Methodology
The multistep procedure to develop performance measures has been previously described
[1 ]. In short, a modified Delphi consensus process was used to develop performance measures
for colonoscopy in IBD patients. These performance measures were categorized into
performance measures for three clinical settings: clinical suspicion of IBD, endoscopic
assessment of disease activity in known IBD patients, and surveillance. Clinical suspicion
of IBD can be defined as: either a clinical suspicion of IBD prior to colonoscopy
(i. e. symptoms of diarrhea, iron deficiency anemia, or raised biomarkers), which
may be confirmed by endoscopic signs of inflammation; or the finding of signs suggestive
of IBD during a colonoscopy initially performed for a different indication, which
then raises the suspicion of IBD. Surveillance colonoscopy is recommended in longstanding
IBD patients (8 years after disease onset) [10 ]. In each clinical category, performance measures were defined for the following
three quality domains: preprocedure, completeness of the procedure, and identification
of pathology. One or two performance measures were defined per domain.
To identify performance measures for IBD colonoscopy, every working group member was
invited to introduce potential performance measures. All of these performance measures
were discussed during a first videoconference in March 2021 and prioritized by all
working group members (see Supporting information, available online). With this prioritization
in mind, subworking groups for each clinical category (clinical suspicion of IBD;
endoscopic assessment of disease activity; surveillance) structured the relevant performance
measures using the PICO framework (where P stands for Population/Patient, I for Intervention/Indicator,
C for Comparator/Control, and O for Outcome) to perform searches for available evidence
to support these performance measures.
The clinical statements and performance measures derived from the PICOs were adapted
or omitted during iterative rounds of comments and suggestions from the working group
members during the Delphi process. This process began with a consensus meeting in
June 2021, where the results of the literature searches were presented by each working
group. Between July and September 2021, three online voting rounds were organized.
After each voting round, a videoconference was scheduled with all working group members
to discuss the comments received. A summary of the discussion during these videoconferences
was added as supporting text to the next round of the Delphi process. The results
of the iterative rounds of the Delphi process can be reviewed in the Supporting information.
In total, working group members participated in three voting rounds to agree on, or
rescind, the definitions of statements and performance measures. A statement was accepted
if at least 80 % agreement was reached after a minimum of two voting rounds. Statements
not reaching agreement were extensively discussed during the online meetings based
on the comments made during the previous voting round. This discussion led to modified
statements that were tested in a subsequent voting round. Statements were discarded
if agreement was not reached ( < 80 %) after three voting rounds. The agreement given
for the different statements in this paper refers to the last voting round in the
Delphi process.
The performance measures are shown below the relevant clinical category and quality
domain. Each box describes a different performance measure, the level of agreement
during the modified Delphi process, and the grading of the available evidence, which
was determined according to the Grading of Recommendations Assessment, Development
and Evaluation [GRADE] system [11 ]. Instructions on how these performance measures should be measured and calculated,
including standards for evaluation, are listed in each box.
The minimum number needed to assess whether the threshold for a certain performance
measure has been reached can be calculated by estimating the 95 % CIs around the predefined
threshold for different sample sizes. For practical reasons and to simplify implementation
and auditing, the working group suggests that at least 100 consecutive procedures
(or all, if < 100 have been performed) should be measured to assess a performance
measure. Ideally, continuous monitoring of performance should be integrated as part
of regular performance management.
All performance measures should be assessed at an individual level; however, in situations
where this is not feasible, an assessment of performance measures should at least
be applied at service level.
Performance measures for colonoscopy in IBD patients
The input from the working group members and the evidence derived from the literature
search resulted in a total of 16 statements and 11 potential performance measures
that were considered relevant for IBD colonoscopies (see Supporting information).
The working group members considered several other performance measures, such as measures
on patient tolerance, sedation, standard terminology, and complications; however,
the working group members agreed that these performance measures were not essential
to assure high quality colonoscopy explicitly for IBD patients. Therefore, general
colonoscopy recommendations and standards for these measures should be considered
for IBD colonoscopy [4 ].
