Catherine Dube

Prevention of NSAID-related upper gastrointestinal toxicity: a meta-analysis of traditional NSAIDs with gastroprotection and COX-2 inhibitors

Background: Traditional NSAIDs (tNSAIDs) and COX-2 inhibitors (COX-2s) are important agents for the treatment of a variety or arthritic conditions. The purpose of this study was to systematically review the effectiveness of misoprostol, H2-receptor antagonists (H2RAs), and proton pump inhibitors (PPIs) for the prevention of tNSAID related upper gastrointestinal (GI) toxicity, and to review the upper gastrointestinal (GI) safety of COX-2s. Methods: An extensive literature search was performed to identify randomized controlled trials (RCTs) of prophylactic agents used for the prevention of upper GI toxicity, and RCTs that assessed the GI safety of the newer COX-2s. Meta-analysis was performed in accordance with accepted techniques. Results: 39 gastroprotection and 69 COX-2 RCTs met inclusion criteria. Misoprostol, PPIs, and double doses of H2RAs are effective at reducing the risk of both endoscopic gastric and duodenal tNSAID-induced ulcers. Standard doses of H2RAs are not effective at reducing the risk of tNSAID-induced gastric ulcers, but reduce the risk of duodenal ulcers. Misoprostol is associated with greater adverse effects than the other agents, particularly at higher doses. COX-2s are associated with fewer endoscopic ulcers and clinically important ulcer complications, and have fewer treatment withdrawals due to GI symptoms than tNSAIDS. Acetylsalicylic acid appears to diminish the benefit of COX-2s over tNSAIDs. In high risk GI patients, tNSAID with a PPI or a COX-2 alone appear to offer similar GI safety, but a strategy of a COX-2 with a PPI appears to offer the greatest GI safety. Conclusion: Several strategies are available to reduce the risk of upper GI toxicity with tNSAIDs. The choice between these strategies needs to consider patients’ underlying GI and cardiovascular risk.

The endoscopy Global Rating Scale - Canada: Development and implementation of a quality improvement tool

BACKGROUND Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality highlight the need for endoscopy facilities to review the quality of the service they offer. OBJECTIVE To adapt the United Kingdom Global Rating Scale (UK-GRS) to develop a web-based and patient-centred tool to assess and improve the quality of endoscopy services provided. METHODS Based on feedback from 22 sites across Canada that completed the UK endoscopy GRS, and integrating results of the Canadian consensus on safety and quality indicators in endoscopy and other Canadian consensus reports, a working group of endoscopists experienced with the GRS developed the GRS-Canada (GRS-C). RESULTS The GRS-C mirrors the two dimensions (clinical quality and quality of the patient experience) and 12 patient-centred items of the UK-GRS, but was modified to apply to Canadian health care infrastructure, language and current practice. Each item is assessed by a yes⁄no response to eight to 12 statements that are divided into levels graded D (basic) through A (advanced). A core team consisting of a booking clerk, charge nurse and the physician responsible for the unit is recommended to complete the GRS-C twice yearly. CONCLUSION The GRS-C is intended to improve endoscopic services in Canada by providing endoscopy units with a straightforward process to review the quality of the service they provide.

Endoscopy reporting standards

OBJECTIVES The Canadian Association of Gastroenterology (CAG) recently published consensus recommendations for safety and quality indicators in digestive endoscopy. The present article focuses specifically on the identification of key elements that should be found in all electronic endoscopy reports detailing recommendations adopted by the CAG consensus group. METHODS A committee of nine individuals steered the CAG Safety and Quality Indicators in Endoscopy Consensus Group, which had a total membership of 35 voting individuals with knowledge on the subject relating to endoscopic services. A comprehensive literature search was performed with regard to the key elements that should be found in an electronic endoscopy report. A task force reviewed all published, full-text, adult and human studies in French or English. RESULTS Components to be entered into the standardized report include identification of procedure, timing, procedural personnel, patient demographics and history, indication(s) for procedure, comorbidities, type of bowel preparation, consent for the procedure, pre-endoscopic administration of medications, type and dose of sedation used, extent and completeness of examination, quality of bowel preparation, relevant findings and pertinent negatives, adverse events and resulting interventions, patient comfort, diagnoses, endoscopic interventions performed, details of pathology specimens, details of follow-up arrangements, appended pathology report(s) and, when available, management recommendations. Summary information should be provided to the patient or family. CONCLUSION Continuous quality improvement should be the responsibility of every endoscopist and endoscopy facility to ensure improved patient care. Appropriate documentation of endoscopic procedures is a critical component of such activities.

