Effectiveness of a continuous quality improvement program on colonoscopy practice

 

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Background and study aim: Continuous quality improvement (CQI) is recommended by professional societies as part of every colonoscopy program, but little is known with regard to its effectiveness for colonoscopy outcomes. We prospectively assessed whether the implementation of a CQI program in routine clinical practice influences the quality performance of colonoscopy.

Methods: In an open-access endoscopy unit at a secondary care center in Northern Italy, 6-monthly audit cycles were carried out over a 4-year period, to identify reasons for poor colonoscopy outcomes and institute appropriate changes to improve performance. The colonoscopy completion rate and the polyp detection rate as detected by endoscopists were considered to be key measures for improvement.

Results: The initial crude colonoscopy completion rate was 84.6 %, with a range for individual endoscopists 80.4 % - 94 %. Four endoscopists had a completion rate lower than 90 %. The overall polyp detection rate was 34 %, with a wide variation among endoscopists (range 14 % - 42 %). Poor patient tolerance and differences in colonoscopist expertise were the main determinants of lack of completion and variation in polyp detection rate. Changes to sedation practice, greater access to endoscopy sessions for the endoscopists with the lowest performance rates, and other organizational arrangements, were implemented to improve quality performance. The crude completion rates improved consistently, up to 93.1 %, over the study period. This trend was confirmed even when adjusted completion rates were calculated. All endoscopists reached a crude completion rate of 90 % or more and a polyp detection rate of over 20 %. The introduction of CQI did not significantly change the overall incidence of procedure-related complications.

Conclusions: The effectiveness of colonoscopy can be improved by implementing a CQI program in routine colonoscopy practice.

References

• 1 Rex D K. Colonoscopy.  Gastrointest Endosc Clinics N Am. 2000;  10 135-160
  PubMedGoogle Scholar
• 2 Rex D K, Rahmani E Y, Haseman J H. et al . Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice.  Gastroenterology. 1997;  112 17-23
  CrossrefPubMedGoogle Scholar
• 3 Hosokawa O, Shirasaki S, Kaizaki Y. et al . Invasive colorectal cancer detected up to 3 years after a colonoscopy negative for cancer.  Endoscopy. 2003;  35 506-510
  Article in Thieme ConnectPubMedGoogle Scholar
• 4 Leaper M, Johnston M J, Barclay M. et al . Reasons for failure to diagnose colorectal carcinoma at colonoscopy.  Endoscopy. 2004;  36 499-503
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 Bressler B, Paszat L F, Vinden C. et al . Colonoscopic miss rates for right-sided colon cancer: a population-based analysis.  Gastroenterology. 2004;  127 452-456
  CrossrefPubMedGoogle Scholar
• 6 Winawer S J, Zauber A G, O’Brien M J. et al . Randomized comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps.  New Engl J Med. 1993;  328 901-906
  CrossrefPubMedGoogle Scholar
• 7 Jeroen C, van Rijn JC, Reitsma JB. et al . Polyp miss rate determined by tandem colonoscopy: a systematic review.  Am J Gastroenterol. 2006;  11 343-350
  PubMedGoogle Scholar
• 8 Haseman J H, Lemmel G T, Rahmani E Y, Rex D K. Failure of colonoscopy to detect colorectal cancer: evaluation of 47 cases in 20 hospitals.  Gastrointest Endosc. 1997;  45 451-455
  CrossrefPubMedGoogle Scholar
• 9 Berwick D M, Nolan T W. Physicians as leaders in improving health care.  Ann Intern Med. 1998;  128 289-292
  PubMedGoogle Scholar
• 10 Johanson J F. Continuous quality improvement in the ambulatory endoscopy center.  Gastrointest Endosc Clin N Am. 2002;  12 351-365
  CrossrefPubMedGoogle Scholar
• 11 Rex D K, Bond J H, Winawer S. et al . US Multi-Society Task Force on Colorectal Cancer. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the US Multi-Society Task Force on Colorectal Cancer.  Am J Gastroenterol. 2002;  97 1296-308
  CrossrefPubMedGoogle Scholar
• 12 ASGE Committee on Outcomes Rresearch . Quality and outcomes assessment in gastrointestinal endoscopy.  Gastrointest Endosc. 2000;  52 827-830
  CrossrefPubMedGoogle Scholar
• 13 Minoli G, Meucci G, Prada A. et al . Quality assurance and colonoscopy.  Endoscopy. 1999;  31 522-527
  Article in Thieme ConnectPubMedGoogle Scholar
• 14 Ball J E, Osbourne J, Jowett S. et al . Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study.  BMJ. 2004;  329 665-667
  PubMedGoogle Scholar
• 15 Terruzzi V, Meucci G, Radaelli F. et al . Routine versus “on demand” sedation and analgesia for colonoscopy: a prospective randomized controlled trial.  Gastrointest Endosc. 2001;  54 169-174
  CrossrefPubMedGoogle Scholar
• 16 Radaelli F, Meucci G, Terruzzi V. et al . Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial.  Gastrointest Endosc. 2003;  57 329-335
  CrossrefPubMedGoogle Scholar
• 17 Bowles C J, Leicester R, Romaya C. et al . A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer tomorrow?.  Gut. 2004;  53 277-283
  CrossrefPubMedGoogle Scholar
• 18 Anderson M L, Pasha T M, Leighton J A. Endoscopic perforation of the colon: lessons from a 10-year study.  Am J Gastroenterol. 2000;  95 3418-3422
  CrossrefPubMedGoogle Scholar
• 19 Joint Commission on Accreditation of Healthcare Organizations .A comprehensive review of development and testing for national implementation of hospital core measures. (Accessed September 24, 2005, at http://www.jcaho.org/pms/core+measures/cr_hos_cm.htm)
  Google Scholar

F. Radaelli, MD

Department of Gastroenterology

Valduce Hospital

Via Dante 11

22100, ComoItaly

Fax: +39-031-308047

Email: francoradaelli@virgilio.it