Quality indicators for gastrointestinal endoscopic procedures

Defining measurements and identifying quality standards in the delivery of colonoscopic care is a major priority for the nation's leading gastrointestinal endoscopic healthcare association.

The American Society for Gastrointestinal Endoscopy (ASGE) recently identified objective measures related to colonoscopy. Using these guidelines and measurements, endoscopists can assess and improve their performance when delivering patient care. "Quality Indicators for Colonoscopy" was published as a supplement to the April 2006 issue of GIE: Gastrointestinal Endoscopy, as part of a collection of quality indicators documents.

"Setting quality standards for colonoscopy is a foremost concern for ASGE. These standards will assist in the fight to prevent colon cancer and for successful diagnosis and treatment of a wide variety of digestive health conditions," said Gary W. Falk, MD, ASGE president and Professor of Medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

Colonoscopy is widely accepted as the most effective method for screening the colon for neoplasia (newly formed, abnormal tissue which can be benign or malignant) in patients over the age of 50 and in younger patients with an increased risk for colorectal cancer. It is considered the preferred method to evaluate the colon in adult patients with bowel symptoms, iron deficiency anemia, abnormal radiographic studies of the colon, positive colorectal screening tests, postpolypectomy and post cancer resection surveillance, surveillance in inflammatory bowel disease, and those with suspected masses. In addition, colonoscopy is the only therapeutic technique which can remove a potentially precancerous growth during the screening procedure.

Effective colonoscopy includes careful and thorough mucosal inspection in order to prevent colon cancer and reduce cancer mortality. As outlined in the documents published by ASGE, quality indicators have been identified to measure the performance of colonoscopy in order to achieve better outcomes. The document also grades the level of evidence in support of each quality indicator. Quality indicators for three stages of colonoscopy were described: Preprocedure, Intraprocedure and Postprocedure.

Preprocedure quality indicators for colonoscopy address several considerations that impact the endoscopic team and the patient before the administration of sedation or insertion of the endoscope. Common issues include:

• Proper Indication -- Endoscopy is indicated when the information gained or the therapy provided will help the patient.
• Informed Consent -- Consent should be obtained and documented for the procedure and any sedation or analgesia provided except in emergency situations. The consent should address all common complications, including bleeding, perforation, missed diagnosis and sedation-related complications.
• Preparation -- Clear documentation of the quality of the bowel preparation is essential to the effectiveness of the screening. Measures such as excellent, good, fair or poor indicate levels of clarity with which the

bowel can be viewed. Poor bowel preparation is a major impediment to the effectiveness of colonoscopy.

Additionally, other measurable areas include the use of surveillance of ulcerative colitis and Crohn's colitis, and application of recommended postpolypectomy and post-cancer surveillance intervals. These areas represent distinct points where issues can be evaluated and quantified.

Intraprocedure quality measures include three major areas to assess the thoroughness of the colonoscopy procedure. These include:

1. Cecal intubation. Cecal intubation is critical to a complete examination. Visualization of the cecum by notation of landmarks and photodocumentation of landmarks should be documented in every procedure. Cecal intubation is defined as passage of the colonoscope tip to a point proximal to the ileocecal valve so that the entire cecal caput, including the medial wall of the cecum between the ileocecal valve and appendiceal orifice, is visible. The need for cecal intubation is based on the persistent finding that a substantial fraction of colorectal neoplasms are located in the proximal colon, including the cecum. Visualization of this area is paramount to the prevention of colon cancer.

"Being confident that you are truly looking at the cecum takes a great deal of expertise and practice. This is why photodocumentation of key landmarks during the procedure is crucial," said Douglas O. Faigel, MD, Co-chair of the ASGE Taskforce on Quality in Endoscopy.

2. Detection of adenomas. Detection of adenomatous polyps (benign premalignant tumors) in asymptomatic patients undergoing screening colonoscopy is an area where expertise is critical. Studies show that colonoscopy findings by endoscopists and gastroenterologists are far more accurate than those conducted by internists or non-gastroenterologists. Suboptimal performance of colonoscopy by some practitioners, as evidenced by variable performance, may be a fundamental obstacle to colonoscopy's ability to provide protection against colorectal cancers. Higher adenoma detection rates are directly related to longer examinations, superior examination of mucosa proximal to folds and flexures, better colonic distention, and better cleaning of debris and fluid from the colon.

3. Withdrawal time. The amount of time spent examining the colon during withdrawal of the colonoscope can be an appropriate quality indicator as longer times are associated with greater detection of neoplastic lesions. With prevalence rates of adenomas in screening colonoscopies at more than 25% in men and 15% in women more than 50 years old, withdrawal time was identified as an appropriate secondary measure of quality in instances of low detection rates of adenomas. To measure withdrawal time, the time at which the cecum is reached and the time at which the scope is withdrawn from the anus must be noted. Physicians who spent longer than six minutes of withdrawal time had a significantly increased detection rate of adenomas compared with those who averaged less than six minutes.

Other intraprocedure areas include the collection of biopsy samples from patients with chronic diarrhea, as well as from those patients undergoing ulcerative colitis and Crohn's disease surveillance. Also, the determination of when to remove pedunculated polyps less than 2cm in size endoscopically rather than surgically is a measurable standard.

Postprocedure documentation and recording of complications are aspects of colonoscopy that should be measured and followed. A complete and accurate report, describing the procedure and findings, must be completed immediately after the procedure and include photodocumentation of abnormalities and identification of any biopsy specimens obtained. Complications can be identified immediately or may be delayed. It is incumbent upon the physician to monitor complications and provide reporting and follow-through.

Measurable complications include:

• Perforation by procedure type -- Perforation is the most serious complication in the short term during or after colonoscopy. Considering all available data, perforation rates greater than 1 in 500 overall or greater than 1 in 1,000 in screening patients should raise concerns as to whether inappropriate practices are the cause.
• Postpolypectomy bleeding and management -- Bleeding is the most common complication of polypectomy. Bleeding can either be immediate (during the procedure) or delayed. Endoscopic series suggests that the overall rate for postpolypectomy bleeding should be less than 1%. For polyps larger than 2 cm, particularly in the proximal (or right sided) colon, bleeding rates may exceed 10%. More than 90% of postpolypectomy bleeding can be managed nonoperatively. Rebleeding seldom occurs after postpolypectomy bleeding has either stopped spontaneously or from endoscopic therapy.

The purpose of the Quality Indicators supplement is to identify objective measures that could be used to define high-quality endoscopic services for the diagnosis and treatment of diseases and conditions of the digestive tract. It is anticipated that reimbursement for endoscopy will soon be linked to reporting and performance on quality measures.

"As with all medical specialties, we anticipate that reimbursement for endoscopy will soon be linked to performance against quality measures. As the experts in endoscopy, we must proactively define those quality measures. We cannot leave the standards-setting to an administrative or regulatory agency with little experience in the practice of endoscopy. It is our responsibility to ensure high-quality care for our patients," said David J. Bjorkman, MD, MSPH, FASGE, ASGE past president and Dean, University of Utah School of Medicine and Executive Medical Director, University of Utah Medical Group.

The newly developed quality indicators assume that specialty training and credentialing in gastrointestinal endoscopy has taken place before a practitioner begins the practice of endoscopy. ASGE has guidelines specifically addressing standards for training, assessing competence and granting privileges to perform endoscopy (available online at www.asge.org).