Roger Hollingworth

Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults - Update 2004

BACKGROUND Gastroesophageal reflux disease (GERD) is the most prevalent acid-related disorder in Canada and is associated with significant impairment of health-related quality of life. Since the last Canadian Consensus Conference in 1996, GERD management has evolved substantially. OBJECTIVE To develop up-to-date evidence-based recommendations relevant to the needs of Canadian health care providers for the management of the esophageal manifestations of GERD. CONSENSUS PROCESS A multidisciplinary group of 23 voting participants developed recommendation statements using a Delphi approach; after presentation of relevant data at the meeting, the quality of the evidence, strength of recommendation and level of consensus were graded by participants according to accepted principles. OUTCOMES GERD applies to individuals who reflux gastric contents into the esophagus causing symptoms sufficient to reduce quality of life, injury or both; endoscopy-negative reflux disease applies to individuals who have GERD and a normal endoscopy. Uninvestigated heartburn-dominant dyspepsia - characterised by heartburn or acid regurgitation - includes erosive esophagitis or endoscopy-negative reflux disease, and may be treated empirically as GERD without further investigation provided there are no alarm features. Lifestyle modifications are ineffective for frequent or severe GERD symptoms; over-the-counter antacids or histamine H2-receptor antagonists are effective for some patients with mild or infrequent GERD symptoms. Proton pump inhibitors are more effective for healing and symptom relief than histamine H2-receptor antagonists; their efficacy is proportional to their ability to reduce intragastric acidity. Response to initial therapy - a once-daily proton pump inhibitor unless symptoms are mild and infrequent (fewer than three times per week) - should be assessed at four to eight weeks. Maintenance medical therapy should be at the lowest dose and frequency necessary to maintain symptom relief; antireflux surgery is an alternative for a small proportion of selected patients. Routine testing for Helicobacter pylori infection is unnecessary before starting GERD therapy. GERD is associated with Barretts epithelium and esophageal adenocarcinoma but the risk of malignancy is very low. Endoscopic screening for Barretts epithelium may be considered in adults with GERD symptoms for more than 10 years; Barretts epithelium and low-grade dysplasia generally warrant surveillance; endoscopic or surgical management should be considered for confirmed high-grade dysplasia or malignancy. CONCLUSION Prospective studies are needed to investigate clinically relevant risk factors for the development of GERD and its complications; GERD progression, on and off therapy; optimal management strategies for typical GERD symptoms in primary care patients; and optimal management strategies for atypical GERD symptoms, Barretts epithelium and esophageal adenocarcinoma.

Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy

BACKGROUND Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy. OBJECTIVE To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery. METHODS A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants. RESULTS Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), quality assurance (statements 10 to 13: 94% to 100%), training, education, competency and privileges (statements 14 to 19: 97% to 100%), endoscopy reporting standards (statements 20 and 21: 97% to 100%) and patient perceptions (statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified. DISCUSSION The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services. CONCLUSIONS The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.

Access to specialist gastroenterology care in Canada : The Practice Audit in Gastroenterology (PAGE) Wait Times Program

BACKGROUND Canadian wait time data are available for the treatment of cancer and heart disease, as well as for joint replacement, cataract surgery and diagnostic imaging procedures. Wait times for gastroenterology consultation and procedures have not been studied, although digestive diseases pose a greater economic burden in Canada than cancer or heart disease. METHODS Specialist physicians completed the practice audit if they provided digestive health care, accepted new patients and recorded referral dates. For patients seen for consultation or investigation over a one-week period, preprogrammed personal digital assistants were used to collect data including the main reason for referral, initial referral and consultation dates, procedure dates (if performed), personal and family history, and patient symptoms, signs and test results. Patient triaging, appropriateness of the referral and timeliness of care were noted. RESULTS Over 10 months, 199 physicians recorded details of 5559 referrals, including 1903 visits for procedures. The distribution of total wait times (from referral to procedure) nationally was highly skewed at 91/203 days (median/75th percentile), with substantial interprovincial variation: British Columbia, 66/185 days; Alberta, 134/284 days; Ontario, 110/208 days; Quebec, 71/149 days; New Brunswick, 104/234 days; and Nova Scotia, 42/84 days. The percentage of physicians by province offering average-risk screening colonoscopy varied from 29% to 100%. DISCUSSION Access to specialist gastroenterology care in Canada is limited by long wait times, which exceed clinically reasonable waits for specialist treatment. Although exhibiting some methodological limitations, this large practice audit sampling offers broadly generalized results, as well as a means to identify barriers to health care delivery and evaluate strategies to address these barriers, with the goals of expediting appropriate care for patients with digestive health disorders and ameliorating the personal and societal burdens imposed by digestive diseases.

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.

Indicators of safety compromise in gastrointestinal endoscopy

INTRODUCTION The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs. OBJECTIVE To identify key indicators of safety compromise in gastrointestinal endoscopy. METHODS The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance. RESULTS A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related - the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm⁄bronchospasm; procedure-related early - perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed - death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications. CONCLUSIONS The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.

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 .

Endoscopy and quality assurance -- It is here!

Over the past year, the Canadian Association of Gastroenterology (CAG) has been exploring ways to measure and address quality aspects of practice. At the 2006 Canadian Digestive Diseases Week, excellent presentations on endoscopy and quality assurance were given by McKenna Memorial Lecturer, Dr Peter Cotton, and in the symposium “Improving Effectiveness and Efficiency of Endoscopy”, in which Dr Roland Valori and Dr John Anderson reviewed the many quality-related activities underway in the United Kingdom (UK). In November 2006, the CAG Regional Representation Committee discussed and agreed unanimously that the CAG should champion a quality assurance program in Canada. In response, the CAG Board appointed representatives from the Endoscopy and Practice Affairs Committees to initiate such a program. Quality in endoscopy remained a focus at the 2007 CDDW and the 3rd Annual CASL Winter Meeting, with an evening event being held on this topic.

M1018 Quality Indicators for Colonoscopy in Canada: the Canadian Association of Gastroenterology (cag) Endoscopy Quality Initiative (EQI) Practice Audit Project

Gastroenterology (CAG) Endoscopy Quality Initiative (EQI) Practice Audit Project David Armstrong,1 Roger Hollingworth,2 Donald MacIntosh,3 Joanne Cabrera,4 Ying Chen,1 Sandra Daniels,5 Stuart Gittens,6 Ron Bridges,4 Paul Sinclair,5 Catherine Dubé4 1McMaster University, Hamilton, 2Credit Valley Hospital, Mississauga, 3Dalhousie University, Halifax, 4University of Calgary, 5Canadian Association of Gastroenterology, Oakville, 6ECD Solutions, Atlanta