Quality Measures In Colonoscopy: Why Should I Care?

Transcription

1 Quality Measures In Colonoscopy: Why Should I Care? David Greenwald, MD, FASGE Professor of Clinical Medicine Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York ACG/ASGE Best Practices Course 2014 It s good to be oriented 1

2 Only in Las Vegas Only in New York City 2

3 Low Quality Driving in New York City Quality Matters in Endoscopy 3

4 Always Aim for a High Quality Experience Ferga Gleeson The Public Eye. Colonoscopies Miss Many Cancers, Study Finds For many years doctors and patients thought colonoscopies, the popular screening test for colorectal cancer, were all but infallible. Have a colonoscopy, get any precancerous polyps removed, and you should almost never get colon cancer..and now a Canadian study, published Tuesday in journal Annals found the test much less accurate than anyone expected. New York Times December 16,

5 Quality Measures in Colonoscopy: Why Should I Care? NEJM article 2012 Colonoscopic polypectomy and long term prevention of colorectal cancer deaths Cohort followed for 20 years Expected # of deaths (SEER) 25 Observed # of deaths 12 Percent reduction in colorectal cancer deaths % Quality: Definitions Dictionary definition Degree of excellence: grade Superiority in kind 5

6 Quality: Names you need to know Agency for Healthcare Research and Quality (AHRQ) Research in the development of valid and reliable measures of the process and outcomes of care, causation and prevention of of errors in health care National Committee for Quality Assurance (NCQA) The quality of care and services provided by health plans HEDIS A set of performance measures that compare how well health plans perform in key areas Quality of care Access to care Member satisfaction Quality Measures in Colonoscopy: Why should I care? Pay for performance Providers are rewarded for quality of health care services provided Also known as P4P or value based purchasing Rewards physicians, hospitals, medical groups for meeting performance measures for quality and efficiency Disincentives have been proposed Eliminating payments in the case of medical errors or increased costs 6

7 Pre-procedure Appropriate indication Informed consent Recommended surveillance intervals Adequate preparation p Appropriate Indications: Diagnostic Evaluation of abnormal imaging study Evaluation of unexplained GI bleeding Hematochezia Melena after UGI source excluded Presence of fecal occult blood Unexplained iron deficiency i anemia Chronic IBD of colon where precise information will influence management Chronic diarrhea of unexplained origin 7

8 Appropriate Indications: Therapeutic Treatment of bleeding Foreign body removal Decompression of acute non toxic megacolon or sigmoid volvulus Balloon dilation of stenosis Anastomotic strictures Palliation of stenosed or bleeding neoplasms Marking a neoplasm for localization Informed Consent Should be obtained on same day or as required by local law or institutional policy Must discuss risks, benefits and alternatives to the procedure Risks Bleeding Perforation Infection Sedation adverse events Misdiagnosis Complications of intravenous line 8

9 Screening and surveillance for colonic neoplasia Screening of asymptomatic, average risk patients for colonic neoplasia Examination to evaluate the entire colon for synchronous cancer or neoplastic polyps in a patient with treatable cancer or a neoplastic polyp Colonoscopy to remove synchronous neoplastic lesions at time of curative resection of cancer After adequate clearance of neoplastic polyps, survey at 3 to 5 year intervals Screening and surveillance for colonic neoplasia Patients with significant family history HNPCC Colonoscopy every two years beginning at age 25 or five years younger than the earlier diagnosis of colorectal cancer Annual colonoscopy should begin at age 40 Sporadic colorectal cancer before age 60 Colonoscopy every five years beginning at age 10 years earlier than the affected relative and every three years if adenomas found In patients with ulcerative colitis or Crohn s pancolitis eight or more years duration or left-sided colitis 15 or more years duration Colonoscopy every 1-2 years with systematic biopsies to detect dysplasia 9

10 Post polypectomy and post cancer surveillance Surveillance depends upon Family history of CRC Personal history of CRC Adenomas Number Histology (cancer, villous, high-grade dysplasia) Screening and surveillance for colonic neoplasia Screening Interval Average risk 10 years, beginning at age 50 Single first degree relative with 10 years, beginning at age 50 cancer or advanced adenomas at age greater than 60 years Greater than or equal to two firstdegree relatives with cancer or years younger, whichever is earlier) 5 years (begin at age 40 years or 10 adenomas or one first degree relative diagnosed at age less than or equal to 60 years Prior endometrial or ovarian cancer 5 years diagnosed at age less than 50 years HNPCC 1 to 2 years 10

