1. Assessing USAF Primary Care Colonoscopy Training and Outcomes Using Quality Indicators Brian Crownover, M.D., FAAFP Ethan Zimmerman, M.D. Family Medicine Residency Nellis AFB, NV

2. Goals of QI review Describe training experience of Family Medicine colonoscopy trainers in USAF Use outcomes based indicators to represent quality of USAF primary care colonoscopy Measure results against national standard quality indicators

3. USAF Primary Care Endoscopists Who? ●Teaching faculty at 4 US Air Force Family Medicine residency locations who perform colonoscopy ●NW Florida, N Calif, Las Vegas, St Louis What? ●Type and amount of training received ●Self-collected procedure log data – post training

4. Primary Quality Indicators Adenoma Detection Rate Cecal Intubation Rate ●Recommended ≥ 95% for screening colonoscopy

5. Primary Care Endoscopy Why evaluate quality indicators? ●Primary care under attack from Gastroenterology ●Polypectomy reduces CRC mortality 53% ● NEJM 2012; 366(8):687 ●Only 65% Americans receive appropriate CRC screening ● https://healthmeasures.aspe.hhs.gov/measure/25 https://healthmeasures.aspe.hhs.gov/measure/25

6. Specialty differences from: Ko et al. ADR?

7. Ko et al.  “Polyp detection and removal rates were significantly lower for nongastroenterologists than gastroenterologists”

8. ACG/AGA/ASGE – ADR Working Gp Screening Colonoscopy Adenoma Detection Rate Measure- Draft: Public Comment (6/2012) Numerator: Number of patients age 50 ‐ 75 with at least one adenoma detected during screening Denominator: Patients age 50 ‐ 75 undergoing a screening colonoscopy Exclusions: Incomplete colonoscopy Measure: The percentage of patients age 50 ‐ 75 with at least one adenoma detected

9. Published GI Norms (PDR Surrogate for ADR) ScreeningWilliams JE 2011 Number patients2,706 LocationUSA - VA Number endoscopists15 @ 1 site SpecialtyGastroenterology Years Experience (mean)18 Cecal intubation rate97 PDR / ADR – all (%)Not reported PDR / ADR mean – male (%)43.5 (18-66) / 29.5 (15-45) PDR / ADR mean – female (%) 25.8 (11-43) / 12.7 (6-26) Cancer detection rate (%)0.36 PRs correlated well with ADRs (r(s) = 0.86, P <.001). To attain the established benchmark ADRs for men (25%) and women (15%), endoscopists needed PDRs of 40% and 30%, respectively.

10. Published GI Norms ScreeningCooper 2005 Number patients1.8 Million – all ≥ 65yo LocationUS Medicare Claims data Number endoscopistsNot reported SpecialtyNot reported Years Experience meanNot reported Cecal intubation rateNot reported PDR / ADR mean– all (%)35.7 / ---- PDR / ADR mean – male (%)41.2 / ---- PDR / ADR mean – female (%)31.5 / ---- Cancer detection rate (%)Not reported

11. Published GI Norms ScreeningImperiale 2009 Number patients2664 LocationIndiana, Eli Lilly Corp Number endoscopists25 SpecialtyGastroenterology Years ExperienceNot reported Cecal intubation rateNot reported PDR / ADR mean– all (%)35 (13-82) / 19 (7-44) PDR / ADR mean – male (%)40 / 24 PDR / ADR mean – female (%)28 / 13 Cancer detection rate (%)0.3

12. Published GI Norms ScreeningGoncalves 2011 Number patients1545 LocationPortugal Number endoscopistsNot reported SpecialtyGI staff/fellows Years ExperienceNot reported Cecal intubation rate91 PDR – all (%)33 / ---- PDR – male (%)44 / ---- PDR – female (%)25 / ---- Cancer detection rate (%)0.3

13. Published GI Norms ScreeningChen, Rex 2007 Number patients10,034 LocationIndiana Number endoscopists9 SpecialtyGastroenterology staff Years Experience mean9 Cecal intubation rate≥ 93 PDR / ADR mean– all (%) ---- / (15.5-41.1) PDR / ADR mean – male (%) ---- / 28.1 PDR / ADR mean – female (%) ----/ 19.2 Cancer detection rate (%)Not reported

