Presentation on theme: "A Quality Colonoscopy: Are You Providing One?"— Presentation transcript:
1A Quality Colonoscopy: Are You Providing One? Robert P Yatto MD Cumberland Medical Center Crossville, Tennessee
2Quality Colonoscopy Patient Perspective Pre 1999-2001 era It was really quick!It didn’t hurt!
3Quality Colonoscopy Patient Perspective Post 1999-2001 era My doctor had a good withdrawal timeMy doctor finds polyps in over 1/3 of his patientsMy doctor reaches the cecum 95% of the timeIt 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”
5Quality Colonoscopy Gastroenterologist Perspective Pre 2006 Prep was ExcellentIt was quick!Patient was quiet (It didn’t hurt)
6Quality Colonoscopy Gastroenterologist Perspective Post 2006 Used ASGE AUGE guideline indication for colonoscopyRisk assessment performed prior to examCecal intubation with photo documentationWithdraw time > 6 minutes on a negative screening examEtc.
7Measuring 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
8Measuring 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
9How 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.
10Variance in Protection Possible Explanations Incomplete examsMissed lesionsSuboptimal prepBiologic differencesOperator factors 41% by general surgeons 42% by internist/family practice 16% by gastroenterologistsClinical Gastroenterology Hepatology 2008; 6:
11Quantity vs. QualityProduction Pressure in Endoscopy: Balancing Quantity and Quality – Lawrence B. CohenIncrease volume in response to decreased reimbursementProduction pressure can adversely impact outcomesBe flexible in schedulingDocument quality and benchmarkGastroenterology 2008; 135:
12Quantity: A Changing Climate The PastPre 2001The PresentThe Future2009 +Provider picked data to disclosePublic data supported provider reputationProvider requested to disclose data in selected areasPublic data supported provider reputation in areas selected by payerAll data available to public?Data support provider reputation only if superior performance in most if not all areas
13Quality indicators for Colonoscopy Appropriate indicationInformed consent obtained including risksUse of recommended polypectomy and post cancer resection surveillance intervalsUse of recommended IBD surveillance intervalsDocumentation of prep quality
14Quality indicators for Colonoscopy Cecal intubation rate with photo documentation - appendiceal orifice - ileocecal valve - terminal ileum - >90% overall > 95% screeningRate of detection of adenomas in screeningWithdraw time documentationBiopsies obtained in patients with diarrhea
15Quality indicators for Colonoscopy Number and description of biopsy samples in IBD surveillance (32)Polyps < 2 cm resected or documented unresectabilityIncidence of perforation by procedure type (all indications vs screening) is measured - all screening 0.001Incidence of post-polypectomy bleeding is measuredPost-polypectomy bleeding managed non-operatively
17Colon WD TimeColonoscopy 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
20Candidate Indicators to Define Quality Cecal intubation rate…quality vs. competence??? - 95% with photo documentationAdenoma detection rate - Equal to or greater than 25% in men - Equal to or greater than 15% in womanPost-polypectomy surveillance- Overuse/underuseHewett, Rex AM Jnl Gastro Sept 2010
21Robert 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