1 / 43

Ambulatory Endoscopy Clinic Day

Ambulatory Endoscopy Clinic Day. Quality of Care: Procedure Related Issues Nancy Baxter, MD PhD. Objectives. To review the concept of “quality of care” To discuss the growing focus on quality of colonoscopy To apply concepts of quality of care to procedural related issues for colonoscopy

hertz
Download Presentation

Ambulatory Endoscopy Clinic Day

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Ambulatory Endoscopy Clinic Day Quality of Care: Procedure Related Issues Nancy Baxter, MD PhD

  2. Objectives • To review the concept of “quality of care” • To discuss the growing focus on quality of colonoscopy • To apply concepts of quality of care to procedural related issues for colonoscopy • To describe current quality indicators and standards for colonoscopy

  3. Quality of Care The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Institute of Medicine

  4. Care Delivered Material Resources, Human Resources, Institutional Organization Health Status El-Jardali Healthcare Quarterly 2005; 40-8.

  5. good structure increases the likelihood of good process, and good process increases the likelihood of good outcomes

  6. Why Now? • Dramatic increase in rate of colonoscopy in Ontario • Change in indication for colonoscopy • Increase use for screening ICES 2004, Use of Large Bowel Procedures in Ontario

  7. Screening • Asymptomatic, healthy individuals with relatively low risk of disease • Benefits outweigh risks when procedure is high quality High Quality Minimized Maximized

  8. Screening • Asymptomatic, healthy individuals with relatively low risk of disease • Benefits outweigh risks when procedure is high quality • Risks may outweigh benefits when procedure is poor quality Poor Quality Less Effective More Complications

  9. Why Endoscopy? • Expensive procedure • Providers tend to be VERY high volume • Administrative data can produce useful metrics • Emerging understanding of limitations • Evidence of meaningful variation at the provider level

  10. Limitations of Colonoscopy • Interval cancer • Rapidly growing • Missed neoplasia • Incompletely resected adenoma • Estimated in administrative data based on timing of colonoscopy • More than 6 months • Less than 36 months

  11. Ontario Data • Rates of new or missed cancers evaluated • Design: Population-based cohort • Study period: 4/1/97-3/31/02 • Study population: ≥ 20 yr with a new diagnosis of CRC • 12,487 persons with a new CRC who had colonoscopy inserted to the site of the CRC within 3 yr prior to the diagnosis

  12. Findings • Right-sided: 195/3,288 (5.9%) • Transverse: 43/777 (5.5%) • Splenic flexure/desc’g: 15/710 (2.1%) • Rectal or sigmoid: 177/7,712 (2.3%) 430/12,487 (3.4%) Increased risk: older age, diverticular disease, right-sided or transverse CRC, internist/FP, non-hospital colonoscopy Bressler B et al. Gastroenterology 2007;132:96-102.

  13. Missed vs. New • Miss rates from tandem colonoscopy studies • 1cm adenoma – 0% to 6% • 6-9mm adenoma – 12%-13% • < 5mm adenoma 15%-27% • Colonoscopy vs. CT colonography • Centres of excellence for CT demonstrate miss rates for > 1cm of 12-17% • Other studies report much lower rates Faigel et al. Gastrointestinal Endoscopy 2006; 63s

  14. Baxter Ann Int Med 2009; 150:1-8

  15. Cases • Diagnosis of CRC between Jan 1996 through Dec 2001 from OCR • No previous diagnosis of CRC • Eligible for OHIP from 1992 to death • At least 4 years of information on history of endoscopy • Age 52-89 • Screen eligible range for at least 2 years • Died of CRC by Dec 2003 • Last mortality data available

  16. Controls • Selected from Registered Persons Database • Eligible for OHIP 1992 through 2003 • Matched to case for • Geographic location • Sex • Income quintile • Calendar year of birth • Referent date assigned

  17. Determination of Exposure • Colonoscopy (any attempted) • Z555 – colonoscopy to descending colon • Colonoscopy (complete) • Z555 – colonoscopy to descending colon plus • E747 – to cecum or E705 – to terminal ileum • > 6 months from diagnosis

