Perspectives| Volume 84, ISSUE 3, P507-511, September 2016

A new quality indicator of colonoscopy: caveat emptor

  • Thomas F. Imperiale
    Reprint requests: Thomas F. Imperiale, MD, Regenstrief Institute, 1101 West 10th Street, Indianapolis, Ind 46202.
    Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA

    Regenstrief Institute, Inc., Indianapolis, Indiana, USA

    Center for Innovation, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
    Search for articles by this author
  • Douglas K. Rex
    Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
    Search for articles by this author
      Quality indicators of health care should measure endpoints that closely reflect patient outcomes. Further, they should be feasible to measure accurately in clinical practice and demonstrate evidence of variable performance. An additional important consideration is the potential for a candidate quality indicator to distort provider behavior in ways that could adversely affect patient outcomes or costs of care or that could be gamed, where the target measure is achieved but without reflecting high-quality care. “Gaming” in reference to quality indicators refers to behaviors that help satisfy the target set for the indicator but do not improve and are likely to detract from optimal or the most cost-effective patient care.


      ADR (adenoma detection rate), ASA (American Society of Anesthesiology), ASC (ambulatory surgery center), HCUP (Healthcare Cost and Utilization Project), HOPD (hospital outpatient department), RSHVR (risk standardized hospital visit rate), WT (withdrawal time)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Rex D.K.
        • Bond J.H.
        • Winawer S.
        • et al.
        Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.
        Am J Gastroenterol. 2002; 97: 1296-1308
        • Kaminski M.F.
        • Regula J.
        • Kraszewska E.
        • et al.
        Quality indicators for colonoscopy and the risk of interval cancer.
        N Engl J Med. 2010; 362: 1795-1803
        • Corley D.
        • Jensen C.D.
        • Marks A.R.
        • et al.
        Adenoma detection rate and risk of colorectal cancer and death.
        N Engl J Med. 2014; 370: 1298-1306
        • Wang H.S.
        • Pisegna J.
        • Modi R.
        • et al.
        Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance.
        Gastrointest Endosc. 2013; 77: 71-78
        • Rex D.K.
        • Cutler C.S.
        • Lemmel G.T.
        • et al.
        Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies.
        Gastroenterology. 1997; 112: 24-28
        • Barclay R.L.
        • Vicari J.J.
        • Doughty A.S.
        • et al.
        Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.
        N Engl J Med. 2006; 355: 2533-2541
        • Sanchez W.
        • Harewood G.C.
        • Petersen B.T.
        Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy.
        Am J Gastroenterol. 2004; 99: 1941-1945
        • Fatima H.
        • Rex D.K.
        • Rothstein R.
        • et al.
        Cecal insertion and withdrawal times with wide-angle versus standard colonoscopes: a randomized controlled trial.
        Clin Gastroenterol Hepatol. 2008; 6: 109-114
        • Butterly L.
        • Robinson C.M.
        • Anderson J.C.
        • et al.
        Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.
        Am J Gastroenterol. 2014; 109: 417-426
        • Shaukat A.
        • Rector T.S.
        • Church T.R.
        • et al.
        Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy.
        Gastroenterology. 2015; 149: 952-957
        • Sawhney M.S.
        • Cury M.S.
        • Neeman N.
        • et al.
        Effect of institution-wide policy of colonoscopy withdrawal time > or = 7 minutes on polyp detection.
        Gastroenterology. 2008; 135: 1892-1898
        • Barclay R.L.
        • Vicari J.J.
        • Greenlaw R.L.
        Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy.
        Clin Gastroenterol Hepatol. 2008; 6: 1091-1098
        • Coe S.
        • Crook J.E.
        • Diehl N.N.
        • et al.
        An endoscopic quality improvement program (EQUIP) improves detection of colorectal adenomas.
        Am J Gastroenterol. 2013; 108: 219-226
        • Rex D.K.
        • Schoenfeld P.S.
        • Cohen J.
        • et al.
        Quality indicators for colonoscopy.
        Gastrointest Endosc. 2015; 81: 31-53
        • Ranasinghe I.
        • Parzynski C.S.
        • Searfoss R.
        • et al.
        Differences in colonoscopy quality among facilities: development of a post-colonoscopy risk-standardized rate of unplanned hospital visits.
        Gastroenterology. 2016; 150: 103-113
        • Metz A.J.
        • Bourke M.J.
        • Moss A.
        • et al.
        Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions.
        Endoscopy. 2011; 43: 506-511
        • Burgess N.G.
        • Metz A.J.
        • Williams S.J.
        • et al.
        Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions.
        Clin Gastroenterol Hepatol. 2014; 12: 651-661.e1-3
        • Liaquat H.
        • Rohn E.
        • Rex D.K.
        Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions.
        Gastrointest Endosc. 2013; 77: 401-407
        • Kwon M.J.
        • Kim Y.S.
        • Bae S.I.
        • et al.
        Risk factors for delayed post-polypectomy bleeding.
        Intest Res. 2015; 13: 160-165
        • Choung B.S.
        • Kim S.H.
        • Ahn D.S.
        • et al.
        Incidence and risk factors of delayed postpolypectomy bleeding: a retrospective cohort study.
        J Clin Gastroenterol. 2014; 48: 784-789
      1. Keswani RN, Law R, Ciolino JD, et al. Adverse events after surgery for benign colon polyps are common and associated with increased length of stay and costs. Gastrointest Endosc. Epub 2016 Mar 12.

        • Midura E.F.
        • Hanseman D.
        • Davis B.R.
        • et al.
        Risk factors and consequences of anastomotic leak after colectomy: a national analysis.
        Dis Colon Rectum. 2015; 58: 333-338
        • Swan M.P.
        • Bourke M.J.
        • Alexander S.
        • et al.
        Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos).
        Gastrointest Endosc. 2009; 70: 1128-1136
        • Law R.
        • Das A.
        • Gregory D.
        • et al.
        Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis.
        Gastrointest Endosc. 2016; 83: 1248-1257
        • Jayanna M.
        • Burgess N.G.
        • Singh R.
        • et al.
        Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions.
        Clin Gastroenterol Hepatol. 2016; 14: 271-278.e1-2
        • Ikard R.W.
        • Snyder R.A.
        • Roumie C.L.
        Postoperative morbidity and mortality among Veterans Health Administration patients undergoing surgical resection for large bowel polyps (bowel resection for polyps).
        Dig Surg. 2013; 30: 394-400
        • Tran A.H.
        • Man Ngor E.W.
        • Wu B.U.
        Surveillance colonoscopy in elderly patients: a retrospective cohort study.
        JAMA Intern Med. 2014; 174: 1675-1682