Pre- and post-procedural quality indicators for colonoscopy: A nationwide survey

doi:10.1016/j.dld.2016.03.017

Digestive and Liver Disease

Volume 48, Issue 7, July 2016, Pages 759-764

https://doi.org/10.1016/j.dld.2016.03.017 Get rights and content

Abstract

Background

The provision of high-quality colonoscopy can be assessed by evaluating technical aspects of the procedure and, at individual center level, by comparing structural indicators and institutional policies for managing peri-procedural issues with guideline recommendations.

Aim

To assess the colonoscopy quality (CQ) in Italy at center level.

Methods

Gastroenterologists participating in a nationwide colonoscopy education initiative provided information on structural indicators of their centers and on institutional policies by answering 10 multiple-choice clinical scenarios. Practice variation across centers and compliance with guidelines were analyzed.

Results

Data from 282 Italian centers were evaluated. Overall, a significant proportion of centers did not meet CQ standards as concerns endoscopy facilities and equipments (e.g., dedicated recovery room, dirty-to-clean path, reporting software). CQ assurance programs were implemented in only 25% of centers. Concerning peri-procedural issues, main discrepancies with guidelines were recorded in the underuse of split-dose preparation (routinely adopted by 18% of centers), the routine request of coagulation tests prior to colonoscopy (30%), the routine interruption of aspirin for polypectomy (18%), and the adoption of 3-year surveillance for low-risk adenoma (49%).

Conclusions

Present survey shows a significant variation in the CQ of endoscopy centers in Italy on many items of colonoscopy practice that should be targeted for future interventions.

Introduction

Colonoscopy plays a pivotal role in colorectal cancer (CRC) prevention and diagnosis, but its effectiveness depends on the quality of the examination. High-quality colonoscopy delivers better health outcomes (i.e., lower risk of interval CRC) [1], [2], better patient experience, and fewer repeated procedures [3]. Although the overall quality of colonoscopy has significantly improved over the last few years, it can still vary considerably across centers and endoscopists.

Despite a set of quality indicators (QI) for the different steps of the colonoscopy procedure (i.e., pre-procedure, intra-procedure, and post-procedure) [4], [5], [6] has been developed, most studies on colonoscopy quality are focused on few key-performance measures mainly related to the technical aspects of the examination, such as adenoma detection and caecal intubation rate [1], [2], [7], [8], [9]. Nevertheless, the provision of high-quality colonoscopy is complex and it results from the interaction of a myriad of factors other than technical ones. To this regard, the characteristics and conditions of the healthcare institutions in which digestive endoscopy is delivered (structural indicators; e.g., endoscopy volume and workforce, type of instruments and other endoscopy equipment), and the institutional policies for patient care before (e.g., bowel preparation, management of anti-thrombotic therapy), during (e.g., sedation) and after (e.g., post-polypectomy surveillance) the examination [10] may also influence the overall quality of colonoscopy. For each of these areas (domains) of clinical practice [10], international professional GI societies have issued practice guidelines in order to advise on the best strategies, according to the available evidence, and optimize patient care. In this perspective, the quality of colonoscopy should be assessed not only by measuring individual endoscopist performance, but also, at endoscopy center level, by comparing local institutional policies for each domain to the evidence-based guideline recommendations [11].

The aim of present survey, including a large number of endoscopy units of both academic and non-academic hospitals all over Italy, was to explore the variability of colonoscopy practice across centers as concerns relevant periprocedural issues and to determine the adherence to current guidelines, in order to provide a snapshot of the quality of Italian endoscopy services and identify areas that might benefit from further research.

Section snippets

Methods

In 2014, a nationwide colonoscopy education initiative (Bowell.it Educational Tour) was held in Italy. Overall, 480 gastroenterologists and GI endoscopists from 289 different endoscopy centers participated in 14 meetings, aimed at increasing awareness on colonoscopy quality issues and optimizing colonoscopy practice. During these meetings, one endoscopist, representative of each participating center, was invited to take part in the survey by filling in a standard questionnaire. The questonnaire

Statistics

Categorical variables were summarized using frequencies and percentages with 95% confidence intervals. Chi-squared (χ²) test was used to compare categorical variables. All statistical tests were two-sided and were considered statistically significant at P < 0.05.

