Endoscopy 2022; 54(05): 455-462
DOI: 10.1055/a-1637-9651
Original article

Case-mix adjustment to compare colonoscopy performance between endoscopy centers: a nationwide registry study

Karlijn J. Nass
1   Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
2   Dutch Institute for Clinical Auditing, Leiden, The Netherlands
,
Manon van der Vlugt
1   Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
,
Arthur K. E. Elfrink
2   Dutch Institute for Clinical Auditing, Leiden, The Netherlands
,
Crispijn L. van den Brand
2   Dutch Institute for Clinical Auditing, Leiden, The Netherlands
,
Janneke A. Wilschut
2   Dutch Institute for Clinical Auditing, Leiden, The Netherlands
,
Paul Fockens
1   Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
,
Evelien Dekker
1   Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
,
Michel W. J. M. Wouters
2   Dutch Institute for Clinical Auditing, Leiden, The Netherlands
3   Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
4   Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
,
in collaboration with the Dutch Gastrointestinal Endoscopy Audit group › Author Affiliations

Abstract

Background Nonmodifiable patient and endoscopy characteristics might influence colonoscopy performance. Differences in these so-called case-mix factors are likely to exist between endoscopy centers. This study aimed to examine the importance of case-mix adjustment when comparing performance between endoscopy centers.

Methods Prospectively collected data recorded in the Dutch national colonoscopy registry between 2016 and 2019 were retrospectively analyzed. Cecal intubation rate (CIR) and adequate bowel preparation rate (ABPR) were analyzed. Additionally, polyp detection rate (PDR) was studied in screening colonoscopies following a positive fecal immunochemical test (FIT). Variation in case-mix factors between endoscopy centers and expected outcomes for each performance measure were calculated per endoscopy center based on case-mix factors (sex, age, American Society of Anesthesiologist [ASA] score, indication) using multivariable logistic regression.

Results 363 840 colonoscopies were included from 51 endoscopy centers. Mean percentages per endoscopy center were significantly different for age > 65 years, male patients, ASA ≥ III, and diagnostic colonoscopies (all P < 0.001). In the FIT-positive screening population, significant differences were observed between endoscopy centers for age > 65 years, male patients, and ASA ≥ III (all P ≤ 0.001). The expected CIR, ABPR, and PDR ranged from 95.0 % to 96.9 %, from 93.6 % to 96.4 %, and from 76.2 % to 79.1 %, respectively. Age, sex, ASA classification, and indication were significant case-mix factors for CIR and ABPR. In the FIT-positive screening population, age, sex, and ASA classification were significant case-mix factors for PDR.

Conclusion Our findings emphasize the importance of considering case-mix adjustment when comparing colonoscopy performance measures between endoscopy centers.

Tables 1 s–4 s, Figs. 1 s–6 s



Publication History

Received: 16 March 2021

Accepted: 06 September 2021

Accepted Manuscript online:
06 September 2021

Article published online:
28 October 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 
  • References

