Colorectal cancer (CRC) screening is capable of reducing CRC-related morbidity and
mortality. Colonoscopy is the reference standard to detect CRC, also providing the
opportunity to detect and resect its precursor lesions: colorectal polyps. Therefore,
colonoscopy is either used as a primary screening tool or as a subsequent procedure
after a positive triage test in screening programs based on non-invasive stool testing
or sigmoidoscopy. However, in both settings, colonoscopy is not fully protective for
the occurrence of post-colonoscopy CRCs (PCCRCs). Because most PCCRCs are the result
of colonoscopy-related factors, a high-quality procedure is of paramount importance
to assure optimal effectiveness of CRC screening programs. For this reason, at the
start of the Dutch fecal immunochemical test (FIT)-based screening program, quality
criteria for endoscopists performing colonoscopies in FIT-positive screenees, as well
as for endoscopy centers, were defined. In conjunction, an accreditation and auditing
system was designed and implemented. In this report, we describe the quality assurance
process for endoscopists participating in the Dutch national CRC screening program,
including a detailed description of the evidence-based quality criteria. We believe
that our experience might serve as an example for colonoscopy quality assurance programs
in other CRC screening programs.
Abbreviations:
ADR (adenoma detection rate), BBPS (Boston Bowel Preparation Scale), CIR (cecal intubation rate), CRC (colorectal cancer), CRCSP (colorectal cancer screening program), DOPS (direct observation of procedure or skills), FIT (fecal immunochemical testing), GCS (Gloucester Comfort Scale), MAP (mean number of adenomas per colonoscopy), MAP+ (mean number of adenomas per positive colonoscopy), PALGA (Pathological Anatomy National Automated Archive), PCCRC (post-colonoscopy colorectal cancer), PICI (performance indicator of colonic intubation), PSPDR (proximal serrated polyp detection rate), RCG (regional coordinating gastroenterologist), SP (serrated polyp), TCG (test coordinating gastroenterologist)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 accessOne-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:
Subscribe to Gastrointestinal EndoscopyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Global cancer statistics, 2012.CA Cancer J Clin. 2015; 65: 87-108
- Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.N Engl J Med. 2012; 366: 687-696
- Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.N Engl J Med. 1993; 329: 1977-1981
- Risk of progression of advanced adenomas to colorectal cancer by age and sex: estimates based on 840,149 screening colonoscopies.Gut. 2007; 56: 1585-1589
- Colorectal cancer screening: a global overview of existing programmes.Gut. 2015; 64: 1637-1649
- Random comparison of guaiac and immunochemical fecal occult blood tests for colorectal cancer in a screening population.Gastroenterology. 2008; 135: 82-90
- Screening for colorectal cancer: random comparison of guaiac and immunochemical faecal occult blood testing at different cut-off levels.Br J Cancer. 2009; 100: 1103-1110
- Screening for colorectal cancer: randomised trial comparing guaiac-based and immunochemical faecal occult blood testing and flexible sigmoidoscopy.Gut. 2010; 59: 62-68
- Participation and yield of colonoscopy versus non-cathartic CT colonography in population-based screening for colorectal cancer: a randomised controlled trial.Lancet Oncol. 2012; 13: 55-64
- Random comparison of repeated faecal immunochemical testing at different intervals for population-based colorectal cancer screening.Gut. 2013; 62: 409-415
- Real-time monitoring of results during first year of Dutch Colorectal Cancer Screening Program and optimization by altering fecal immunochemical test cut-off levels.Gastroenterology. 2017; 152 (767-75.e2)
- Definition and taxonomy of interval colorectal cancers: a proposal for standardising nomenclature.Gut. 2015; 64: 1257-1267
- Association of colonoscopy and death from colorectal cancer.Ann Internal Med. 2009; 150: 1-8
- Interval cancers after negative colonoscopy: population-based case-control study.Gut. 2012; 61: 1576-1582
- The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer.Gastroenterology. 2010; 139: 1128-1137
- Post-colonoscopy colorectal cancer: characteristics and predictive factors.Med Clin (Barc). 2018; 150: 1-7
- Rate and predictors of early/missed colorectal cancers after colonoscopy in Manitoba: a population-based study.Am J Gastroenterol. 2010; 105: 2588-2596
- Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis.Gastroenterology. 2007; 132: 96-102
- Postcolonoscopy colorectal cancers are preventable: a population-based study.Gut. 2014; 63: 957-963
- Clinical and molecular characteristics of post-colonoscopy colorectal cancer: a population-based study.Gastroenterology. 2016; 151 (870-8.e3)
- A comparison of tumour and host prognostic factors in screen-detected vs nonscreen-detected colorectal cancer: a contemporaneous study.Colorectal Dis. 2016; 18: 967-975
- Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. The National Polyp Study Workgroup.N Engl J Med. 1993; 328: 901-906
- Post-colonoscopy colorectal cancer (PCCRC) rates vary considerably depending on the method used to calculate them: a retrospective observational population-based study of PCCRC in the English National Health Service.Gut. 2015; 64: 1248-1256
- Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study.Gastroenterology. 2013; 144: 74-80.e1
- Chilton A. Rutter M. NHS Bowel Cancer Screening Program. Quality assurance guidelines for colonoscopy. NHS Cancer Screening Programmes, Sheffield2011
- Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme.Gut. 2012; 61: 1050-1057
- A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow?.Gut. 2004; 53: 277-283
National Institute for Public Health and the Environment. Protocol for the authorization and auditing of colonoscopy centers and endoscopists. National screening programme for bowel cancer, first version. The Netherlands; 2012.
