Quality, competency and endosonography

For all of us committed to the practice of medicine, the provision of high-quality patient care has been of paramount importance. This is particularly true of invasive procedures where patients place their trust in us to provide a safe, accurate, and technically successful procedure, and that we will use the information gained to advance their health and well being. These principles apply especially to technically complex procedures such as endoscopic ultrasonography (EUS), which is often done in ill patients suffering from cancer.

There are several consequences to an improperly or incompetently performed EUS. The most obvious is patient injury such as perforation from the stiff transducer end of the echoendoscope [1]. But there are other, more likely and equally harmful, consequences. If the procedure is incomplete it may have to be repeated. Repeating the procedure exposes the patient to a second round of procedure-associated risks, and also results in delay in establishing a diagnosis and instituting therapy. The staging information gained from EUS is often used in making critical patient care decisions [2]. For example, at our institution we use EUS to stage esophageal cancers and select patients for surgery, palliation or neoadjuvant protocols, a practice which is not only cost effective but cost saving [3]. However, this algorithm presupposes that an accurate EUS staging has been made. An inaccurate exam could result in patient mismanagement, the receipt of unneeded treatments, or even the erroneous denial of life-saving therapy. And finally, the less-than-competent endosonographer may not have the training to recognize and manage complications, or recognize the limitations of EUS in making recommendations.

It is obvious that as patient advocates we should care about quality. But there are selfish reasons to do so as well. Proving one’s competency and provision of high quality services will go a long way towards defense of any allegations of malpractice. By creating a quality ”Report Card” experts may be able to differentiate themselves from their less-skillful competition [4]. It is possible, and even likely, that in the near future payers (e. g., insurance companies) will publish these report cards on the internet so that their subscribers (patients) may use them to select a doctor.

In the United States, these discussions surrounding quality have taken on a new dimension with the advent of ”Pay for Performance”. Pay for performance, or ”P4P” is the buzzword on nearly everybody’s lips with a financial stake in clinical medicine. The idea is that payers (in the US this would primarily be Medicare and private insurance companies) would financially reward practitioners who provide high-quality service. How this would work in practice is still being determined. But it will likely apply to endoscopic procedures in general, and possibly to EUS in specific.

How can we ensure that only high quality EUS procedures are performed? As a recent Chair of both the Standards of Practice Committee and the Quality Assurance Taskforce of the American Society for Gastrointestinal Endoscopy (ASGE), I spent considerable time pondering this question. The first step, I believe, begins with adequate training. The next is to ensure that only competent endosonographers are credentialed and given privileges to perform EUS. The endosonographer then needs an adequate case volume and mix to maintain clinical skills. And quality assurance programs based on measurable quality endpoints need to be in place.

References

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• 2 Jacobson B C, Hirota W, Baron T H, Leighton J A, Faigel D O. The role of endoscopy in the assessment and treatment of esophageal cancer.  Gastrointestinal Endoscopy. 2003;  57 (7) 817-822
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