Advertisement

Colonoscopy quality: if you cannot measure it, you cannot improve it

  • Nastazja D. Pilonis
    Affiliations
    Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
    Department of Gastroenterology, Hepatology, and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
    MRC Cancer Unit, University of Cambridge, Cambridge, UK
    Search for articles by this author
  • Michal F. Kaminski
    Affiliations
    Department of Cancer Prevention and Department of Oncological Gastroenterology, The Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
    Department of Gastroenterology, Hepatology, and Oncology, Medical Center for Postgraduate Education, Warsaw, Poland
    Institute of Health and Society, University of Oslo, Oslo, Norway
    Search for articles by this author

      Abbreviations:

      ADR (adenoma detection rate), DGEA (Dutch Gastrointestinal Endoscopy Audit)
      Over the past 2 decades, numerous studies have shown the fundamental importance of colonoscopy quality in the fight against colorectal cancer. As a result, multiple colonoscopy quality improvement initiatives have been launched. But how do we know whether we are improving? Without unbiased measurements, we are constantly stuck guessing. A belief popularized by management mastermind Peter Drucker, with roots in the work of American quality improvement specialist Edwards Deming, may be a good ethos regarding repetitive quality measurement. If you cannot measure it, you cannot improve it. Developing audit and feedback mechanisms for evaluating endoscopist and service performance has been recognized by the United States and European endoscopy societies as a priority for all endoscopy units.
      • Kaminski M.F.
      • Thomas-Gibson S.
      • Bugajski M.
      • et al.
      Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.
      • Rex D.K.
      • Schoenfeld P.S.
      • Cohen J.
      • et al.
      Quality indicators for colonoscopy.
      • Rutter M.D.
      • Senore C.
      • Bisschops R.
      • et al.
      The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures.
      • Rees C.J.
      • Thomas-Gibson S.
      • Bourke M.J.
      • et al.
      Managing underperformance in endoscopy: a pragmatic approach.
      In this issue of Gastrointestinal Endoscopy, de Neree tot Babberich et al
      • de Neree tot Babberich M.P.M.
      • Ledeboer M.
      • van Leerdam M.E.
      • et al.
      Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement.
      describe the implementation process of an automated colonoscopy audit registry in the Netherlands and the first results from its subsequent analysis. Over a 3-year period between January 2016 and March 2019, colonoscopy data were collected from 48 hospitals voluntarily participating in the Dutch Gastrointestinal Endoscopy Audit (DGEA). Throughout this period, 313,511 coloscopies of 275,017 patients were registered with less than 1% missing value per variable recorded. The data registered included patient age and gender, indication for colonoscopy, American Society of Anesthesiologists score, Boston Bowel Preparation Score, cecal intubation, and polyp detection rate (adenoma detection rate whenever possible) for colonoscopies in which fecal immunochemical test results were positive. The first results of the audit showed high overall quality standards but with significant variations between participating hospitals and by certain categories of indications for colonoscopy. The DGEA fulfills the majority of requirements and standards that facilitate quality improvement for reporting systems in GI endoscopy.
      • Bretthauer M.
      • Aabakken L.
      • Dekker E.
      • et al.
      Requirements and standards facilitating quality improvement for reporting systems in gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) position statement.
      At least 4 unique characteristics of this audit should be highlighted (Fig. 1).
      Figure thumbnail gr1
      Figure 1Four key features of the Dutch Gastrointestinal Endoscopy Audit.
      First, to minimize double data entry and mismatches between endoscopic and pathologic data, the DGEA developed an automated data extraction process. This tool combined data from several different endoscopy reporting systems and a nationwide pathology registry. One major difficulty with implementing colonoscopy quality measurement is accurately recording an endoscopist’s adenoma detection rate (ADR), an independent predictor for a patient’s risk of postcolonoscopy colorectal cancer.
      • Kaminski M.F.
      • Regula J.
      • Kraszewska E.
      • et al.
      Quality indicators for colonoscopy and the risk of interval cancer.
      ,
      • Corley D.A.
      • Jensen C.D.
      • Marks A.R.
      • et al.
      Adenoma detection rate and risk of colorectal cancer and death.
      Calculating ADR requires data collection from the endoscopic procedure, pathologic analysis of tissue samples, and matching these data together. This seemingly straightforward process is a significant challenge. Even when pathologic data are available, matching these data to the original endoscopic data can be difficult. Manual matching can be hampered by discrepancies regarding polyp quantity, size, or location. A study by Greene et al,
      • Greene M.A.
      • Butterly L.F.
      • Goodrich M.
      • et al.
      Matching colonoscopy and pathology data in population-based registries: development of a novel algorithm and the initial experience of the New Hampshire Colonoscopy Registry.
      who reviewed impediments encountered in matching colonoscopic and pathologic data in a New Hampshire population-based registry, showed that only 50% of polyps removed during screening and diagnostic colonoscopies were correctly matched with pathologic data with no assumption or discrepancy. Although the DGEA could calculate ADR for only 54% of the participating centers, and some other European screening colonoscopy registries showed more complete data,
      • Bugajski M.
      • Rupinski M.
      • Wieszczy P.
      • et al.
      Key performance measures for colonoscopy in the Polish Colonoscopy Screening Program.
      • Adler A.
      • Lieberman D.
      • Aminalai A.
      • et al.
      Data quality of the German screening colonoscopy registry.
      • Waldmann E.
      • Gessl I.
      • Sallinger D.
      • et al.
      Trends in quality of screening colonoscopy in Austria.
      the former used an automated system and the latter used manual data entry. Because manual matching of endoscopic and pathologic data is one of the major impediments to widespread and accurate measurement of ADR,
      • Peng M.
      • Rex D.K.
      Surveying ADR knowledge and practices among US gastroenterologists.
      the introduction of an automated data extraction and analysis tool is a major achievement.
      Second, although the DGEA included only centers willing to participate, its coverage was virtually nationwide. Registries involving a limited number of selected centers willing to participate might have failed to identify underperforming units working in relative isolation. Therefore, implementing a national registry and collecting data from these units may provide an effective tool for both quality assessment and performance improvement. A nationwide approach provides feedback and benchmarking to all endoscopists, allowing them to assess their performance and to identify best practices trending through their peer group. Furthermore, comprehensive geographic coverage within registry data provides researchers and policy makers the opportunity to gain valuable evidence on the effectiveness of procedures from a real-life setting.
      Third, in contrast to the majority of existing registries, the DGEA collected data on all indications for colonoscopy, including colorectal cancer screening (20%), diagnostic examinations for abdominal symptoms and signs (12.1%), rectal blood loss (10.7%), and surveillance colonoscopies after adenoma resection (10.4%). Because some of the recommended quality indicators are indication specific or need adjustment for indication, incorporating a breadth of indications facilitates more robust assessment of endoscopist performance.
      Fourth, the DGEA retrieved and analyzed data on 3 key performance indicators endorsed by professional endoscopy societies.
      • Kaminski M.F.
      • Thomas-Gibson S.
      • Bugajski M.
      • et al.
      Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.
      ,
      • Rex D.K.
      • Schoenfeld P.S.
      • Cohen J.
      • et al.
      Quality indicators for colonoscopy.
      Although there are almost 2 dozen endorsed performance indicators, collecting data on all of them at the beginning of the process is challenging and may hamper measurement on the population level. This pragmatic approach—to first select the most important, scientifically proven, and feasible quality indicators—sets a good example for other countries. The number of assessed indicators could be increased over time as registry implementation progresses. This is supported by the study of Bugajski et al,
      • Bugajski M.
      • Rupinski M.
      • Wieszczy P.
      • et al.
      Key performance measures for colonoscopy in the Polish Colonoscopy Screening Program.
      which showed that collecting data on all 7 quality indicators endorsed by the European Society of Gastrointestinal Endoscopy was feasible 10 years after the introduction of quality assurance programs within the Polish Colonoscopy Screening Program.
      The report by de Neree tot Babberich et al
      • de Neree tot Babberich M.P.M.
      • Ledeboer M.
      • van Leerdam M.E.
      • et al.
      Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement.
      provides an important lesson on the key features of colonoscopy quality audit, which include automated data extraction and analysis, nationwide coverage, comprehensive measurement across all colonoscopy indications, and stepwise introduction, starting with a limited number of key quality measures. This sets an example on how to implement a feasible colonoscopy quality measurement registry, which is a first and indispensable step to the ultimate goal of quality improvement.

