of colorectal cancer screening by patient characteristics and by primary care physician and practice group. This paper describes data flow in the endoscopy unit, the minimum data set of colorectal cancer and key features of endoscopic electronic medical record. In addition, the researchers state standards in different aspects, especially terminology standards and interoperability standards for image and text.

Quality assurance as an integrated part of the electronic medical record - a prototype applied for colonoscopy

OBJECTIVE

Electronic medical records (EMRs) have not developed much beyond the days of typewritten journals when it comes to facilitating extraction of data for quality assurance (QA) and improvement of health-care performance.

MATERIAL AND METHODS

Based on 5 years' experience from the Norwegian Gastronet QA programme, we have developed a highly QA-profiled EMR for colonoscopy. We used a three-tier solution (client, server and database) written in the Java programming language using a number of open-source libraries. QA principles from the Norwegian paper-based Gastronet QA programme formed the basis for development of the ColoReg software. ColoReg is developed primarily for colonoscopy reporting in a screening trial, but may be used in routine clinical work. The QA module in ColoReg is well suited for intervention towards suboptimal performance in both settings.

RESULTS

We have developed user-friendly software dominated by clickable boxes and curtain menus reducing free text to a minimum. The software gives warnings when illogical registrations are entered and reasons have to be given for divergence from software recommendations for work-up and surveillance. At any time, defined performance quality parameters are readily accessible in tabular form with the named, logged-in endoscopist being compared with all other anonymized endoscopists in the database.

CONCLUSION

The ColoReg software is developed for use in an international, multicentre trial on colonoscopy screening. It is user-friendly and secures continuous QA of the endoscopist's performance. The principles used are applicable to development of EMRs in general.

Sustaining the vitality of colonoscopy quality improvement programmes over time. Experience from the Norwegian Gastronet programme

OBJECTIVE

An important challenge of any quality assurance (QA) programme is to maintain interest among participants to ensure high data quality over time. The primary aim of this study was to identify factors associated with endoscopist compliance with the Norwegian QA programme for colonoscopies (Gastronet).

MATERIAL AND METHODS

The Gastronet registration tools are an endoscopy report form to be filled in directly after the procedure by the endoscopist, and a satisfaction questionnaire to be filled in by the patient on the day after the examination. During the study period from 1 January 2004 to 31 December 2006, endoscopist compliance was measured by assessing patient report coverage, defined as the percentage of patient satisfaction questionnaires received by the Gastronet secretariat divided by the total number of colonoscopy reports registered by the individual endoscopists during the study period. Multivariate logistic regression models were applied to identify individual factors related to patient report coverage.

RESULTS

Eighty-eight endoscopists from 10 hospitals contributed a total of 16,149 colonoscopies. Overall patient report coverage decreased from 87% in 2004 to 80% in 2006. A low patient report coverage was associated with time since the registrations started [odds ratio (OR) 0.98, 95% confidence interval (CI) 0.97-0.98; P < 0.001], use of sedation (OR 0.7, 95% CI 0.61-0.76; P < 0.001), and incomplete colonoscopy (OR 0.6, 95% CI 0.54-0.76; P < 0.001).

CONCLUSIONS

Decreasing compliance with registration over time may compromise data quality and the validity of the results. Lower coverage of patient's reports (presumably for the most difficult examinations) may lead to erroneous conclusions regarding colonoscopy performance.

[Development and validation of quality standards for colonoscopy]

BACKGROUND AND OBJECTIVES

Before starting programs for colorectal cancer screening it is necessary to evaluate the quality of colonoscopy. Our objectives were to develop a group of quality indicators of colonoscopy easily applicable and to determine the variability of their achievement.

PATIENTS AND METHODS

After reviewing the bibliography we prepared 21 potential indicators of quality that were submitted to a process of selection in which we measured their facial validity, content validity, reliability and viability of their measurement. We estimated the variability of their achievement by means of the coefficient of variability (CV) and the variability of the achievement of the standards by means of chi(2).