  • 1 Brenner H, Chang-Claude J, Jansen L. et al. Reduced risk of colorectal cancer up to 10 years after screening, surveillance, or diagnostic colonoscopy. Gastroenterology 2014; 146: 709-717
  • 2 Brenner H, Chang-Claude J, Seiler CM. et al. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 2011; 154: 22-30
  • 3 Zauber AG, Winawer SJ, O’Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
  • 4 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397
  • 5 Beck N, van Bommel AC, Eddes EH. et al. The Dutch Institute for Clinical Auditing: achieving Codman’s Dream on a nationwide basis. Ann Surg 2020; 271: 627-631
  • 6 Ivers N, Jamtvedt G, Flottorp S. et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; CD000259
  • 7 de Neree Tot Babberich MPM, Ledeboer M, van Leerdam ME. et al. Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement. Gastrointest Endosc 2020; 92: 154-162
  • 8 Beck N, Hoeijmakers F, van der Willik EM. et al. National comparison of hospital performances in lung cancer surgery: the role of case mix adjustment. Ann Thorac Surg 2018; 106: 412-420
  • 9 Elfrink AKE, van Zwet EW, Swijnenburg RJ. et al. Case-mix adjustment to compare nationwide hospital performances after resection of colorectal liver metastases. Eur J Surg Oncol 2021; 47: 649-659
  • 10 Kolfschoten NE, Marang van de Mheen PJ, Gooiker GA. et al. Variation in case-mix between hospitals treating colorectal cancer patients in the Netherlands. Eur J Surg Oncol 2011; 37: 956-963
  • 11 Corley DA, Jensen CD, Marks AR. et al. Variation of adenoma prevalence by age, sex, race, and colon location in a large population: implications for screening and quality programs. Clin Gastroenterol Hepatol 2013; 11: 172-180
  • 12 Van Leersum NJ, Snijders HS, Henneman D. et al. The Dutch surgical colorectal audit. Eur J Surg Oncol 2013; 39: 1063-1070
  • 13 Kastenberg D, Bertiger G, Brogadir S. Bowel preparation quality scales for colonoscopy. World J Gastroenterol 2018; 24: 2833-2843
  • 14 Lai EJ, Calderwood AH, Doros G. et al. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009; 69: 620-625
  • 15 Belderbos TD, Grobbee EJ, van Oijen MG. et al. Comparison of cecal intubation and adenoma detection between hospitals can provide incentives to improve quality of colonoscopy. Endoscopy 2015; 47: 703-709
  • 16 Bhangu A, Bowley DM, Horner R. et al. Volume and accreditation, but not specialty, affect quality standards in colonoscopy. Br J Surg 2012; 99: 1436-1444
  • 17 Ferlitsch M, Reinhart K, Pramhas S. et al. Sex-specific prevalence of adenomas, advanced adenomas, and colorectal cancer in individuals undergoing screening colonoscopy. JAMA 2011; 306: 1352-1358
  • 18 Shah HA, Paszat LF, Saskin R. et al. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 2007; 132: 2297-2303
  • 19 Toes-Zoutendijk E, van Leerdam ME, Dekker E. et al. Real-time monitoring of results during first year of Dutch Colorectal Cancer Screening Program and optimization by altering fecal immunochemical test cut-off levels. Gastroenterology 2017; 152: 767-775
  • 20 Nederlandse vereniging voor Maag-, darm- en leverartsen. Dutch guideline for sedation practices outside of the operation room [in Dutch]. 2010 https://www.mdl.nl/files/richlijnen/Richtlijn_sedatie_of_analgesie_op_locaties_buiten_de_OK_definitief.pdf Accessed 16 March 2021
  • 21 Sankar A, Johnson SR, Beattie WS. et al. Reliability of the American Society of Anesthesiologists physical status scale in clinical practice. Br J Anaesth 2014; 113: 424-432
  • 22 Harris JK, Froehlich F, Wietlisbach V. et al. Factors associated with the technical performance of colonoscopy: an EPAGE Study. Dig Liver Dis 2007; 39: 678-689
  • 23 Radaelli F, Meucci G, Sgroi G. et al. Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol 2008; 103: 1122-1130
  • 24 Mahmood S, Farooqui SM, Madhoun MF. Predictors of inadequate bowel preparation for colonoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2018; 30: 819-826
  • 25 Ness RM, Manam R, Hoen H. et al. Predictors of inadequate bowel preparation for colonoscopy. Am J Gastroenterol 2001; 96: 1797-1802
  • 26 Brand EC, Crook JE, Thomas CS. et al. Development and validation of a prediction model for adenoma detection during screening and surveillance colonoscopy with comparison to actual adenoma detection rates. PLoS One 2017; 12: e0185560
  • 27 Almoudaris AM, Burns EM, Bottle A. et al. Single measures of performance do not reflect overall institutional quality in colorectal cancer surgery. Gut 2013; 62: 423-429
  • 28 Anderson JC, Gonzalez JD, Messina CR. et al. Factors that predict incomplete colonoscopy: thinner is not always better. Am J Gastroenterol 2000; 95: 2784-2787
  • 29 Anderson JC, Weiss JE, Robinson CM. et al. Adenoma detection rates for screening colonoscopies in smokers and obese adults: data from the New Hampshire Colonoscopy Registry. J Clin Gastroenterol 2017; 51: e95-e100
  • 30 Boroff ES, Gurudu SR, Hentz JG. et al. Polyp and adenoma detection rates in the proximal and distal colon. Am J Gastroenterol 2013; 108: 993-999