Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...
Transcript of Ambulatory Endoscopy Clinic Day Quality of Care: Procedure ...
Ambulatory Endoscopy Clinic Day
Quality of Care: Procedure Related Issues
Nancy Baxter, MD PhD
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
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
El-Jardali Healthcare Quarterly 2005; 40-8.
Material Resources, Human Resources, Institutional Organization
Care Delivered
Health Status
good structure increases the likelihood of good process, and
good process increases the likelihood of good outcomes
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
Screening Asymptomatic,
healthy individuals with relatively low risk of disease
Benefits outweigh risks when procedure is high quality
High Quality
Maximized
Minimized
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
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
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
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
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.
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
Baxter Ann Int Med 2009; 150:1-8
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
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
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
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
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
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
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
Factors Affecting Completion
Wells BMC Gastroenterol. 2007; 7: 19
Quality of Preparation % with good
preparation Patient factors
Elderly Socioeconomically
deprived
Modifiable factors Split dose
preparations Timing of
colonoscopy
Quality of Inspection
Barclay NEJM 2006; 355:2533-41
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
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
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
Bressler Gastroenterology 2007; 136; 96-102
Complications
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
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
Current Standards
and Indicators
Current Quality Indicators
Current Quality Indicators
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
United States
United States
United States
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
Recommendations Understand your
practice Completion rate % poor preparation Withdrawal time Adenoma detection
rate
Consider undertaking a QI project yearly based on your data