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Quality of colonoscopy: How to improve it?
Digestive and Liver Disease 44 (2012) 893–894
Contents lists available at SciVerse ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Editorial
Quality of colonoscopy: How to improve it? Cesare Hassan a,∗ , Douglas K. Rex b a b
Digestive Endoscopy Unit, “Nuovo Regina Margherita” Hospital, Roma, Italy Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
In the last 30 years, colonoscopy has rapidly become one of the most widely used diagnostic procedures in Western countries. Because of the efficacy of faecal occult blood tests and primary endoscopy prevention in reducing colorectal cancer (CRC) incidence and/or mortality [1–3], most European countries have already started or planned population screening programs, in which colonoscopy plays a major role. Although colonoscopy is a reasonably safe technique, it is hampered by a small but definite risk of severe complications. Moreover, suboptimal procedure performance – mainly related with inter-operator ability – has been associated with suboptimal CRC prevention or diagnosis [4,5]. For this reason, when considering the widespread practise of this technology, a robust policy of risk minimization and quality assurance should be expected to be in place in Western countries. In this issue of Digestive and Liver Disease, two interesting articles addressed the process of colonoscopy quality improvement in Europe from two different – albeit complementary – perspectives [6,7]. Sint Nicolaas et al. assessed the feasibility of the Global Rating Scale (GRS) – initially implemented in the United Kingdom – when applied in a different country [6]. Differently from the wellknown adenoma detection (or caecal intubation) rates, which may be defined as procedural indicators, GRS is a patient-centred multidimensional tool created to assess the structural level of endoscopic departments, such as the availability of policies to improve the efficiency and the safety of colonoscopy. The GRS is a web-based quality tool, required for participation in the UK national colorectal cancer screening program; therefore participation is high among endoscopy centres in the UK, and periodic performance assessments in the UK have showed steady improvements [8]. In detail, the authors applied the GRS tool to 11 Dutch endoscopy units, in order to assess the level of performance of the two main endoscopic “dimensions” of the GRS, namely clinical quality and patient experience [6]. The clinical quality dimension deals with critical items, such as the procedures of patient-information/consent/comfort, the availability of systems to manage complications and to audit clinical outcomes (i.e. the adenoma detection rate), and the implementation of policies for the appropriateness of (surveillance) endoscopies, as well as for the communication of endoscopic
∗ Corresponding author at: Digestive Endoscopy Unit, “Nuovo Regina Margherita” Hospital, Via Morosini 30, 00153 Roma, Italy. E-mail address: [email protected] (C. Hassan).
results. Most Dutch endoscopies scored the basic (lowest) level for two major items, such as ‘safety’ (64% basic score) and ‘quality’ (100% basic score), indicating that policies able to minimize risks and to maximize the efficacy of colonoscopy are far from being formally implemented in the Netherlands. The patient experience dimension mainly deals with the availability of policies regarding needs of minority populations, waiting list, patient privacy and dignity. Similarly to the previous dimension, most Dutch centres obtained a basic score for policies on equality and waiting list, whilst there was variability for those on privacy/dignity. The authors also succeeded in validating – at least partially – the application of GRS in the Netherlands by successfully matching the GRS collected data with a previous colonoscopy audit data. The study of GRS in the Netherlands represents two advances in European endoscopy quality improvement. First, it brings a degree of validation to some of the measures included in the GRS. The GRS is regarded as a considerable success in the UK, and validation of the GRS component measurements as predictors of clinically important outcomes supports the rationale for continuation of the GRS within the UK and makes its expansion outside the UK more attractive. Second, the GRS was successfully translated into another language and then implemented in a feasible and informative fashion outside the UK. Thus, the status of the GRS is increased by this study and the GRS may be a viable option for European countries establishing national colorectal cancer screening programs and looking for systems to improve colonoscopy quality. The Dutch clinicians found the most troublesome features of using the GRS to be lack of familiarity and the time required to complete the program questions. This brings up a familiar problem encountered in the quality improvement process, i.e. it