A Call to Action — Measuring the Quality of Colonoscopy
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《新英格兰医药杂志》
Several years ago I visited the Ming Tombs near Beijing. The Ming emperors were buried in elaborate structures, hidden away in the hills to prevent looting. Bricks were embedded with the signature of the brick maker. My guide told me that if the brick collapsed during the life of the brick maker, he would be beheaded. Needless to say, the tombs still survive, many centuries later.
This variation on pay for performance (i.e., death for poor performance) highlights issues of quality. In medicine, focusing attention on quality improvement has given rise to systems for measuring quality, including the Health Plan Employer Data and Information Set (HEDIS) and pay-for-performance standards by the Centers for Medicare and Medicaid Services (CMS). Quality improvement is rapidly progressing from a lofty goal to a fiscal reality. At some point, patients (with health savings accounts) and third-party payers will expect to know that they are paying for high-quality care.
In the specialty of gastroenterology, attention has been focused on the quality of colonoscopy.1,2 Since the publication in 2000 and 2001 of two large screening-colonoscopy studies,3,4 there has been a dramatic increase in the use of colonoscopy for the screening and surveillance of colorectal cancer.5,6,7 There is new evidence that patients with normal results on a colonoscopy have a reduced incidence of colorectal cancer over a period of 10 years.8 An important objective of screening colonoscopy is the detection and removal of adenomas, which can prevent many cancers.9 If colonoscopy is to be a successful screening tool for colorectal cancer, it must be performed with a low rate of missed lesions and complications and by properly trained endoscopists who are committed to continuous quality improvement.
In this issue of the Journal, Barclay et al.10 report results of screening colonoscopy within a private group practice in gastroenterology. They measured a key outcome — rate of adenoma detection. The authors report an overall rate of adenoma detection of 23.5%, with advanced adenomas (defined as adenomas with a diameter of at least 10 mm or with villous histologic features, high-grade dysplasia, or invasive cancer) in 5.2%, which is very similar to the percentages seen in previous work.3,4
The unique contribution of this study is the observation of significant variation among the 12 endoscopists in the rates of detection of any adenomas and of advanced adenomas. The variable associated with low rates of detection was colonoscopic withdrawal time of less than 6 minutes during normal examinations. Longer procedure time does not necessarily mean higher quality; the endoscopist must be able to recognize important pathologic features and have the technical skills to ensure appropriate management. However, the results of this study are intuitive — careful endoscopic examination of the colon should improve the rate of detection of adenomas, which is the important indicator of quality. The quality of the preparation of the bowel and complete examination from the cecum to the rectum are other factors that may affect the rate of detection of adenomas, though they were not important variables in the current study.
Why is the quality of colonoscopy important, and is quality a problem? New evidence shows that colonoscopies, even in the hands of experts, are not performed perfectly. Studies evaluating the use of aspirin, cyclooxygenase-2 inhibitors, calcium, or diet for chemoprevention have shown that in 0.3 to 0.9% of patients who had adenomas removed, invasive colorectal cancer developed within 3 years after a baseline colonoscopy during which all polyps were removed.11,12,13,14,15 Possible reasons for the development of these cancers include missed lesions, incomplete removal of adenomas, and new fast-growing lesions. Important missed lesions, including adenomas greater than 1 cm in diameter, have been noted in studies that compared optical colonoscopy with computed tomographic colonography.16,17,18 Diagnostic tools such as colonoscopy have inherent limitations, which may be both technical and operator-dependent. New technology may improve our ability to see some lesions. It is the operator-dependent variables that are the focus of efforts to improve quality.
Quality has an important effect on use. Lack of confidence in the baseline colonoscopy, due to an incomplete or rapid examination, may result in overuse of colonoscopy for surveillance because of concern about finding serious pathological features on subsequent examinations. There is evidence that many physicians do not follow the surveillance guidelines described by Levine and Ahnen in this issue of the Journal19 and perform examinations at shorter intervals than are recommended.20 This overuse consumes valuable colonoscopy resources, drives up health care costs, and exposes patients to unnecessary risk.
How can we improve quality? One answer is to measure it every day. A task group from the National Colorectal Cancer Roundtable is developing a reporting system for colonoscopy that could be adopted in every clinical practice. This system would capture key quality indicators (including the rate of detection of adenomas), provide benchmarking information for the endoscopist, and enable continuous quality improvement. Primary care providers would have information that they could use to refer patients to an endoscopist.
