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

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

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!

1999-2001? 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”

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

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.

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

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

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.

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; 6:1117-1121

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; 135:1842-1844

Quantity: A Changing Climate The Past Pre 2001 The Present 2002-2009 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

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

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

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 0.002 - screening 0.001 Incidence of post-polypectomy bleeding is measured Post-polypectomy bleeding managed non-operatively

Quality indicators for Colonoscopy

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

Quality indicators for Colonoscopy

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

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