14. Published GI Norms ScreeningLieberman 2000 Number patients3121 VA pts (98% men) Location13 VA centers Number endoscopistsNot reported SpecialtyGastroenterology Years Experience mean“Extensive” Cecal intubation rate97.7 PDR / ADR mean– all (%)---- / ---- PDR / ADR mean – male (%)53.8 / 37.5 PDR / ADR mean – female (%)---- / ---- Cancer detection rate (%)1.0

15. Published GI Norms ScreeningHeitman 2009 Meta-Analysis Number patients18 pooled studies Avg Risk Pts LocationVarious Number endoscopistsNot reported SpecialtyGastroenterology Years Experience meanNot reported Cecal intubation rateNot reported PDR / ADR mean– all (%)---- / 30.2 (random effects model) PDR / ADR mean – male (%)---- / ---- PDR / ADR mean – female (%)---- / ---- Cancer detection rate (%)0.3

16. Published GI Norms ScreeningCotton 2003 Number patients17,868 Location7 Academic Centers N. America Number endoscopists69 using GI-TRAC software SpecialtyGastroenterology Years Experience meanAll > 50 cases Cecal intubation rate88 PDR / ADR mean– all (%)---- / ---- (none reported) PDR / ADR mean – male (%)---- / ---- PDR / ADR mean – female (%)---- / ---- Cancer detection rate (%)---- Data reported in arbitrary group thresholds, not comparable to other published data

17. Published FM Norms ScreeningKolber 2009 Number patients1178 (1/4 c/o bleeding) LocationRural Canadian practice Number endoscopists1 SpecialtyFamily Med Years Experience meanCovered 0-8 yrs post trng Cecal intubation rate92.3 PDR / ADR mean– all (%)---- / 23.0 PDR / ADR mean – male (%)---- / 29.8 PDR / ADR mean – female (%)---- / 18.0 Cancer detection rate (%)2.1

18. Published FM Norms ScreeningKolber 2010 Number patients577 over 2 months LocationMultisite Canada Number endoscopists10 SpecialtyFamily Med – 8, Internal Med - 2 Years Experience meanNot reported Cecal intubation rate96.5 PDR / ADR mean– all (%)---- / ---- PDR / ADR mean – male (%)---- / 46.4 PDR / ADR mean – female (%)---- / 30.2 Cancer detection rate (%)----

19. Published FM Norms ScreeningEckert 2009 Number patients660 – all Asx > 50yo LocationUS Army base Number endoscopists1 (newly credentialed) SpecialtyFamily Med Years Experience meanFirst 4 yrs post training (residency) Cecal intubation rate98.6 PDR / ADR mean– all (%)---- / 27.1 PDR / ADR mean – male (%)---- / 33.7 PDR / ADR mean – female (%)---- / 21.6 Cancer detection rate (%)0.75

20. Published FM Norms ScreeningWilkins 2009 Number patients18,292 LocationMisc: Meta-analysis Number endoscopists73 SpecialtyPrimary Care – mostly Family Med Years Experience meanNot reported Cecal intubation rate89.2 (92.0 if only include sedated cases) PDR / ADR mean– all (%)---- / 28.9 PDR / ADR mean – male (%)---- / ---- PDR / ADR mean – female (%)---- / ---- Cancer detection rate (%)1.7

21. Published Norms ScreeningDenis 2011 Number patients5852 (all were FOBT +) LocationFrance Number endoscopists100 SpecialtyGastroenterology Years Experience mean“Extensive” Cecal intubation rate97.7 PDR / ADR mean– all (%)43 / 35.6 (14.3-53.4) PDR / ADR mean – male (%)52 / 45.2 PDR / ADR mean – female (%)33 / 26.3 Cancer detection rate (%)6.5

22. So what did we find???

23. Descriptive Statistics LocationNumber of Teaching Faculty Eglin AFB (NW Florida)5 Nellis AFB (Las Vegas)4 Scott AFB (St Louis)2 Travis AFB (N. California)3 14 total

24. Descriptive Statistics prior to independent practice Preceptor for training casesMean % (sd) General Surgeon6 (16) Gastroenterologist32 (33) Family Physician62 (31)

25. Descriptive Statistics prior to independent practice Additional TrainingN (%) Fellowship0 (0) Simulator8 (57) CME conference (NPI, State chapter)6 (43)

26. Descriptive Statistics Experience in trainingMean (sd) Cases prior to independent practice 117 (60) Years of practice post training2.6 (1.3) Post training cases - all207 (191) - males101 (91) - females83 (87)

