High quality colonoscopy: using textbook process as a composite quality measure

Abstract

Background High quality colonoscopy is fundamental to good patient outcomes. “Textbook outcome” has proven to be a feasible multidimensional measure for quality assurance between surgical centers. In this study, we sought to establish the “textbook process” (TP) as a new composite measure for the optimal colonoscopy process and assessed how frequently TP was attained in clinical practice and the variation in TP between endoscopists.

Methods To reach consensus on the definition of TP, international expert endoscopists completed a modified Delphi consensus process. The achievement of TP was then applied to clinical practice. Prospectively collected data in two endoscopy services were retrospectively evaluated. Data on colonoscopies performed for symptoms or surveillance between 1 January 2018 and 1 August 2021 were analyzed.

Results The Delphi consensus process was completed by 20 of 27 invited experts (74.1 %). TP was defined as a colonoscopy fulfilling the following items: explicit colonoscopy indication; successful cecal intubation; adequate bowel preparation; adequate withdrawal time; acceptable patient comfort score; provision of post-polypectomy surveillance recommendations in line with guidelines; and the absence of the use of reversal agents, early adverse events, readmission, and mortality. In the two endoscopy services studied, TP was achieved in 5962/8227 colonoscopies (72.5 %). Of 48 endoscopists performing colonoscopy, attainment of TP varied significantly, ranging per endoscopist from 41.0 % to 89.1 %.

Conclusion This study proposes a new composite measure for colonoscopy, namely “textbook process.” TP gives a comprehensive summary of performance and demonstrates significant variation between endoscopists, illustrating the potential benefit of TP as a measure in future quality assessment programs.

Publication History

Received: 06 May 2022

Accepted after revision: 04 April 2023

Accepted Manuscript online:
05 April 2023

Article published online:
22 May 2023

• References

• 1 Ivers N, Jamtvedt G, Flottorp S. et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 2012: CD000259
• 2 Tinmouth J, Patel J, Hilsden RJ. et al. Audit and feedback interventions to improve endoscopist performance: Principles and effectiveness. Best Pract Res Clin Gastroenterol 2016; 30: 473-485
• 3 Corley DA, Levin TR, Doubeni CA. Adenoma detection rate and risk of colorectal cancer and death. NEJM 2014; 370: 2541
• 4 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. NEJM 2010; 362: 1795-1803
• 5 Bishay K, Causada-Calo N, Scaffidi MA. et al. Associations between endoscopist feedback and improvements in colonoscopy quality indicators: a systematic review and meta-analysis. Gastrointest Endosc 2020; 92: 1030-1040.e9
• 6 Nolan T, Berwick DM. All-or-none measurement raises the bar on performance. JAMA 2006; 295: 1168-1170
• 7 Karthaus EG, Lijftogt N, Busweiler LAD. et al. Textbook outcome: a composite measure for quality of elective aneurysm surgery. Ann Surg 2017; 266: 898-904
• 8 Kolfschoten NE, Kievit J, Gooiker GA. et al. Focusing on desired outcomes of care after colon cancer resections; hospital variations in 'textbook outcome'. Eur J Surg Oncol 2013; 39: 156-163
• 9 Kuhrij LS, Karthaus EG, Vahl AC. et al. A composite measure for quality of care in patients with symptomatic carotid stenosis using textbook outcome. Eur J Vasc Endovasc Surg 2020; 60: 502-508
• 10 Merath K, Chen Q, Bagante F. et al. A multi-institutional international analysis of textbook outcomes among patients undergoing curative-intent resection of intrahepatic cholangiocarcinoma. JAMA Surg 2019; 154: e190571
• 11 Poelemeijer YQM, Marang-van de Mheen PJ, Wouters M. et al. Textbook outcome: an ordered composite measure for quality of bariatric surgery. Obes Surg 2019; 29: 1287-1294
• 12 ten Berge MG, Beck N, Steup WH. et al. Textbook outcome as a composite outcome measure in non-small-cell lung cancer surgery. Eur J Cardiothorac Surg 2021; 59: 92-99
• 13 van Roessel S, Mackay TM, van Dieren S. et al. Textbook outcome: nationwide analysis of a novel quality measure in pancreatic surgery. Ann Surg 2020; 271: 155-162
• 14 Warps AK, Detering R, Tollenaar R. et al. Textbook outcome after rectal cancer surgery as a composite measure for quality of care: A population-based study. Eur J Surg Oncol 2021; 47: 2821-2829
• 15 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
• 16 Rees CJ, Bevan R, Zimmermann-Fraedrich K. et al. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut 2016; 65: 2045-2060
• 17 Rees CJ, Thomas Gibson S, Rutter MD. et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65: 1923-1929
• 18 Rutter MD, Senore C, Bisschops R. et al. The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures. Endoscopy 2016; 48: 81-89
• 19 Nass KJ, van der Schaar PJ, van der Vlugt M. et al. Continuous monitoring of colonoscopy performance in the Netherlands: first results of a nationwide registry. Endoscopy 2022; 54: 488-495
• 20 Kastenberg D, Bertiger G, Brogadir S. Bowel preparation quality scales for colonoscopy. World J Gastroenterol 2018; 24: 2833-2843
• 21 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
• 22 Ekkelenkamp VE, Dowler K, Valori RM. et al. Patient comfort and quality in colonoscopy. World J Gastroenterol 2013; 19: 2355-2361
• 23 Dutch Association of Gastroenterologists. Nederlandse Richtlijn Coloscopie Surveillance [in Dutch]; 1.0. 2013 Available at (Accessed: 6 April 2023): https://www.mdl.nl/files/richlijnen/Richtlijn_Coloscopie_Surveillance_definitief_2013.pdf
• 24 van Doorn SC, van Vliet J, Fockens P. et al. A novel colonoscopy reporting system enabling quality assurance. Endoscopy 2014; 46: 181-187
• 25 Clavien PA, Barkun J, de Oliveira ML. et al. The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250: 187-196
• 26 Ball AJ, Rees CJ, Corfe BM. et al. Sedation practice and comfort during colonoscopy: lessons learnt from a national screening programme. Eur J Gastroenterol Hepatol 2015; 27: 741-746
• 27 Bugajski M, Wieszczy P, Hoff G. et al. Modifiable factors associated with patient-reported pain during and after screening colonoscopy. Gut 2018; 67: 1958-1964
• 28 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
• 29 Seip B, Bretthauer M, Dahler S. et al. Patient satisfaction with on-demand sedation for outpatient colonoscopy. Endoscopy 2010; 42: 639-646
• 30 Nass KJ, van Doorn SC, van der Vlugt M. et al. Impact of sedation on the Performance Indicator of Colonic Intubation. Endoscopy 2021; 53: 619-626
• 31 Neilson LJ, Sharp L, Patterson JM. et al. The Newcastle ENDOPREM™: a validated patient reported experience measure for gastrointestinal endoscopy. BMJ Open Gastroenterol 2021; 8: e00065