Defining Benchmarks for Adenoma Detection Rate and Adenomas Per Colonoscopy in Patients Undergoing Colonoscopy Due to a Positive Fecal Immunochemical Test

Objectives:Although there is an accepted benchmark for adenoma detection rate (ADR) in average risk screening colonoscopy, a benchmark for ADR or the associated quality indicator, adenomas per colonoscopy (APC), for colonoscopies performed for a positive fecal immunochemical test (FIT+) has not been established. The purpose of this study was to propose methods for establishing a benchmark ADR and APC for FIT+ patients.Methods:In this historical cohort study, we included 15,329 patients aged 50–74 years who underwent a colonoscopy at Alberta Health Services’ Colon Cancer Screening Centre, Calgary, Canada, from 1 January 2014 to 30 June 2015 for either investigation of a positive FIT or average risk screening. Using meta-regression, we estimated for FIT+ patients the ADR and APC that corresponded to (Method #1: minimally acceptable) an ADR of 25% in average risk individuals, (Method #2: standard of care) the average ADR or APC in all FIT+ patients, and (Method #3: aspirational) the average FIT+ ADR or APC in colonoscopies performed by endoscopists with an ADR of ≥35% in average risk patients.Results:At least one adenoma was detected in 30% of average risk patients and 58% of FIT+ patients. The calculated benchmark FIT+ ADRs for the three methods were 55, 60, and 65%, respectively. The calculated benchmarks for FIT+ APC were 1.2, 1.4, and 1.7, respectively. To account for expected random variation in individual endoscopists’ ADR or APC, we propose using the upper bound of the 95% confidence interval of an endoscopist’s ADR or APC to determine if they fall below a given benchmark.Conclusions:We have proposed methods of defining benchmarks for ADR and APC in FIT+ patients that go beyond the current “minimally acceptable” threshold currently recommended in average risk patients. These new thresholds represent results obtained by all peers and by a group of expert adenoma detectors defined in an independent patient cohort (average risk). Because the true adenoma burden in FIT+ patients could vary based on factors such as the threshold used to define a positive FIT, screening programs or endoscopy units may need to calculate their own benchmarks using local data.

Patient-identified quality indicators for colonoscopy services.

BACKGROUND Current quality improvement tools for endoscopy services, such as the Global Rating Scale (GRS), emphasize the need for patient-centred care. However, there are no studies that have investigated patient expectations and/or perceptions of quality indicators in endoscopy services. OBJECTIVES To identify quality indicators for colonoscopy services from the patient perspective; to rate indicators of importance; to determine factors that influence indicator ratings; and to compare the identified indicators with those of the GRS. METHODS A two-phase mixed methods study was undertaken in Montreal (Quebec), Calgary (Alberta) and Hamilton (Ontario) among patients ≥18 years of age who spoke and read English or French. In phase 1, focus group participants identified quality indicators that were then used to construct a survey questionnaire. In phase 2, survey questionnaires, which were completed immediately after colonoscopy, prompted respondents to rate the 20 focus group-derived indicators according to their level of importance (low, medium, high) and to list up to nine additional items. Multiple logistic regression analysis was used to determine the factors that influenced focus group-derived indicator ratings. Patient-identified indicators were compared with those used in the GRS to identify novel indicators. RESULTS Three quality indicator themes were identified by 66 participants in 12 focus groups: communication, comfort and service environment. Of the 828 surveys distributed, 402 (48.6%) were returned and 65% of focus group-derived indicators were rated highly important by at least 55% of survey respondents. Indicator ratings differed according to age, sex, site and perceived colorectal cancer risk. Of the 29 patient-identified indicators, 17 (58.6%) were novel. CONCLUSIONS Patients identified 17 novel quality indicators, suggesting that patients and health professionals differ in their perspectives with respect to quality in colonoscopy services.

The Canadian Association of Gastroenterology Endoscopy Quality Initiative: Leading the Wave

