Quality in gastrointestinal endoscopy
30 April 2014 (eFirst)
Endoscopy is a powerful and pivotal tool in the diagnosis and management of gastrointestinal pathology. Ensuring that endoscopy is of high quality is fundamental to providing the best care and experience for our patients. High quality endoscopy delivers better health outcomes, better patient experience, and fewer repeat procedures.
Although intuitive, it is only in recent years that the evidence base to support the value of quality has grown, primarily in colonoscopy. Clear evidence exists for the role of detection and removal of polyps in preventing colorectal cancer (CRC)   , and we know that patients endoscoped by clinicians with poorer adenoma detection rates (ADR) have poorer outcomes and higher rates of postcolonoscopy CRC  . A further study using polypectomy rate as a surrogate marker for ADR reached the same conclusion , and additional studies have shown a correlation between postcolonoscopy CRC rates and other markers of quality such as failed cecal intubation  .
The quality of endoscopy being delivered in endoscopy units is known to vary considerably. Globally, back-to-back colonoscopy studies have demonstrated that 22 % of all adenomas are missed . In addition, studies have shown a 3 – 6-fold variation in ADR between endoscopists  , with a 10-fold range in the mean number of adenomas detected in one study – put another way, the lowest detector missed 90 % of adenomas. There is also wide variation in detection rates of serrated polyps (7 – 18-fold) between endoscopists  ; these polyps may be an important precursor of CRC, and detecting them may be important in reducing the incidence of proximal cancer. Even when polyps are found, removal may be incomplete: the recent CARE study demonstrated that 10 % of nonpedunculated polyps of 5 – 20 mm and 23 % of nonpedunculated polyps of 15 – 20 mm were not fully resected .
These gaps in quality are clinically significant: the majority of postcolonoscopy CRCs arise from missed adenomas, cancers, or incomplete polypectomies , and shortcomings in right-sided diagnostic rates may explain the relative failure of colonoscopy to protect against proximal CRC in many studies  .
In the upper gastrointestinal tract, missed gastric cancer rates are an important measure of quality, albeit a relatively insensitive measure. In one series, 7.2 % of patients with gastric cancer did not have the lesion detected at endoscopy performed within the previous year. Of these missed lesions, almost three-quarters were judged to be due to endoscopist error . An Australian study also reported that although upper gastrointestinal malignancies were relatively rare after a normal esophagogastroduodenoscopy within the preceding 3 years, often an abnormality was detected but not recognized as potentially malignant by the endoscopist .
Additional quality measures within upper gastrointestinal endoscopy are more limited. The American Society for Gastrointestinal Endoscopy and American College of Gastroenterology task force developed 16 quality indicators for upper gastrointestinal endoscopy involving pre-, intra-, and postprocedural indicators   . Only 5 of these 16 quality indicators, however, had robust evidence to support a clear benefit with their use. The Canadian Association of Gastroenterology has developed a similar set of quality indicators for all gastrointestinal endoscopy . In endoscopic retrograde cholangiopancreatography, which is one of the most complex and highest risk procedures performed regularly in endoscopy practice, there is evidence of wide variation in both completion and complication rates . Quality measures and reporting of these measures are variable and some success has been achieved with database reporting . Quality markers within small-bowel and capsule endoscopy are not yet clearly established.
Knowledge that quality is central to better health outcomes and that there is significant variation in quality between endoscopists is important, but does nothing to redress the problem. Evidence-based guidelines on endoscopy service structure and process, along with clinical performance indicators and minimum standards, provide endoscopy units and endoscopists (many of whom may work in relative isolation) with a framework and benchmark against which they can compare and improve their service. However guidelines also need to be high quality. In this issue of Endoscopy, Malheiro et al.  report on the growing number and variable quality of guidelines that now exist. In their study, 100 gastrointestinal guidelines published in the past 16 years were measured against the AGREE II assessment tool. Nearly all guidelines failed to seek the views of the target population (often not even identifying the target population), an essential consideration as we rightly move to a more patient-centered endoscopy service. Effective guidelines should do more than simply distil the evidence – they should translate this into practical recommendations and should facilitate guideline implementation in everyday endoscopy units. The guideline review found that very few of the guidelines provided advice or tools on how to put the recommendations into practice. Nevertheless, improvements in guideline quality were seen over time – there is hope that we are moving into an era of fewer, higher quality guidelines. What should endoscopy units do until such consensus is achieved? A simple, early step is to select appropriate guidelines (high quality of course) for their service, formally adopt them, and ensure that they are readily available to all endoscopy staff.
