Not all colonoscopies are the same…

Colonoscopy is our most important tool in the fight against colon cancer.  Unfortunately, it has a serious problem – inconsistent quality.  While colonoscopy is now widely available in the United States and around the world, studies have shown that there is marked variation from one facility and doctor to another in the quality of the procedure that is performed.  A patient may want to assume, if he or she was well treated by the staff and physician, and had a comfortable exam, that a high-quality procedure was provided.  Sadly, it may have actually been a “bad” colonoscopy and have failed to provide the protection from colon cancer that would have resulted from a “good” colonoscopy.   The colorectal cancer screening and prevention benefits of colonoscopy can only be fully realized when it is performed in a high-quality manner.

This page discusses how gastroenterologists differentiate “good” from “bad” colonoscopies and what we measure to help us continuously improve what we do.

The U.S. Multi-Society Task Force on Colorectal Cancer has defined a high-quality colonoscopy to depend on the following elements:

(1) appropriate training and experience
(2) proper documentation of risk assessment
(3) complete exam to the cecum with adequate mucosal visualization and bowel preparation
(4) ability to detect and remove polyps safely
(5) documentation of polypoid lesions and methods of removal
(6) timely and appropriate management of adverse events
(7) appropriate follow-up of histopathology findings
(8) appropriate recommendation for surveillance or repeat screening based on published guidelines

Levin B, Lieberman DA, McFarland B, Andrews KS, Brooks D, Bond J, Dash C, Giardiello FM, Glick S, Johnson D, Johnson CD, Levin TR, Pickhardt PJ, Rex DK, Smith RA, Thorson A, Winawer SJ; American Cancer Society Colorectal Cancer Advisory Group; US Multi-Society Task Force; American College of Radiology Colon Cancer Committee. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology. 2008 May;134(5):1570-95.

Are all colonoscopists equally effective at finding polyps and cancers during colonoscopy?

“Colonoscopy is what we in medicine call a highly “operator dependent” procedure. That is, some doctors are not only better than others at doing colonoscopy, they are a lot better.  Stated in reverse, some doctors are really bad at doing colonoscopy. Virtually every study that has looked for evidence that some people are better than others has found it, and the differences between doctors in how many precancerous polyps they find varies by 4- to 10-fold.”

–Douglas K. Rex, MD in the New York Times 2009

Yes!  Our performance is superior to that of our national peer group for the most important generally accepted quality indicators (see GI Quality Improvement Consortium, below).  Our peer group is comprised of over 4,000 endoscopists practicing in over 500 U.S. endoscopy facilities.  Of these physicians, 1,300 are additionally submitting quality data to the Center for Medicare and Medicaid Services (CMS) through GIQuIC’s Quality Clinical Data Registry.  Only a minority of endoscopists and endoscopists collect and share their quality data in this manner.

Quality improvement processes that incorporate the collection and analysis of structured data with comparative benchmarking (measuring our own performance against that of other specialists in our field) are necessary to ensure that colonoscopy services are high quality.  Choose a doctor and facility that can demonstrate the quality of the procedures they provide.  This page describes some of the quality improvement processes we use at Digestive Health and the Southwest Endoscopy Center to ensure that we are providing you with high-quality colonoscopy services.  We encourage interested patients to discuss this information with their primary care provider and to request similar data from other facilities for comparison before choosing a colonoscopy provider.

“Patients who want the best results should pick an outstanding colonoscopist”
-New York Times editorial, December 19, 2008“Patients who opt for a colonoscopy — which lets doctors detect and remove polyps in one procedure — should look for the most skilled gastroenterologist possible”
-Robert Smith, American Cancer Society, from USA Today, December 21, 2008

We participated in GIQuIC, the GI Quality Improvement Consortium, Ltd. – a non-profit collaboration of the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE) since January 2013.  The Center for Medicare and Medicaid Services (CMS) has designated GIQuIC as a Qualified Clinical Data Registry (QCDR) for PQRS in the 2014, 2015, 2016 and for MIPS in the 2017 reporting years.  As a quality benchmarking registry, GIQuIC is raising the bar on endoscopic effectiveness and reliability.

