Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

Transcription

1 Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative Name: Institution: Michal F. Kaminski, MD, PhD Dept. of Cancer Prevention and Dept. of Gastroenterological Oncology Center of Oncology Institute, Warsaw, Poland Medical Centre for Postgraduate Education, Warsaw, Poland Institute of Health and Society, Univeristy of Oslo, Norway

2 Disclosures I (and if applicable, my spouse/partner) disclose the following financial relationship with a commercial interest: Olympus Polska, Speaking and Teaching Alfa Wassermann, Advisory Board

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4 k ey P erformance M easures m inor P erformance M easures 15 PMs27 44 not PMs 23 overlapping QMs PMs!

5 Lower GI Quality Domains 1. Pre procedure 2. Completeness of procedure 3. Identification of pathology 4. Management of pathology 5. Complications Competence of endoscopists 6. Patients experience 7. Post procedure 1 kpm Rutter MD, et al. Endoscopy and UEG J, 2016 Bretthauer M, et al. Endoscopy and UEG J, 2016 Bisschops R, et al. Endoscopy and UEG J, 2016 Kaminski MF, et al. Endoscopy and UEG J, 2017

6 1. Pre procedure k PM Rate of adequate bowel preparation Construct Denominator: Patients undergoing colonoscopy Numerator: Patients in denominator with adequate bowel preparation using validated scale (excl. emergency) Calculation: Proportion (%) Level of analysis: Service and individual Minimum: 90% Standards Target: 95% Consensus Agreement 100% Evidence Moderate quality evidence Grading

7 Evidence: Rate of adequate bowel preparation Importance Associated with ADR and CIR Repeated exam: cost and inconvenience Scientific acceptability Validated scales (ADR, advadr) Adequate: BBPS 6 Ottawa 7, Aronchick exl. fair Feasibility 90% measured in population based studies Froehlich F, et al. Gastrointest Endosc, 2005 Rex DK, et al. Am J Gastroenterol 2002 Calderwood AH, et al. Gastrointestinal Endosc, 2014 Bretthauer M, et al. JAMA Intern Med 2016

8 2. Completeness of procedure k PM Construct Standards Consensus Agreement Evidence Grading Cecal intubation rate Denominator: Patients undergoing colonoscopy Numerator: Patients in denominator reached cecum + photo (excl. Emergency & specific therapeutic) Calculation: Proportion (%) Level of analysis: Service and individual Minimum: 90% Target: 95% 97.9% Moderate quality evidence

9 Evidence: Cecal intubation rate Importance Cecal photo associated with PDR Repeated exam: cost and inconvenience Scientific acceptability Well defined landmarks CIR <80% associated with interval CRC Feasibility 95% measured in population based studies Thoufeeq MH, et al. Endoscopy IO, 2015 Baxter NN, et al. Gastroenterology 2011 Lee TJ et al. Gut 2012 Bretthauer M, et al. JAMA Intern Med 2016

10 3. Identification of pathology k PM Construct Standards Consensus Agreement Evidence Grading Adenoma detection rate (ADR) Denominator: Patients 50 years of age undergoing cspy Numerator: Patients in denominator with 1 adenoma (excl. Emergency & specific therapeutic) Calculation: Proportion (%) Level of analysis: Service and individual Minimum: 25% Target: not defined 100% Moderate to high quality evidence

11 Evidence: Adenoma detection rate Importance 2 10 fold variation among endoscopist Associated with interval CRC and CRC death Scientific acceptability Well defined with low risk of gaming Susceptible for improvement Feasibility 25% reached in recent population based studies Kaminski MF, et al. NEJM 2010 Corley DA et al. NEJM 2014 Kaminski MF et al. Gut 2015 Bretthauer M, et al. JAMA Intern Med 2016

12 4. Management of pathology kpm Construct Standards Consensus Agreement Evidence Grading Appropriate polypectomy technique Denominator: Polyps >3mm in size removed at colonoscopy Numerator: Polyps in the denominator removed with snare polypectomy (cold/diathermy) Calculation: Proportion (%) Level of analysis: Service and individual Minimum: 80% Target: 90% 100% Low quality evidence

13 Evidence: Appropriate polypectomy technique Importance 3 fold variation in incomplete resection Incomplete resection: up to 25% of icrc Scientific acceptability Biopsy forceps resection inferior to snare for polyps 4mm Feasibility Easy to retrieve from electronic reports 72 90% polyps >3mm resected with snare Pohl H et al. Gastroenterology 2013 Lee CK et al. Am J Gastroenterol 2013 Britto Arias M et al. Endoscopy 2015 Din S, et al. Surg Endosc 2015

14 5. Complications kpm Construct Standards Consensus Agreement Evidence Grading Complication rate Denominator: All colonoscopies Numerator: Denominator with a complication registered (early compl. + 7 day readmission + 30 day mortality rate) Calculation: Proportion (%) Level of analysis: Service Minimum: 0.5% 7 day readmissions, N/A Target: N/A 93.8% Low quality evidence

15 Evidence: Complication rate Importance 6(7) day readmission predicts mortality rate Lenghtening hospital stay, add. procedure Scientific acceptability 30 day mortality and 7 day readmission well defined and significant for patient Feasibility Administrative data claims Direct phone call or hospital records Levin TR et al. Ann Intern Med 2006 Rabeneck L et al. Gastroenterology 2008 Adler A et al. Endoscopy 2013 Sarkar S, et al. Eur J Gastro Hep 2012

16 6. Patient experience kpm Construct Standards Consensus Agreement Evidence Grading Patient experience Denominator: All colonoscopies Numerator: Denominator with patient experience measured Calculation: Proportion (%) Level of analysis: Service and individual Minimum: Unknown Target: 90% 93.8% Very low quality evidence

17 Evidence: Patient experience Importance Potentially painful and embarassing Scientific acceptability Intra and post procedure pain levels Validated questionnaires (Gastronet & Global Rating Scale) Patient recorded pain & VAS/VRS 4 Feasibility 80 90% coverage with Gastronet / GRS Sint Nicolas J et al. Endoscopy 2012 Seip B et al. Endoscopy 2010 Hoff G et al. Scand J Gastroenterol 2006 Ghanouni A, et al. Endoscopy 2016

18 7. Post procedure kpm Construct Standards Consensus Agreement Evidence Grading Appropriate post polypectomy surveillance recommendations Denominator: Patients after colorectal polypectomy Numerator: Denominator with proper recommendations Calculation: Proportion (%) Level of analysis: Service and individual Minimum: Unknown Target: 95% 93.8% Low quality evidence

19 Evidence: Appropriate post polyp. surveillance Importance Surveillance: balance between benefit (CRC prevention) & harms (too frequent, invasive) < 30% patient compliance Scientific acceptability Recommendations by gastroenterologist / PCP strongest predictor of compliance Feasibility Endoscopy reporting systems Hassan C et al. Endoscopy 2013 Loberg M et al. NEJM 2014 Boolchand V et al. Ann Intern Med 2006 van Heijningen EM, et al. Gut 2015

20 Summary of lower GI Performance measures