The statements and performance measures were categorized into three clinical categories
and six domains. To minimize overlap between the different categories, some statements
and potential performance measures were combined into a “general IBD colonoscopy”
category after the first voting round. After three voting rounds, a total of 15 statements,
eight key performance measures, and one minor performance measure were accepted ([Fig. 1 ]). The process of the development of these statements and performance measures can
be reviewed in the Supporting information. The performance measures are presented
below using the descriptive framework proposed by the Quality Improvement Committee
and a short summary of the available literature [1 ]. The performance measures are listed according to the clinical categories and domains
to which they were attributed.
Fig. 1 The clinical categories, domains, and performance measures chosen by the expert working
group for colonoscopy in patients with inflammatory bowel disease (IBD).
1 General IBD colonoscopy: preprocedure
Key performance measure
Rate of reported indication for colonoscopy
Description
Percentage of colonoscopies explicitly including the indication for the procedure
Clinical category
General IBD colonoscopy
Domain
Preprocedure
Category
Process
Rationale
Colonoscopies with an appropriate indication are associated with higher diagnostic
yield for relevant lesions than colonoscopies without an appropriate indication
Construct
Denominator : All colonoscopies performed in IBD patients
Numerator : Procedures in the denominator that explicitly include the indication in the endoscopy
report
Standards
Minimum standard: ≥ 95 %
Target standard: ≥ 98 %
Consensus agreement
100 %
PICO
1.5 and 2.3 (see Supporting information)
Evidence grading
Moderate
The acceptance of this performance measure is based on agreement with the following
statement:
For colonoscopies performed in IBD patients, the endoscopy report should explicitly
include the indication for the procedure: i. e. clinical suspicion of IBD, endoscopic
assessment of disease activity, or surveillance. Agreement: 100 %
Inappropriate referral for colonoscopy might lead to the misuse of limited endoscopic
resources, an increase in potential harm to patients from unnecessary invasive procedures,
and an increase in healthcare costs. In general, colonoscopies with an appropriate
indication are associated with significantly higher diagnostic yields for relevant
lesions than colonoscopies without an appropriate indication [4 ]. There is also literature that supports these findings specifically for IBD colonoscopies.
The diagnostic yield for IBD-related lesions is significantly higher in colonoscopies
with an appropriate indication compared with colonoscopies without an appropriate
indication [12 ]
[13 ]. The proposed minimum standard rate for reporting of the indication for colonoscopy
(≥ 95 %) was set because this is a prerequisite for the monitoring and evaluation
of explicit performance measures in each clinical category for IBD patients.
Key performance measure
Rate of adequate bowel preparation
Description
The percentage of patients with an adequately prepared bowel
Clinical category
General IBD colonoscopy
Domain
Preprocedure
Category
Process
Rationale
The quality of bowel preparation affects the efficacy of colonoscopy
Construct
Denominator : All colonoscopies performed in IBD patients
Numerator : Patients in the denominator with adequate bowel preparation (assessed with a validated
scale)
Standards
Minimum standard: ≥ 90 %
Target standard: none set
Consensus agreement
95 %
PICO
1.6, 2.4, and 3.1 (see Supporting information)
Evidence grading
Moderate
The acceptance of this performance measure is based on agreement with the following
statements:
For colonoscopies performed in IBD patients, the endoscopy report should include the
adequacy of bowel preparation using a validated score. Agreement: 100 %
Adequate bowel preparation should be obtained in 90 % of the colonoscopies performed
in IBD patients. Agreement: 95 %
Inadequate bowel preparation has a detrimental effect on all quality aspects of colonoscopy
[14 ]. Adequate bowel preparation in IBD patients is essential for disease assessment
and for the detection of dysplasia during colonoscopy [14 ]. A successful surveillance colonoscopy requires adequate bowel preparation to detect
any nonpolypoid flat lesions hidden by debris and stool [15 ]. A recent study has shown that inadequate bowel preparation and active colonic inflammation
were the most frequent factors resulting in unsuccessful chromoendoscopy in surveillance
colonoscopies in IBD patients [16 ].