National Institute for Public Health and the Environment. Protocol for the authorization and auditing of colonoscopy centers and endoscopists. National screening programme for bowel cancer, 5th version. The Netherlands; 2016 [in Dutch].
Dutch Colonoscopy Quality Assurance working group. Accreditation process of endoscopists. 2017 [in Dutch]. Available at: http://www.bevolkingsonderzoekoost.nl/custom3470/formulieren-overzicht.
- Development and validation of a novel method for assessing competency in polypectomy: direct observation of polypectomy skills.Gastrointest Endosc. 2011; 73 (1232-9 e2)
- Pathology databanking and biobanking in The Netherlands, a central role for PALGA, the nationwide histopathology and cytopathology data network and archive.Cell Oncol. 2007; 29: 19-24
- A novel colonoscopy reporting system enabling quality assurance.Endoscopy. 2014; 46: 181-187
- Requirements and standards facilitating quality improvement for reporting systems in gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.Endoscopy. 2016; 48: 291-294
- Expert opinions and scientific evidence for colonoscopy key performance indicators.Gut. 2016; 65: 2045-2060
- Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice.Gastroenterology. 2008; 135 (1899-906.e1)
- Colonoscopy and its complications across a Canadian regional health authority.Gastrointest Endosc. 2009; 69: 665-671
- Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications.Gastrointest Endosc. 2013; 77: 436-446
- Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer.Gastroenterology. 2011; 140: 65-72
- A new composite measure of colonoscopy: the Performance Indicator of Colonic Intubation (PICI).Endoscopy. 2018; 50: 40-51
- Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.Endoscopy. 2017; 49: 378-397
- Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia.Gastrointest Endosc. 2003; 58: 76-79
- A prospective study of factors that determine cecal intubation time at colonoscopy.Gastrointest Endosc. 2005; 61: 72-75
- The impact of poor bowel preparation on colonoscopy: a prospective single centre study of 10,571 colonoscopies.Colorectal Dis. 2007; 9: 745-748
- Colonoscopy quality begins with a clean colon.Endoscopy. 2012; 44: 639-640
- Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study.Gastrointest Endosc. 2005; 61: 378-384
- Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12,134 examinations (Berlin colonoscopy project 3, BECOP-3).Gut. 2013; 62: 236-241
- Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies.Gastrointest Endosc. 2013; 77: 381-389.e1
- The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research.Gastrointest Endosc. 2009; 69: 620-625
- Good is better than excellent: bowel preparation quality and adenoma detection rates.Gastrointest Endosc. 2015; 81: 691-699.e1
- Comprehensive validation of the Boston Bowel Preparation Scale.Gastrointest Endosc. 2010; 72: 686-692
- Impact of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire colonoscopy registry by using a standardized preparation-quality rating.Gastrointest Endosc. 2014; 80: 463-470
- Validated scales for colon cleansing: a systematic review.Am J Gastroenterol. 2016; 111 (quiz 205): 197-204
- Quantification of adequate bowel preparation for screening or surveillance colonoscopy in men.Gastroenterology. 2016; 150 (quiz e14-15): 396-405
- Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline.Endoscopy. 2013; 45: 142-150
- Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.N Engl J Med. 2006; 355: 2533-2541
- Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos).Gastrointest endosc. 2011; 74: 128-134
- UK key performance indicators and quality assurance standards for colonoscopy.Gut. 2016; 65: 1923-1929
- Quality indicators for colonoscopy and the risk of interval cancer.N Engl J Med. 2010; 362: 1795-1803
- Adenoma detection rate and risk of colorectal cancer and death.N Engl J Med. 2014; 370: 1298-1306
- Quality indicators for colonoscopy.Gastrointest Endosc. 2015; 81: 31-53
- Quality indicators for colonoscopy.Am J Gastroenterol. 2006; 101: 873-885
- Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience.Gastrointest Endosc. 2014; 79: 448-454
- adenoma and polyp detection rates in colonoscopy according to indication.Gastroenterol Res Pract. 2017; 2017: 7207595
- Differences in detection rates of adenomas and serrated polyps in screening versus surveillance colonoscopies, based on the new hampshire colonoscopy registry.Clin Gastroenterol Hepatol. 2013; 11: 1308-1312
- Defining benchmarks for adenoma detection rate and adenomas per colonoscopy in patients undergoing colonoscopy due to a positive fecal immunochemical test.Am J Gastroenterol. 2016; 111: 1743-1749
- Correlation between adenoma detection rate in colonoscopy- and fecal immunochemical testing-based colorectal cancer screening programs.United European Gastroenterol J. 2017; 5: 255-260
- Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.Endoscopy. 2017; 49: 270-297
- Endoscopic four quadrant tattoo for the identification of colonic lesions at surgery.Gastrointest endosc. 1991; 37: 56-58
- Post-colonoscopy complications: a systematic review, time trends, and meta-analysis of population-based studies.Am J Gastroenterol. 2016; 111: 1092-1101
Lin JS, Piper MA, Perdue LA, et al. Screening for colorectal cancer: A systematic review for the U.S. Preventive Services Task Force. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. Rockville, MD: 2016.
