Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...
Transcript of Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...
![Page 1: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/1.jpg)
Ambulatory Endoscopy Clinic Day
Quality of Care: Procedure Related Issues
Nancy Baxter, MD PhD
![Page 2: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/2.jpg)
Objectives
To review the concept of “quality of care”
To discuss the growing focus on quality of colonoscopy
To apply concepts of quality of care to procedural related issues for colonoscopy
To describe current quality indicators and standards for colonoscopy
![Page 3: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/3.jpg)
Quality of Care
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Institute of Medicine
![Page 4: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/4.jpg)
El-Jardali Healthcare Quarterly 2005; 40-8.
Material Resources, Human Resources, Institutional Organization
Care Delivered
Health Status
![Page 5: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/5.jpg)
good structure increases the likelihood of good process, and
good process increases the likelihood of good outcomes
![Page 6: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/6.jpg)
Why Now?
Dramatic increase in rate of colonoscopy in Ontario
Change in indication for colonoscopy Increase use for
screeningICES 2004, Use of Large Bowel Procedures in Ontario
![Page 7: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/7.jpg)
Screening Asymptomatic,
healthy individuals with relatively low risk of disease
Benefits outweigh risks when procedure is high quality
High Quality
Maximized
Minimized
![Page 8: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/8.jpg)
Screening Asymptomatic,
healthy individuals with relatively low risk of disease
Benefits outweigh risks when procedure is high quality
Risks may outweigh benefits when procedure is poor quality
Poor Quality
Less Effective
More Complications
![Page 9: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/9.jpg)
Why Endoscopy? Expensive procedure Providers tend to be
VERY high volume Administrative data
can produce useful metrics
Emerging understanding of limitations
Evidence of meaningful variation at the provider level
![Page 10: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/10.jpg)
![Page 11: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/11.jpg)
Limitations of Colonoscopy Interval cancer
Rapidly growing Missed neoplasia Incompletely resected
adenoma
Estimated in administrative data based on timing of colonoscopy More than 6 months Less than 36 months
![Page 12: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/12.jpg)
Ontario DataRates of new or missed cancers
evaluatedDesign: Population-based cohortStudy period: 4/1/97-3/31/02Study population: ≥ 20 yr with a
new diagnosis of CRC12,487 persons with a new CRC who
had colonoscopy inserted to the site of the CRC within 3 yr prior to the diagnosis
![Page 13: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/13.jpg)
Findings
Right-sided: 195/3,288 (5.9%)Transverse: 43/777 (5.5%)Splenic flexure/desc’g: 15/710 (2.1%)Rectal or sigmoid: 177/7,712 (2.3%)
430/12,487 (3.4%)
Increased risk: older age, diverticular disease, right-sided or transverse CRC, internist/FP, non-hospital colonoscopy
Bressler B et al. Gastroenterology 2007;132:96-102.
![Page 14: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/14.jpg)
Missed vs. New Miss rates from tandem colonoscopy
studies 1cm adenoma – 0% to 6% 6-9mm adenoma – 12%-13% < 5mm adenoma 15%-27%
Colonoscopy vs. CT colonography Centres of excellence for CT demonstrate miss
rates for > 1cm of 12-17% Other studies report much lower rates
Faigel et al. Gastrointestinal Endoscopy 2006; 63s
![Page 15: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/15.jpg)
Baxter Ann Int Med 2009; 150:1-8
![Page 16: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/16.jpg)
![Page 17: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/17.jpg)
![Page 18: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/18.jpg)
Cases
Diagnosis of CRC between Jan 1996 through Dec 2001 from OCR
No previous diagnosis of CRC Eligible for OHIP from 1992 to death
At least 4 years of information on history of endoscopy
Age 52-89 Screen eligible range for at least 2 years
Died of CRC by Dec 2003 Last mortality data available
![Page 19: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/19.jpg)
Controls
Selected from Registered Persons Database Eligible for OHIP 1992 through 2003
Matched to case for Geographic location Sex Income quintile Calendar year of birth
Referent date assigned
![Page 20: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/20.jpg)
Determination of Exposure
Colonoscopy (any attempted) Z555 – colonoscopy to
descending colon
Colonoscopy (complete) Z555 – colonoscopy to
descending colon plus E747 – to cecum or E705 – to
terminal ileum
> 6 months from diagnosis
![Page 21: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/21.jpg)
Primary Site
1.0 (referent)
0.63(0.49-0.81)
0.33(0.28-0.39)
Left
0.90(0.73-1.10)
0.99 (0.86-1.14)
Complete
1.0 (referent)
1.0 (referent)
No
0.91(0.61-1.35)
1.35(1.07-1.69)
Incomplete
Colonoscopy
UnknownRightVariable
![Page 22: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/22.jpg)
Procedural FactorsAccess Timeliness Appropriate use
Other Adequate consent process Patient tolerance and
satisfaction Quality reporting,
recommendations and feedback
Technical Complete colonic
assessment Completion rate Quality of Preparation Quality of Inspection
Adenoma detection Minimal Complications
![Page 23: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/23.jpg)
Completion Rate
Recommendation >90% all colonoscopies >95% for screening Exclude poor prep from
denominator > 97% completion
rate reported in screening studies
Documentation Verbal Pictorial
Faigel et al. Gastrointestinal Endoscopy 2006; 63s
![Page 24: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/24.jpg)
Ontario Patients age 50-74 331,608 colonoscopies performed between
1999-2003 13% were incomplete Factors affecting rate
Age: OR 1.20 per 10-year increment (95% CI=1.18-1.22)
Female sex: OR 1.35 (95% CI: 1.30-1.39) History of prior abdominal surgery: OR 1.07
(95% CI: 1.05-1.09) or prior pelvic surgery: OR 1.04 (95% CI: 1.01-1.06).