GIQuIC participants take the time and expend the effort necessary to voluntarily report their procedure data and monitor their comparative performance at considerable expense.  This group likely represents the best performing endoscopists in the United States.

The GIQuIC registry now contains over 4 million deidentified colonoscopy reports, against which we are comparing our own data, which includes over 8,000 colonoscopy procedures performed at the Southwest Endoscopy Center since we began submitting date in 2013, for quality improvement purposes.

---

 

What These Data Mean and Why These Measures Matter

Adenoma Detection Rates

The adenoma detection rate (ADR) is generally accepted to be the single most important current quality measure by gastroenterologists performing screening colonoscopy.  We know that colonoscopy is not a perfect cancer prevention tool.  Cancers occasionally are found in patients who have had a prior colonoscopy (interval cancer).  Studies have shown a near-linear inverse relationship between an individual colonoscopists’ ADR and the frequency with which interval cancers arise in his or her patients. Said another way, a colonoscopist’s ADR provides a direct measure of that colonoscopists effectiveness in reducing the risk of interval cancer and cancer-related mortality.  Nearly all studies addressing this issue have shown marked variation in adenoma detection rates among colonoscopists.  In a widely reported recent New England Journal of Medicine paper (Corley D, Jensen CD, Marks AR et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370:1298?306) each 1% increase in ADR above 20% was associated with a 3% reduction in colorectal cancer incidence and a 5% reduction in colorectal cancer-related mortality. Industry-defined benchmark target ADRs in 2014 were ≥15% in women and ≥25% in men (or ≥20% in a male/female population).  In 2015 these target benchmark ADRs were increased to ≥20% for women and ≥30% for men (or ≥25% in a male/female population). Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015;81:31-53. Ask your doctor about his or her adenoma detection rate.

Adequacy of Bowel Preparation

High‐quality colonoscopy requires adequate bowel cleansing.  Unfortunately, up to 20‐25% of colonoscopies in some studies are reported to have inadequate bowel preparation.  Adverse consequences of inadequate bowel preparation include lower adenoma detection rates, longer procedural time, lower cecal intubation rates, increased electrocautery risk and shorter intervals between examinations. Adenoma miss rates in patients with suboptimal bowel preparation are high. Bowel cleansing for colonoscopy is the subject of recent detailed guideline developed by the U.S. Multi‐Society Task Force on Colorectal Cancer (Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi‐society task force on colorectal cancer. Gastrointest Endosc. 2014;80:543‐62). Ask your facility about the quality of its colonoscopy preps.

 

Photodocumentation of the cecum (also known as cecal intubation rate)

Colon polyps and the cancers that may arise from them form in all sections of the colon.  A complete colonoscopyis one that reaches and fully examines the cecum.  A colonoscopy that fails to reach the cecum is incomplete, and will fail to detect lesions in the unexamined areas.  Incomplete colonoscopies require consideration of additional testing, such as repeating colonoscopy, referring the patient to a more experienced colonoscopist, or performing an alternative examination, such as CT colonography (virtual colonoscopy) or capsule colonoscopy (pill camera colonoscopy).  The ability to perform a complete colonoscopy is a well‐accepted measure of a colonoscopist’s technical skill. Ask your doctor about his or her cecal intubation rate. 

Average Withdrawal Time
While it might seem that a fast colonoscopy is a good one, the opposite is true.  Once we reach the cecum we begin a meticulous examination of the entire colon lining, looking behind each fold, which takes time.  The time necessary to perform a high quality examination varies from patient to patient, but most of us use timers to help us perform a well structured withdrawal.  Withdrawal times that are short have been associated with both a low adenoma (polyp) detection rate (meaning a high miss rate) and a higher rate of “interval” (some of which are missed) colon cancers. Ask your doctor how fast he or she withdraws the instrument. 

Read the New York Times: 10 Questions You Need to Ask About Colonoscopy