- Colorectal cancer screening: systematic review of screen-related morbidity and mortality.Cancer Treat Rev. 2017; 54: 87-98
Dutch Registration of Complications in Endoscopy (DRCE). 2017. Available at: https://dica.nl/drce/home.
Nederlandse Vereniging van Maag- Darm- en Leverartsen (Dutch Society of Gastroenterologists). Dutch guideline for sedation practices outside outside of the operation room. 2010 [in Dutch].
- Sedation practice and comfort during colonoscopy: lessons learnt from a national screening programme.Eur J Gastroenterol Hepatol. 2015; 27: 741-746
- Patient comfort and quality in colonoscopy.World J Gastroenterol. 2013; 19: 2355-2361
- Development and validation of a nurse-assessed patient comfort score for colonoscopy.Gastrointest endosc. 2013; 77: 255-261
Dutch Gastrointestinal Endoscopy Audit (DGEA). 2017. Available at: https://dica.nl/drce/home.
- Microsatellite instability in interval colon cancers.Gastroenterol. 2006; 131: 1700-1705
- A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy.Gastroenterology. 2009; 136: 832-841
- Interval colorectal cancer incidence among subjects undergoing multiple rounds of fecal immunochemical testing.Gastroenterology. 2017; 153: 439-447
- Serrated lesions of the colorectum: review and recommendations from an expert panel.Am J Gastroenterol. 2012; 107: 1315-1329
- Classification of colorectal cancer based on correlation of clinical, morphological and molecular features.Histopathology. 2007; 50: 113-130
- The serrated pathway to colorectal carcinoma: current concepts and challenges.Histopathology. 2013; 62: 367-386
- CIMP status of interval colon cancers: another piece to the puzzle.Am J Gastroenterol. 2010; 105: 1189-1195
- Colorectal-cancer incidence and mortality after screening.N Engl J Med. 2013; 369: 2355
- Endoscopic features of sessile serrated adenomas: validation by international experts using high-resolution white-light endoscopy and narrow-band imaging.Gastrointest Endosc. 2013; 779: 16-24
- The proximal serrated polyp detection rate is an easy-to-measure proxy for the detection rate of clinically relevant serrated polyps.Gastrointest Endosc. 2015; 82: 870-877
- Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clinical gastroenterology and hepatology.Clin Gastroenterol Hepatol. 2011; 9: 42-46
- Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time.Gastrointest Endosc. 2013; 77: 617-623
- Detection rate and predictive factors of sessile serrated polyps in an organised colorectal cancer screening programme with immunochemical faecal occult blood test: the EQuIPE study (Evaluating Quality Indicators of the Performance of Endoscopy).Gut. 2017; 66: 1233-1240
- A new composite measure of colonoscopy: the Performance Indicator of Colonic Intubation (PICI).Endoscopy. 2018; 50: 40-51
Article info
Publication history
Published online: September 18, 2018
Accepted:
September 10,
2018
Received:
May 31,
2018
Footnotes
The Dutch Colonoscopy Quality Assurance working group further consists of:
M. van Haastert,a J.J. Keller,b A.D. Koch,c J.J. Koornstra,d M.C.A. van Kouwen,e A. Masclee,f M.W. Mundt,g R.J. de Ridder,f A. van der Sluys-Veer,h M. van Wiereni
aDepartment of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
bDepartment of Gastroenterology and Hepatology, Haaglanden MC, The Hague, the Netherlands
cDepartment of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
dDepartment of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
eDepartment of Gastroenterology and Hepatology, University Medical Center St. Radboud, Radboud University Nijmegen, Nijmegen, the Netherlands
fDepartment of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht University, Maastricht, the Netherlands
gDepartment of Gastroenterology and Hepatology, Flevo Hospital, Almere, the Netherlands
hDepartment of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
iNational Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
DISCLOSURE: Dr Dekker received research equipment on loan from Olympus and FujiFilm, an unrestricted research grant from FujiFilm and consulting fees from Olympus, FujiFilm, and Tillots. All other authors disclosed no financial relationships relevant to this publication.
Identification
Copyright
© 2019 by the American Society for Gastrointestinal Endoscopy
