Evidence that existing quality standards increase colonoscopy polyp detection rates1 has fueled a search for new measures with the potential to further lower risk for colorectal cancer (CRC). The initiatives have broad support, not least of which comes from expert endoscopists. “The quality revolution in colonoscopy has matured. There is broad acceptance that performance standards can increase the diagnostic yield, which has created a consensus that it is important to demonstrate that these standards are being met,” said David A. Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

For some centers, the incentive to adhere to performance standards is being created by payors, who increasingly are demanding documentation of established quality indicators for reimbursement. Yet, the underlying movement toward defining indicators is driven by clinical studies that have demonstrated improvements in lesion detection with strategies now recommended in guidelines.2 These include documentation of time to endoscope withdrawal, visualization of the cecum, meeting minimal rates of adenoma detection, and establishing the quality of the bowel preparation.2 Widespread adoption of these strategies aims to reduce the number of patients who experience an incomplete colonoscopy. Use of these techniques also may help clinicians better understand when other visualization tools, such as capsule endoscopy, are needed to ensure proper CRC evaluation.

“With or without incentives, we should all be paying close attention to the variables that define a high-quality colonoscopy,” said Seth Gross, MD, director of endoscopy at Tisch Hospital, New York University Langone Medical Center in New York City. The same assessment was made by Toyia James-Stevenson, MD, assistant professor of clinical medicine in the Division of Gastroenterology/Hepatology at Indiana University School of Medicine in Indianapolis: “There is good literature to support the performance standards that have already been established with a reasonable expectation that others may yet be identified.”

The expectation of improvements in quality measures is driven by several factors and not least of these are registries, the American Gastroenterological Association (AGA) Digestive Health Outcomes Registry® and the GI Quality Improvement Consortium (GIQuIC) created through collaboration between the ACG and the American Society for Gastrointestinal Endoscopy (ASGE). GIQuIC has gathered data from 650,000 colonoscopies.3 Such large data sets are useful for fielding queries about the risk–benefit ratio of pursuing any quality indicator.

“It is important to differentiate the opportunities for measurable improvements in outcome from quality measures that are theoretically attractive but not fully vetted for their clinical impact,” Dr. Johnson cautioned. For example, he suggested that conducting surveillance at intervals too short to justify cost and complications might counterbalance the risk involved with conducting surveillance too infrequently.

Many coming quality measures including documenting complications and achieving target rates of good or excellent bowel preparation appear to be straightforward, but there is also the potential for large data sets to allow guidance for complex issues, such as performing noninvasive or less-invasive surveillance in high-risk patients, such as those with multiple comorbidities.

More detailed algorithms also may evolve from ongoing data collection in regard to surveillance intervals based on the histopathology of excised lesions, family history, or other risk factors, Dr. Gross observed. He, too, cited the opportunities for more advanced quality metrics derived from registry data.

“Quality measures grew out of the evidence that some centers did much better than others in detecting polyps,” Dr. James-Stevenson reported. “The result has been object- ive and evidence-based strategies to bring performance up to a common standard while pursuing opportunities to make further gains.”

References

  1. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2002;97(6):1296-1308.
  2. Kahi CJ, Ballard D, Shah AS, et al. Impact of a quarterly report card on colonoscopy quality measures. Gastrointest Endosc. 2013;77(6):925-931.
  3. GIQuIC. CMS approves GIQuIC as a PQRS qualified clinical data registry. June 2, 2014. http://giquic.gi.org/​docs/​GIQuIC_QCDR_Media_Advisory_6-2-14.pdf. Accessed September 30, 2014.