      Disclosure

      Dr Kaminski is the recipient of honoraria and consultation fees from Olympus, Fujifilm, Boston Scientific, Medtronic, Alfa Sigma, and Norgine and travel grants from Alfa Sigma and ERBE. The other author disclosed no financial relationships.

      References

        • Kaminski M.F.
        • Thomas-Gibson S.
        • Bugajski M.
        • et al.
        Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.
        Endoscopy. 2017; 49: 378-397
        • Rex D.K.
        • Schoenfeld P.S.
        • Cohen J.
        • et al.
        Quality indicators for colonoscopy.
        Gastrointest Endosc. 2015; 81: 31-53
        • Rutter M.D.
        • Senore C.
        • Bisschops R.
        • et al.
        The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures.
        Endoscopy. 2016; 48: 81-89
        • Rees C.J.
        • Thomas-Gibson S.
        • Bourke M.J.
        • et al.
        Managing underperformance in endoscopy: a pragmatic approach.
        Gastrointest Endosc. 2018; 88: 737-744.e1
        • de Neree tot Babberich M.P.M.
        • Ledeboer M.
        • van Leerdam M.E.
        • et al.
        Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement.
        Gastrointest Endosc. 2020; 92: 154-162.e1
        • Bretthauer M.
        • Aabakken L.
        • Dekker E.
        • et al.
        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
        • 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.A.
        • 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
        • Greene M.A.
        • Butterly L.F.
        • Goodrich M.
        • et al.
        Matching colonoscopy and pathology data in population-based registries: development of a novel algorithm and the initial experience of the New Hampshire Colonoscopy Registry.
        Gastrointest Endosc. 2011; 74: 334-340
        • Bugajski M.
        • Rupinski M.
        • Wieszczy P.
        • et al.
        Key performance measures for colonoscopy in the Polish Colonoscopy Screening Program.
        Endoscopy. 2019; 51: 858-865
        • Adler A.
        • Lieberman D.
        • Aminalai A.
        • et al.
        Data quality of the German screening colonoscopy registry.
        Endoscopy. 2013; 45: 813-818
        • Waldmann E.
        • Gessl I.
        • Sallinger D.
        • et al.
        Trends in quality of screening colonoscopy in Austria.
        Endoscopy. 2016; 48: 1102-1109
        • Peng M.
        • Rex D.K.
        Surveying ADR knowledge and practices among US gastroenterologists.
        J Clin Gastroenterol. 2020; 54: 158-163

      Linked Article