Quality in Endoscopy and Cost Effective Practice

Transcription

1 Quality in Endoscopy and Cost Effective Practice Sunanda Kane, MD MSPH FACG Director, ACG Quality Council 1

2 What is Quality and/or Cost Effectiveness in an Endoscopic Practice? Value Equation Quality (Outcomes, Safety, Service) Cost (price x use rate) Increasing Value Increase Quality Improve outcomes Improve safety/decrease harm Increase service Decrease cost Bundling Efficiency changes 2

3 Quality Indicators for Colonoscopy Current ADR Appropriate use of surveillance/screening intervals Cecal intubation rates Future Adequacy of Bowel Prep Adequacy of polypectomy ADR-plus Periprocedural management of antiplatelet and anticoagulant drugs Rate of interval cancers Rate of lost specimens Rate of surgical referrals Recognition of sessile serrated lesions Fundamental of High Quality Colonoscopy Careful inspection At least 6-8 minutes Looking behind folds Attentive to flat mucosal changes Proper documentation Prep quality Patient acceptance and compliance 3

4 How Can We Improve Colonoscopy Quality Mandate longer withdrawal time? Education/Attention to good methods? Washing, look behind folds Advanced Imaging methods? Improved bowel prep? Improve acceptance? What s the Problem? 10 fold Variation In ADR Barclay et al. NEJM;2006;355:2533 4

5 High ADR Reduces Interval Cancers Corley Kaiser study DDW 2013, ADR associated with interval CA Kaminski et al. NEJM;2010;362:1795 Mandated Withdrawal Time and Adenoma Detection Mandating longer WD time does not increase ADR Sawhaney Gastro 2008;135;1892 Compliance w/ mandate ADR after Mandate 5

6 Notification (personal and public) Does Not Increase ADR Group ADR presented (blinded) Indiv. ADR presented (private) Indiv. ADR presented (public) Indiv. 1:1 meeting w/ chair Shaukat et al. CGH 2009;7:1335 Mayo Endoscopic Quality Improvement Project (EQUIP study) Randomized, single blind, education intervention Focus on Adenoma Detection Rate 2 Educational sessions (1-1.5 hrs each) Techniques to improve detection (with videos) Videos of highest ADR doctors Monthly feedback on ADR and WD time Results posted on ASC wall (de-identified) Individual informed of ADR and group data Measured ADR baseline (3 months, 1200 cases) Repeat after intervention (1200 cases) Coe et al. Am J Gastro 2013;108:219 6

7 Effect of EQUIP Training 36% 36% 36% 47% P<0.01 ADR by adenoma size and study phase (Trained group) Detection Rate* 40% 30% 20% 10% 0% Adenoma size Phase I Phase II 7

8 Detection Rate e* 50% 0% ADR by adenoma shape (Trained group) Polypoid Non- polypoid Adenoma shape Phase I Phase II Withdrawal time Did not change with intervention ti Untrained group 8 min (6-11) Phase I 9 min (6-12) Phase II Trained group 10 min (8-13) Phase I 11 min (9-14) Phase II 8

9 ADR Increase Was Durable (in fact continued to increase) Beyond Study 65% ADR 55% 45% 35% 25% 36% 47% 35% 46% 39% Untrained Trained 15% Phase 1 Phase 2 Phase 3 Summary Adenoma Detection can be improved by education Variable results Focus on Withdrawal time does not change ADR Passive Notification does not change ADR Active education + public/private notification durably increases ADR Create a Culture of Quality Focus on ADR alone has potential for gaming 9

10 How Can We Improve Colonoscopy Quality Mandate longer withdrawal time? Education/Attention to good methods? Washing, look behind folds Advanced Imaging methods? Improved bowel prep? Improve acceptance? High Definition Colonoscopy: A Meta-Analysis Study N (std def) N (HD) ADR (total) East % Pellise % Burke % Buchner % Tribonias % Net effect of HD 3.5% 35%[09 [ ] increase in all ADR -0.1% [ ] for advanced ADR Adapted from Subramanian et al Endoscopy 2011;43:499 10

11 NBI Does Not Increase Adenoma Detection Meta Analysis: 6 Randomized Trials Dinesen, GIE, 2012;75: How Can We Improve Colonoscopy Quality Mandate longer withdrawal time? Education/Attention to good methods? Washing, look behind folds Advanced Imaging methods? Improved bowel prep? Improve acceptance? 11

12 Split Dose: Better Prep, Better Tolerated Bowel Prep Quality Patient Willingness to Repeat Same Prep Kilgore et al. GIE 2011;73:1240 Poor Prep Quality: It Will be our Fault! I have bad patients won t cut it Split dosing acceptable to patients t Smartphone Apps available to help patients through the process Free app download at itunes store ?mt=8&Is=1 Recent RCT on LR diet comparable to clear liquids the day before colonoscopy (Stolpman D et al DDW 2013) 12

13 Summary Good technique is paramount Looking behind folds Slow withdrawal Looking for flat mucosal change Technology helps but no substitute ADR is well validated measure of quality CAN be improved and maintained in practice PDR is reasonable surrogate PDR 30% correlated with ADR 20% In practice, we audit if PDR < 40% Both have potential for gaming Split dose prep improves quality and tolerance 13