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Tu1399 Colonoscopy Quality Indicators From a Nationwide Consortium of GI Practices
Abstracts
colonoscopy performance. Methods: We conducted a quasi-experimental (pre/ post) study in a large, Australian teaching hospital endoscopy unit. Endoscopists were asked to prospectively self-record performance data for all colonoscopies. We measured the quality of colonoscopy before and after audit implementation using established process and outcome indicators (Rex et al GIE 2006). For analysis of adenoma detection rates, we excluded patients with inflammatory bowel disease, aged ⬍50, or participants in the Australian Bowel Cancer Screening Program, and adjusted for colonoscopist, age, sex and bowel preparation using logistic regression. Results: The pre-audit dataset comprised 1310 colonoscopies (47% male, median age 56y) and the post-audit dataset comprised 3460 colonoscopies (49% male, median age 58y). Significant differences in unadjusted rates of terminal ileal intubation and adenoma detection were found pre- and post-audit (see Table). The significant difference in adenoma detection rate persisted after adjusting for colonoscopist, age, sex and quality of bowel preparation (OR 2.18, 95% CI 1.58-3.00, P⬍0.001). Significant improvements in the quality of colonoscopy reporting were also evident, specifically in documentation of withdrawal time and bowel preparation. Conclusions: The introduction of a clinical audit process to a large teaching hospital endoscopy unit significantly improved the quality of colonoscopy and colonoscopic reporting. These findings support a role for continuous quality improvement programs in routine colonoscopic practice. Further research is needed to evaluate the long-term impact of clinical audit on colonoscopy quality.
Quality indicator Cecal intubation rate Terminal ileal intubation rate Adenoma detection rate Documentation of indication Documentation of bowel preparation quality Documentation of withdrawal time
Pre-audit, nⴝ1310
Post-audit, nⴝ3460
P value
96.1% 84.5% 27.6% 98.9% 59.8%
96.3% 89.7% 43.1% 99.4% 98.6%
NS ⬍0.001 ⬍0.001 NS ⬍0.001
5.8%
92.0%
⬍0.001
Tu1398 Clinical Factors Associated With Complications After Outpatient Colonoscopy in the Medicare Population M. Fuad Azrak1, Ya-Lin A. Huang2, David H. Howard2, Florence Tangka3, Joan Warren4, Carrie Klabunde4, Laura C. Seeff3 1 Medicine, Emory University, Atlanta, GA; 2Health Policy and Management, Emory University, Atlanta, GA; 3Cancer Prevention and Control, Centers for Disease Control and Preventions (CDC), Atlanta, GA; 4National Cancer Institute, Bethesda, MD Objective: To define the predictors for developing complications after outpatient colonoscopy. Methods: Retrospective, matched cohort study of a random 5% sample of Medicare beneficiaries who underwent outpatient colonoscopy from 1992-2007 and resided in the Surveillance, Epidemiology, and End Results cancer registry areas. Cases were matched to Medicare beneficiaries who did not have colonoscopy. Using Medicare claims, we identified all individuals who, within 30 days after colonoscopy, visited emergency departments or were hospitalized with possible gastrointestinal and cardiovascular complications including bleeding, perforation, angina/myocardial infarction, arrhythmias, pneumonia, and death. Logistic regression models were used in the colonoscopy cohort to identify predictors of complications (patient age, sex, race; comorbidity scores; ecological variables; physician specialty; and type of colonoscopy). Results: A total of 174,352 persons undergoing outpatient colonoscopy were included and were matched to 174,352 controls. ER visits and hospitalizations associated with the measured adverse events following outpatient colonoscopy occurred in 3.25 % of Medicare beneficiaries in the colonoscopy group versus 0.75 % in the control group (p ⬍ 0.001). The complication rates were higher among procedures performed by general surgeons compared to gastroenterolgists. Procedures performed by general surgeons were associated with two fold increased risk of perforation, 45% increased risk of bleeding, 31% increase risk of arrhythmias compared to procedures performed by gastroenterologists (p ⬍ 0.001). Colorectal surgeons had similar outcomes to gastroenterologists regarding most serious complications but had 28% less bleeding (p⫽0.05). Primary care physicians had comparable risk to gastroenterologists. Other predictors of adverse events included co-morbidities, age, and receipt of colonoscopy in an office setting versus an ambulatory surgical center. Performing biopsy or polypectomy were associated with increased risk for bleeding (29% and 71%, p⬍0.001 respectively) compared to no intervention, but perforation and cardiovascular risks were comparable. Blacks and whites experienced similar rates of complications. Conclusions: Physician specialty (general surgery compared to gastroenterology and colorectal surgery), increased age, comorbidites, and to a lesser extent- intervention during colonoscopy and performing colonoscopy in the office are associated with higher complication rates after outpatient colonoscopy in persons ⬎ 65.
