1. A Quality Colonoscopy: Are You Providing One?
Robert P Yatto MD Cumberland Medical Center Crossville, Tennessee

2. Quality Colonoscopy Patient Perspective Pre 1999-2001 era
It was really quick!
It didn’t hurt!

3. Quality Colonoscopy Patient Perspective Post 1999-2001 era
My doctor had a good withdrawal time
My doctor finds polyps in over 1/3 of his patients
My doctor reaches the cecum 95% of the time
It didn’t hurt!

4. ?
1999 Institute of Medicine (IOM) published “To ERR is Human: Building a Safer Health System”
2001 IOM report “Crossing the Quality Chasm: A New Health System for 21st Century”

5. Quality Colonoscopy Gastroenterologist Perspective Pre 2006
Prep was Excellent
It was quick!
Patient was quiet (It didn’t hurt)

6. Quality Colonoscopy Gastroenterologist Perspective Post 2006
Used ASGE AUGE guideline indication for colonoscopy
Risk assessment performed prior to exam
Cecal intubation with photo documentation
Withdraw time > 6 minutes on a negative screening exam
Etc.

7. Measuring the Quality of Endoscopy
“…It becomes clear that we have no reliable way to distinguish a high-quality endoscopic procedure done by a trained endoscopist from a procedure performed by an inadequately trained provider. Fortunately, adverse events are too rare to track as a meaningful indicator of quality… We need objective, practical ways to grade our performance.”
John W. Popp, MD FACG David J. Bjorkman, M.D., MSPH

8. Measuring the Quality of Endoscopy
“The ASGE and ACG recognize that if we do not develop evidence-based quality measures, an administrative or governmental agency without experience or insight into the practice of endoscopy will define these measures for us.”
John W. Popp, MD FACG David J. Bjorkman, M.D., MSPH

9. How Good Is Your Colonoscopy?
New York Times December 16, 2008 “Colonoscopies Miss Many Cancers, Study Finds”
For many years doctors and patient thought colonoscopies, the popular screening test for colorectal cancer, were all but infallible. Have a colonoscopy, get any precancerous polyps removed, and you should almost never get colon cancer……And now a Canadian study, published Tuesday in journal Annals……found the test much less accurate than anyone expected.

10. Variance in Protection Possible Explanations
Incomplete exams
Missed lesions
Suboptimal prep
Biologic differences
Operator factors 41% by general surgeons 42% by internist/family practice 16% by gastroenterologists
Clinical Gastroenterology Hepatology 2008; 6:

11. Quantity vs. Quality
Production Pressure in Endoscopy: Balancing Quantity and Quality – Lawrence B. Cohen
Increase volume in response to decreased reimbursement
Production pressure can adversely impact outcomes
Be flexible in scheduling
Document quality and benchmark
Gastroenterology 2008; 135:

12. Quantity: A Changing Climate
The Past
Pre 2001
The Present
The Future
2009 +
Provider picked data to disclose
Public data supported provider reputation
Provider requested to disclose data in selected areas
Public data supported provider reputation in areas selected by payer
All data available to public?
Data support provider reputation only if superior performance in most if not all areas

13. Quality indicators for Colonoscopy
Appropriate indication
Informed consent obtained including risks
Use of recommended polypectomy and post cancer resection surveillance intervals
Use of recommended IBD surveillance intervals
Documentation of prep quality

14. Quality indicators for Colonoscopy
Cecal intubation rate with photo documentation - appendiceal orifice - ileocecal valve - terminal ileum - >90% overall > 95% screening
Rate of detection of adenomas in screening
Withdraw time documentation
Biopsies obtained in patients with diarrhea

15. Quality indicators for Colonoscopy
Number and description of biopsy samples in IBD surveillance (32)
Polyps < 2 cm resected or documented unresectability
Incidence of perforation by procedure type (all indications vs screening) is measured - all screening 0.001
Incidence of post-polypectomy bleeding is measured
Post-polypectomy bleeding managed non-operatively

16. Quality indicators for Colonoscopy

17. Colon WD Time
Colonoscopy Withdrawal Time and Risk of Neoplasia at 5 Years: Results From VA Cooperative Studies Program 380.
Conclusion
“In this study with a mean baseline WT > 12 min, there was no detectable association between WT and risk of future neoplasia. The medial center-level WT was positively correlated with adenoma detection. Therefore, above a certain threshold, WT may no longer be an adequate quality measure for screening colonoscopy.”
Gellad et al, Am Jnl Gastro Aug 2010

18. Quality indicators for Colonoscopy

20. Candidate Indicators to Define Quality
Cecal intubation rate…quality vs. competence??? - 95% with photo documentation
Adenoma detection rate - Equal to or greater than 25% in men - Equal to or greater than 15% in woman
Post-polypectomy surveillance
- Overuse/underuse
Hewett, Rex AM Jnl Gastro Sept 2010

21. Robert P Yatto MD Cumberland Medical Center Crossville, Tennessee
The future is now. Start reporting. The future will change. Be prepared for it.
Robert P Yatto MD Cumberland Medical Center Crossville, Tennessee