27. Descriptive Statistics PerformanceMean (sd) Withdrawal time w/o trainee22 (7) minutes Withdrawal time with trainee26 (4) minutes Cecal intubation rate97 (3) percent Adenoma detection rate (ADR) - ALL27.8 (9.3) - MALES33.7 (10.7) - FEMALES21.6 (9.8) Cancer detection rate0.74 (0.69) cases per 100 patients

28. Specialty Comparison GastroenterologyFamily Medicine USAF GME FM Faculty ADR – total19, 32, 15.5-41.123, 27.1, 28.927.8 ADR – male24, 28, 29.5, 37.529.8, 33.7, 46.433.7 ADR – female12.7, 13, 19.218, 21.6, 30.221.6 Cecal intubation rate88, 91, 97, 98 89, 92, 97, 98.697 Cancer detection0.3, 0.36, 1.0 0.75, 1.7, 2.10.74

29. Descriptive Statistics Indication for colonoscopyN (%) Mean (sd) per faculty Average Risk1819 (82) 165 (152) High Risk (prior polyps, +Fam hx)359 (16) 33 (36) Extreme Risk (genetic syndrome, IBD, CA)2 (0) 0 (1) Diagnosis of symptoms (bleeding, pain)43 (2) 3 (8) Total (indication tracked)2223 TOTAL CASES DONE2893 *Small % Diagnostic cases d/t GI input into referral mgt process

30. Descriptive Statistics ComplicationsN (mean per 100 cases) Nausea/Vomiting27 (1.2) Rescue (need assist to complete) 25 (2.0) Hypotension 17 (1.1) Bradycardia 13 (0.8) Inability to biopsy/remove polyps 7 (0.6) Agitation 5 (0.3) Bleeding endoscopic cautery req 3 (0.1) Bleeding admitted postop 2 (0.1) Perforation 1 (0.1) Post-polypectomy Syndrome 0 OVERALL 100 (3.9)

31. Correlations Training experience to ADR ●No correlation to receipt of simulator training Fisher's Exact Test (two-sided) p-value = 0.083 ●No correlation to CME conference attendance Fisher's Exact Test (two-sided) p-value = 0.4755

32. Correlations with ADR Quality factorR 2 correlation coefficient Training by Surgery0.008 Training by GI 0.192 Training by Family Med 0.242 Cases done prior to independence 0.090 Cases done as independent faculty 0.001 Years experience 0.149 Bottom line: No significant correlation with independent factors and ADR

33. Take home points Recently trained faculty working with residents achieve high quality ADR rates (27.8%) comparable to published GI and FM numbers ●Mean 2.6 years experience, 207 cases post training (117 cases in training) Complications rates were low No correlations were found between training experience variables and ADR

34. Questions?

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37. Biblio Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012 Feb 23;366(8):687-96. Imperiale TF, Glowinski EA, Juliar BE, et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc.2009 Jun;69(7):1288–95

38. Biblio Williams JE, Le TD, Faigel DO. Polypectomy rate as a quality measure for colonoscopy. Gastrointest Endosc 2011;73(3):498–506. Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007;102(4):856-61.

39. Biblio Goncalves AR, Ferreira C, Marques A, et al. Assessment of quality in screening colonoscopy for colorectal cancer. Clin Experimental Gastroenterology 2011;4: 277–281. Denis B, Sauleau EA, Gendre I, et al. Measurement of adenoma detection and discrimination during colonoscopy in routine practice: an exploratory study. Gastrointest Endosc. 2011;74(6):1325-36.

40. Biblio Ko CW, Dominitz JA, Green P, et al. Specialty differences in polyp detection, removal, and biopsy during colonoscopy. Am J Med 2010;123 (6): 528–35. Kolber M, Szafran O, Suwal J, et al. Outcomes of 1949 endoscopic procedures. Can Fam Physician 2009; 55(2): 170–175.

41. Biblio Kolber M. Prospective Study of the Quality of Colonoscopies performed by Primary Care Physicians in Alberta, Canada – The Alberta Primary Care Endoscopy (APC –Endo) Study. ClinicalTrials.gov Identifier: NCT01320826. Publication pending Eckert LD, Short MW, Domagalski JE, et al. Assessing Colonoscopy Training Outcomes Using Quality Indicators. J Grad Med Educ 2009;1(1):89-92.

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43. Biblio Heitman SJ, Ronksley PE, Hilsden RJ, et al. Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2009 Dec;7(12):1272-8.