Ambulatory Endoscopy Clinic Day

Quality of Care: Procedure Related Issues

Nancy Baxter, MD PhD

Objectives

To review the concept of “quality of care”

To discuss the growing focus on quality of colonoscopy

To apply concepts of quality of care to procedural related issues for colonoscopy

To describe current quality indicators and standards for colonoscopy

Quality of Care

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Institute of Medicine

El-Jardali Healthcare Quarterly 2005; 40-8.

Material Resources, Human Resources, Institutional Organization

Care Delivered

Health Status

good structure increases the likelihood of good process, and

good process increases the likelihood of good outcomes

Why Now?

Dramatic increase in rate of colonoscopy in Ontario

Change in indication for colonoscopy Increase use for

screeningICES 2004, Use of Large Bowel Procedures in Ontario

Screening Asymptomatic,

healthy individuals with relatively low risk of disease

Benefits outweigh risks when procedure is high quality

High Quality

Maximized

Minimized

Screening Asymptomatic,

healthy individuals with relatively low risk of disease

Benefits outweigh risks when procedure is high quality

Risks may outweigh benefits when procedure is poor quality

Poor Quality

Less Effective

More Complications

Why Endoscopy? Expensive procedure Providers tend to be

VERY high volume Administrative data

can produce useful metrics

Emerging understanding of limitations

Evidence of meaningful variation at the provider level

Limitations of Colonoscopy Interval cancer

Rapidly growing Missed neoplasia Incompletely resected

adenoma

Estimated in administrative data based on timing of colonoscopy More than 6 months Less than 36 months

Ontario DataRates of new or missed cancers

evaluatedDesign: Population-based cohortStudy period: 4/1/97-3/31/02Study population: ≥ 20 yr with a

new diagnosis of CRC12,487 persons with a new CRC who

had colonoscopy inserted to the site of the CRC within 3 yr prior to the diagnosis

Findings

Right-sided: 195/3,288 (5.9%)Transverse: 43/777 (5.5%)Splenic flexure/desc’g: 15/710 (2.1%)Rectal or sigmoid: 177/7,712 (2.3%)

430/12,487 (3.4%)

Increased risk: older age, diverticular disease, right-sided or transverse CRC, internist/FP, non-hospital colonoscopy

Bressler B et al. Gastroenterology 2007;132:96-102.

Missed vs. New Miss rates from tandem colonoscopy

studies 1cm adenoma – 0% to 6% 6-9mm adenoma – 12%-13% < 5mm adenoma 15%-27%

Colonoscopy vs. CT colonography Centres of excellence for CT demonstrate miss

rates for > 1cm of 12-17% Other studies report much lower rates

Faigel et al. Gastrointestinal Endoscopy 2006; 63s

Baxter Ann Int Med 2009; 150:1-8

Cases

Diagnosis of CRC between Jan 1996 through Dec 2001 from OCR

No previous diagnosis of CRC Eligible for OHIP from 1992 to death

At least 4 years of information on history of endoscopy

Age 52-89 Screen eligible range for at least 2 years

Died of CRC by Dec 2003 Last mortality data available

Controls

Selected from Registered Persons Database Eligible for OHIP 1992 through 2003

Matched to case for Geographic location Sex Income quintile Calendar year of birth

Referent date assigned

Determination of Exposure

Colonoscopy (any attempted) Z555 – colonoscopy to

descending colon

Colonoscopy (complete) Z555 – colonoscopy to

descending colon plus E747 – to cecum or E705 – to

terminal ileum

> 6 months from diagnosis

Primary Site

1.0 (referent)

0.63(0.49-0.81)

0.33(0.28-0.39)

Left

0.90(0.73-1.10)

0.99 (0.86-1.14)

Complete

1.0 (referent)

1.0 (referent)

No

0.91(0.61-1.35)

1.35(1.07-1.69)

Incomplete

Colonoscopy

UnknownRightVariable

Procedural FactorsAccess Timeliness Appropriate use

Other Adequate consent process Patient tolerance and

satisfaction Quality reporting,

recommendations and feedback

Technical Complete colonic

assessment Completion rate Quality of Preparation Quality of Inspection

Adenoma detection Minimal Complications

Completion Rate

Recommendation >90% all colonoscopies >95% for screening Exclude poor prep from

denominator > 97% completion

rate reported in screening studies

Documentation Verbal Pictorial

Faigel et al. Gastrointestinal Endoscopy 2006; 63s

Ontario Patients age 50-74 331,608 colonoscopies performed between

1999-2003 13% were incomplete Factors affecting rate

Age: OR 1.20 per 10-year increment (95% CI=1.18-1.22)

Female sex: OR 1.35 (95% CI: 1.30-1.39) History of prior abdominal surgery: OR 1.07

(95% CI: 1.05-1.09) or prior pelvic surgery: OR 1.04 (95% CI: 1.01-1.06).

Shah Gastroenterology 2007; 132: 2297-303

Factors Affecting Completion

Wells BMC Gastroenterol. 2007; 7: 19

Quality of Preparation % with good

preparation Patient factors

Elderly Socioeconomically

deprived

Modifiable factors Split dose

preparations Timing of

colonoscopy

Quality of Inspection

Barclay NEJM 2006; 355:2533-41

How to Measure 6 minute withdrawal time

has been suggested as quality measure

Patients with no adenoma detected

If implemented should be at the PROVIDER and not patient level

Start recording withdrawal time Feedback May be mandated in

future

Adenoma Detection ASGE/ACG task force

recommendations Screening colonoscopy

over age 50 >25% men >15% women

Some studies report substantially higher rates

Influenced by age, sex, family history

Provider Variation Single institution study All colonoscopy between 1999-2004 9 endoscopists and 10,034 procedures Range of adenoma detection for patients

> 50 Any adenoma: 15.5% - 41.1% At least two adenomas: 4.9% - 20.0% At least one adenoma > 1.0 cm: 1.7-6.2%

Range of adenomas detected per colonoscopy by endoscopist: 0.21-0.86

Chen Am J Gastro 2007; 102:856-201

Bressler Gastroenterology 2007; 136; 96-102

Complications

Serious ComplicationsBC, Alberta, Ontario, Nova ScotiaPopulation 50-75 yr: 4.6 millionPersons 50-75 yrs who underwent

outpatient colonoscopy between 4/1/2002 and 3/31/2003

Outcome: Bleeding and perforation requiring admission within 30 days of colonoscopy

Rabeneck et al. Gastroenterology 2008;135:1899-1906

Results97,091 persons had an outpatient

colonoscopy from 4/1/2002 to 3/31/2003

Bleeding 1.64/1000 Perforation 0.85/1000 Death 0.074/1000 or 1/14,000 Risk factors: increased age, male sex,

polypectomy, volume < 283/yr

Current Standards

and Indicators

Current Quality Indicators

Current Quality Indicators

Germany

Gastroenterology board license > 200 colonoscopies and > 50

polypectomies in past 2 years Adequate technical equipment for

resuscitation and infection control monitoring

> 200 colonoscopies documented by photo per year

> 10 polypectomies with histology per year

United States

United States

United States

Summary System-wide drive to

assess, monitor and improve quality Endoscopic procedures

ideal target Multiple procedural

factors are important Meaningful and fair

indicators difficult to develop

Current standards unlikely to have impact

Recommendations Understand your

practice Completion rate % poor preparation Withdrawal time Adenoma detection

rate

Consider undertaking a QI project yearly based on your data