The quality of bowel preparation should be assessed with a validated scale, as has
also been recommended by the ESGE for general colonoscopy [4 ]. Three scales have been comprehensively validated: the Boston Bowel Preparation
Scale (BBPS), the Ottawa Scale, and the Aronchick Scale. Adequate bowel preparation
may be defined as: BBPS ≥ 6; Ottawa Scale ≤ 7; or Aronchick Scale excellent, good,
or fair [4 ].
The proposed minimum standard of adequate bowel preparation for colonoscopy in IBD
patients (≥ 90 %) was adopted from the ESGE guideline on performance measures for
lower GI endoscopy [4 ], as no evidence was found to support adjusted standards for the subpopulation of
IBD patients. Few data explored an association between IBD disease activity and the
quality of bowel preparation. Hence, there is no definitive proof that patients with
IBD have an increased likelihood of inadequate bowel preparation. In a retrospective
analysis of 348 colonoscopies from 169 consecutively enrolled IBD patients, no differences
were found in the quality of bowel preparation between patients with active disease
and those with mucosal healing, suggesting that the efficacy of bowel preparation
is not influenced by disease inflammation [17 ].
2 General IBD colonoscopy: completeness of procedure and identification of pathology
Key performance measure
Rate of adequate photodocumentation
Description
The percentage of patients with adequate photodocumentation
Clinical category
General IBD colonoscopy
Domain
Completeness of procedure and identification of pathology
Category
Process
Rationale
It is recommended that adequate photodocumentation be included in the endoscopy report
to enable quality control
Construct
Denominator : All colonoscopies performed in patients with endoscopic suspicion of IBD, for endoscopic
assessment of disease activity in IBD patients, and for surveillance colonoscopies
in longstanding IBD patients
Numerator : Procedures in the denominator with adequate photodocumentation
Standards
Minimum standard: ≥ 90 %
Target standard: ≥ 95 %
Consensus agreement
100 %
PICO
1.3 and 2.7 (see Supporting information)
Evidence grading
Very low
The acceptance of this performance measure is based on agreement with the following
statements:
When colonoscopies are performed because of endoscopic suspicion of IBD or for endoscopic
assessment of disease activity in IBD patients, at least one image should be recorded
per segment. Agreement: 89 %
For surveillance colonoscopies in longstanding IBD patients, at least one annotated
image should be recorded for every lesion biopsied or resected. Agreement: 95 %
Photodocumentation of endoscopic landmarks or lesions during colonoscopy is embedded
in several quality recommendations for GI endoscopy [4 ]
[5 ]. It allows continuous monitoring for quality purposes and it should be considered
to be as important as text descriptions for endoscopic findings [18 ]. Despite the lack of supporting evidence, the working group members agreed that
photodocumentation supports quality control in colonoscopy in IBD patients. Photodocumentation
of each inspected segment (i. e. ileum, cecum, ascending, transverse, descending,
and sigmoid colon, and rectum) could support optimal diagnosis, assessment of disease
activity, and the assessment of future changes in IBD patients, as low interobserver
agreement exists regarding endoscopic assessment of disease activity [19 ]
[20 ].
Annotated photodocumentation of every lesion (biopsied or resected) facilitates accurate
interpretation, assists with onward referral, and enables direct comparison if subsequent
follow-up procedures are required. The working group members agreed on the definition
of annotation, meaning anything that indicates where the picture is taken. Annotation
should be interpreted in its most simple form, for example it could be written on
the pictures or simply described in the endoscopy report. A minimum standard of 90 %
is recommended for adequate photodocumentation in colonoscopy in IBD patients.
