Vincent de Jonge

Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice

BACKGROUND Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting. OBJECTIVE This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance. DESIGN Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department. SETTING Daily clinical practice in 12 Dutch endoscopy departments. PATIENTS Consecutive patients undergoing scheduled colonoscopy procedures. MAIN OUTCOME MEASUREMENTS Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR). RESULTS A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurse-endoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%). LIMITATIONS Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist. CONCLUSION Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved.

Quality assurance of endoscopy in colorectal cancer screening

This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership.

Features of Adenoma and Colonoscopy Associated With Recurrent Colorectal Neoplasia Based on a Large Community-Based Study

BACKGROUND & AIMS We investigated adenoma and colonoscopy characteristics that are associated with recurrent colorectal neoplasia based on data from community-based surveillance practice. METHODS We analyzed data of 2990 consecutive patients (55% male; mean age 61 years) newly diagnosed with adenomas from 1988 to 2002 at 10 hospitals throughout The Netherlands. Medical records were reviewed until December 1, 2008. We excluded patients with hereditary colorectal cancer (CRC) syndromes, a history of CRC, inflammatory bowel disease, or without surveillance data. We analyzed associations among adenoma number, size, grade of dysplasia, villous histology, and location with recurrence of advanced adenoma (AA) and nonadvanced adenoma (NAA). We performed a multivariable multinomial logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS During the surveillance period, 203 (7%) patients were diagnosed with AA and 954 (32%) patients with NAA. The remaining 1833 (61%) patients had no adenomas during a median follow-up of 48 months. Factors associated with AA during the surveillance period included baseline number of adenomas (ORs ranging from 1.6 for 2 adenomas; 95% CI: 1.1-2.4 to 3.3 for ≥5 adenomas; 95% CI: 1.7-6.6), adenoma size ≥10 mm (OR = 1.7; 95% CI: 1.2-2.3), villous histology (OR = 2.0; 95% CI: 1.2-3.2), proximal location (OR = 1.6; 95% CI: 1.2-2.3), insufficient bowel preparation (OR = 3.4; 95% CI: 1.6-7.4), and only distal colonoscopy reach (OR = 3.2; 95% CI: 1.2-8.5). Adenoma number had the greatest association with NAA. High-grade dysplasia was not associated with AA or NAA. CONCLUSIONS Large size and number, villous histology, proximal location of adenomas, insufficient bowel preparation, and poor colonoscopy reach were associated with detection of AA during surveillance based on data from community-based practice. These characteristics should be used jointly to develop surveillance policies for adenoma patients.

A prospective audit of patient experiences in colonoscopy using the Global Rating Scale: A cohort of 1187 patients

BACKGROUND The Global Rating Scale (GRS) comprehensively evaluates the quality of an endoscopy department, providing a patient-centred framework for service improvement. OBJECTIVE To assess patient experiences during colonoscopy and identify areas that need service improvement using the GRS. METHODS Consecutive outpatients undergoing colonoscopy were asked to complete a pre- and postprocedure questionnaire. Questions were based on GRS items and a literature review. The preprocedure questionnaire addressed items such as patient characteristics and information provision. The postprocedure questionnaire contained questions regarding comfort, sedation, the attitude of endoscopy staff and aftercare. RESULTS The preprocedure questionnaire was completed by 1,187 patients, whereas the postprocedure part of the questionnaire was completed by 851 patients (71.9%). Fifty-four per cent of patients were first seen in the outpatient clinic. The indication for colonoscopy was explained to 85% of the patients. Sixty-five per cent of the patients stated that information about the risks of colonoscopy was provided. Sedation was used in 94% of the patients; however, 23% judged the colonoscopy to be more uncomfortable than expected. Ten per cent of patients rated the colonoscopy as (very) uncomfortable. Preliminary results of the colonoscopy were discussed with 87% of patients after the procedure. Twenty-one per cent of the patients left the hospital without knowing how to obtain their final results. Being comfortable while waiting for the procedure (OR 9.93) and a less uncomfortable procedure than expected (OR 2.99) were important determinants of the willingness to return for colonoscopy. CONCLUSIONS The present study provided evidence supporting the GRS in identifying service gaps in the quality of patient experiences for colonoscopy in a North American setting. Assessing experiences is useful in identifying areas that need improvement such as the provision of pre- and postprocedure information.

