Colonoscopy: Quality Indicators

Effective endoscopic screening for colorectal cancer (CRC), one of the few preventable cancers, is dependent on the adequate detection and removal of potentially precancerous lesions. However, observed variation in colonoscopy performance in practice and outcomes has highlighted the need for consistent quality measures. Quality indicators or measures are tools that help to quantify health-care processes and can aid in providing high-quality health care. The primary colonoscopy quality indicator is the adenoma detection rate (ADR), which is defined as the proportion of an endoscopist’s screening colonoscopies in which one or more adenomas have been detected. The risk of post-colonoscopy CRC is inversely correlated with an endoscopist’s ADR. However, ADR is dependent on other quality measures, including cecal intubation rates, withdrawal times, and quality of bowel preparation. Achieving suggested benchmarks for these other quality measures will aid the endoscopist in achieving the recently updated ADR benchmark of 25% in their practice. In addition, beyond ensuring adequate ADRs, endoscopists should have high compliance rates with guideline-recommended and evidence-based screening and surveillance intervals. Compliance with quality measures will ensure effective and safe CRC prevention and better patient outcomes.

[1]  Douglas K. Rex,et al.  Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: Recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer , 2002 .

[2]  E. Kuipers,et al.  Exposure to colorectal examinations before a colorectal cancer diagnosis: a case–control study , 2010, European journal of gastroenterology & hepatology.

[3]  T. Stukel,et al.  Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. , 2012, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[4]  G. Spinzi,et al.  Effectiveness of a continuous quality improvement program on colonoscopy practice , 2007, Endoscopy.

[5]  Alfred I. Neugut,et al.  The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. , 2011, Gastrointestinal endoscopy.

[6]  D. Early,et al.  Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. , 2012, Gastrointestinal endoscopy.

[7]  Rebecca L. Siegel Mph,et al.  Colorectal cancer statistics, 2014 , 2014 .

[8]  C. Messina,et al.  Delivering colonoscopy screening for low‐income populations in Suffolk County , 2013, Cancer.

[9]  M. Matteson,et al.  Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. , 2011, Gastrointestinal endoscopy.

[10]  Muhammad F Dawwas,et al.  Adenoma detection rate and risk of colorectal cancer and death. , 2014, The New England journal of medicine.

[11]  J. Johanson,et al.  Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. , 2006, The New England journal of medicine.

[12]  Rinku Sutradhar,et al.  Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. , 2011, Gastroenterology.

[13]  Douglas K. Rex,et al.  Quality Indicators for Colonoscopy , 2006, Gastrointestinal endoscopy.

[14]  Ken R. Smith,et al.  Characteristics of missed or interval colorectal cancer and patient survival: a population-based study. , 2014, Gastroenterology.

[15]  David F Ransohoff,et al.  Variation in polyp detection rates at screening colonoscopy. , 2009, Gastrointestinal endoscopy.

[16]  Linda Rabeneck,et al.  Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. , 2007, Gastroenterology.

[17]  K. Rajan,et al.  Advanced Adenoma Detection Rate Is Independent of Nonadvanced Adenoma Detection Rate , 2013, The American Journal of Gastroenterology.

[18]  B. Jacobson,et al.  Reliability of adenoma detection rate is based on procedural volume. , 2013, Gastrointestinal endoscopy.

[19]  Michael Gluck,et al.  The effect of periodic monitoring and feedback on screening colonoscopy withdrawal times, polyp detection rates, and patient satisfaction scores. , 2008, Gastrointestinal endoscopy.

[20]  R. Pearson.  Low Risk of Colorectal Cancer and Advanced Adenomas More Than 10 Years After Negative Colonoscopy , 2010 .

[21]  P. Thota,et al.  Polypectomy rate: a surrogate for adenoma detection rate varies by colon segment, gender, and endoscopist. , 2014, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[22]  S. Moss,et al.  Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme , 2011, Gut.

[23]  Charles J. Kahi,et al.  High colonoscopic prevalence of proximal colon serrated polyps in average-risk men and women. , 2012, Gastrointestinal endoscopy.

[24]  Christopher I Amos,et al.  Serrated and Adenomatous Polyp Detection Increases With Longer Withdrawal Time: Results From the New Hampshire Colonoscopy Registry , 2014, The American Journal of Gastroenterology.

[25]  J. Hardcastle,et al.  Colorectal cancer , 1993, Europe Against Cancer European Commission Series for General Practitioners.

[26]  D. Lieberman,et al.  Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. , 2000, The New England journal of medicine.

[27]  J. Raufman,et al.  Quality Assessment of Colonoscopic Cecal Intubation: An Analysis of 6 Years of Continuous Practice at a University Hospital , 2006, The American Journal of Gastroenterology.

[28]  D. Ransohoff,et al.  Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. , 2000, The New England journal of medicine.

[29]  O. Hosokawa,et al.  Invasive Colorectal Cancer Detected up to 3 Years after a Colonoscopy Negative for Cancer , 2003, Endoscopy.

[30]  Douglas K Rex,et al.  Optimizing Adequacy of Bowel Cleansing for Colonoscopy: Recommendations From the US Multi-Society Task Force on Colorectal Cancer , 2014, The American Journal of Gastroenterology.

[31]  B. Enestvedt,et al.  4-Liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis. , 2012, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[32]  M. Wallace,et al.  Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. , 2011, Gastrointestinal endoscopy.

[33]  L. Laine,et al.  Influence of Colonoscopy Quality Measures on Patients’ Colonoscopist Selection , 2015, The American Journal of Gastroenterology.

[34]  Charles J Kahi,et al.  Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. , 2011, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[35]  Marcin Polkowski,et al.  Quality indicators for colonoscopy and the risk of interval cancer. , 2010, The New England journal of medicine.