When endoscopic software and endoscopy reporting systems support videodocumentation
during colonoscopy, this might be superior to photodocumentation in certain situations
[21 ]. However, videodocumentation is not yet widely available and not always easy to
incorporate in the endoscopy report. Where videodocumentation is used, annotation
by marking the colon segments is recommended to support the interpretation of the
videos afterward.
3 Clinical suspicion of IBD: completeness of procedure
Key performance measure
Ileal intubation rate
Description
The percentage of colonoscopies reaching the terminal ileum
Clinical category
Clinical suspicion of IBD
Domain
Completeness of procedure
Category
Process
Rationale
Complete visualization of the colon and ileal intubation are prerequisites for an
adequate inspection of the mucosa of the colon and terminal ileum
Construct
Denominator: All colonoscopies in suspected IBD patients
Numerator: Procedures in the denominator that report reaching the ileum
Standards
Minimum standard: ≥ 80 %
Target standard: ≥ 90 %
Consensus agreement
95 %
PICO
1.1 (see Supporting information)
Evidence grading
Low
The acceptance of this performance measure is based on agreement with the following
statement:
Ileal intubation is essential for identifying ileal Crohn’s disease [22 ]. Most studies support that ileoscopy increases the diagnostic yield when evaluating
suspected IBD [23 ]
[24 ]
[25 ]
[26 ]. Reported rates for ileal intubation in colonoscopies in patients with diarrhea
have varied widely from 46 % to 96 % [24 ]
[25 ]
[26 ]. There is a scarcity of data regarding the preferred depth of ileal intubation and
patient discomfort with ileal intubation in correlation with the sedation used. Furthermore,
the existing guidelines do not comment on this subject [27 ]
[28 ]. Despite the absence of concrete supporting evidence, the members of this working
group recommend that endoscopists should aim to achieve terminal ileal intubation
in suspected IBD patients (minimum standard: ≥ 80 %; target standard ≥ 90 %).
4 Clinical suspicion of IBD: identification of pathology
Key performance measure
Rate of adequate biopsies
Description
The percentage of colonoscopies with adequate biopsies
Clinical categories
Clinical suspicion of IBD
Domain
Identification of pathology
Category
Process
Rationale
Adequate biopsies are essential for correct diagnosis in patients with suspected IBD
Construct
Denominator : All colonoscopies in patients with suspected IBD
Numerator : Procedures in the denominator with adequate biopsies
Standards
Minimum standard: ≥ 80 %
Target standard: ≥ 85 %
Consensus agreement
89 %
PICO
1.2 (see Supporting information)
Evidence grading
Moderate
The acceptance of this performance measure is based on agreement with the following
statements:
Adequate biopsies should be taken in patients with a clinical suspicion of IBD, as
these are essential for correct diagnosis. Agreement: 89 %
Adequate biopsies in patients with endoscopic suspicion of IBD should include two
biopsies from each of the ileum, cecum, ascending colon, transverse colon, descending
colon, sigmoid, and rectum, including affected and macroscopically normal (if present)
mucosa. Agreement: 95 %
Adequate biopsies in patients with clinically suspected IBD and endoscopically normal
mucosa should include at least two biopsies from the terminal ileum in a separate
vial. Agreement: 84 %
Adequate biopsies in patients with suspected Crohn’s disease should include biopsies
taken from the largest ulcers. Agreement: 95 %
For the clinical category “Endoscopic assessment of disease activity in known IBD,”
the working group members reached consensus on the following statement:
According to clinical practice, evidence from the literature, and statements in relevant
guidelines, ileocolonoscopy with histology is the fundamental basis for diagnosing
IBD [27 ]
[28 ]
[29 ]. Histology plays a pivotal role in the differentiation between Crohn’s disease and
UC. Within this context, the distribution and extent of histological pathology can
further aid in the differential diagnosis of IBD. This requires a sufficient number
of biopsies that are collected separately from the ileum, all colonic segments, and
the rectum, as well from endoscopically affected areas and macroscopically normal
areas [30 ]. Providing the pathologist with endoscopic and clinical information further aids
in establishing a diagnosis [30 ]. Biopsies are also crucial for differentiating IBD from other diseases, such as
intestinal tuberculosis, amebiasis, amyloidosis, and strongyloidiasis [31 ]
[32 ]
[33 ]
[34 ]
[35 ].