RESULTS

Six indicators overcome the selection process: informed consent, medication administered, completed colonoscopy, complications, every polyp removed and recovered, and adenoma detection rate in patients older than 50 years. 1928 colonoscopies were included from eight endoscopy units. Every unit included the same number of colonoscopies selected by means of simple random sampling with substitution. There was an important variability in the achievement of some indicators and standards: medication administered (CV 43%, p<0.01), complications registered (CV 37%, p<0.01), every polyp removed and recovered (CV 12%, p<0.01) and adenoma detection rate in older than fifty years (CV 2%, p<0.01).

CONCLUSIONS

We have validated six quality indicators for colonoscopy which are easily measurable. An important variability exists in the achievement of some indicators and standards. Our data highlight the importance of the development of continuous quality improvement programmes for colonoscopy before starting colorectal cancer screening.

Patient satisfaction after endoscopic retrograde cholangiopancreatography for biliary stones: a prospective multicenter study in Lombardy

AIMS

To measure patients' satisfaction after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stones in a large number of unselected endoscopy units.

METHODS

A prospective study using a questionnaire (Group Health Association of America-9 [GHAA-9], modified) was administered 24 h and 30 days after the procedure. Patients undergoing endoscopy for biliary stones for the first time were enrolled in a large number of endoscopy units, regardless of their size and workload.

RESULTS

In all, 700 patients were enrolled in 15 units. A high proportion of patients expressed satisfaction (80%). Satisfaction was less extensive for pain control and the quality of information provided before the procedure. There were no differences in the replies to questionnaires at 24 h and 30 days.

CONCLUSION

It is feasible to record patients' satisfaction and in this series most patients were very satisfied. Criticisms concerned pain control and explanations provided before the procedure.

[Patient satisfaction in gastrointestinal endoscopy: results of a multicenter study]

BACKGROUND AND AIM

The aim of this study was to determine the main quality problems perceived by patients in gastrointestinal endoscopy through a satisfaction survey.

PATIENTS AND METHODS

A total of 321 patients from five gastrointestinal endoscopy units were included. Telephone interviews using a previously validated questionnaire on several aspects related to the procedure were carried out. Pareto analyses were performed to pinpoint the most common aspects among the vital few causes at each medical center. Based on the questionnaire, the satisfaction indicators were calculated for each center: the overall satisfaction score (the sum of the responses to the eight questions) and the rate of perceived problems (number of questions with a negative response divided by the number of questions asked).

RESULTS

The most frequent aspects among the vital few were waiting time for an appointment and discomfort during the examination, since both factors were included in the vital few in four of the five medical centers. Significant differences were found among centers in the overall satisfaction score (questionnaire score) (p < 0.001) and for the rate of perceived problems (p < 0.001).

CONCLUSION

According to the patients, the most problematic aspects were waiting time until the day of the appointment and discomfort during the examination. Perceived quality differed among the participating centers.

Endoscopic biliopancreatic investigations and therapy

The management of most biliopancreatic diseases benefits from endoscopic treatment. Forty years after the first endoscopic cannulation of the ampulla of Vater, the overall effectiveness and safety of endoscopic retrograde cholangiopancreatography (ERCP) can be evaluated using the quality assurance programs that have recently been developed for gastrointestinal endoscopy, including ERCP. Such evaluation does not mean simply reporting therapeutic success and complication rates; rather, it involves a complex analysis of the entire gastrointestinal unit, of the medical practises, and of patient satisfaction. The overall quality of ERCP has been analysed and many quality deficits identified, even in referral centres. Training for such a specialised procedure is difficult and expensive. Competence in ERCP requires as many as 200 ERCP procedures. Quality assurance programs can help to improve the overall quality of endoscopic practise, including training of young endoscopists.

Patients' satisfaction: an important factor in quality control of gastroscopies

OBJECTIVE

Although oesophagogastroduodenoscopies (OGDs) are associated with few medical complications, substantial pre-procedural anxiety and discomfort during the procedure have been reported. The aims of the present study were to evaluate OGD-related discomfort assessed by the patient and to identify the possibilities for improvement.

