ambulatory endoscopy clinic day l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Ambulatory Endoscopy Clinic Day PowerPoint Presentation
Download Presentation
Ambulatory Endoscopy Clinic Day

Loading in 2 Seconds...

play fullscreen
1 / 43

Ambulatory Endoscopy Clinic Day - PowerPoint PPT Presentation


  • 335 Views
  • Uploaded on

Ambulatory Endoscopy Clinic Day. Quality of Care: Procedure Related Issues Nancy Baxter, MD PhD. Objectives. To review the concept of “quality of care” To discuss the growing focus on quality of colonoscopy To apply concepts of quality of care to procedural related issues for colonoscopy

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Ambulatory Endoscopy Clinic Day' - hertz


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
ambulatory endoscopy clinic day

Ambulatory Endoscopy Clinic Day

Quality of Care: Procedure Related Issues

Nancy Baxter, MD PhD

objectives
Objectives
  • To review the concept of “quality of care”
  • To discuss the growing focus on quality of colonoscopy
  • To apply concepts of quality of care to procedural related issues for colonoscopy
  • To describe current quality indicators and standards for colonoscopy
quality of care
Quality of Care

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Institute of Medicine

slide4

Care Delivered

Material Resources, Human Resources, Institutional Organization

Health Status

El-Jardali Healthcare Quarterly 2005; 40-8.

slide5
good structure increases the likelihood of good process, and good process increases the likelihood of good outcomes
why now
Why Now?
  • Dramatic increase in rate of colonoscopy in Ontario
  • Change in indication for colonoscopy
    • Increase use for screening

ICES 2004, Use of Large Bowel Procedures in Ontario

screening
Screening
  • Asymptomatic, healthy individuals with relatively low risk of disease
  • Benefits outweigh risks when procedure is high quality

High Quality

Minimized

Maximized

screening8
Screening
  • Asymptomatic, healthy individuals with relatively low risk of disease
  • Benefits outweigh risks when procedure is high quality
  • Risks may outweigh benefits when procedure is poor quality

Poor Quality

Less Effective

More Complications

why endoscopy
Why Endoscopy?
  • Expensive procedure
  • Providers tend to be VERY high volume
  • Administrative data can produce useful metrics
  • Emerging understanding of limitations
  • Evidence of meaningful variation at the provider level
limitations of colonoscopy
Limitations of Colonoscopy
  • Interval cancer
    • Rapidly growing
    • Missed neoplasia
    • Incompletely resected adenoma
  • Estimated in administrative data based on timing of colonoscopy
    • More than 6 months
    • Less than 36 months
ontario data
Ontario Data
  • Rates of new or missed cancers evaluated
  • Design: Population-based cohort
  • Study period: 4/1/97-3/31/02
  • Study population: ≥ 20 yr with a new diagnosis of CRC
  • 12,487 persons with a new CRC who had colonoscopy inserted to the site of the CRC within 3 yr prior to the diagnosis
findings
Findings
  • Right-sided: 195/3,288 (5.9%)
  • Transverse: 43/777 (5.5%)
  • Splenic flexure/desc’g: 15/710 (2.1%)
  • Rectal or sigmoid: 177/7,712 (2.3%)

430/12,487 (3.4%)

Increased risk: older age, diverticular disease, right-sided or transverse CRC, internist/FP, non-hospital colonoscopy

Bressler B et al. Gastroenterology 2007;132:96-102.

missed vs new
Missed vs. New
  • Miss rates from tandem colonoscopy studies
    • 1cm adenoma – 0% to 6%
    • 6-9mm adenoma – 12%-13%
    • < 5mm adenoma 15%-27%
  • Colonoscopy vs. CT colonography
    • Centres of excellence for CT demonstrate miss rates for > 1cm of 12-17%
    • Other studies report much lower rates

Faigel et al. Gastrointestinal Endoscopy 2006; 63s

cases
Cases
  • Diagnosis of CRC between Jan 1996 through Dec 2001 from OCR
  • No previous diagnosis of CRC
  • Eligible for OHIP from 1992 to death
    • At least 4 years of information on history of endoscopy
  • Age 52-89
    • Screen eligible range for at least 2 years
  • Died of CRC by Dec 2003
    • Last mortality data available
controls
Controls
  • Selected from Registered Persons Database
    • Eligible for OHIP 1992 through 2003
  • Matched to case for
    • Geographic location
    • Sex
    • Income quintile
    • Calendar year of birth
  • Referent date assigned
determination of exposure
Determination of Exposure
  • Colonoscopy (any attempted)
    • Z555 – colonoscopy to descending colon
  • Colonoscopy (complete)
    • Z555 – colonoscopy to descending colon plus
    • E747 – to cecum or E705 – to terminal ileum
  • > 6 months from diagnosis
procedural factors
Access