11 Screening and surveillance for colonic neoplasia Post adenoma resection 1-2 tubular adenomas of less than 1 cm 3-10 adenomas or adenoma with villous features greater than 1 cm or with high-grade dysplasia Greater than 10 adenomas Large sessile adenoma removed piecemeal Post CRC resection Interval/intervention 5 to 10 years 3 years 3 years 2 to 6 months 1/3/5 years post resection Preparation Quality Split dose purgative preparation Multiple trials have addressed directly split dosing with PEG, sodium phosphate, or both All have shown split dosing to be superior to single-dose administration on the day before colonoscopy Quality diminishes as the interval increases between prep and procedure 11

12 The Impact of Split Dosing Not split Split Intra-procedure Cecal intubation i rates Adenoma detection rates Withdrawal times Biopsy specimens for chronic diarrhea Number of biopsy samples in IBD surveillance Polyps endoscopically removed 12

13 Cecal intubation rates Definition: iti Passage of the colonoscope to a point proximal to the ileocecal valve Photo documentation recommended Landmarks Appendiceal orifice Ileocecal valve Cecal intubation Greater than 90% of all cases Greater than 95% of CRC cases Adenoma Detection Rates Proportion of 50-year old asymptomatic screening population in which adenomas should be detected Greater than or equal to 25% Greater than or equal to 15% men women 13

14 Withdrawal Times Increase detection of significant neoplastic lesions in colonoscopic examinations where withdrawal times greater than six minutes Mean withdrawal time should be greater than six minutes in colonoscopies with normal results performed patients with intact colons Limitations of Colonoscopy Rapidly growing tumors Increased risk of MSI interval cancers Technical limitations of colonoscopy Hidden mucosa Flat lesions Ineffective application of current colonoscopic detection technology Ineffective polypectomy Poor bowel preparation 14

15 Ulcerative and Crohn s Colitis Goals: location and number of biopsies Four quadrant biopsies every 10 cm of colon 28 to 32 biopsy samples minimum Colonoscopic removal of polyps Mucosally based pedunculated or sessile polyps within 2 cm should not be sent for surgical resection without an attempt at endoscopic resection or documentation of endoscopic inaccessibility Modifying factors Location Access Patient stability 15

16 Post -procedure Incidence of perforation Incidence of postpolypectomy bleeding Management of postpolypectomy bleeding Post procedure Incidence of perforation by procedure type Overall perforation rate all indications screening colonoscopies 5% of colonoscopic perforations are fatal 16

17 Post procedure Bleeding is most common complication of polypectomy Measure incidence of postpolypectomy bleeding Risk for post-polypectomy bleeding Overall risk is less than 1% Exceeds 10% for polyps greater than 2 cm Post procedure Greater than 90% of postoperative bleeding can be managed nonoperatively Repeat colonoscopy Stalk of pedunculated polyp can be treated by clips, injection, MPEG, loops 17

18 Standard colonoscopy report Patient t demographics in history Assessment of risk and comorbidities Procedure indications Procedure technical description Colonoscopic findings Assessment Interval/unplanned events Follow-up plan Pathology Colonoscopy report: Key points Documentation of informed consent Documentation of ASA class Documentation of the management plan for anticoagulation Documentation of management plan for patients with implantable defibrillators and pacemakers 18

19 Colonoscopy report: Key points Use of recommended screening intervals based on family history risk factors Use of recommended post polypectomy and post cancer resection surveillance intervals Document reasons for deviation from recommended guidelines Colonoscopy report: Key points Documentation of sedation goals, medications, and dosages Documentation of cecal intubation by photographing landmarks Documentation of withdrawal time Documentation of quality of bowel preparation 19

20 Bowel prep documentation No standardization of quality for bowel prep has been validated Excellent: detect polyps less than 5 mm Good: detect polyps greater than 5 mm Fair: detect polyps greater than 1 cm Poor: cannot detect polyps greater than 1 cm ASGE Task Force considers procedure adequate if polyps greater than 5 mm detectable No guidance on timing of repeat colonoscopy for poor prep provided Colonoscopy report: Key points Assessment of procedure results Documentation of unplanned interventions during procedure Record of any intra or post-procedural complications Document the patients t received instruction ti on how to manage adverse events after discharge Plan for follow-up Plan for distributing results and recommendations to patients and referring doctor 20

21 Colonoscopy report: Key points Pathology requires systematic review of pathology reports, documentation of results, and subsequent follow plan The final endoscopy report should include the pathology results as an addendum with the recommendation for follow-up OR An endoscopy report that does not include pathology results should be accompanied by separate report that provides pathology results and recommendations Summary Colonoscopy is an excellent procedure for removing polyps and reducing colorectal cancer You do need to care about quality!!! HEDIS, P4P Procedure Pre-assessment Intra-procedural Post-procedural Meticulous documentation 21

22 Quality Matters Quality Matters 22

23 Quality Parenting. (not) It s all about high quality views into the GI tract 23

24 That s All Folks!!! 24