MATERIAL AND METHODS

All outpatients undergoing OGDs at a single centre during 2004 were eligible for the study. On site, the endoscopy team completed a questionnaire on age of patients, gender and the use of sedation/anaesthesia. After the examination, the patients were given a questionnaire focusing on discomfort during and after the examination. The questionnaire was to be completed at home the following day and returned in a prepaid envelope.

RESULTS

During the study period, 1283 examinations were registered, giving 92% coverage of OGDs. The patient response rate was 80%. Patients' mean age was 55 years, and 45% were men. The sedation rate was 7.3%. None or only slight discomfort was experienced by 68% of the patients and severe discomfort by 14%. In patients, the odds ratio (OR) for experiencing moderate or severe discomfort decreased with increasing age (OR 0.96, 95% CI 0.95-0.97, p < 0.001). There were significant differences in patient discomfort depending on the level of experience of the endoscopists.

CONCLUSIONS

The majority of patients reported no or only slight discomfort during the examination, but as many as 32% did not. Increased use of sedation in selected patients is recommended. Our quality assurance program included a limited number of variables for registration, with satisfactory compliance by endoscopists and patients.

How do we ensure that trainees learn to perform biliary sphincterotomy safely, appropriately, and effectively?

Sphincterotomy is a high-risk procedure with considerable complications. Trainees should learn and understand the basics of endoscopic retrograde cholangiopancreatography and sphincterotomy to ensure good clinical outcomes. Teaching of sphincterotomy usually involves supervised hands-on clinical practice with patients. Proper positioning of the endoscope allows for correct orientation with the papilla, and performing the cut along the "ideal" biliary axis optimizes results and reduces complications. Learning and practicing sphincterotomy can be supplemented by simulator models. The Neo-Papilla model uses a modified chicken heart attached to the porcine ex vivo model and allows for cutting of actual tissue. The mechanical simulator allows trainees to practice cutting an artificial papilla marked with the "perfect" axis to understand the proper sphincterotomy technique. Understanding the indications and contraindications helps with appropriate application of sphincterotomy. Objective criteria should be available for assessing performance. Improved technique and avoiding a deviated cut may improve overall results and prevent complications.

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

OBJECTIVE

The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet).

MATERIAL AND METHODS

A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists.

RESULTS

There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies.

CONCLUSIONS

In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.

Quality assurance and gastrointestinal endoscopy: an audit of 500 colonoscopic procedures

The aim of this study was to assess the quality of colonoscopic procedures in our endoscopy unit with the goal of improving performance.

METHODS

We prospectively audited 500 consecutive colonoscopic procedures and assessed sixty-two process or outcome indicators for each procedure.

RESULTS

Most of the measured indicators were within standard limits: cecal intubation rate (92%), inadequate bowel preparations (24%), inappropriate procedures (9.7%), normal procedures (54%), yield for neoplasia (32%), morbidity (0.4%), and overall patient satisfaction (95.8%). Some indicators were outside standard limits suggesting our practices should be modified: endoscopy withdrawal time less than 6 minutes (78%), forceps removal of polyps (31%), resected polyps not recovered for pathological examination (12%), adenomas with villous elements (22%), patients unsatisfied because of time spent waiting for the procedure (19%), patients unsatisfied because of inadequate explanations (10%). There was no standard for a few indicators: patient discomfort (6.9%), diagnostic success (89%), therapeutic success (92%). Three new indicators were proposed: proportion of patients aged<50 years, number of normal colonoscopic procedures to perform to detect one advanced adenoma or cancer, and proportion of colonoscopic procedures causing discomfort. The diagnostic yield of colonoscopy was dependent on age, gender, indication and appropriateness of indication but not on the prescriber.

CONCLUSION

This audit allowed us to evaluate our endoscopic practices and to detect certain shortcomings and deviations from standards. It enabled us to change some of our practices with the goal of improving the quality of our colonoscopic procedures.