1. Quality Improvement in Gastroenterology Aparajita Singh, MD, MPH Assistant Clinical Professor Division of Gastroenterology

2. Objectives Overview of the quality of care movement Why do we need quality indicators ? What are some quality indicators for colonoscopy ? Introduction to patient safety and satisfaction measurement and reporting

3. IOM report: To Err is Human This number exceeds people who die annually from: -Highway accidents -Breast Cancer -AIDS

4. To Err is Human-1999  Health care in the US is NOT as safe as it should be and can be  Not acceptable for patients to be harmed by the health care

5. Crossing the Quality Chasm- 2001 Between the health care we have and the care we could have lies not just a gap, but a chasm It made urgent call for fundamental change to close the quality gap Asked for redesign of the American health care system

6. IOM Definition of Health Care Quality “ The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge ”

7. IOM’s six domains of quality care: STEEP Safe Timely (Reducing wait and harmful delays) Effective (Avoiding underuse and misuse)

8. IOM’s six domains of quality care: STEEP Efficient (Avoiding waste) Equitable (Independent of socioeconomic status, race or gender) Patient centered (respectful of patients needs and preferences)

9. The Medicare Improvements for Patients and Providers Act: 2008 Plans to create a fundamental shift in reimbursement from CMS for medicare patients Aim is to transition payments into a value-based purchasing program Reimbursement would be based on efficiency and the quality of services provided, instead of the quantity Private payors are following as well

10. Patient Protection and Affordable Care Act (PPACA) Also emphasizes quality measurements Requires new delivery model that rewards groups of providers with payments if they can: Contain costs Improve quality Assume financial risk for their outcomes

11. Why did we need quality indicators for colonoscopy? Colorectal cancer detection rate Adenoma detection rate Perforation rate (1 in 500 to 1 in 4000) Colonoscopy Surveillance Interval Reports of wide variability in:

12. Overuse of Colonoscopy A 50 year old man with normal screening colonoscopy with good bowel prep and no family history of GI malignancy- Recommended follow up in 5 years !

13. Evidence of misuse and overuse of colonoscopy Medicare study of 24,000 patients: 46% underwent a repeat exam in < 7 years after a normal screening colonoscopy Goodwin et al, Archives of Internal Medicine 2011 Aug 8;171(15):1335-43,

14. Example of under use of steroid sparing agents 35 year old woman with Crohn’s disease receives six courses of Prednisone in one year but not offered steroid sparing therapy

15. ASGE Colonoscopy Quality Indicators

18. Screening vs. Surveillance Screening Colonoscopy: 50- 75 years and no past history of polyps Surveillance: Personal history of polyps, colon cancer, IBD

19. Adenoma Detection Rate Frequency with which adenomas are detected in asymptomatic average-risk individuals (screening) Evidence of Marked Variation in ADR by providers within practice groups ADR Goal Men > 30% Women > 20%

20. Adenoma Detection Rate & Interval Cancer Adenoma detection rate is inversely associated with the risks of – Interval colorectal cancer N England Journal of Medicine 2014 Apr 3;370(14):1298-306.

21. Do quality indicators predict better patient outcome?

22. Public Reporting of Quality Data Adenoma Detection Rate Cecum Intubation Rate

23. Minnesota Gastroenterology Quality Report

24. GI Quality Improvement Consortium established by ACG and ASGE Tool for collection, measurement and comparison of colonoscopy quality indicators

26. Cecum Intubation Rate Goal >95% in healthy adults Photodocument :  Appendicecal Orifice  Cecal folds  Ileocecal Valves

27. Cecum Withdrawal Time Average withdrawal time in normal colonoscopy Goal ≥6 min  Can be variable:  Colon length  Fold anatomy  Endoscopist’s technique

28. Documentation of last oral intake ASA Practice Guidelines Clear Liquids2 hours Milk6 hours Light Meal6 hours Meal with fried or fatty food8 hours Exceptions: Gastroparesis, Achalasia

29. Antithrombotic therapy Plan Low Risk procedures can be done on patients on Aspirin Low-risk procedures Diagnostic (EGD, colonoscopy, flexible sigmoidoscopy) including mucosal biopsy ERCP with stent (biliary or pancreatic) placement or papillary balloon dilation without sphincterotomy Push enteroscopy and diagnostic balloon-assisted enteroscopy EUS without FNA Argon plasma coagulation Barrett's ablation

30. Know the newer Anticoagulants ! Oral direct thrombin or factor Xa inhibitor Dabigatran ( Pradaxa) Rivaroxaban ( Xarelto) Apixaban ( Eliquis) Edoxaban ( Lixiana)

31. Ensure appropriate follow up interval after colonoscopy Screening Interval for common polyps No polyps or Hyperplastic polyp10 years One or Two Small adenoma ( <10 mm)5-10 years 3-10 adenoma or >10 mm adenoma3 years

32. Screening Interval for family History CRC in first degree relative <60 Or Two first degree relatives at any age  Start at age 40 OR 10 years before the youngest case  Repeat every 5 years

33. Patient Safety

34. How to define Safety? The prevention of harm to patients Examples: Hand Hygiene Giving right dose of medicine Endoscope Cleaning and disinfection

35. How common are preventable hospital errors? In one report, hospital errors are: Third leading cause of death in U.S 440,000 died annually due to preventable hospital error The epidemic of patient harm in hospitals must be taken more seriously Journal of Patient Safety: Sept 2013, Vol 9, Issue 3, p122-128

36. Where are patients looking for safety data? www.hospitalsafetyscore.org

37. Example of public safety data

40. Press Ganey Questions Access: Ease of getting clinic on phone Convenience of our office hours Ease of scheduling appointments Courtesy of registration staff Information about delays Wait time at clinic

41. Press Ganey Questions Friendliness/courtesy How well staff protect safety, privacy Ease of obtaining test results Cleanliness of practice Staff addressed disability needs Staff respected sex orientation/gender identity Staff worked together Likelihood of recommending practice

42. Press Ganey Questions

43. Conclusion Issues related to quality of care, patient satisfaction have permeated all areas of health-care delivery Its time to critically examine our practice and embrace the quality and safety culture to Provide better and safe care for our patients Improve reimbursements Comply with future regulations

44. Thanks! Questions?