requires resources. Quality programs often have to prioritize among a number of possible quality measures in order to make the process feasible. European countries will want to consider the GRS and alternative quality tools to determine the best initial approach. Some will likely choose (as some already have) systems more focused on procedural quality indicators, hopefully facilitated by electronic report-generating programs that automatically transfer procedural data to central databases that create benchmarking data. Such systems will miss many of the patient experience centred measures that are the focus of the GRS. It would seem that the GRS and electronic systems gathering procedural data are complementary. In the second published article, Minoli et al. performed an audit in 9 Italian Endoscopic Departments on any unintended, potentially dangerous events occurring during routine endoscopic testing,
1590-8658/$36.00 © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.dld.2012.08.015
894
C. Hassan, D.K. Rex / Digestive and Liver Disease 44 (2012) 893–894
differentiating between errors (already happened) and near misses (indicating an event that could have caused harm to the patient if it had happened) [7]. The overall rate of these events was 10%, and unexpectedly nearly 1 out of 3 reported events was an error. Most of the errors and near misses occurred before the procedure (i.e. informed consent, patient information) or – less frequently – after the procedure (i.e. incomplete nursing/endoscopic/pathology report), whilst operative events (i.e. during endoscopy) were much less frequent. The authors also noticed that nurses were much more efficient than physicians in reporting errors/near misses, and that the most frequent underlying reasons were individual oversight, failure to follow the procedure, little importance attributed to the mistake, or organizational deficit. Corrective interventions were feasible for the majority of these events. The approach taken in the Italian paper is notable not only for the “near misses” but also for the range of endoscopy unit operational and organizational issues addressed in the study. Certainly the issues addressed represent a wide range of lesser or greater relevance to clinical outcomes. Nonetheless the list of occurrences represents a familiar and annoying set of occurrences to any experienced endoscopist. In a relatively short 2-week process, the authors demonstrated that nurses and other non-physician personnel as well as physicians, can identify operational issues that lead to meaningful corrective measures. The process was relatively resource-intensive, but the short duration is helpful in this regard, and would lend itself to being periodically repeated. More study of this process and its impact on unit performance over time is warranted. The advent of national screening programs, requiring a high degree of certainty in the level of quality achieved for each step of the program, represents a unique opportunity to implement quality control measures for colonoscopy with a systematic
and consistent approach across Europe. The need for quality programs seems obvious when considering the massive volume of endoscopic resources resulting from a screening program, which represent an additional challenge to already overloaded endoscopic centres. The robust evidence supporting the association between quality of colonoscopy and the efficacy and safety of such a procedure in preventing CRC represents a strong incentive for nationwide implementation of quality assurance programs, similarly to what has already been done in the surgical field. Such an effort will certainly also improve the quality of non-screening procedures. References [1] Towler B, Irwig L, Glasziou P, et al. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ 1998;317:559–65. [2] Atkin WS, Edwards R, Kralj-Hans I, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010;375:1624–33. [3] Segnan N, Armaroli P, Bonelli L, et al. Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the italian randomized controlled trial—SCORE. Journal of National Cancer Institute 2011;103:1310–22. [4] Hewett DG, Kahi CJ, Rex DK. Efficacy and effectiveness of colonoscopy: how do we bridge the gap? Gastrointestinal Endoscopy Clinics of North America 2010;20:673–84. [5] Hassan C, Rex DK, Zullo A, et al. Loss of efficacy and cost-effectiveness when screening colonoscopy is performed by nongastroenterologists. Cancer 2012, http://dx.doi.org/10.1002/cncr.27664. [6] Sint Nicolaas J, De Jonge V, de Man RA, et al. The Global Rating Scale in clinical practice: a comprehensive quality assurance programme for endoscopy departments. Digestive and Liver Disease 2012;44:919–24. [7] Minoli G, Borsato P, Colombo E, et al. Errors and near misses in digestive endoscopy units. Digestive and Liver Disease 2012;44:914–8. [8] Gavin DR, Valori RM, Anderson JT, et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2012. PMID: 22661458.