Shah Gastroenterology 2007; 132: 2297-303
![Page 25: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/25.jpg)
Factors Affecting Completion
Wells BMC Gastroenterol. 2007; 7: 19
![Page 26: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/26.jpg)
Quality of Preparation % with good
preparation Patient factors
Elderly Socioeconomically
deprived
Modifiable factors Split dose
preparations Timing of
colonoscopy
![Page 27: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/27.jpg)
Quality of Inspection
Barclay NEJM 2006; 355:2533-41
![Page 28: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/28.jpg)
How to Measure 6 minute withdrawal time
has been suggested as quality measure
Patients with no adenoma detected
If implemented should be at the PROVIDER and not patient level
Start recording withdrawal time Feedback May be mandated in
future
![Page 29: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/29.jpg)
Adenoma Detection ASGE/ACG task force
recommendations Screening colonoscopy
over age 50 >25% men >15% women
Some studies report substantially higher rates
Influenced by age, sex, family history
![Page 30: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/30.jpg)
Provider Variation Single institution study All colonoscopy between 1999-2004 9 endoscopists and 10,034 procedures Range of adenoma detection for patients
> 50 Any adenoma: 15.5% - 41.1% At least two adenomas: 4.9% - 20.0% At least one adenoma > 1.0 cm: 1.7-6.2%
Range of adenomas detected per colonoscopy by endoscopist: 0.21-0.86
Chen Am J Gastro 2007; 102:856-201
![Page 31: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/31.jpg)
Bressler Gastroenterology 2007; 136; 96-102
![Page 32: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/32.jpg)
Complications
![Page 33: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/33.jpg)
Serious ComplicationsBC, Alberta, Ontario, Nova ScotiaPopulation 50-75 yr: 4.6 millionPersons 50-75 yrs who underwent
outpatient colonoscopy between 4/1/2002 and 3/31/2003
Outcome: Bleeding and perforation requiring admission within 30 days of colonoscopy
Rabeneck et al. Gastroenterology 2008;135:1899-1906
![Page 34: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/34.jpg)
Results97,091 persons had an outpatient
colonoscopy from 4/1/2002 to 3/31/2003
Bleeding 1.64/1000 Perforation 0.85/1000 Death 0.074/1000 or 1/14,000 Risk factors: increased age, male sex,
polypectomy, volume < 283/yr
![Page 35: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/35.jpg)
Current Standards
and Indicators
![Page 36: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/36.jpg)
Current Quality Indicators
![Page 37: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/37.jpg)
Current Quality Indicators
![Page 38: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/38.jpg)
Germany
Gastroenterology board license > 200 colonoscopies and > 50
polypectomies in past 2 years Adequate technical equipment for
resuscitation and infection control monitoring
> 200 colonoscopies documented by photo per year
> 10 polypectomies with histology per year
![Page 39: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/39.jpg)
United States
![Page 40: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/40.jpg)
United States
![Page 41: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/41.jpg)
United States
![Page 42: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/42.jpg)
Summary System-wide drive to
assess, monitor and improve quality Endoscopic procedures
ideal target Multiple procedural
factors are important Meaningful and fair
indicators difficult to develop
Current standards unlikely to have impact
![Page 43: Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...](https://reader033.fdocuments.net/reader033/viewer/2022042816/559770281a28ab3d0e8b45f6/html5/thumbnails/43.jpg)
Recommendations Understand your
practice Completion rate % poor preparation Withdrawal time Adenoma detection
rate
Consider undertaking a QI project yearly based on your data