Results

Overall, questionnaires from 282 centers were collected, representing the 58.1% of the 485 endoscopy centers in Italy, according to a Italian Society of Digestive Endoscopy (SIED) census spread in year 2014. Information was provided by 146 (51.8%) centers in Northern Italy, 70 (24.8%) from the center and 66 (23.4%) from the South and Islands. Of the participating centers, 234 (83%) were community hospitals, 39 (13.8%) academic hospitals and 9 (3.2%) private practice centers. Structure and

Discussion

Data from the present survey show that there is a large variability across centers as concerns multiple colonoscopy domains and an overall scarce compliance with available guideline recommendations. This may negatively impact on safety, costs and patient experience, with related risks of suboptimal care and poor health outcomes.

Despite some structural indicators are essential prerequisites of any endoscopy center, the present survey shows significant shortcoming in facilities (e.g., lack of

Conflict of interest

None declared.

Acknowledgements

The authors would like to thank Dr. Anastasios Koulaouzidis MD, FACG (Endoscopy Unit, The Royal Infirmary of Edinburgh) for manuscript content and language revision.

References (37)

D.K. Rex et al.
Quality indicators for colonoscopy
Gastrointestinal Endoscopy
(2006)
D.K. Rex et al.
Quality indicators for colonoscopy
Gastrointestinal Endoscopy
(2015)
V. Chandrasekhara et al.
Open-access endoscopy
Gastrointestinal Endoscopy
(2015)
D.A. Johnson et al.
Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi-society task force on colorectal cancer
Gastrointestinal Endoscopy
(2014)
M. Martel et al.
Split-dose preparations are superior to day-before bowel cleansing regimens: a meta-analysis
Gastroenterology
(2015)
C. Hassan et al.
A predictive model identifies patients most likely to have inadequate bowel preparation for colonoscopy
Clinical Gastroenterology and Hepatology
(2012)
S.F. Pasha et al.
Routine laboratory testing before endoscopic procedures
Gastrointestinal Endoscopy
(2014)
D.K. Rex et al.
Sedation and the technical performance of colonoscopy
Gastrointestinal Endoscopy Clinics of North America
(2005)
F. Radaelli et al.
Colonoscopy practice in Italy: a prospective survey on behalf of the Italian Association of Hospital Gastroenterologists
Digestive and Liver Disease
(2008)
M.A. Anderson et al.
Management of antithrombotic agents for endoscopic procedures
Gastrointestinal Endoscopy
(2009)

L.B. Gerson et al.

The management of anticoagulants in the periendoscopic period for patients with atrial fibrillation: a decision analysis

American Journal of Medicine

(2004)

L.A. Feagins et al.

Low rate of postpolypectomy bleeding among patients who continue thienopyridine therapy during colonoscopy

Clinical Gastroenterology and Hepatology

(2013)

D.A. Lieberman et al.

Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer

Gastroenterology

(2012)

M.R. Sanaka et al.

Improving compliance with postpolypectomy surveillance guidelines: an interventional study using a continuous quality improvement initiative

Gastrointestinal Endoscopy

(2006)

M.F. Kaminski et al.

Quality indicators for colonoscopy and the risk of interval cancer

New England Journal of Medicine

(2010)

D.A. Corley et al.

Adenoma detection rate and risk of colorectal cancer and death

New England Journal of Medicine

(2014)

M.D. Rutter et al.

Quality in gastrointestinal endoscopy

Endoscopy

(2014)

B. Rembacken et al.

Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE)

Endoscopy

(2012)

Cited by (9)

