Original Research

A Nationwide Survey and Needs Assessment of Colonoscopy Quality Assurance Programs

Variability exists in quality documentation, measurement, and reporting practices of colonoscopy screening in VA facilities, and most do not have formal performance improvement plans.

Fed Pract. 2018 March;35(3):26-32

Author(s):

Andrew J. Gawron, MD, PhD, MS

Phillip Lawrence, PharmD

Morgan M. Millar, PhD

Jason A. Dominitz, MD

Samir Gupta, MD

Mary Whooley, MD

Tonya Kaltenbach, MD

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References

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2. Meester RGS, Doubeni CA, Lansdorp-Vogelaar I, et al. Colorectal cancer deaths attributable to nonuse of screening in the United States. Ann Epidemiol. 2015;25(3):208-213.e1.

3. Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370(26):1298-1306.

4. Meester RGS, Doubeni CA, Lansdorp-Vogelaar I, et al. Variation in adenoma detection rate and the lifetime benefits and cost of colorectal cancer screening: a microsimulation model. JAMA. 2015;313(23):2349-2358.

5. Boroff ES, Gurudu SR, Hentz JG, Leighton JA, Ramirez FC. Polyp and adenoma detection rates in the proximal and distal colon. Am J Gastroenterol. 2013;108(6):993-999.

6. Center for Medicare and Medicaid Services. Quality measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Qual ityMeasures/index.html. Updated December 19, 2017. Accessed January 17, 2018.

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9. de Jonge V, Sint Nicolaas J, Cahen DL, et al; SCoPE Consortium. Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice. Gastrointest Endosc. 2012;75(1):98-106.

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13. U.S. Department of Veterans Affairs, Veterans Health Administration. Colorectal cancer screening. VHA Directive 1015. Published December 30, 2014.

14. U.S. Department of Veterans Affairs, VA Office of the Inspector General, Office of Healthcare Inspections. Healthcare inspection: alleged access delays and surgery service concerns, VA Roseburg Healthcare System, Roseburg, Oregon. Report No.15-00506-535. https://www.va.gov/oig /pubs/VAOIG-15-00506-535.pdf. Published July 11, 2017. Accessed January 9, 2018.

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16. The American Association for Public Opinion Research. Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 9th edition. http://www.aapor.org/AAPOR_Main/media/publications/Standard-Definitions20169theditionfinal.pdf. Revised 2016. Accessed January 9, 2018.

17. Kahi CJ, Imperiale TF, Juliar BE, Rex DK. Effect of screening colonoscopy on colorectal cancer incidence and mortality. Clin Gastroenterol Hepatol. 2009;7(7):770-775.

18. Manser CN, Bachmann LM, Brunner J, Hunold F, Bauerfeind P, Marbet UA. Colonoscopy screening markedly reduces the occurrence of colon carcinomas and carcinoma-related death: a closed cohort study. Gastrointest Endosc. 2012;76(1):110-117.

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Colorectal cancer (CRC) is an important concern for the VA, and colonoscopy is one primary screening, surveillance, and diagnostic modality used. The observed reductions in CRC incidence and mortality over the past decade largely have been attributed to the widespread use of CRC screening options.^1,2Colonoscopy quality is critical to CRC prevention in veterans. However, endoscopy skills to detect and remove colorectal polyps using colonoscopy vary in practice.^3-5

Quality benchmarks, linked to patient outcomes, have been established by specialty societies and proposed by the Centers for Medicare and Medicaid Services as reportable quality metrics.⁶ Colonoscopy quality metrics have been shown to be associated with patient outcomes, such as the risk of developing CRC after colonoscopy. The adenoma detection rate (ADR), defined as the proportion of average-risk screening colonoscopies in which 1 or more adenomas are detected, has the strongest association to interval or “missed” CRC after screening colonoscopy and has been linked to a risk for fatal CRC despite colonoscopy.³