Tu1399 Colonoscopy Quality Indicators From a Nationwide Consortium of GI Practices Lyndon V. Hernandez1, John I. Allen2, Dominic Klyve3, Joseph E. Geenen1, Michael J. Schmalz1, Marc F. Catalano1 1 GI Associates, LLC, Milwaukee, WI; 2Minnesota Gastroenterology, P.A.,, St. Paul, MN; 3Central Washington University, Ellensburg, WA Background: With payment reform looming imminent, gastroenterologists must embrace measuring and reporting quality indicators. Use of validated outcome registries may help practices benchmark results and be eligible for pay-forperformance initiatives and public reporting. Previous studies on quality metrics have been derived mostly from single institutions without long-term follow-up. Aim: To compare colonoscopy quality metrics among 13 GI practices representing 370 gastroenterologists. Methods: This is a cross-sectional study of ongoing data collected by Gastroenterology Practice Management Group (GPMG) from 2007 to 2010. At each participating site, a research coordinator collected de-identified group-level data from ambulatory centers across the US. Adenoma detection rate (ADR) ⫽ # colonoscopies with adenomatous polyp/total # of colonoscopies. ADR was not stratified by gender or indication, and each center had varying patient demographics; thus ADR was also adjusted for age⬎50. Prep quality was recorded as excellent, good, fair, and poor. Each group has its own quality management framework, and provided data on several quality measures at different time points. Results: Data from 256,362 colonoscopies were collected, of which 84,507 were initial screening (male, 45%, 78% over age 50, cecum reached 97%). Table 1 shows the ADR of each group with the corresponding % colonoscopies with fair to poor prep, and ADR adjusted for age ⬎50. High-performers, defined as groups in the highest quartile of ADR, had on average 10.4% higher ADR than groups belonging to the lowest quartile (p⬍ 0.005). ADR ranged from 19.7% to 32.9% (p⬍0 .001). There was a non-statistically significant negative correlation among high-performers and those having the lowest withdrawal rate ⬍5 min (r ⫽ ⫺0.48, p⫽0.11), as well as % colonoscopies with fair to poor prep (r ⫽ ⫺0.45, p⫽0.15). The mean ADR remained stable over 3 years except for 2 groups. Regression analysis showed that 2 groups had significant improvements in ADR during the study period: group 11 (mean 1.3% increase in ADR per quarter, p⫽0.014) and group 5 (mean 1.0% increase in ADR per quarter, p⫽ 0.037), both of which were high-performers. Conclusion: Using a large collaborative database focused on ADR, we found performance disparities among groups remaining relatively consistent over time. High-performing groups tend to improve even more, and appear to have distinct advantages to do so. This merits further research to identify key internal processes and physician incentives that enhance the quality of colonoscopy. Table 1. Adenoma Detection Rate (ADR) Among 13 GI Groups Group
ADR (SD)
% Fair to Poor Prep (SD)
Adjusted ADR
1 2 3 4 5 6 7 8 9 10 11 12 13
23.48 (3) 24.52 (2) 19.75 (3) 26.84 (3) 27.32 (2) 19.64 (1) 23.08 (2) 24.77 (1) 30.67 (2) 23.97 (2) 30.22 (3) 24.96 (6) 32.92 (4)
26.92 (1) 8.81 (4) 20.74 (10) 6.92 (2) 18.56 (1) 22.49 (2) 5.31 (N/A) N/A 11.58 (7) 20.51 (1) 5.94 (1) 17.27 (2) 14.83 (3)
26.24 (5) 22.21 (2) 20.62 (4) 25.76 (2) 27.97 (2) 23.35 (N/A) 23.60 (3) 24.73 (1) 27.69 (2) 20.60 (N/A) 29.01 (1) 23.97 (5) 31.18 (2)
(SD), ⫾Standard Deviation; N/A, data not available.