An Italian prospective multicenter study on colonoscopy practice and quality: What has changed in the last 10 years
2023, Digestive and Liver Disease
Citation Excerpt :
While using low-volume preparations, the split-dose intake of the preparation (with the last dose taken 3–5 h before examination) was also associated with significantly better cleansing and was adopted in 71.1% of cases. In an Italian survey on quality indicators for colonoscopy carried out in 2016, a split-dose was routinely adopted in only 18% of centers [24]. In a comparable study which was carried out in Poland, adequate bowel preparation was seen on 91.3% of cases, which ranged from 79.2 to 99.2% among individual centers [25].
A relevant number of adenomas can be missed during colonoscopy.
Assess the current status of colonoscopy procedures in Italian centers.
A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1.
A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold.
High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs.
Impact of Physicians’ and Patients’ Compliance on Outcomes of Colonoscopic Polypectomy With Anti-Thrombotic Therapy
2021, Clinical Gastroenterology and Hepatology
Citation Excerpt :
Physician compliance to guidelines remained low throughout the years despite emerging evidence showing the safety of interruption of anticoagulants before endoscopy.14 Lack of awareness of guidelines, reluctance to change practice, low-quality evidence of guideline recommendations, variations between different guidelines, and potential medicolegal concerns are the most commonly alleged causes for nonadherence to guidelines.11,15,16 Few studies have looked at patient compliance to clinician suggestions on antithrombotics.
Although there are international guidelines on the management of antithrombotic therapy in patients undergoing colonoscopic polypectomy, whether clinicians and patients follow these recommendations are largely unknown. We aimed to evaluate clinician adherence and patient compliance to periendoscopic management of antithrombotic therapy and their impact on clinical outcomes.
Consecutive patients on antithrombotic therapy scheduled for elective colonoscopy in a tertiary referral center were recruited prospectively. Demographic data, indications and periprocedural management of antithrombotic drugs, colonoscopy findings, postpolypectomy bleeding, and serious cardiovascular events were collected systematically. We used Joint Asian Pacific Association of Gastroenterology–Asian Pacific Society for Digestive Endoscopy Practice Guidelines 2018 and assumed clinicians should hold antithrombotics for polypectomy in all colonoscopy patients. Patient compliance was assessed by checking whether discontinuation and resumption of antithrombotic drugs were in accordance with clinician advice.
Between December 2017 and October 2019, there were 602 patients recruited who were on antithrombotic drugs undergoing colonoscopy with polypectomy. A total of 98.4%, 41.2%, and 40.0% of clinicians adhered to the guidelines for aspirin alone, clopidogrel alone, and dual-antiplatelet therapy, respectively. Adherence rates were 8.5% for warfarin and 5.2% for direct oral anticoagulants. Compliance to instructions for aspirin alone, clopidogrel alone, dual-antiplatelet therapy, warfarin, and direct oral anticoagulants were achieved in 74.8%, 41.2%, 0%, 36.2%, and 17.5% of patients, respectively. Clinician nonadherence to guidelines was a risk factor for delayed postpolypectomy bleeding (adjusted hazard ratio, 3.54; 95% CI, 1.46–8.58; P = .005), and serious cardiovascular events (hazard ratio, 15.63; 95% CI, 1.83–133.80; P = .012).
Physician adherence to the guideline and patient compliance, with the exception of aspirin, were poor and contributed to adverse clinical outcomes. ClinicalTrials.gov number: NCT03363061.
Second-generation thrombopoietin receptor agonists: New players in the management of cirrhotic patients undergoing therapeutic endoscopy?
2021, Digestive and Liver Disease
Preparation for colonoscopy: Recommendations by an expert panel in Italy
2018, Digestive and Liver Disease
Citation Excerpt :
Indeed, the quality of preparation is a key factor of the ADR and improves the results of screening tests. Despite this evidence, even in the most recent series, inadequate preparation is observed in up to 20% of all colonoscopies [4–6]. For this reason, national and international scientific societies and the “United States Multi-Society Task Force on Colorectal Cancer” have produced guidelines on bowel preparation before colonoscopy [1,2,7,8].
Despite several guidelines on bowel preparation being available, their applicability in Italy is poorly investigated.
(1) To create expert-based recommendations for the Italian setting based on available international guidelines on bowel preparation for colonoscopy; (2) to assess consensus across the Italian endoscopy community.
The study was conducted in 2 phases: (a) statements formulation, (b) assessment of consensus. For the first phase, 6 topics related to bowel preparation were identified: (1) efficacy/tolerability; (2) timing; (3) assessment of quality of bowel preparation; (4) factors associated with inadequate preparation; (5) patient education and (6) impact of organisational factors. For each topic, statements were produced and voted by a panel of experts. For consensus assessment, the invited participants were asked to rate the statements. The statement achieved a good level of agreement when at least 70% of voters agreed with it.
25 statements were agreed in the first phase. Agreement was not achieved by the endoscopy community for 7 statements, mainly concerning practical aspects (i.e. strategies for management of patients with inadequate preparation, organisational factors).