[36]  C D Langefeld,et al.  Colonic neoplasia in asymptomatic persons with negative fecal occult blood tests: influence of age, gender, and family history. , 1993, The American journal of gastroenterology.

[37]  M. Crowell,et al.  Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. , 2012, Gastrointestinal endoscopy.

[38]  T. Church,et al.  Variation in detection of adenomas and polyps by colonoscopy and change over time with a performance improvement program. , 2009, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[39]  F. Leung.  Editorial: PDR or ADR as a Quality Indicator for Colonoscopy , 2013, The American Journal of Gastroenterology.

[40]  R. Barclay,et al.  Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. , 2008, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[41]  R. Chuttani,et al.  Effect of institution-wide policy of colonoscopy withdrawal time > or = 7 minutes on polyp detection. , 2008, Gastroenterology.

[42]  C. Messina,et al.  Clinical case management and navigation for colonoscopy screening in an academic medical center , 2013, Cancer.

[43]  A. Dietrich,et al.  Improving the Quality of Colorectal Cancer Screening: Assessment of Familial Risk , 2010, Digestive Diseases and Sciences.

[44]  W. Cohn,et al.  Factors predictive of difficult colonoscopy. , 2001, Gastrointestinal endoscopy.

[45]  E. Kuipers,et al.  Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. , 2012, Gastrointestinal endoscopy.

[46]  Michael B Wallace,et al.  An Endoscopic Quality Improvement Program Improves Detection of Colorectal Adenomas , 2013, The American Journal of Gastroenterology.

[47]  B J Ott,et al.  Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time. , 2006, Alimentary pharmacology & therapeutics.

[48]  D A Johnson,et al.  A prospective study of the prevalence of colonic neoplasms in asymptomatic patients with an age-related risk. , 1990, The American journal of gastroenterology.

[49]  A. Zauber,et al.  Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. , 1993 .

[50]  A. Jemal,et al.  Colorectal cancer statistics, 2014 , 2014, CA: a cancer journal for clinicians.

[51]  V. Sharma,et al.  Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. , 2003, Gastrointestinal endoscopy.

[52]  D. Lieberman,et al.  Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12 134 examinations (Berlin colonoscopy project 3, BECOP-3) , 2012, Gut.

[53]  M. Goodrich,et al.  Differences in detection rates of adenomas and serrated polyps in screening versus surveillance colonoscopies, based on the new hampshire colonoscopy registry. , 2013, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[54]  Timothy D. Imler,et al.  The effect of colonoscopy preparation quality on adenoma detection rates. , 2012, Gastrointestinal endoscopy.

[55]  H. Brenner,et al.  Protection from colorectal cancer after colonoscopy: Population-based case-control study , 2010 .

[56]  M. Wallace,et al.  Stability of Increased Adenoma Detection at Colonoscopy. Follow-Up of an Endoscopic Quality Improvement Program-EQUIP-II , 2015, The American Journal of Gastroenterology.

[57]  P. Schoenfeld,et al.  The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. , 2013, Gastrointestinal endoscopy.

[58]  Douglas K Rex,et al.  American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008 , 2022 .

[59]  D. McGee,et al.  Prospective study of the frequency and size distribution of polyps missed by colonoscopy. , 1990, Journal of the National Cancer Institute.

[60]  Loren Laine,et al.  What Level of Bowel Prep Quality Requires Early Repeat Colonoscopy: Systematic Review and Meta-Analysis of the Impact of Preparation Quality on Adenoma Detection Rate , 2014, The American Journal of Gastroenterology.

[61]  Tracy Onega,et al.  Matching colonoscopy and pathology data in population-based registries: development of a novel algorithm and the initial experience of the New Hampshire Colonoscopy Registry. , 2011, Gastrointestinal endoscopy.

[62]  Charles J. Kahi,et al.  Quality measures for colonoscopy: a critical evaluation. , 2014, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[63]  L. Rabeneck,et al.  Association of Colonoscopy and Death From Colorectal Cancer , 2009, Annals of Internal Medicine.

[64]  Á. Lanas,et al.  Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies. , 2013, Gastrointestinal endoscopy.

[65]  B. Spiegel,et al.  Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance. , 2013, Gastrointestinal Endoscopy.

[66]  Christopher D. Jensen,et al.  Can we improve adenoma detection rates? A systematic review of intervention studies. , 2011, Gastrointestinal endoscopy.

[67]  D. Rex,et al.  Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. , 1997, Gastroenterology.

[68]  M. Murad,et al.  Prevalence, Risk Factors, and Outcomes of Interval Colorectal Cancers: A Systematic Review and Meta-Analysis , 2014, The American Journal of Gastroenterology.

[69]  D. Rex,et al.  Still photography versus videotaping for documentation of cecal intubation: a prospective study. , 2000, Gastrointestinal endoscopy.

[70]  M. Goodrich,et al.  Impact of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire colonoscopy registry by using a standardized preparation-quality rating. , 2014, Gastrointestinal endoscopy.

[71]  C. Messina,et al.  Factors that predict incomplete colonoscopy: thinner is not always better , 2000, American Journal of Gastroenterology.

[72]  Douglas K Rex,et al.  Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. , 2012, Gastroenterology.

[73]  Cynthia S. Johnson,et al.  Impact of a quarterly report card on colonoscopy quality measures. , 2013, Gastrointestinal endoscopy.

[74]  J. Hentz,et al.  Polyp and Adenoma Detection Rates in the Proximal and Distal Colon , 2013, The American Journal of Gastroenterology.

[75]  A. Zauber,et al.  Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. , 2012, The New England journal of medicine.

[76]  E. Kliewer,et al.  The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. , 2010, Gastroenterology.