Quality of colonoscopy reporting in community practice

Background

Quality endoscopy reporting is essential when community endoscopists perform colonoscopies for veterans who cannot be scheduled at a Veterans Administration (VA) facility.

Objective

To examine the quality of colonoscopy reports received from community practices and to determine factors associated with more complete reporting, by using national documentation guidelines.

Design

Cross-sectional analysis.

Setting

Reports submitted to the Durham VA Medical Center, Durham, North Carolina, from 2007 to 2008.

Patients

Subjects who underwent fee-basis colonoscopy.

Main Outcome Measurements

Scores created by comparing community reports with published documentation guidelines. Three scores were created, one for each category of information: Universal Elements (found on all endoscopy reports), Indication Elements (specific to the procedure indication), and Finding Elements (specific to examination findings).

Results

For the 135 included reports, the summary scores were Universal Elements, 57.6% (95% confidence interval [CI], 55%-60%); Indication Elements, 73.7% (95% CI, 69%-78%); and Finding Elements, 75.8% (95% CI, 73%-79%). Examples of poor reporting included patient history (20.7%), last colonoscopy date (18.0%), average versus high risk screening (32.0%), withdrawal time (5.9%), and cecal landmark photographs (45.2%). Only the use of automated reporting software was associated with more thorough reporting.

Limitations

Modest sample size, mostly male participants, frequent pathologic findings, limited geography, and lack of complete reporting by a minority of providers.

Conclusions

The overall completeness of colonoscopy reports was low, possibly reflecting a lack of knowledge of reporting guidelines or a lack of agreement regarding important colonoscopy reporting elements. Automated endoscopy software may improve reporting compliance but may not completely standardize reporting quality.

Abbreviations: ASGE, American Society for Gastrointestinal Endoscopy, CI, confidence interval, CO-RADS, colonoscopy reporting and data system, CORI, Community Outcomes Research Initiative, CPRS, computerized patient reporting system, EMR, electronic medical record, NCCRT, National Colorectal Cancer Roundtable, P-P, standardized normal probability, Q-Q, quantile-quantile, VA, Veterans Administration