Original article
Clinical endoscopy
Impact of a quarterly report card on colonoscopy quality measures

https://doi.org/10.1016/j.gie.2013.01.012Get rights and content

Background

Colonoscopy quality is operator-dependent. Studies assessing the effect of interventions to decrease variation in colonoscopy quality have shown inconsistent results. Since 2009, endoscopists at our university-affiliated, Veterans Affairs medical center have received a quarterly “report card” summarizing individual colonoscopy quality indicators as part of an ongoing quality assurance program.

Objective

To determine the effect of the quality report card intervention on colonoscopy performance.

Design

Retrospective study.

Setting

Tertiary-care, academic, university-affiliated, Veterans Affairs medical center in Indianapolis, Indiana.

Patients

Data from 6 endoscopists practicing at the Roudebush Veterans Affairs Medical Center were included. Patients were average-risk, aged 50 years or older, undergoing their first screening colonoscopy.

Intervention

Quarterly report card. The study time frame was July 1, 2008 to December 31, 2008 (before-intervention) and April 1, 2009 to March 31, 2011 (intervention).

Main Outcome Measurements

The primary outcomes were cecal intubation and adenoma detection rates (ADR), adjusted for physician, patient age, and sex. Multivariable logistic regression was performed to determine factors associated with adenoma detection.

Results

A total of 928 patients (male 93%, white 78%) were included (before-intervention 336; intervention 592). There were no significant differences in patient age, sex, smoking status, body mass index, bowel preparation quality, colonoscope model, and proportion of colonoscopies performed with a trainee between the before-intervention and intervention phases. In the intervention phase, the adjusted adenoma detection and cecal intubation rates were significantly higher: 53.9% (95% confidence interval [CI], 49.7%-58.1%) vs 44.7% (95% CI, 39.1%-50.4%); P = .013 and 98.1% (95% CI, 96.7%-99.0%) vs 95.6% (95% CI, 92.5%-97.5%); P = .027, respectively. A higher ADR trend in the intervention phase was found for 5 of the 6 physicians. The increment in ADR was due mostly to increased detection of proximal adenomas. There were no significant changes in serrated polyp detection, advanced neoplasm detection, number of adenomas detected per colonoscopy, and mean size of adenomas after implementation of the intervention. The report card intervention remained significantly associated with higher ADRs after adjustment for patient age, sex, and physician (odds ratio 1.45; 95% CI, 1.08-1.94).

Limitations

Single center, small number of endoscopists.

Conclusion

A quarterly report card was associated with improved colonoscopy quality indicators. This intervention is practical to generate and implement and may serve as a model for quality improvement programs in different patient and physician groups.

Section snippets

Methods

The study was approved by the Institutional Review Board at Indiana University-Purdue University at Indianapolis and by the Richard L. Roudebush Veterans Affairs Medical Center Research and Development Committee. We conducted a retrospective review of screening colonoscopies performed at the Medical Center between July 1, 2008 and March 31, 2011. Data sources included the Medical Center GI endoscopy electronic database (ProVation Medical; Minneapolis, Minn), and the Veterans Affairs Vista

Results

During the study time frame, a total of 928 average-risk patients underwent eligible screening colonoscopies by 6 attending physicians. Characteristics of the patients and procedures performed are listed in Table 1. The majority of patients were male (93%) and white (78%), with a mean (± SD) age of 59.8 ± 7 years and mean (± SD) body mass index of 30.5 ± 6.6. The prevalence of smoking was 31%. There were 336 before-intervention colonoscopies and 592 intervention-phase colonoscopies. There were

Discussion

In this study, conducted within a group of endoscopists at a university-affiliated, Veterans Affairs medical center, a quarterly report card was independently associated with improved colonoscopy quality indicators. The overall adjusted ADR for the 6 endoscopists increased from 44.7% to 53.9%, whereas the cecal intubation rate increased from 95.6% to 98.1%. These two metrics are validated measures of colonoscopy performance quality. In a large study that used data from the Ontario Cancer

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    Notably, colonoscopists with lower baseline ADRs derived greater benefit from this intervention compared with colonoscopists with higher baseline ADRs (RR: 1.62, 95% CI: 1.18–2.23 compared with RR: 1.06, CI: 0.99–1.13, respectively). While one single-center study also showed improvement in cecal intubation rates from 95.6% to 98.1% with quarterly report cards,53 there was no significant improvement in cecal intubation rate nor WT in a larger meta-analysis.52 Establishing minimum standards of practice alongside report card feedback may also augment ADR improvement.54

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DISCLOSURE: Supported in part by the Cordelia Collins Research Fund (C. Kahi). No other financial relationships relevant to this publication were disclosed.

If you would like to chat with an author of this article, you may contact Dr Kahi at [email protected].

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