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Enhancing Patient Outcomes Through Effective Colonoscopy Performance Management

This presentation by Derek Gillen explores strategies for optimizing patient outcomes in colonoscopy procedures. It emphasizes how improved safety, comfort, and reduced missed pathology can be achieved through sustainable audits in symptomatic and screened populations. The focus is on the Scottish Bowel Cancer Screening Programme and various performance metrics, including adenoma detection rates, completion rates, and complication rates. The importance of evidence-based practices and continuous quality assurance is highlighted to enhance procedural effectiveness and patient care.

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Enhancing Patient Outcomes Through Effective Colonoscopy Performance Management

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  1. Performance Management Derek Gillen

  2. Why? • To try to optimise outcomes for patients • ↑ safety • ↑ comfort • ↓ missed pathology

  3. How? • Sustainable audit: • Symptomatic population: GRS Audits • Screened population: GRS Audits + BCS Audits

  4. For Whom? • Scottish BCSP • NHS GGC • QIS/JAG (GRS) • GMC (Revalidation) • Ourselves • (Patients?)

  5. GRS Colonoscopy-related Audits • Level C: • Flumazenil usage* • No of procedures* • Completion rate* • Adenoma Detection Rate • Sedation/analgesia*

  6. GRS Colonoscopy-related Audits • Level B: • Colonic Polyp recovery • 8 day readmission • 30 day mortality

  7. GRS Colonoscopy-related Audits • Level A: • Comfort levels for colonoscopy • Diagnostic biopsies for diarrhoea*

  8. English v Scottish BCS Audits • English: BSG/BCSP/AUGIS/ACPGBI (ratified by JAG) • Scottish: SBCSP and NHS Scotland

  9. English BCS Audits • 1) Minimum no of colonoscopies • 2) Caecal Intubation rate • 3) Cancer detection rate • 4) Adenoma detection rate • 5) Withdrawal time • 6) Polyp retrieval • 7) Tattooing • 8)Sedation • 9) Complication rates

  10. English BCS Audits • 1) Minimum number of BCS Colonoscopies • ≥ 150 per annum

  11. English BCS Audits • 2) Caecal Intubation rate • American and Canadian Standards: • > 95% adjusted for poor prep/strictures • → 90% unadjusted in UK • How? • Photo evidence of ICV or appendix • NB ITT

  12. English BCS Audits • 3) Cancer Detection Rate • ≥ 11 per 100 screening colonoscopies • 4) Adenoma Detection rate • ≥ 35% (target ≥ 40%) • (NB ADR more important than cancer detection rate)

  13. Adenoma Detection Rate • Evidence is important? • Kaminski et al (NEJM 2010) • 186 endoscopists; 45000 screened patients • ADR correlates with interval cancer rate (P=0.008) • Rate < 20% has a hazard ratio of interval cancer of 12.8

  14. English BCS Audits • 5) Withdrawal time in –ve colonoscopies • ≥ 6 minutes (target ≥ 10 minutes) • Basis? • Barclay et al NEJM 2006 • 12 GI with 2053 screening colonoscopies • Minimum adequate time 6 minutes (expert opinion)

  15. Proportion of colonoscopies with adenomata found Withdrawal time (minutes)

  16. Withdrawal times • Barclay et al- Results: • Overall neoplasia rate: • 23.5% (range 9.4-32.7%) • Withdrawal range: • 3.1 to 16.8 minutes • < 6 minutes versus > 6 minutes: • Any neoplasia: 11.8 v 28.3% (P<0.001) • Advanced neoplasia: 2.6 v 6.4% (P<0.005)

  17. Withdrawal times • Further study: • ↑ to ≥ 8 minutes (2325 screening colonoscopies) • ADR ↑ • No. of adenomata per patient ↑ • No. of advanced adenomata ↑

  18. English BCS Audits • 6) Polyp retrieval • > 90% (target > 95%) • No. of polyps with tissue for histology/ no. of polyps recorded

  19. English BCS Audits • 7) Tattooing: • By local agreement between screeners and Colorectal MDT

  20. English BCS Audits • 8) Sedation: • In line with BSG Guidance • < 5mg < 70 • ≤ 2mg > 70 • Use of reversal agents

  21. English BCS Audits • 9) Complications: • Perforation rate: • <1 in a 1000 • Therapeutic Perforation rate: • <1 in 500 • Post-polypectomy bleeding: • transfusion in <1 in 100 (polyps >1 cm)

  22. Scottish BCS Audits • Completion rate • Complications • Admissions • Perforations • Bleeding • deaths • Cancer detection rate • Adenoma detection rate • PPV: • Cancer • Adenoma • High risk adenoma • For any neoplasm

  23. GGC BCS Audits • 1) Minimum no. of colonoscopies • 2) Caecal Intubation rate • 3)Cancer detection rate • 4) Adenoma detection rate • 5)Withdrawal time • 6)Polyp retrieval • 7)Tattooing • 8)Sedation • 9) Complication rates

  24. Performance management • Audits performed • → Local GRS Lead • → Local Resolution with action plan • → No resolution/safety issue • → Lead clinician • → No resolution/safety issue • → relevant CD/Clinical Governance pathways

  25. Completion rates • 85-90% • Review reasons for recent incompletes • Continue colonoscopy • > But further skills improvement training • 80-84.9% • Own measures to improve performance within 3/12 • Consider skills course • Reaudit next 100 colonoscopies (or 12 months)

  26. Completion rate • 75-79.9% (or 80-85% with unsatisfactory reaudit) • Action plan with endoscopy lead over 3/12: • JAG approved skills course • And/or mentoring by a TTT trainer • And/or masterclass session • > Reaudit next 100 (or 12 months) • > If rate still <80%, colonoscopy only under supervision until cusum >85%

  27. Completion rate • <75% • Independent colonoscopy suspended • Colonoscopy only with a TTT trainer • Attend JAG course • Independent practice only at cusum of 85

  28. Summary • We need to QA our performance • Necessary audits and standards defined • Sustainable audits available soon • Governance processes in place

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