Tu1400 Management of Pancreatic Fluid Collections (PFCs): A Changing of the Guard From Surgery to Endoscopy Sahibzada U. Latif1, Milind A. Phadnis1, John D. Christein2, Mel Wilcox1, Whitney Jennings1, Jessica Trevino1, Shyam Varadarajulu1 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2Suregry, University of Alabama at Birmingham, Birmingham, AL Background: Although surgery is the gold standard, recent trend favors endoscopy for the minimally invasive management of PFCs. Aim: Assess the recent trend in management of PFCs and identify factors impacting this trend. Methods: The endoscopy and surgical databases were queried for patients treated for symptomatic PFCs over 6-yrs (2004-2010). Inpatients were evaluated by both surgical and medical teams and outpatients by interdepartmental consultations. PFCs were categorized as pseudocysts (PP) or complex collections
AB396 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
colonoscopy performance. Methods: We conducted a quasi-experimental (pre/ post) study in a large, Australian teaching hospital endoscopy unit. Endoscopists were asked to prospectively self-record performance data for all colonoscopies. We measured the quality of colonoscopy before and after audit implementation using established process and outcome indicators (Rex et al GIE 2006). For analysis of adenoma detection rates, we excluded patients with inflammatory bowel disease, aged ⬍50, or participants in the Australian Bowel Cancer Screening Program, and adjusted for colonoscopist, age, sex and bowel preparation using logistic regression. Results: The pre-audit dataset comprised 1310 colonoscopies (47% male, median age 56y) and the post-audit dataset comprised 3460 colonoscopies (49% male, median age 58y). Significant differences in unadjusted rates of terminal ileal intubation and adenoma detection were found pre- and post-audit (see Table). The significant difference in adenoma detection rate persisted after adjusting for colonoscopist, age, sex and quality of bowel preparation (OR 2.18, 95% CI 1.58-3.00, P⬍0.001). Significant improvements in the quality of colonoscopy reporting were also evident, specifically in documentation of withdrawal time and bowel preparation. Conclusions: The introduction of a clinical audit process to a large teaching hospital endoscopy unit significantly improved the quality of colonoscopy and colonoscopic reporting. These findings support a role for continuous quality improvement programs in routine colonoscopic practice. Further research is needed to evaluate the long-term impact of clinical audit on colonoscopy quality.
Quality indicator Cecal intubation rate Terminal ileal intubation rate Adenoma detection rate Documentation of indication Documentation of bowel preparation quality Documentation of withdrawal time
Pre-audit, nⴝ1310
Post-audit, nⴝ3460
P value
96.1% 84.5% 27.6% 98.9% 59.8%
96.3% 89.7% 43.1% 99.4% 98.6%
NS ⬍0.001 ⬍0.001 NS ⬍0.001
5.8%
92.0%
⬍0.001
Tu1398 Clinical Factors Associated With Complications After Outpatient Colonoscopy in the Medicare Population M. Fuad Azrak1, Ya-Lin A. Huang2, David H. Howard2, Florence Tangka3, Joan Warren4, Carrie Klabunde4, Laura C. Seeff3 1 Medicine, Emory University, Atlanta, GA; 2Health Policy and Management, Emory University, Atlanta, GA; 3Cancer Prevention and Control, Centers for Disease Control and Preventions (CDC), Atlanta, GA; 4National Cancer Institute, Bethesda, MD Objective: To define the predictors for developing complications after outpatient colonoscopy. Methods: Retrospective, matched cohort study of a random 5% sample of Medicare beneficiaries who underwent outpatient colonoscopy from 1992-2007 and resided in the Surveillance, Epidemiology, and End Results cancer registry areas. Cases were matched to Medicare beneficiaries who did not have colonoscopy. Using Medicare claims, we identified all individuals who, within 30 days after colonoscopy, visited emergency departments or were hospitalized with possible gastrointestinal and cardiovascular complications including bleeding, perforation, angina/myocardial infarction, arrhythmias, pneumonia, and death. Logistic regression models were used in the colonoscopy cohort to identify predictors of complications (patient age, sex, race; comorbidity scores; ecological variables; physician specialty; and type of colonoscopy). Results: A total of 174,352 persons undergoing outpatient colonoscopy were included and were matched to 174,352 controls. ER visits and hospitalizations associated with the measured adverse events following outpatient colonoscopy occurred in 3.25 % of Medicare beneficiaries in the colonoscopy group versus 0.75 % in the control group (p ⬍ 0.001). The complication rates were higher among procedures performed by general surgeons compared to gastroenterolgists. Procedures performed by general surgeons were associated with two fold increased risk of perforation, 45% increased risk of bleeding, 31% increase risk of arrhythmias compared to procedures performed by gastroenterologists (p ⬍ 0.001). Colorectal surgeons had similar outcomes to gastroenterologists regarding most serious complications but had 28% less bleeding (p⫽0.05). Primary care physicians had comparable risk to gastroenterologists. Other predictors of adverse events included co-morbidities, age, and receipt of colonoscopy in an office setting versus an ambulatory surgical center. Performing biopsy or polypectomy were associated with increased risk for bleeding (29% and 71%, p⬍0.001 respectively) compared to no intervention, but perforation and cardiovascular risks were comparable. Blacks and whites experienced similar rates of complications. Conclusions: Physician specialty (general surgery compared to gastroenterology and colorectal surgery), increased age, comorbidites, and to a lesser extent- intervention during colonoscopy and performing colonoscopy in the office are associated with higher complication rates after outpatient colonoscopy in persons ⬎ 65.