The Canadian Association of Gastroenterology’s (CAG) Endoscopy Quality Initiative (EQI) was developed in 2007 to promote quality assurance and quality improvement, and to facilitate these activities in becoming standard of care for endoscopy services in Canada. To achieve these goals, the Steering Committee of the EQI has established a quality assurance program based on two essential tools: the Global Rating Scale (GRS) and the EQI practice audit. The GRS is a scale designed for periodic, repeated use within the endoscopy unit to provide an assessment of the quality of endoscopy services and to guide quality improvement efforts. Its key construct of quality is that of a patient-centred service. Use of the GRS is supported by a dedicated Internet site for data entry, tracking of progress, action planning and access to a large electronic library of resources and case studies. Since its creation in 2004 by Dr Roland Valori and colleagues, the GRS has enjoyed rapid uptake and success in the United Kingdom (UK); this was paralleled by dramatic wait time reductions within the National Health Service. EQI participants are expected to complete the GRS biannually and to perform activities that will improve their GRS rating over time. To support participation in Canada, the CAG, with the help of the UK’s GRS leadership, has developed the Canadian GRS Web site. In addition, in May 2008, CAG sponsored a series of workshops at several Canadian centres led by Debbie Johnston, a member of the UK’s National Endoscopy Committee and co-author of the GRS. A pilot practice audit on colonoscopy was completed in 2007, with findings reported at the Canadian Digestive Diseases Week (CDDW) 2008 meeting (1). This pilot audit formed the basis for the current EQI colonoscopy practice audit, the preliminary results from which were presented at CDDW 2009 (Figure 1) (2–4). As of May 2009, more than 60 endoscopists from 21 sites across the country have provided data on 1260 colonoscopies. Figure 1 Screening (A) and surveillance (B) intervals from 822 colonoscopies recorded in the Endoscopy Quality Initiative practice audit. Data adapted from reference 4 This database, collected in real-time on smartphones, provides a comprehensive profile of the patient encounter including demographics, indication for the procedure, quality of the procedure, findings and any complications. The reporting site allows individual endoscopists to review their own data and compare with national data; individuals will also have the ability to longitudinally track improvements. Members of the EQI Steering Committee attended the American Society for Gastrointestinal Endoscopy (ASGE) ‘Improving Quality and Safety in Your Endoscopy Unit’ Course, which is part of the ASGE Endoscopy Recognition Program, in October 2008, and future collaboration with the ASGE and World Organization of Digestive Endoscopy quality programs are in the planning stages. Funding is a major hurdle for a national quality initiative. The CAG EQI has recently received support from The Canadian Partnership Against Cancer. Since most provinces are now planning or implementing a colorectal cancer screening program, it is anticipated that initiatives such as the EQI, together with screening programs, will have a synergistic effect on the quality of endoscopy services and the adoption of quality assurance activities. The EQI was introduced at the gastroenterology fellow endoscopy course at McMaster University (Hamilton, Ontario) in July 2008, and was well received by the next generation of endoscopists. It is abundantly clear that nationally and around the world, endoscopy stakeholders are catching the quality wave. A national consensus meeting on quality and safety indicators for endoscopy in Canada is planned for 2010. Previously, in this article we outlined the aims of the EQI: Demonstrate a mechanism for continuous quality improvement in endoscopy. The Canadian GRS Web site is up and running. More than 60 endoscopists from 21 centres have contributed data on 1260 colonoscopies. Demonstrate that gastroenterologists provide quality care. Following CDDW 2009, the University of Calgary (Calgary, Alberta) hosted a ‘Train-the-Colonoscopy-Trainers’ course led by Drs Roland Valori and John Anderson from the UK. Gastroenterologists from Alberta, Quebec and Ontario participated in this intensive two-day course assessing endoscopy, training, communication and evaluation skills. Allow gastroenterologists a ‘quality endorsement’. The EQI has proposed a quality ‘brand’ of recognition to units committed to participation in the EQI. Communication among endoscopists, endoscopic nurses and administrators. The EQI/GRS provides the template for collaboration and communication within and between units. A monthly EQI newsletter has helped participants with first steps and stumbles in the process. The CAG, with support from the Canadian Association of General Surgeons, is also extending the EQI program to general surgeons practicing endoscopy. Demonstrate improvements in outcome measures. The groundwork has been laid for a national strategy on outcome measures. Much has been achieved in the past few years and there has been a groundswell of interest in quality endoscopy from all quarters. However, there is much still to be accomplished. The national consensus meeting on safety and quality indicators, formally recognizing units committed to quality in endoscopy, measuring patient satisfaction and improving outcomes, introducing quality assurance measures to trainees and developing ‘Train-the-Colonoscopy-Trainer’ programs for gastroenterologists across the country are all on the next wave. Check out the EQI on the CAG Web site and catch the wave at .

Colorectal Cancer Screening in Average Risk Populations: Evidence Summary

Introduction. The objectives of this systematic review were to evaluate the evidence for different CRC screening tests and to determine the most appropriate ages of initiation and cessation for CRC screening and the most appropriate screening intervals for selected CRC screening tests in people at average risk for CRC. Methods. Electronic databases were searched for studies that addressed the research objectives. Meta-analyses were conducted with clinically homogenous trials. A working group reviewed the evidence to develop conclusions. Results. Thirty RCTs and 29 observational studies were included. Flexible sigmoidoscopy (FS) prevented CRC and led to the largest reduction in CRC mortality with a smaller but significant reduction in CRC mortality with the use of guaiac fecal occult blood tests (gFOBTs). There was insufficient or low quality evidence to support the use of other screening tests, including colonoscopy, as well as changing the ages of initiation and cessation for CRC screening with gFOBTs in Ontario. Either annual or biennial screening using gFOBT reduces CRC-related mortality. Conclusion. The evidentiary base supports the use of FS or FOBT (either annual or biennial) to screen patients at average risk for CRC. This work will guide the development of the provincial CRC screening program.