  18. Primary Site

  19. Access Timeliness Appropriate use Other Adequate consent process Patient tolerance and satisfaction Quality reporting, recommendations and feedback Technical Complete colonic assessment Completion rate Quality of Preparation Quality of Inspection Adenoma detection Minimal Complications Procedural Factors

  20. Completion Rate • Recommendation • >90% all colonoscopies • >95% for screening • Exclude poor prep from denominator • > 97% completion rate reported in screening studies • Documentation • Verbal • Pictorial Faigel et al. Gastrointestinal Endoscopy 2006; 63s

  21. Ontario • Patients age 50-74 • 331,608 colonoscopies performed between 1999-2003 • 13% were incomplete • Factors affecting rate • Age: OR 1.20 per 10-year increment (95% CI=1.18-1.22) • Female sex: OR 1.35 (95% CI: 1.30-1.39) • History of prior abdominal surgery: OR 1.07 (95% CI: 1.05-1.09) or prior pelvic surgery: OR 1.04 (95% CI: 1.01-1.06). Shah Gastroenterology 2007; 132: 2297-303

  22. Factors Affecting Completion Wells BMC Gastroenterol. 2007; 7: 19

  23. Quality of Preparation • % with good preparation • Patient factors • Elderly • Socioeconomically deprived • Modifiable factors • Split dose preparations • Timing of colonoscopy

  24. Quality of Inspection Barclay NEJM 2006; 355:2533-41

  25. How to Measure • 6 minute withdrawal time has been suggested as quality measure • Patients with no adenoma detected • If implemented should be at the PROVIDER and not patient level • Start recording withdrawal time • Feedback • May be mandated in future

  26. Adenoma Detection • ASGE/ACG task force recommendations • Screening colonoscopy over age 50 • >25% men • >15% women • Some studies report substantially higher rates • Influenced by age, sex, family history

  27. Provider Variation • Single institution study • All colonoscopy between 1999-2004 • 9 endoscopists and 10,034 procedures • Range of adenoma detection for patients > 50 • Any adenoma: 15.5% - 41.1% • At least two adenomas: 4.9% - 20.0% • At least one adenoma > 1.0 cm: 1.7-6.2% • Range of adenomas detected per colonoscopy by endoscopist: 0.21-0.86 Chen Am J Gastro 2007; 102:856-201

  28. Bressler Gastroenterology 2007; 136; 96-102

  29. Complications

  30. Serious Complications • BC, Alberta, Ontario, Nova Scotia • Population 50-75 yr: 4.6 million • Persons 50-75 yrs who underwent outpatient colonoscopy between 4/1/2002 and 3/31/2003 • Outcome: Bleeding and perforation requiring admission within 30 days of colonoscopy Rabeneck et al. Gastroenterology 2008;135:1899-1906

  31. Results • 97,091 persons had an outpatient colonoscopy from 4/1/2002 to 3/31/2003 • Bleeding 1.64/1000 • Perforation 0.85/1000 • Death 0.074/1000 or 1/14,000 • Risk factors: increased age, male sex, polypectomy, volume < 283/yr

  32. Current Standards and Indicators

  33. Current Quality Indicators

  34. Current Quality Indicators

  35. Germany • Gastroenterology board license • > 200 colonoscopies and > 50 polypectomies in past 2 years • Adequate technical equipment for resuscitation and infection control monitoring • > 200 colonoscopies documented by photo per year • > 10 polypectomies with histology per year

  36. United States

  37. United States

  38. United States

  39. Summary • System-wide drive to assess, monitor and improve quality • Endoscopic procedures ideal target • Multiple procedural factors are important • Meaningful and fair indicators difficult to develop • Current standards unlikely to have impact

  40. Recommendations • Understand your practice • Completion rate • % poor preparation • Withdrawal time • Adenoma detection rate • Consider undertaking a QI project yearly based on your data

More Related