Quality Indicators for Gastrointestinal Endoscopic Procedures: An Introduction

The assurance that high-quality endoscopic procedures are performed has taken increased importance. A high-quality endoscopy ensures that the patient receives an indicated procedure, that correct and clinically relevant diagnoses are made (or excluded), that therapy is properly performed, and that all these are accomplished with minimum risk. The motivation for developing quality indicators for endoscopy begins with the desire to provide patients with the best possible care. These indicators may then be used in programs to improve the overall quality of endoscopic services. The American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG), as leaders in promoting the highest quality patient care, formed a task force to identify end points that could be used to document high-quality endoscopic services. In most cases these end points will require validation before they can be generally adopted. The task force consisted of expert endoscopists selected by the board of directors of the ASGE and the ACG (Table 1). These documents were then reviewed and approved by the governing boards. The task force developed quality indicators for the 4 major endoscopic procedures: colonoscopy, esophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasonography (EUS). Wherever possible, these indicators were chosen because there were published supporting data. These studies were identified through a computerized search of Medline followed by review of the bibliographies of relevant articles. When such data were absent, indicators were chosen by expert consensus. Our goal was to create a comprehensive list of potential quality indicators, recognizing that only a small subset may ultimately be implemented. The resultant quality indicators were graded on the strength of the supporting evidence (Table 2) (1). For each endoscopic procedure, indicators were considered for 3 time periods: preprocedure, intraprocedure, and postprocedure. Preprocedure indicators include proper indication for the procedure, consent, antibiotic prophylaxis, etc. Intraprocedure indicators include completeness of the examination and completion of therapeutic procedures. Postprocedure indicators include follow-up of pathology and recognition and management of complications. Our aim was to create indicators that in most cases could be extracted from the endoscopy report or procedural documentation. Although the endoscopist’s goal may be to achieve 100% compliance with every indicator in every patient, it is recognized that this will not be practically achievable in all cases. In most cases, acceptable compliance levels are unknown and should be determined by prospective study. Underlying this discussion of quality indicators is the assumption that adequate training and credentialing has taken place before a practitioner begins the practice of endoscopy. The ASGE has guidelines specifically addressing standards for training, assessing competence, and granting privileges to perform endoscopy (2). It is the task force’s recommendation that these guidelines be adopted by facilities where endoscopic procedures are performed. Although each endoscopic procedure will have quality indicators specific to that procedure, there will be some common to all. This introduction will review the general principles and end points that are common to all endoscopic procedures. The following articles will focus on indicators unique to specific procedures.