Contents lists available at SciVerse ScienceDirect
Digestive and Liver Disease journal homepage: www.elsevier.com/locate/dld
Editorial
Quality of colonoscopy: How to improve it? Cesare Hassan a,∗ , Douglas K. Rex b a b
Digestive Endoscopy Unit, “Nuovo Regina Margherita” Hospital, Roma, Italy Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, IN, USA
In the last 30 years, colonoscopy has rapidly become one of the most widely used diagnostic procedures in Western countries. Because of the efficacy of faecal occult blood tests and primary endoscopy prevention in reducing colorectal cancer (CRC) incidence and/or mortality [1–3], most European countries have already started or planned population screening programs, in which colonoscopy plays a major role. Although colonoscopy is a reasonably safe technique, it is hampered by a small but definite risk of severe complications. Moreover, suboptimal procedure performance – mainly related with inter-operator ability – has been associated with suboptimal CRC prevention or diagnosis [4,5]. For this reason, when considering the widespread practise of this technology, a robust policy of risk minimization and quality assurance should be expected to be in place in Western countries. In this issue of Digestive and Liver Disease, two interesting articles addressed the process of colonoscopy quality improvement in Europe from two different – albeit complementary – perspectives [6,7]. Sint Nicolaas et al. assessed the feasibility of the Global Rating Scale (GRS) – initially implemented in the United Kingdom – when applied in a different country [6]. Differently from the wellknown adenoma detection (or caecal intubation) rates, which may be defined as procedural indicators, GRS is a patient-centred multidimensional tool created to assess the structural level of endoscopic departments, such as the availability of policies to improve the efficiency and the safety of colonoscopy. The GRS is a web-based quality tool, required for participation in the UK national colorectal cancer screening program; therefore participation is high among endoscopy centres in the UK, and periodic performance assessments in the UK have showed steady improvements [8]. In detail, the authors applied the GRS tool to 11 Dutch endoscopy units, in order to assess the level of performance of the two main endoscopic “dimensions” of the GRS, namely clinical quality and patient experience [6]. The clinical quality dimension deals with critical items, such as the procedures of patient-information/consent/comfort, the availability of systems to manage complications and to audit clinical outcomes (i.e. the adenoma detection rate), and the implementation of policies for the appropriateness of (surveillance) endoscopies, as well as for the communication of endoscopic
∗ Corresponding author at: Digestive Endoscopy Unit, “Nuovo Regina Margherita” Hospital, Via Morosini 30, 00153 Roma, Italy. E-mail address: [email protected] (C. Hassan).
results. Most Dutch endoscopies scored the basic (lowest) level for two major items, such as ‘safety’ (64% basic score) and ‘quality’ (100% basic score), indicating that policies able to minimize risks and to maximize the efficacy of colonoscopy are far from being formally implemented in the Netherlands. The patient experience dimension mainly deals with the availability of policies regarding needs of minority populations, waiting list, patient privacy and dignity. Similarly to the previous dimension, most Dutch centres obtained a basic score for policies on equality and waiting list, whilst there was variability for those on privacy/dignity. The authors also succeeded in validating – at least partially – the application of GRS in the Netherlands by successfully matching the GRS collected data with a previous colonoscopy audit data. The study of GRS in the Netherlands represents two advances in European endoscopy quality improvement. First, it brings a degree of validation to some of the measures included in the GRS. The GRS is regarded as a considerable success in the UK, and validation of the GRS component measurements as predictors of clinically important outcomes supports the rationale for continuation of the GRS within the UK and makes its expansion outside the UK more attractive. Second, the GRS was successfully translated into another language and then implemented in a feasible and informative fashion outside the UK. Thus, the status of the GRS is increased by this study and the GRS may be a viable option for European countries establishing national colorectal cancer screening programs and looking for systems to improve colonoscopy quality. The Dutch clinicians found the most troublesome features of using the GRS to be lack of familiarity and the time required to complete the program questions. This brings up a familiar problem encountered in the quality improvement process, i.e. it requires resources. Quality programs often have to prioritize