A clinically relevant consensus was achieved on the main topics of bowel preparation, such as the choice of laxative and the time of administration, and it may help to homogenize the colonoscopy practice in Italy. Nevertheless, there are a few country-specific preparation-related issues that need to be addressed.
Periendoscopic management of antiplatelet therapy: Prospective evaluation of adherence to guidelines
2019, Gastroenterologia y Hepatologia
Citation Excerpt :
For instance, a recent report that reviewed the colonoscopy preparation instruction sheets of 317 endoscopy units in the USA found that in about 50% of cases, instructions were against most of the guidelines’ recommendations.6 Lack of awareness, inertia to change policies, low grade of evidence of guideline's recommendations, variation between guidelines and medicolegal concerns are the most frequently alleged causes for non-adherence.6–8 Therefore, a great effort has been put on improving guidelines design and implementation.
Adherence to guidelines on the periendoscopic management of antiplatelet therapy (APT) has not been analyzed in detail. Our aim was to assess adherence to guidelines in patients referred to our Endoscopy Unit on a case-by-case basis, describing in detail the detected deviations and identifying areas of improvement.
Cross-sectional study of outpatients consecutively scheduled for an unsedated upper or lower gastrointestinal endoscopy between January and June 2015. Patients on anticoagulant therapy were excluded.
675 patients were evaluated, including 91 (13.5%) patients on APT [upper GI endoscopy 25 (27.5%), lower GI endoscopy 66 (72.5%)]. Contrary to the clinical guidelines, aspirin was discontinued in 25 of the 77 patients previously prescribed the drug (32.5%) but this modification was patient's own decision in 11 cases. Most of the apparent deviations in the management of clopidogrel and dual antiplatelet therapy (DAPT) were not true non-adherence cases. The Primary Care physician modified an APT prescribed by another physician in 8 of 9 cases (88.9%), always in cases with aspirin. No relationship was found between the endoscopic procedure's predicted risk of bleeding or the patient's thrombotic risk and modification of therapy.
In many patients, the peri-procedural management of APT goes against current guidelines, but some of these inconsistencies cannot be considered true deviations from practice. Identified areas for improvement are increasing patient awareness about APT, disseminating the guidelines in Primary Care, and underscoring the significance of thrombotic risk related to APT withdrawal.
El cumplimiento de las guías clínicas sobre el manejo periendoscópico del tratamiento antiagregante plaquetario (TAP) no se ha analizado con detalle. Nuestro objetivo fue analizar caso por caso el cumplimiento de las guías en los pacientes que acuden a nuestra Unidad de Endoscopia, describiendo con detalle las desviaciones detectadas e identificando áreas de mejora.
Estudio transversal sobre pacientes consecutivos programados para gastroscopia o colonoscopia realizadas sin sedación entre enero y junio de 2015. Se excluyeron los pacientes en tratamiento anticoagulante.
Se evaluaron 675 pacientes de los que se incluyeron 91 (13,5%) por estar en tratamiento con antiagregante plaquetario (gastroscopias 25 [27,5%], colonoscopias 66 [72,5%]). La aspirina se interrumpió contrariamente a las guías clínicas en 25 de los 77 pacientes que la llevaban (32,5%), pero esta modificación fue una decisión del propio paciente en 11 casos. Muchas de las aparentes desviaciones en el manejo del clopidogrel y del tratamiento antiagregante plaquetario doble (TAPD) no eran verdaderos casos de no cumplimiento. El médico de Atención Primaria modificó el TAP prescrito por otro especialista en 8 de 9 casos (88,9%), siempre en casos de aspirina. No se encontró relación entre el riesgo de sangrado del procedimiento endoscópico o el riesgo de trombosis del paciente y la modificación del tratamiento.
En una proporción significativa de pacientes el manejo periprocedimiento del TAP va en contra de las guías clínicas, pero algunas de estas desviaciones no pueden considerarse verdaderos incumplimientos. Áreas de mejora son aumentar la información al paciente sobre el TAP, extender la diseminación de las guías a atención primaria y resaltar la importancia del riesgo trombótico relacionado con la suspensión del TAP.
Effect of Body Size on Quality of Bowel Preparation among Patients Experiencing Colonoscopy
2021, Gastroenterology Nursing

View all citing articles on Scopus

View full text

Digestive EndoscopyPre- and post-procedural quality indicators for colonoscopy: A nationwide survey

Abstract

Background

Aim

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Statistics

Results

Discussion

Conflict of interest

Acknowledgements

Gastrointestinal Endoscopy

Gastrointestinal Endoscopy

Gastrointestinal Endoscopy

Gastrointestinal Endoscopy

Gastroenterology

Clinical Gastroenterology and Hepatology

Gastrointestinal Endoscopy

Gastrointestinal Endoscopy Clinics of North America

Digestive and Liver Disease

Gastrointestinal Endoscopy

American Journal of Medicine

Clinical Gastroenterology and Hepatology

Gastroenterology

Gastrointestinal Endoscopy

Quality indicators for colonoscopy and the risk of interval cancer

New England Journal of Medicine

Adenoma detection rate and risk of colorectal cancer and death

New England Journal of Medicine

Quality in gastrointestinal endoscopy

Endoscopy

Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE)

Endoscopy

Digestive Endoscopy
Pre- and post-procedural quality indicators for colonoscopy: A nationwide survey