The added value of terminal ileal biopsies in patients with clinically suspected IBD
and endoscopically normal mucosa was supported by the literature [36 ]. Baker et al. reported, in a retrospective analysis, that histological inflammation
in biopsies of endoscopically normal terminal ileum was significantly associated with
the development of Crohn’s disease during a mean follow-up of 6 years compared with
the finding of normal histology. Furthermore, no real disadvantages for biopsies in
the terminal ileum exist when there is a clinical suspicion of IBD. Therefore, terminal
ileal biopsies were recommended to histologically confirm a normal ileum and prevent
a patient undergoing a second colonoscopy to exclude IBD in the future.
In active Crohn’s disease, histological disease activity scores, proinflammatory gene
expression levels, and numbers of myeloperoxidase-positive cells were significantly
higher in biopsies from the ulcer edge in the colon and ileum, with decreasing gradients
observed with distance from the ulcer edge [37 ].
In an endoscopically completely normal colon, biopsies are also important to rule
out microscopic colitis. Here, ESGE recommends two biopsies from the left colon and
two biopsies from the right colon, placed in separate containers and labelled as such
[30 ]. This is supported by the finding of lymphocytic and collagenous colitis presenting
histologically as pancolitis, excluding the rectum [38 ].
The recently published ESGE guideline on tissue sampling in the lower GI tract recommends
biopsies in UC patients to evaluate disease activity [30 ]. A minimum of two biopsies from the worst affected area or the most representative
area of mucosal healing, preferably at the edge of any ulcers was recommended. The
worst affected area might include an ulcerated anastomosis, where biopsies might differentiate
between an IBD-associated ulcer or an ischemic lesion. Histological assessment of
biopsies can be used to assess disease activity, the presence of cytomegalovirus,
or histological healing, and to optimize therapy by either escalation or exit strategies,
predict long-term adverse outcome, and manage patients to achieve treatment targets
[30 ].
Although data on actual adequate biopsies rates are lacking, based on available evidence
and expert opinion, a minimum standard of ≥ 80 % was considered appropriate by the
working group members.
5 Endoscopic assessment of disease activity in known IBD: identification of pathology
Key performance measure
Rate of endoscopic activity score use
Description
The percentage of colonoscopies using endoscopic activity scores for assessment of
ulcerative colitis activity
Clinical category
Endoscopic assessment of disease activity in known IBD
Domain
Endoscopic assessment of disease activity
Category
Process
Rationale
The use of endoscopic activity scores for the assessment of disease activity in ulcerative
colitis is recommended for evaluation of prognosis and efficacy of medical therapy
Construct
Denominator: All colonoscopies performed to assess disease activity in ulcerative colitis patients
Numerator: Procedures in the denominator that explicitly include the activity score in the endoscopy
report
Standards
Minimum standard: ≥ 90 %
Target standard: ≥ 95 %
Consensus agreement
100 %
PICO
2.1 and 2.5 (see Supporting information)
Evidence grading
Moderate
The acceptance of this performance measure is based on agreement with the following
statement:
Accurate assessment of disease activity and disease extent in patients with IBD is
of paramount importance for planning and tailoring treatment strategies [39 ]. The use of endoscopic disease activity indices to evaluate the prognosis and efficacy
of medical treatment in UC patients has been recommended by international guidelines
[39 ]. There are insufficient data to set the minimum and target standards reliably, but
the proposed values for the use of an endoscopic activity score for the assessment
of disease activity in UC patients of ≥ 90 % and ≥ 95 %, respectively, seem achievable.
