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Assessing USAF Primary Care Colonoscopy Training and Outcomes Using Quality Indicators

Assessing USAF Primary Care Colonoscopy Training and Outcomes Using Quality Indicators. Brian Crownover, M.D., FAAFP Ethan Zimmerman, M.D. Family Medicine Residency Nellis AFB, NV. Goals of QI review. Describe training experience of Family Medicine colonoscopy trainers in USAF

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Assessing USAF Primary Care Colonoscopy Training and Outcomes Using Quality Indicators

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  1. Assessing USAF Primary Care Colonoscopy Training and Outcomes Using Quality Indicators Brian Crownover, M.D., FAAFP Ethan Zimmerman, M.D. Family Medicine Residency Nellis AFB, NV

  2. Goals of QI review • Describe training experience of Family Medicine colonoscopy trainers in USAF • Use outcomes based indicators to represent quality of USAF primary care colonoscopy • Measure results against national standard quality indicators

  3. USAF Primary Care Endoscopists • Who? • Teaching faculty at 4 US Air Force Family Medicine residency locations who perform colonoscopy • NW Florida, N Calif, Las Vegas, St Louis • What? • Type and amount of training received • Self-collected procedure log data – post training

  4. Primary Quality Indicators • Adenoma Detection Rate • Cecal Intubation Rate • Recommended ≥ 95% for screening colonoscopy

  5. Primary Care Endoscopy • Why evaluate quality indicators? • Primary care under attack from Gastroenterology • Polypectomy reduces CRC mortality 53% • NEJM 2012; 366(8):687 • Only 65% Americans receive appropriate CRC screening • https://healthmeasures.aspe.hhs.gov/measure/25

  6. Specialty differences from: Ko et al. ADR?

  7. Ko et al. • “Polyp detection and removal rates were significantly lower for nongastroenterologists than gastroenterologists”

  8. ACG/AGA/ASGE – ADR Working Gp • Screening Colonoscopy Adenoma Detection Rate Measure- Draft: Public Comment (6/2012) • Numerator: Number of patients age 50‐75 with at least one adenoma detected during screening • Denominator: Patients age 50‐75 undergoing a screening colonoscopy • Exclusions: Incomplete colonoscopy • Measure: The percentage of patients age 50‐75 with at least one adenoma detected

  9. Published GI Norms (PDR Surrogate for ADR) To attain the established benchmark ADRs for men (25%) and women (15%), endoscopists needed PDRs of 40% and 30%, respectively. PRs correlated well with ADRs (r(s) = 0.86, P < .001).

  10. Published GI Norms

  11. Published GI Norms

  12. Published GI Norms

  13. Published GI Norms

  14. Published GI Norms

  15. Published GI Norms

  16. Published GI Norms Data reported in arbitrary group thresholds, not comparable to other published data

  17. Published FM Norms

  18. Published FM Norms

  19. Published FM Norms

  20. Published FM Norms

  21. Published Norms

  22. So what did we find???

  23. Descriptive Statistics

  24. Descriptive Statistics prior to independent practice

  25. Descriptive Statistics prior to independent practice

  26. Descriptive Statistics

  27. Descriptive Statistics

  28. Specialty Comparison

  29. Descriptive Statistics

  30. Descriptive Statistics

  31. Correlations • Training experience to ADR • No correlation to receipt of simulator training Fisher's Exact Test (two-sided) p-value = 0.083 • No correlation to CME conference attendance Fisher's Exact Test (two-sided) p-value = 0.4755

  32. Correlations with ADR Bottom line: No significant correlation with independent factors and ADR

  33. Take home points • Recently trained faculty working with residents achieve high quality ADR rates (27.8%) comparable to published GI and FM numbers • Mean 2.6 years experience, 207 cases post training (117 cases in training) • Complications rates were low • No correlations were found between training experience variables and ADR

  34. Questions?

  35. Biblio • Rex DK, Petrini JL, Baron TH, et al. Quality Indicators for Colonoscopy. Am J Gastroenterol 2006;101:873–885 • Kaminski MF, Regula J, Kraszewska E, et al. Quality Indicators for Colonoscopy and the Risk of Interval Cancer. N Engl J Med 2010; 362: 1795‐803.

  36. Biblio • Cooper GS, Chak A, Koroukian S. The polyp detection rate of colonoscopy: A national study of Medicare beneficiaries. American Journal of Medicine 2005; 118, 1413.e11‐1413. • Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. NEJM 2000; 343: 162-8.

  37. Biblio • Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012 Feb 23;366(8):687-96. • Imperiale TF, Glowinski EA, Juliar BE, et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc.2009 Jun;69(7):1288–95

  38. Biblio • Williams JE, Le TD, Faigel DO. Polypectomy rate as a quality measure for colonoscopy. Gastrointest Endosc 2011;73(3):498–506. • Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007;102(4):856-61.

  39. Biblio • Goncalves AR, Ferreira C, Marques A, et al. Assessment of quality in screening colonoscopy for colorectal cancer. Clin Experimental Gastroenterology 2011;4: 277–281. • Denis B, Sauleau EA, Gendre I, et al. Measurement of adenoma detection and discrimination during colonoscopy in routine practice: an exploratory study. Gastrointest Endosc. 2011;74(6):1325-36.

  40. Biblio • Ko CW, Dominitz JA, Green P, et al. Specialty differences in polyp detection, removal, and biopsy during colonoscopy. Am J Med 2010;123 (6): 528–35. • Kolber M, Szafran O, Suwal J, et al. Outcomes of 1949 endoscopic procedures. Can Fam Physician 2009; 55(2): 170–175.

  41. Biblio • Kolber M. Prospective Study of the Quality of Colonoscopies performed by Primary Care Physicians in Alberta, Canada – The Alberta Primary Care Endoscopy (APC –Endo) Study. ClinicalTrials.gov Identifier: NCT01320826. Publication pending • Eckert LD, Short MW, Domagalski JE, et al. Assessing Colonoscopy Training Outcomes Using Quality Indicators. J Grad Med Educ 2009;1(1):89-92.

  42. Biblio • Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary care physicians: a meta-analysis. Ann Fam Med 2009;7(1):56-62. • Cotton PB, Connor P, McGee D, et al. Colonoscopy: practice variation among 69 hospital-based endoscopists. Gastrointest Endosc 2003;57(3):352-357.

  43. Biblio • Heitman SJ, Ronksley PE, Hilsden RJ, et al. Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2009 Dec;7(12):1272-8.

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