Timeliness

Appropriate use

Other

Adequate consent process

Patient tolerance and satisfaction

Quality reporting, recommendations and feedback

Technical

Complete colonic assessment

Completion rate

Quality of Preparation

Quality of Inspection

Adenoma detection

Minimal Complications

Procedural Factors
completion rate
Completion Rate
  • Recommendation
    • >90% all colonoscopies
    • >95% for screening
    • Exclude poor prep from denominator
  • > 97% completion rate reported in screening studies
  • Documentation
    • Verbal
    • Pictorial

Faigel et al. Gastrointestinal Endoscopy 2006; 63s

ontario
Ontario
  • Patients age 50-74
  • 331,608 colonoscopies performed between 1999-2003
  • 13% were incomplete
  • Factors affecting rate
    • Age: OR 1.20 per 10-year increment (95% CI=1.18-1.22)
    • Female sex: OR 1.35 (95% CI: 1.30-1.39)
    • History of prior abdominal surgery: OR 1.07 (95% CI: 1.05-1.09) or prior pelvic surgery: OR 1.04 (95% CI: 1.01-1.06).

Shah Gastroenterology 2007; 132: 2297-303

factors affecting completion
Factors Affecting Completion

Wells BMC Gastroenterol. 2007; 7: 19

quality of preparation
Quality of Preparation
  • % with good preparation
  • Patient factors
    • Elderly
    • Socioeconomically deprived
  • Modifiable factors
    • Split dose preparations
    • Timing of colonoscopy
quality of inspection
Quality of Inspection

Barclay NEJM 2006; 355:2533-41

how to measure
How to Measure
  • 6 minute withdrawal time has been suggested as quality measure
  • Patients with no adenoma detected
  • If implemented should be at the PROVIDER and not patient level
  • Start recording withdrawal time
    • Feedback
    • May be mandated in future
adenoma detection
Adenoma Detection
  • ASGE/ACG task force recommendations
    • Screening colonoscopy over age 50
    • >25% men
    • >15% women
  • Some studies report substantially higher rates
  • Influenced by age, sex, family history
provider variation
Provider Variation
  • Single institution study
  • All colonoscopy between 1999-2004
  • 9 endoscopists and 10,034 procedures
  • Range of adenoma detection for patients > 50
    • Any adenoma: 15.5% - 41.1%
    • At least two adenomas: 4.9% - 20.0%
    • At least one adenoma > 1.0 cm: 1.7-6.2%
  • Range of adenomas detected per colonoscopy by endoscopist: 0.21-0.86

Chen Am J Gastro 2007; 102:856-201

serious complications
Serious Complications
  • BC, Alberta, Ontario, Nova Scotia
  • Population 50-75 yr: 4.6 million
  • Persons 50-75 yrs who underwent outpatient colonoscopy between 4/1/2002 and 3/31/2003
  • Outcome: Bleeding and perforation requiring admission within 30 days of colonoscopy

Rabeneck et al. Gastroenterology 2008;135:1899-1906

results
Results
  • 97,091 persons had an outpatient colonoscopy from 4/1/2002 to 3/31/2003
  • Bleeding 1.64/1000
  • Perforation 0.85/1000
  • Death 0.074/1000 or 1/14,000
  • Risk factors: increased age, male sex, polypectomy, volume < 283/yr
current standards

Current Standards

and Indicators

germany
Germany
  • Gastroenterology board license
  • > 200 colonoscopies and > 50 polypectomies in past 2 years
  • Adequate technical equipment for resuscitation and infection control monitoring
  • > 200 colonoscopies documented by photo per year
  • > 10 polypectomies with histology per year
summary
Summary
  • System-wide drive to assess, monitor and improve quality
    • Endoscopic procedures ideal target
  • Multiple procedural factors are important
    • Meaningful and fair indicators difficult to develop
  • Current standards unlikely to have impact
recommendations
Recommendations
  • Understand your practice
    • Completion rate
    • % poor preparation
    • Withdrawal time
    • Adenoma detection rate
  • Consider undertaking a QI project yearly based on your data