Nineteen different endoscopic scoring indices have been partially validated [40 ]. Among these, the most commonly used are the Mayo Endoscopic score (MES) and the
Ulcerative Colitis Endoscopic Index of Severity (UCEIS). Both have been validated
for reliability, construct validity, and responsiveness [19 ]
[41 ]
[42 ]
[43 ]
[44 ]. The operating properties of both scores are comparable. However, because the MES
is easier to use, it remains the outcome of choice for clinical trials and daily practice
[43 ]. Electronic chromoendoscopy-based scores, such as the Paddington International Virtual
Chromoendoscopy Score (PICaSSO), require more real-life, treatment-related studies
for their full establishment in both daily practice and clinical trials [45 ].
Endoscopic activity scores for Crohn’s disease are more complex to use; hence their
broad implementation into routine clinical practice might be difficult [39 ]. Therefore, the working group members agreed not to include activity scores for
Crohn’s disease in the performance measure and statements. Nevertheless, whenever
feasible, the working group members recommend using the Simple Endoscopic Score for
Crohn’s Disease (SES-CD) to assess disease activity in Crohn’s disease [46 ].
6 Surveillance: identification of pathology
Key performance measure
Rate of high definition endoscopy use
Description
Percentage of colonoscopies using high definition endoscopy
Clinical category
Surveillance
Domain
Identification of pathology
Category
Process
Rationale
High definition endoscopy improves the visualization of the mucosa
Construct
Denominator: All surveillance colonoscopies in IBD patients
Numerator: Colonoscopies in the denominator using high definition endoscopy
Standards
Minimum standard: ≥ 90 %
Target standard: ≥ 95 %
Consensus agreement
100 %
PICO
3.2 (see Supporting information)
Evidence grading
Moderate
The acceptance of this performance measure is based on agreement with the following
statement:
Patients with longstanding IBD are at increased risk of developing colorectal cancer,
with an estimated risk of approximately 18 % after 30 years with the diagnosis [47 ]
[48 ]. Consequently, patients are recommended to undergo screening colonoscopy with the
aim of detecting premalignant dysplastic lesions [8 ]
[28 ] The use of high definition endoscopy is strongly recommended in current guidelines
for surveillance in longstanding IBD patients [8 ]
[27 ]
[28 ]
[29 ]. High definition endoscopy significantly improves the detection of dysplastic lesions
in surveillance colonoscopy in IBD patients compared with standard definition endoscopy
[49 ]. The improved visualization of the mucosa enables detection of most dysplastic lesions
[50 ]
[51 ]. This improved visualization, combined with a lack of adverse effects when using
high definition endoscopy, resulted in a proposed minimum standard of ≥ 90 % and target
standard of ≥ 95 % for the use of high definition endoscopy in longstanding IBD patients.
Key performance measure
Rate of chromoendoscopy use
Description
Percentage of surveillance colonoscopies using dye-based or virtual chromoendoscopy
combined with targeted biopsies in longstanding IBD patients
Clinical category
Surveillance
Domain
Identification of pathology
Category
Process
Rationale
The use of chromoendoscopy and targeted biopsies during surveillance colonoscopy in
longstanding IBD patients improves the detection of dysplastic lesions
Construct
Denominator : All surveillance colonoscopies in longstanding IBD patients
Numerator : Colonoscopies in the denominator using dye-based or virtual chromoendoscopy combined
with targeted biopsies
Standards
Minimum standard: ≥ 70 %
Target standard: none set
Consensus agreement
95 %
PICO
3.2 and 3.3 (see Supporting information)
Evidence grading
Moderate
The acceptance of this performance measure is based on agreement with the following
statement:
The routine use of dye-based pancolonic chromoendoscopy or virtual chromoendoscopy
with targeted biopsies for neoplasia surveillance in patients with longstanding colitis,
in the situation of quiescent disease activity and adequate bowel preparation, has
already been recommended by the ESGE Guideline on advanced imaging for detection and
differentiation of colorectal neoplasia [52 ]. Virtual chromoendoscopy has emerged as an attractive alternative to overcome the
laboriousness of dye-based chromoendoscopy. The current evidence showed no significant
difference between the two techniques for dysplasia detection [53 ]
[54 ]
[55 ].