among a number of possible quality measures in order to make the process feasible. European countries will want to consider the GRS and alternative quality tools to determine the best initial approach. Some will likely choose (as some already have) systems more focused on procedural quality indicators, hopefully facilitated by electronic report-generating programs that automatically transfer procedural data to central databases that create benchmarking data. Such systems will miss many of the patient experience centred measures that are the focus of the GRS. It would seem that the GRS and electronic systems gathering procedural data are complementary. In the second published article, Minoli et al. performed an audit in 9 Italian Endoscopic Departments on any unintended, potentially dangerous events occurring during routine endoscopic testing,
1590-8658/$36.00 © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.dld.2012.08.015
894
C. Hassan, D.K. Rex / Digestive and Liver Disease 44 (2012) 893–894
differentiating between errors (already happened) and near misses (indicating an event that could have caused harm to the patient if it had happened) [7]. The overall rate of these events was 10%, and unexpectedly nearly 1 out of 3 reported events was an error. Most of the errors and near misses occurred before the procedure (i.e. informed consent, patient information) or – less frequently – after the procedure (i.e. incomplete nursing/endoscopic/pathology report), whilst operative events (i.e. during endoscopy) were much less frequent. The authors also noticed that nurses were much more efficient than physicians in reporting errors/near misses, and that the most frequent underlying reasons were individual oversight, failure to follow the procedure, little importance attributed to the mistake, or organizational deficit. Corrective interventions were feasible for the majority of these events. The approach taken in the Italian paper is notable not only for the “near misses” but also for the range of endoscopy unit operational and organizational issues addressed in the study. Certainly the issues addressed represent a wide range of lesser or greater relevance to clinical outcomes. Nonetheless the list of occurrences represents a familiar and annoying set of occurrences to any experienced endoscopist. In a relatively short 2-week process, the authors demonstrated that nurses and other non-physician personnel as well as physicians, can identify operational issues that lead to meaningful corrective measures. The process was relatively resource-intensive, but the short duration is helpful in this regard, and would lend itself to being periodically repeated. More study of this process and its impact on unit performance over time is warranted. The advent of national screening programs, requiring a high degree of certainty in the level of quality achieved for each step of the program, represents a unique opportunity to implement quality control measures for colonoscopy with a systematic
and consistent approach across Europe. The need for quality programs seems obvious when considering the massive volume of endoscopic resources resulting from a screening program, which represent an additional challenge to already overloaded endoscopic centres. The robust evidence supporting the association between quality of colonoscopy and the efficacy and safety of such a procedure in preventing CRC represents a strong incentive for nationwide implementation of quality assurance programs, similarly to what has already been done in the surgical field. Such an effort will certainly also improve the quality of non-screening procedures. References [1] Towler B, Irwig L, Glasziou P, et al. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ 1998;317:559–65. [2] Atkin WS, Edwards R, Kralj-Hans I, et al. Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010;375:1624–33. [3] Segnan N, Armaroli P, Bonelli L, et al. Once-only sigmoidoscopy in colorectal cancer screening: follow-up findings of the italian randomized controlled trial—SCORE. Journal of National Cancer Institute 2011;103:1310–22. [4] Hewett DG, Kahi CJ, Rex DK. Efficacy and effectiveness of colonoscopy: how do we bridge the gap? Gastrointestinal Endoscopy Clinics of North America 2010;20:673–84. [5] Hassan C, Rex DK, Zullo A, et al. Loss of efficacy and cost-effectiveness when screening colonoscopy is performed by nongastroenterologists. Cancer 2012, http://dx.doi.org/10.1002/cncr.27664. [6] Sint Nicolaas J, De Jonge V, de Man RA, et al. The Global Rating Scale in clinical practice: a comprehensive quality assurance programme for endoscopy departments. Digestive and Liver Disease 2012;44:919–24. [7] Minoli G, Borsato P, Colombo E, et al. Errors and near misses in digestive endoscopy units. Digestive and Liver Disease 2012;44:914–8. [8] Gavin DR, Valori RM, Anderson JT, et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2012. PMID: 22661458.