A Quality Colonoscopy: Are You Providing One?

Robert P Yatto MDCumberland Medical CenterCrossville, Tennessee

Quality Colonoscopy Patient Perspective Pre 1999-2001 era

1. It was really quick!2. It didn’t hurt!3. It didn’t hurt!4. It didn’t hurt!5. It didn’t hurt!

Quality Colonoscopy Patient Perspective Post 1999-2001 era

1. My doctor had a good withdrawal time2. My doctor finds polyps in over 1/3 of his patients3. My doctor reaches the cecum 95% of the time4. It didn’t hurt!

1999-2001?

1999 Institute of Medicine (IOM) published “To ERR is Human: Building a Safer Health System”

2001 IOM report “Crossing the Quality Chasm: A New Health System for 21st Century”

Quality Colonoscopy Gastroenterologist Perspective Pre 2006

1. Prep was Excellent2. It was quick!3. Patient was quiet (It didn’t hurt)

Quality Colonoscopy Gastroenterologist Perspective Post 2006

1. Used ASGE AUGE guideline indication for colonoscopy

2. Risk assessment performed prior to exam3. Cecal intubation with photo documentation4. Withdraw time > 6 minutes on a negative

screening exam5. Etc.

Measuring the Quality of Endoscopy

“…It becomes clear that we have no reliable way to distinguish a high-quality endoscopic procedure done by a trained endoscopist from a procedure performed by an inadequately trained provider. Fortunately, adverse events are too rare to track as a meaningful indicator of quality… We need objective, practical ways to grade our performance.”

John W. Popp, MD FACGDavid J. Bjorkman, M.D., MSPH

Measuring the Quality of Endoscopy

“The ASGE and ACG recognize that if we do not develop evidence-based quality measures, an administrative or governmental agency without experience or insight into the practice of endoscopy will define these measures for us.”

John W. Popp, MD FACGDavid J. Bjorkman, M.D., MSPH

How Good Is Your Colonoscopy?

For many years doctors and patient thought colonoscopies, the popular screening test for colorectal cancer, were all but infallible. Have a colonoscopy, get any precancerous polyps removed, and you should almost never get colon cancer……And now a Canadian study, published Tuesday in journal Annals……found the test much less accurate than anyone expected.

New York Times December 16, 2008“Colonoscopies Miss Many Cancers, Study Finds”

Variance in Protection Possible Explanations

Incomplete exams Missed lesions Suboptimal prep Biologic differences Operator factors

41% by general surgeons42% by internist/family practice16% by gastroenterologists

Clinical Gastroenterology Hepatology 2008; 6:1117-1121

Quantity vs. Quality

Increase volume in response to decreased reimbursement

Production pressure can adversely impact outcomes

Be flexible in scheduling Document quality and benchmark

Gastroenterology 2008; 135:1842-1844

Production Pressure in Endoscopy: Balancing Quantity and Quality – Lawrence B. Cohen

Quantity: A Changing Climate

The Past

Pre 2001

The Present

2002-2009

The Future

2009 +

Provider picked data to disclosePublic data supported provider reputation

Provider requested to disclose data in selected areasPublic data supported provider reputation in areas selected by payer

All data available to public?Data support provider reputation only if superior performance in most if not all areas

Quality indicators for Colonoscopy

Appropriate indication Informed consent obtained

including risks Use of recommended

polypectomy and post cancer resection surveillance intervals

Use of recommended IBD surveillance intervals

Documentation of prep quality

Quality indicators for Colonoscopy

Cecal intubation rate with photo documentation- appendiceal orifice- ileocecal valve- terminal ileum- >90% overall > 95% screening

Rate of detection of adenomas in screening

Withdraw time documentation Biopsies obtained in patients

with diarrhea

Quality indicators for Colonoscopy

Number and description of biopsy samples in IBD surveillance (32)

Polyps < 2 cm resected or documented unresectability

Incidence of perforation by procedure type (all indications vs screening) is measured- all 0.002- screening 0.001

Incidence of post-polypectomy bleeding is measured

Post-polypectomy bleeding managed non-operatively

Quality indicators for Colonoscopy

Colon WD Time

“In this study with a mean baseline WT > 12 min, there was no detectable association between WT and risk of future neoplasia. The medial center-level WT was positively correlated with adenoma detection. Therefore, above a certain threshold, WT may no longer be an adequate quality measure for screening colonoscopy.”

Gellad et al, Am Jnl Gastro Aug 2010

Colonoscopy Withdrawal Time and Risk of Neoplasia at 5 Years: Results From VA Cooperative Studies Program 380.

Conclusion

Quality indicators for Colonoscopy

Candidate Indicators to Define Quality

1. Cecal intubation rate…quality vs. competence???- 95% with photo documentation

2. Adenoma detection rate- Equal to or greater than 25% in men- Equal to or greater than 15% in woman

3. Post-polypectomy surveillance- Overuse/underuse

Hewett, Rex AM Jnl Gastro Sept 2010

The future is now. Start reporting. The future will change. Be prepared for it.

Robert P Yatto MDCumberland Medical CenterCrossville, Tennessee