The Appropriateness of Surveillance Colonoscopy Intervals after Polypectomy

BACKGROUND Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload. OBJECTIVE To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC. METHODS Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval. RESULTS A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared. CONCLUSION Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.

The Incidence of 30-Day Adverse Events After Colonoscopy Among Outpatients in the Netherlands

OBJECTIVES:Colonoscopy is the gold standard for visualization of the colon. It is generally accepted as a safe procedure and major adverse events occur at a low rate. However, few data are available on structured assessment of (minor) post-procedural adverse events.METHODS:Consecutive outpatients undergoing colonoscopy were asked for permission to be called 30 days after their procedure. A standard telephone interview was developed to assess the occurrence of (i) major adverse events (hospital visit required), (ii) minor adverse events, and (iii) days missed from work. Adverse events were further categorized in definite-, possible-, and unrelated adverse events. Patients were contacted between January 2010 and September 2010.RESULTS:Out of a total of 1,528 patients who underwent colonoscopy and gave permission for a telephone call, 1,144 patients were contacted (response: 75%), 49% were male, the mean age was 59 years (s.d.: 14). Thirty-four patients (3%) reported major adverse events. These were definite-related in nine (1%) patients, possible-related in 6 (1%), and unrelated in 19 patients (2%). Minor adverse events were reported by 466 patients (41%). These were definite-related in 336 patients (29%), possible-related in 36 (3%), and unrelated in the remaining 94 patients (8%). Female gender (odds ratio (OR): 1.5), age <50 years (OR: 1.5), colonoscopy for colorectal cancer screening/surveillance (OR: 1.6), and fellow-endoscopy (OR: 1.7) were risk factors for the occurrence of any definite-related adverse event. Patients who reported definite-related adverse events were significantly less often willing to return for colonoscopy (81 vs. 88%, P<0.01) and were less often positive about the entire colonoscopy experience (84 vs. 89%, P=0.04).CONCLUSIONS:Structured assessment of post-colonoscopy adverse events shows that these are more common than generally reported. Close to one-third of patients report definite-related adverse events, which are major in close to 1 in 100 patients. The occurrence of adverse events does have an impact on the willingness to return for colonoscopy.

Awareness of Postpolypectomy Surveillance Guidelines: A Nationwide Survey of Colonoscopists in Canada

INTRODUCTION Due to the increasing demand for colonoscopy, adherence to postpolypectomy surveillance guidelines is important. Suboptimal compliance can lead to unnecessary risks and ineffective use of resources. OBJECTIVE To determine the awareness of and adherence to postpolypectomy surveillance guidelines among members of the Canadian Association of Gastroenterology (CAG). METHODS A survey describing 14 clinical cases was mailed to all physician members (n=411) of the CAG. Respondents were required to recommend a surveillance interval and a reason for his or her choice. RESULTS A total of 150 colonoscopists (37%) completed the survey. Adherence to the guidelines varied from 23% to 96% per clinical scenario (median 63%). Recommended surveillance intervals were too short in 0% to 60% of the different cases (median 8%). The recommended interval was most often (60%) too short for a patient with one tubular adenoma with high-grade dysplasia. Surveillance intervals were too long in 4% to 75% of the cases (median 9%). The recommended interval was most often too long in a patient with a villous adenoma 15 mm in size and removed piecemeal (75%). Most often, recommendations were reported to be based on guidelines (median 74%; range 31% to 94%). However, in nine of 14 cases, more than 10% (median 18%; range 12% to 38%) of the respondents stated that their recommendation was based on guidelines, but did not provide the appropriate surveillance interval. CONCLUSIONS Compliance to colonoscopy surveillance guidelines is suboptimal and reflects both overuse and underuse. The results show that awareness about the content of guidelines needs to be raised and strategies implemented to increase adherence.

Overview of the quality assurance movement in health care

This chapter aims to describe the origin and current status of quality assurance (QA) in health care and to provide a background of similar developments in other industries, which have provided a major impetus for QA initiatives in health care. The interest in quality and safety in the health care sector has rapidly risen over the past decade. Without important lessons learnt from other industries, the interest and obtained improvements would have been far less fast. Knowledge on basic principles and challenges faced by other industries like the airline, car, and nuclear energy industry, that drove quality improvement projects, is of major relevance to understand the evolutions taking place in health care. To fully appreciate the QA movement, and design or implement quality improvement projects, its basic principles need to be understood. This chapter aims to give insights in basic principles underlying QA, and to discuss historical lessons that have been learnt from other industries. Furthermore, it discusses how to implement and assure a sustainable QA program.