In a landmark study of 314,872 examinations performed by 136 gastroenterologists, the ADR ranged from 7.4% to 52.5%.³ Among patients with ADRs in the highest quintile compared with patients in the lowest, the adjusted hazard ratios (HRs) for any interval cancer was 0.52 (95% confidence interval [CI], 0.39-0.69) and for fatal interval cancers was 0.38 (95% CI, 0.22-0.65).³ Another pooled analysis from 8 surveillance studies that followed more than 800 participants with adenoma(s) after a baseline colonoscopy showed 52% of incident cancers as probable missed lesions, 19% as possibly related to incomplete resection of an earlier, noninvasive lesion, and only 24% as probable new lesions.⁷ These interval cancers highlight the current imperfections of colonoscopy and the focus on measurement and reporting of quality indicators for colonoscopy.^8-12

According to VHA Directive 1015, in December 2014, colonoscopy quality should be monitored as part of an ongoing quality assurance program.¹³ A recent report from the VA Office of the Inspector General (OIG) highlighted colonoscopy-quality deficiencies.¹⁴ The OIG report strongly recommended that the “Acting Under Secretary for Health require standardized documentation of quality indicators based on professional society guidelines and published literature.”¹⁴However, no currently standardized and readily available VHA resource measures, reports, and ensures colonoscopy quality.

The authors hypothesized that colonoscopy quality assurance programs vary widely across VHA sites. The objective of this survey was to assess the measurement and reporting practices for colonoscopy quality and identify both strengths and areas for improvement to facilitate implementation of quality assurance programs across the VA health care system.

Methods

The authors performed an online survey of VA sites to assess current colonoscopy quality assurance practices. The institutional review boards (IRBs) at the University of Utah and VA Salt Lake City Health Care System and University of California, San Francisco and San Francisco VA Health Care System classified the study as a quality improvement project that did not qualify for human subjects’ research requiring IRB review.

The authors iteratively developed and refined the questionnaire with a survey methodologist and 2 clinical domain experts. The National Program Director for Gastroenterology, and the National Gastroenterology Field Advisory Committee reviewed the survey content and pretested the survey instrument prior to final data collection. The National Program Office for Gastroenterology provided an e-mail list of all known VA gastroenterology section chiefs. The authors administered the final survey via e-mail, using the Research Electronic Data Capture (REDCap; Vanderbilt University Medical Center) platform beginning January 9, 2017.¹⁵

A follow-up reminder e-mail was sent to nonresponders after 2 weeks. After this second invitation, sites were contacted by telephone to verify that the correct contact information had been captured. Subsequently, 50 contacts were updated if e-mails bounced back or the correct contact was obtained. Points of contact received a total of 3 reminder e-mails until the final closeout of the survey on March 28, 2017; 65 of 89 (73%) of the original contacts completed the survey vs 31 of 50 (62%) of the updated contacts.

Analysis

Descriptive statistics of the responses were calculated to determine the overall proportion of VA sites measuring colonoscopy quality metrics and identification of areas in need of quality improvement. The response rate for the survey was defined as the total number of responses obtained as a proportion of the total number of points of contact. This corresponds to the American Association of Public Opinion Research’s RR1, or minimum response rate, formula.¹⁶ All categoric responses are presented as proportions. Statistical analyses were performed using STATA SE12.0 (College Station, TX).

Results

Of the 139 points of contact invited, 96 completed the survey (response rate of 69.0%), representing 93 VA facilities (of 141 possible facilities) in 44 different states. Three sites had 2 responses. Sites used various and often a combination of methods to measure quality (Table 1).

The majority of sites reported using manual chart review (79.2%) to collect colonoscopy quality metrics, although only 39.6% reported using endoscopic software to collect quality metrics. A variety of personnel collected quality metrics, the most common being nursing staff (44.8% of participating sites), division/section chiefs (38.5%), multiple other staff (29.2%), and attending physicians (22.9%). The most common reporting frequencies were quarterly (41.7%), monthly (17.7%), and biannually (13.5%).