Tu1399 Colonoscopy Quality Indicators From a Nationwide Consortium of GI Practices Lyndon V. Hernandez1, John I. Allen2, Dominic Klyve3, Joseph E. Geenen1, Michael J. Schmalz1, Marc F. Catalano1 1 GI Associates, LLC, Milwaukee, WI; 2Minnesota Gastroenterology, P.A.,, St. Paul, MN; 3Central Washington University, Ellensburg, WA Background: With payment reform looming imminent, gastroenterologists must embrace measuring and reporting quality indicators. Use of validated outcome registries may help practices benchmark results and be eligible for pay-forperformance initiatives and public reporting. Previous studies on quality metrics have been derived mostly from single institutions without long-term follow-up. Aim: To compare colonoscopy quality metrics among 13 GI practices representing 370 gastroenterologists. Methods: This is a cross-sectional study of ongoing data collected by Gastroenterology Practice Management Group (GPMG) from 2007 to 2010. At each participating site, a research coordinator collected de-identified group-level data from ambulatory centers across the US. Adenoma detection rate (ADR) ⫽ # colonoscopies with adenomatous polyp/total # of colonoscopies. ADR was not stratified by gender or indication, and each center had varying patient demographics; thus ADR was also adjusted for age⬎50. Prep quality was recorded as excellent, good, fair, and poor. Each group has its own quality management framework, and provided data on several quality measures at different time points. Results: Data from 256,362 colonoscopies were collected, of which 84,507 were initial screening (male, 45%, 78% over age 50, cecum reached 97%). Table 1 shows the ADR of each group with the corresponding % colonoscopies with fair to poor prep, and ADR adjusted for age ⬎50. High-performers, defined as groups in the highest quartile of ADR, had on average 10.4% higher ADR than groups belonging to the lowest quartile (p⬍ 0.005). ADR ranged from 19.7% to 32.9% (p⬍0 .001). There was a non-statistically significant negative correlation among high-performers and those having the lowest withdrawal rate ⬍5 min (r ⫽ ⫺0.48, p⫽0.11), as well as % colonoscopies with fair to poor prep (r ⫽ ⫺0.45, p⫽0.15). The mean ADR remained stable over 3 years except for 2 groups. Regression analysis showed that 2 groups had significant improvements in ADR during the study period: group 11 (mean 1.3% increase in ADR per quarter, p⫽0.014) and group 5 (mean 1.0% increase in ADR per quarter, p⫽ 0.037), both of which were high-performers. Conclusion: Using a large collaborative database focused on ADR, we found performance disparities among groups remaining relatively consistent over time. High-performing groups tend to improve even more, and appear to have distinct advantages to do so. This merits further research to identify key internal processes and physician incentives that enhance the quality of colonoscopy. Table 1. Adenoma Detection Rate (ADR) Among 13 GI Groups Group
ADR (SD)
% Fair to Poor Prep (SD)
Adjusted ADR
1 2 3 4 5 6 7 8 9 10 11 12 13
23.48 (3) 24.52 (2) 19.75 (3) 26.84 (3) 27.32 (2) 19.64 (1) 23.08 (2) 24.77 (1) 30.67 (2) 23.97 (2) 30.22 (3) 24.96 (6) 32.92 (4)
26.92 (1) 8.81 (4) 20.74 (10) 6.92 (2) 18.56 (1) 22.49 (2) 5.31 (N/A) N/A 11.58 (7) 20.51 (1) 5.94 (1) 17.27 (2) 14.83 (3)
26.24 (5) 22.21 (2) 20.62 (4) 25.76 (2) 27.97 (2) 23.35 (N/A) 23.60 (3) 24.73 (1) 27.69 (2) 20.60 (N/A) 29.01 (1) 23.97 (5) 31.18 (2)
(SD), ⫾Standard Deviation; N/A, data not available.
Tu1400 Management of Pancreatic Fluid Collections (PFCs): A Changing of the Guard From Surgery to Endoscopy Sahibzada U. Latif1, Milind A. Phadnis1, John D. Christein2, Mel Wilcox1, Whitney Jennings1, Jessica Trevino1, Shyam Varadarajulu1 1 Gastroenterology-Hepatology, University of Alabama at Birmingham, Birmingham, AL; 2Suregry, University of Alabama at Birmingham, Birmingham, AL Background: Although surgery is the gold standard, recent trend favors endoscopy for the minimally invasive management of PFCs. Aim: Assess the recent trend in management of PFCs and identify factors impacting this trend. Methods: The endoscopy and surgical databases were queried for patients treated for symptomatic PFCs over 6-yrs (2004-2010). Inpatients were evaluated by both surgical and medical teams and outpatients by interdepartmental consultations. PFCs were categorized as pseudocysts (PP) or complex collections
AB396 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org