Numerous academic studies, predominantly at tertiary centers, have demonstrated the
low yield of nontargeted biopsies for dysplasia detection [56 ]
[57 ]
[58 ]
[59 ]. In addition, nontargeted random biopsies cause a significant workload for both
endoscopists and pathologists. The value of continuing four-quadrant biopsies, both
in terms of effort and cost, has been questioned as their yield is so low compared
with targeted approaches, on the basis of both dysplasia detected per patient and
dysplasia detected per sample. However, the literature supports that, for certain
high risk subsets of IBD patients (i. e. primary sclerosing cholangitis), four-quadrant
or random biopsies may still have a role [60 ]
[61 ]. Therefore, when using chromoendoscopy for IBD surveillance, the use of targeted
biopsies only is recommended as an easily measurable quality indicator.
A minimum standard of ≥ 70 % may seem relatively low. However, it allows a different
strategy to be followed in a selected number of colonoscopies. For example, in high
risk patients with a family history of colonic neoplasia, a tubular-appearing colon,
or primary sclerosing cholangitis, where endoscopists may opt to take random biopsies
in addition to targeted biopsies, as suggested in the ESGE tissue sampling guideline
for the lower GI tract [30 ].
Although no significant learning curve was observed for the use of chromoendoscopy
[62 ], the working group members agreed that endoscopists should be adequately trained
according to the recently published ESGE curriculum [63 ].
Minor performance measure
Neoplasia detection rate
Description
Percentage of colonoscopies with at least one neoplastic lesion detected during surveillance
of longstanding colitis
Clinical category
Surveillance
Domain
Identification of pathology
Category
Process
Rationale
Neoplasia detection rate reflects adequate inspection of the bowel mucosa
Construct
Denominator : All surveillance colonoscopies in longstanding IBD patients
Numerator : Colonoscopies in the denominator in which at least one neoplastic lesion was identified
Exclusions : Patients with incomplete colonoscopy
Standards
Minimum standard: ≥ 8 %
Target standard: none set
Consensus agreement
89 %
PICO
3.4 (see Supporting information)
Evidence grading
Low
The acceptance of this performance measure is based on agreement with the following
statement:
Current surveillance strategies in IBD patients aim to identify dysplasia and prevent
progression to CRC. Interval cancers are significantly more frequent in IBD patients
compared with non-IBD patients and are most likely due to undetected or incompletely
resected dysplastic lesions [8 ]
[64 ]
[65 ]. While the correlation between the adenoma detection rate and the risk of developing
interval cancers is solid in a screening population [66 ]
[67 ], it is still debatable in IBD. Nevertheless, applying a neoplasia detection rate
as a performance measure for surveillance colonoscopy in IBD patients seems reasonable.
The neoplasia detection rate has already been incorporated into the ESGE curriculum
for optical diagnosis [63 ]. In the literature, neoplasia detection rates vary between 10 % and 26 % in surveillance
colonoscopies in longstanding IBD patients [53 ]
[62 ]
[68 ]. Current literature on neoplasia detection rates in longstanding IBD patients comes
mainly from academic services and it can be assumed that there will likely be differences
in the prevalence of dysplasia and treatment preferences between countries [69 ]
[70 ]. Furthermore, owing to improved treatment of IBD, the prevalence of neoplasia might
also fall and, with frequent surveillance, it seems unlikely that many dysplastic
lesions will be found in longstanding IBD patients. Therefore, the working group members
considered a minimum standard of ≥ 8 % achievable for the neoplasia detection rate
in surveillance colonoscopies in longstanding IBD patients. In addition, because of
the uncertainty of the prevalence and incidence in a nontertiary setting, this quality
indicator was qualified as a minor performance measure.