Having a guideline does not result in improved health outcomes per se; in order to improve quality, it is essential to implement guidance and measure performance. Performing regular quality audits allows identification of potential underperformance, which provides an opportunity for discussion and support for the endoscopist. In addition, the simple act of monitoring a service will improve performance (the Hawthorne Effect): it is powerful, essentially free, and results in improved quality of patient care.
We recommend that all units develop mechanisms for audit and feedback of endoscopists’ performance using quality markers. In addition, standards should be set with clear strategies on how to manage the performance of those who fall below the agreed standards, such as further training and mentoring. Audit results should be fed back to endoscopists in a sensitive and timely manner – we are unlikely to change or improve unless we are aware of our performance and how it compares with peers and quality standards. Performing these audits need not be time-consuming but must be resourced. Advances in electronic endoscopy reporting systems can greatly facilitate the capture and analysis of endoscopy data .
There is clear evidence that implementing the above measures, along with additional measures such as structured training programs, can result in significant improvement in endoscopy quality. For example, in the UK, following a decade of quality improvement initiatives, cecal intubation rate improved nationally from 76.9 % to 92.3 % . However despite the dramatic overall improvement, there was still unacceptable variation in quality, and more work is required . It is imperative that we engage with endoscopists who have lower performance levels and assist them in improving. One of the biggest gains in endoscopy quality improvement would be to raise the standards of the lower performers to above minimum quality standard thresholds. However, this process is not always straightforward; there are barriers to the uptake of endoscopy quality improvement by individuals and services, ranging from complacency (“it doesn’t apply to me,” “I’m fine and don’t need to measure to know”), to fear that one’s abilities might be demonstrated to be suboptimal. The latter may be perceived to be of particular consequence if there are financial or service imperatives to continue with the status quo. Moreover, evidence suggests that although people whose performance is lower than average may improve, their performance tends to remain below average . Some specific interventions such as mandating slow withdrawal times during colonoscopy to increase ADR have not been particularly successful , despite the clear evidence of the benefit of these measures  . We owe it to our patients, however, to ensure that endoscopy is of the highest quality and these barriers should be overcome. Various organizations have developed structured processes for the management of underperforming endoscopists, and when handled sensitively, these processes are usually helpful and supportive for the endoscopist.
There is some evidence that endoscopy proficiency increases with increasing number of procedures performed, and that endoscopy complications are more common with endoscopists who perform fewer procedures per year   . A trend towards fewer endoscopists performing more procedures each may be appropriate, and setting a minimum number of procedures per year for endoscopists may be one strategy to improve quality.
Change is usually best implemented as an evolution rather than a revolution. Nevertheless, evolution involves continual change and improvement and we, as endoscopists, should embrace a constant drive towards higher quality for our patients. The European Society of Gastrointestinal Endoscopy has highlighted quality of endoscopy as a major priority and is embarking on a major new Quality Improvement initiative. We urge all endoscopists to prioritize quality and ensure that standards are implemented and monitored at a local level to ensure that we provide the best possible care for our patients.