Monitoring postcolonoscopy colorectal cancers: dangerous crossroads?

Quality indicators for colonoscopy should be designed to render the outcomes of healthcare services measurable and transparent for both patients and physicians. For example, as the goal of colonoscopy is to prevent and detect colorectal cancer (CRC), improved quality should minimise the postcolonoscopy colorectal cancer (PCCRC) rate. In fact, most other indicators of procedural quality, such as adenoma detection rate and caecal intubation rate, owe their validation to a correlation with PCCRC rate. In an ideal world, rigorous monitoring of PCCRC rates can be used for benchmarking at multiple levels (regional, national, international) and would be a key driver of colonoscopy quality improvement within and outside screening programmes. It is therefore crucial to use a common language and common methodology when measuring, monitoring and reporting PCCRC. The process of benchmarking is neither quick nor simple. It starts with the implementation of a uniform terminology for a PCCRC. The term ‘PCCRC’ refers to colonoscopy in general, performed for screening, surveillance or symptoms, whereas the term ‘interval CRC’ refers to screening and colonoscopy surveillance, when a follow-up time interval is specified (intention-to-screen).1 The next key issue is what and how to monitor for calculating PCCRC rates. Several caveats should be recalled, foremost of which are the lack of complete clinical information, hurdles in crosslinking a cancer registry to colonoscopy databases and ambiguity on how to calculate rates. Such factors hinder meaningful interpretation of PCCRC rates and defining of quality standards, as shown by Morris et …

Temporal trends in postcolonoscopy colorectal cancer rates in 50- to 74-year-old persons: a population-based study

BACKGROUND AND AIMS Colorectal cancers (CRCs) diagnosed between 6 and 36 months after colonoscopy, termed postcolonoscopy CRCs (PCCRCs), arise primarily due to missed or inadequately treated neoplasms during colonoscopy. Introduction of multiple quality indicators and technological advances to colonoscopy practice should have reduced the PCCRC rate over time. We assessed temporal trends in the population rate of PCCRC as a measure of changing colonoscopy quality. METHODS We conducted a population-based retrospective cohort study of persons aged 50 to 74 years without advanced risk factors for CRC who underwent complete colonoscopy in Ontario, Canada between 1996 and 2010. We defined the PCCRC rate as the proportion of individuals diagnosed with CRC within 36 months of colonoscopy that had PCCRC. We compared age-adjusted and sex-adjusted rates of PCCRC over time based on 3 periods (1996-2001, 2001-2006 and 2006-2010) and assessed the independent association between time period and PCCRC risk through multivariable regression, with respect to all PCCRCs, proximal PCCRC and distal PCCRC. RESULTS There was a marked increase in colonoscopy volumes over the study period, particularly in younger age groups and non-hospital settings. Among 1,093,658 eligible persons the PCCRC rate remained stable at approximately 8% over the 15-year study period. The adjusted odds of PCCRC, distal PCCRC and proximal PCCRC, comparing the 2006 to 2010 period with the 1996 to 2001 period, were 1.14 (95% confidence interval [CI], 1.0-1.31), 1.11 (95% CI, 0.91-1.34), and 1.14 (95% CI, 0.94-1.38), respectively. Temporal trends in PCCRC risk did not differ by endoscopist specialty or institutional setting after covariate adjustment. CONCLUSION The PCCRC rate in Ontario has remained consistently high over time. Widespread initiatives are needed to improve colonoscopy quality.

Split-Dose Polyethylene Glycol Is Superior to Single Dose for Colonoscopy Preparation: Results of a Randomized Controlled Trial.

Background. The efficacy of colonoscopy in detecting abnormalities within the colon is highly dependent on the adequacy of the bowel preparation. The objective of this study was to compare the efficacy, safety, and tolerability of PEG lavage and split-dose PEG lavage with specific emphasis on the cleanliness of the right colon. Methods. The study was a prospective, randomized, two-arm, controlled trial of 237 patients. Patients between the age of 50 and 75 years were referred to an outpatient university screening clinic for colonoscopy. Patients were allocated to receive either a single 4 L PEG lavage or a split-dose PEG lavage. Results. Overall, the bowel preparation was superior in the split-dose group compared with the single-dose group (mean Ottawa score 3.50 ± 2.89 versus 5.96 ± 3.53; P < 0.05) and resulted in less overall fluid in the colon. This effect was observed across all segments of the colon assessed. Conclusions. The current study supports use of a split-dose PEG lavage over a single large volume lavage for superior bowel cleanliness, which may improve polyp detection. This trial is registered with ClinicalTrials.gov identifier NCT01610856.