Opinion of gastroenterologists towards quality assurance in endoscopy

BACKGROUND Quality assurance has become an important issue. Many societies are adopting quality assurance programs in order to monitor and improve quality of care. AIM To assess the opinion of gastroenterologists towards quality assurance on the endoscopy department. METHODS A survey was sent to all gastroenterologists (n=319) in the Netherlands. It assessed their opinion on a quality assurance program for endoscopy units, including its design, logistics, and content. RESULTS 200 gastroenterologists (63%) completed the questionnaire. 95% had a positive opinion towards quality assurance and 67% supposed an increase in quality. 28% assumed a negative impact on the time available for patient contact by introducing a quality assurance program and 35% that the capacity would decrease. A negative attitude towards disclosure of results to insurance companies (23%) and media (53%) was reported. Female gastroenterologists were less positive to share the results with other stakeholders (p<0.05). Most important quality measurements were assessment of complications (97%), standardised reporting (96%), and adequate patient information (95%). CONCLUSION Gastroenterologists have a positive attitude towards quality assurance. However, concerns do exist about time investment and disclosure of results to others. Information provision and procedure characteristics were considered the most important aspects of quality assurance.

Risk Factors for Metachronous Advanced Colorectal Neoplasia in a Cohort of Adenoma Patients: Advanced Morphology and Multiplicity

Background Surveillance of adenoma patients aims to prevent colorectal cancer (CRC) by removing recurrent adenomas. Adenoma removal and subsequent surveillance can reduce CRC incidence by 76-90%. Colonoscopy is however scarce, expensive and potentially harmful. To ensure efficient use of resources, surveillance colonoscopy should be targeted at patients who will benefit most from the procedure. Current surveillance guidelines use advanced morphology or multiplicity as criteria for surveillance interval. However, none of the guidelines have separate recommendations for patients with both multiple and advanced adenomas.AimTo assess the relative risks of advanced andmultiple (≥3) adenomas separately and combined on metachronous advanced colorectal neoplasia in a representative cohort of adenoma patients. Methods We collected prospective data on adenoma patients from 10 hospitals throughout the Netherlands, using a nationwide histopathology registry to select newly diagnosed adenoma patients from 1988 to 2002. Patients with CRC history or CRC at index colonoscopy, hereditary cancer syndromes or IBD were excluded. Electronic medical records were reviewed until December 1, 2008 for follow-up. Index colonoscopy was defined as colonoscopy with first adenoma diagnosis. Presence of advanced (≥10 mm, a villous histology or high-grade dysplasia) or multiple (≥3) adenomas and the combination at index colonoscopy were considered as potential risk factors for metachronous advanced colorectal neoplasia (advanced adenoma or CRC) at first follow-up endoscopy. To assess hazard ratios (HR) for the relative risk we performed a Cox-regression analysis, adjusted for age and gender. Results 3,041 adenoma patients (55% male, mean age 61 yrs (range 40 88)) were analyzed, of whom 1,351 (44%) patients had advanced adenomas at index endoscopy, and 161 (6%) ≥3 non-advanced adenomas. Median interval (interquartile range) to first surveillance endoscopy was 21 months (12-39); 15 months (11-35) for patients with advanced and/or ≥3 adenomas, and 27 months (13-45) for patients with 1-2 non-advanced adenomas at index endoscopy (p<0.01). At follow-up, 831 patients had any colorectal neoplasia (adenoma or CRC), of whom 182 patients had advanced colorectal neoplasia, including 26 CRC cases. Relative risks for metachronous advanced colorectal neoplasia are given in Table 1. Conclusion Advanced adenomas and ≥3 adenomas at index colonoscopy are equally important risk factors for metachronous advanced colorectal neoplasia, resulting in a 3-fold increased risk of developing advanced colorectal neoplasia during follow-up. However, having both risk factors results in a 6-fold increased risk. The results suggest that advanced morphology and multiplicity should be used to tailor surveillance guidelines with a separate recommendation for adenoma patients that have both these risk factors. Table 1. Relative risk of advanced and multiple (≥3) adenomas on metachronous advanced colorectal neoplasia