- 1 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
- 2 Atkin WS, Edwards R, Kralj-Hans I et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010; 375: 1624-1633
- 3 Winawer SJ, Zauber AG, O’Brien MJ et al. Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup. N Engl J Med 1993; 328: 901-906
- 4 Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
- 5 Corley DA, Jensen CD, Marks AR et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
- 6 Baxter NN, Sutradhar R, Forbes SS et al. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology 2011; 140: 65-72
- 7 Brenner H, Chang-Claude J, Seiler CM et al. Interval cancers after negative colonoscopy: population-based case-control study. Gut 2012; 61: 1576-1582
- 8 van Rijn JC, Reitsma JB, Stoker J et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol 2006; 101: 343-350
- 9 Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006; 355: 2533-2541
- 10 Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007; 102: 856-861
- 11 Kahi CJ, Hewett DG, Norton DL et al. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 2011; 9: 42-46
- 12 Hetzel JT, Huang CS, Coukos JA et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol 2010; 105: 2656-2664
- 13 Pohl H, Srivastava A, Bensen SP et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74.e1-80.e1
- 14 Pabby A, Schoen RE, Weissfeld JL et al. Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary Polyp Prevention Trial. Gastrointest Endosc 2005; 61: 385-391
- 15 Singh H, Nugent Z, Demers AA et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology 2010; 139: 1128-1137
- 16 Baxter NN, Goldwasser MA, Paszat LF et al. Association of colonoscopy and death from colorectal cancer. Ann Intern Med 2009; 150: 1-8
- 17 Yalamarthi S, Witherspoon P, McCole D et al. Missed diagnoses in patients with upper gastrointestinal cancers. Endoscopy 2004; 36: 874-879
- 18 Raftopoulos SC, Segarajasingam DS, Burke V et al. A cohort study of missed and new cancers after esophagogastroduodenoscopy. Am J Gastroenterol 2010; 105: 1292-1297
- 19 Cohen J, Safdi MA, Deal SE et al. Quality indicators for esophagogastroduodenoscopy. Am J Gastroenterol 2006; 101: 886-891
- 20 Faigel DO, Pike IM, Baron TH et al. Quality indicators for gastrointestinal endoscopic procedures: an introduction. Am J Gastroenterol 2006; 101: 866-872
- 21 Park WG, Cohen J. Quality measurement and improvement in upper endoscopy. Tech Gastrointest Endosc 2012; 14: 13-20
- 22 Armstrong D, Barkun A, Bridges R et al. Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy. Can J Gastroenterol 2012; 26: 17-31
- 23 Cotton PB, Garrow DA, Gallagher J et al. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc 2009; 70: 80-88
- 24 Oppong KW, Romagnuolo J, Cotton PB. The ERCP quality network benchmarking project: a preliminary comparison of practice in UK and USA. Frontline Gastroenterol 2012; 3: 157-161
- 25 Malheiro R, Monteiro-Soares M, Hassan C et al. Methodological quality of guidelines in gastroenterology. Endoscopy 2014; 46: 513-525
- 26 van Doorn SC, van Vliet J, Fockens P et al. A novel colonoscopy reporting system enabling quality assurance. Endoscopy 2014; 46: 181-187
- 27 Gavin DR, Valori RM, Anderson JT et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
- 28 Atkin W, Rogers P, Cardwell C et al. Wide variation in adenoma detection rates at screening flexible sigmoidoscopy. Gastroenterology 2004; 126: 1247-1256
- 29 Corley DA, Jensen CD, Marks AR. Can we improve adenoma detection rates?. A systematic review of intervention studies. Gastrointest Endosc 2011; 74: 656-665
- 30 Lee TJ, Blanks RG, Rees CJ et al. Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England. Endoscopy 2013; 45: 20-26
- 31 Kapral C, Duller C, Wewalka F et al. Case volume and outcome of endoscopic retrograde cholangiopancreatography: results of a nationwide Austrian benchmarking project. Endoscopy 2008; 40: 625-630
- 32 Rabeneck L, Paszat LF, Hilsden RJ et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 2008; 135: 1899-1906
- 33 Singh H, Penfold RB, DeCoster C et al. Colonoscopy and its complications across a Canadian regional health authority. Gastrointest Endosc 2009; 69: 665-671