Effective reporting of key performance indicators is essential for balancing the benefits and drawbacks of colonoscopyReferring to Holme et al. p. 871–877 and Derbyshire et al. p. 861–870
29 August 2018 (online)
Colonoscopy is the reference standard for the detection and prevention of colorectal cancer (CRC). However, it is associated with the development of post-colonoscopy CRCs, which predominantly result from colonoscopy-related factors, such as missed lesions or incomplete polypectomies . Another drawback of colonoscopy is its invasive nature, which is associated with patient discomfort and complication risks . For an optimal balance between the benefits and drawbacks of colonoscopy, it is important that these procedures are of high quality.
“As more and more evidence on performance indicators becomes available, it is of utmost importance to critically assess the added value of each newly proposed indicator above the current indicator set.”
Colonoscopy quality can be measured by key performance indicators, which are preferably evidence-based measures that have an impact on clinical outcomes or quality of life . Several key performance indicators are available, most of which are quantitative and could be calculated from data readily available in endoscopy reports. However, this requires systematic and uniform data registration, ideally directly within the endoscopy reporting system. This would avoid double data entry, which might result in mistakes and imposes a barrier to routine monitoring of colonoscopy quality  . Thus, structured data entry of colonoscopy in daily practice should be facilitated, and solutions to simplify data entry, for instance by developing voice-recognition software, should be further explored and endorsed.
Two landmark publications demonstrated an inverse correlation between adenoma detection rate (ADR) and the occurrence of post-colonoscopy CRC and CRC-related mortality; thus, ADR is regarded as a robust performance indicator for colonoscopy  . However, a limitation of this key performance indicator is that per-polyp histopathology results are necessary for accurate reporting. Therefore, ADR is a somewhat more complicated performance indicator for routine monitoring . Direct coupling of the endoscopy reporting database and histopathology database would be an ideal solution to facilitate easy and quick ADR reporting, and is therefore an urgent asset for routine endoscopy reporting systems .
Other important parameters for colonoscopy quality are the so-called patient-reported outcome measures. During colonoscopy, patients should experience as little discomfort as possible. Sedation practice might influence patient comfort during colonoscopy; a previous study showed that patient comfort was directly related to the depth of sedation . However, more recent evidence showed an inverse association: unsedated patients were the least likely to have significant discomfort, whereas patients receiving a combination of sedatives and opiates experienced the most significant discomfort . This inverse correlation could be caused by anxiety and/or previous negative experiences with colonoscopy, as patients who previously experienced discomfort during colonoscopy might be offered more sedation than patients anticipating minor discomfort, who might opt for little or no sedation .
In this issue of Endoscopy, Holme et al. describe the impact of endoscopy assistants on key performance indicators of colonoscopy quality . Assistants have an important role in preparing the patient for colonoscopy, supporting the patient during the procedure, and detecting pathology while watching the screen with the endoscopist. This exploratory study was based on a large Norwegian prospective colonoscopy database for outpatient colonoscopies. Interestingly, after adjusting for patient demographics, endoscopist, cecal intubation, and bowel preparation, large differences in the use of sedation were found between endoscopy assistants. There were smaller differences in severe pain reported by patients . The authors conclude that endoscopy assistants might be able to effectively select patients who may benefit from sedation during colonoscopy .
In the study by Holme et al., patient comfort levels were adjusted for age, sex, and previous history of abdominal surgery. Besides patient-related factors, the skills of the endoscopist are relevant to patient comfort levels, as endoscopists performing better on key performance indicators are the ones causing less patient discomfort with less sedation . Another topic of debate is the method for measuring patient comfort. Notable discrepancies between patient-reported and clinician-reported patient comfort during colonoscopy have led to the development of nurse-reported comfort scales, such as the adjusted Gloucester Comfort Scale . To date, however, no validated patient-derived measurements of patient comfort are available. Besides, the most relevant and reliable time point for measurement is also unknown. Further research focusing on this important topic is eagerly awaited and will hopefully facilitate further improvements in patient-reported outcome measures.
Per- and post-procedural bleeding and perforation are among the most frequently reported and serious colonoscopy-related complications. The study by Derbyshire et al., also published in this issue of Endoscopy, describes the clinical presentation of patients with per- and post-colonoscopy perforation, and its subsequent management and outcomes . Data were derived from the English Bowel Cancer Screening Programme, resulting in the largest European retrospective observational case series of 263 129 colonoscopies. These data showed a perforation rate of 0.06 %, and confirm that perforations frequently result in surgical interventions, stoma formation and post-perforation morbidity. Only 12.8 % of the perforations were visualized by the endoscopist during colonoscopy. Of these, 83.3 % were successfully managed conservatively, thereby avoiding important surgery-related morbidity in these patients.
This study demonstrates that endoscopic recognition of perforations is important but imperfect, and should therefore be improved in clinical practice. To monitor and improve the current knowledge of colonoscopy safety, all endoscopy-related complications should be uniformly and completely registered in regional or national complication registries. Coverage of patients with colonoscopy-related complications presenting at endoscopy centers other than the center in which the initial colonoscopy was performed should also be secured. Ideally, this should be accomplished by automatic linkage to endoscopy reporting systems, thus avoiding double data entry but also assuring complete registration, including subsequent management and outcomes of complications.
In conclusion, performing high-quality colonoscopies as well as facilitating effective reporting of colonoscopy quality and adverse events are essential to balance the benefits, limitations, and risks of colonoscopy. However, it is essential that registration and monitoring of the key performance indicators remains practical and feasible for endoscopists. As more and more evidence on performance indicators becomes available, it is of utmost importance to critically assess the added value of each newly proposed indicator above the current indicator set. Moreover, its use and practical implementation should be endorsed by national and international endoscopy societies, resulting in the use of minimal and regularly updated datasets of key performance indicators that require minimal administrative work for endoscopists.
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