Temporal trends and variability of colonoscopy performance in gastroenterology practice

Colonoscopy is the investigation of choice for assessment of the large bowel. High-quality colonoscopy is essential to ensure maximal pathology detection and has been shown to reduce the incidence of postcolonoscopy colorectal cancer (CRC) [1] [2]. Low complication rates and low incidence of postcolonoscopy CRC are the most important quality outcome measures. Procedures should also be well tolerated by patients, whose colonoscopy experience should be at least acceptable.

High-quality colonoscopy should include a complete procedure in which the cecum is reached, the mucosa is inspected thoroughly, patient comfort is maintained, and any pathology is adequately diagnosed and dealt with [3] [4]. Surrogate markers of colonoscopy quality include colonoscopy withdrawal time, adenoma detection rate (ADR), mean number of adenomas per procedure (MAP), polyp detection rate, polyp retrieval rate, and bowel preparation scores [5]. In addition, a complete report of the procedure is required, including photodocumentation of specific landmarks and any abnormalities [6].

Unacceptable variation in the quality of colonoscopy and evidence of poor performance have been widely described [7] [8]. Interventions and programs to improve performance and reduce variation have been developed. A previous national colonoscopy audit in the UK demonstrated variation in performance and low cecal intubation rates (CIRs) [9]. As a result, a wide-ranging quality improvement program was implemented. Measures to improve performance included: development of the Joint Advisory Group on GI Endoscopy (JAG), which implements standards; development of the JAG Endoscopy Training System, which oversees a training e-portfolio to monitor competency in endoscopy; and the introduction of the Endoscopy Global Rating Scale, which measures endoscopy unit performance covering clinical care, patient and staff experiences, and training environment. Furthermore, the development of the National Health Service Bowel Cancer Screening Programme (BCSP) led to an increased focus on quality. These measures resulted in a significant improvement in the quality of UK colonoscopy, with particularly high standards in the BCSP [8] [10] [11]. Longitudinal improvements in the quality of colonoscopy over time have also been demonstrated in the USA [12].

In this issue of Endoscopy, Le Clercq et al. demonstrate that colonoscopy performance in three Dutch hospitals improved over a period of 6 years, from 2007 to 2013 [13]. A total of 100 consecutive colonoscopies undertaken by 23 different colonoscopists in three different time periods were analyzed. The study reports significant improvement in mean adjusted CIR, ADR, MAP, and proximal ADR. This is an important paper, demonstrating that the performance of individual colonoscopists improved over time. Previous work in this area has been limited by the inclusion of different endoscopists in each time period. This study’s strength is that it follows the same group of colonoscopists and therefore more convincingly demonstrates improvement in performance at the level of the individual colonoscopist. It also reports the important finding that colonoscopists with poorer initial performance improved. Improving the performance of endoscopists performing below the expected standard is a very important aspect of improving quality and reducing variation. Additional strengths of this paper are that key quality measures such as ADR, CIR, and MAP were evaluated at different time periods, across a range of different hospitals, including endoscopists of varying clinical backgrounds, and therefore it is likely that it provides an accurate impression of change over time. One limitation of the study is that the sample size of 100 consecutive patients from each colonoscopist may be insufficient to reliably assess individual ADR [14].

Noting improvement in performance over time is important but it is even more important to understand the factors responsible for improved performance. Understanding these may allow the same or similar models to be applied in different settings and may also allow targeted training for endoscopists who require improvement. Over an extended time period many factors may lead to improved performance, including organizational approaches, formal training programs, standard setting, and benchmarking such as in the UK, Poland, and The Netherlands [8] [10] [15] [16]. Le Clercq et al. report that in their university hospital, a training program consisting of lectures, videos, and individual feedback began during the period studied. In addition, the national Dutch bowel cancer screening program started in 2014, and colonoscopists underwent strict certification and continuous monitoring of quality measures. These may have influenced the performance of colonoscopists in nonuniversity hospitals through shared education and training within the same clinical care framework, in addition to the stimulus of healthy competition.

The development of screening programs has almost certainly contributed to wider improvements in the quality of colonoscopy practice beyond screening. The UK BCSP has demonstrated high standards within a national program, and it is likely that this program has served to help drive up standards more widely [11]. In Germany, a steady increase in ADR was observed in the screening population [17]. The European Society of Gastrointestinal Endoscopy (ESGE) recommends that national screening boards monitor quality indicators by gathering accurate data from screening centers thus allowing targeted improvements to be made [6].

Benchmarking of standards and the publication of performance measures are likely to have contributed to improved performance over time. Utilization of key performance indicators and quality assurance standards are important, and a number of countries have established minimal standards for performance [6] [18] [19]. The ESGE is currently leading an ambitious program to set quality standards for European gastrointestinal endoscopy [20].

In addition to setting standards and benchmarking, further approaches to improving quality should also be considered. Many aspects of quality improvement are inexpensive and easy to implement but may deliver significant results. A regional study in the UK demonstrated that a bundle of simple interventions improved ADR from 16 % to 18.1 %, and the EQUIP study in the USA demonstrated an ADR improvement of 11 % using simple educational interventions [21] [22]. In Poland, an intensive training and feedback program aimed at colonoscopy trainers resulted in a significant increase in ADR of 7.1 % [15].

The implications of an aging population coupled with the development of regional and national screening programs will result in a continuing increase in demand for colonoscopy. It is essential that high-quality colonoscopy is delivered, and where performance is poor it should be improved and variation reduced. It is commendable that as demand has increased, improvement in quality has also been demonstrated. It is important that we seek to maintain this and to understand what measures allow improvement in quality so that these can be replicated and implemented more widely. Delivering the highest possible standard of procedure to our patients should be the goal of every colonoscopy program and every individual colonoscopist.

• References

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