Some may argue that measuring quality is onerous and cannot be accomplished efficiently in busy clinical practices. The current study by Barclay et al. shows that the members of a private group practice can "take a look in the mirror" by asking critical questions about their daily practice and by measuring key outcomes to improve the quality of patient care. There is a lesson here for every practitioner in every specialty — research in quality improvement not only is an activity for academic centers and funded investigators, but also needs to be part of the culture of everyday clinical practice.
Finally, many persons believe that if they have a colonoscopy, their risk of developing colorectal cancer will be eliminated. This is not a realistic expectation. Colonoscopy screening performed with the highest quality can reduce, but will never eliminate, the risk of colorectal cancer. Future research may identify less invasive screening tests and risk-reduction strategies.19 Colonoscopy will continue to be the preeminent test for evaluating any positive colon-screening test. It is time for all endoscopists to routinely measure quality indicators in their practice and strive for continuous quality improvement.
No potential conflict of interest relevant to this article was reported.
Source Information
From the Division of Gastroenterology, Oregon Health and Science University, Portland Veterans Affairs Medical Center, Portland.
References
Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002;97:1296-1308.
Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873-885.
Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med 2001;345:555-560.
Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med 2000;343:169-174.
Cram P, Fendrick AM, Inadomi J, Cowen ME, Carpenter D, Vijan S. The impact of a celebrity promotional campaign on the use of colon cancer screening: the Katie Couric effect. Arch Intern Med 2003;163:1601-1605.
Harewood GC, Lieberman DA. Colonoscopy practice patterns since introduction of Medicare coverage for average-risk screening. Clin Gastroenterol Hepatol 2004;2:72-77.
Lieberman DA, Holub J, Eisen G, Kraemer D, Morris CD. Utilization of colonoscopy in the United States: results from a national consortium. Gastrointest Endosc 2005;62:875-883.
Singh H, Turner D, Xue L, Targownik LE, Bernstein CN. Risk of developing colorectal cancer following a negative colonoscopy examination: evidence for a 10-year interval between colonoscopies. JAMA 2006;295:2366-2373.
Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993;329:1977-1981.
Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533-2541.
Schatzkin A, Lanza E, Corle D, et al. Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. N Engl J Med 2000;342:1149-1155.
Alberts DS, Martínez ME, Roe DJ, et al. Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. N Engl J Med 2000;342:1156-1162.
Robertson DJ, Greenberg ER, Beach M, et al. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005;129:34-41.
Bertagnolli MM, Eagle CJ, Zauber AG, et al. Celecoxib for the prevention of sporadic colorectal adenomas. N Engl J Med 2006;355:873-884.
Arber N, Eagle CJ, Spicak J, et al. Celecoxib for the prevention of colorectal adenomatous polyps. N Engl J Med 2006;355:885-895.
Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349:2191-2200.
Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 2004;291:1713-1719.
Rockey DC, Paulson E, Niedzwiecki D, et al. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005;365:305-311.
Levine JS, Ahnen DJ. Adenomatous polyps of the colon. N Engl J Med 2006;355:2551-2557.
Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004;141:264-271.(David Lieberman, M.D.)
This variation on pay for performance (i.e., death for poor performance) highlights issues of quality. In medicine, focusing attention on quality improvement has given rise to systems for measuring quality, including the Health Plan Employer Data and Information Set (HEDIS) and pay-for-performance standards by the Centers for Medicare and Medicaid Services (CMS). Quality improvement is rapidly progressing from a lofty goal to a fiscal reality. At some point, patients (with health savings accounts) and third-party payers will expect to know that they are paying for high-quality care.
In the specialty of gastroenterology, attention has been focused on the quality of colonoscopy.1,2 Since the publication in 2000 and 2001 of two large screening-colonoscopy studies,3,4 there has been a dramatic increase in the use of colonoscopy for the screening and surveillance of colorectal cancer.5,6,7 There is new evidence that patients with normal results on a colonoscopy have a reduced incidence of colorectal cancer over a period of 10 years.8 An important objective of screening colonoscopy is the detection and removal of adenomas, which can prevent many cancers.9 If colonoscopy is to be a successful screening tool for colorectal cancer, it must be performed with a low rate of missed lesions and complications and by properly trained endoscopists who are committed to continuous quality improvement.
In this issue of the Journal, Barclay et al.10 report results of screening colonoscopy within a private group practice in gastroenterology. They measured a key outcome — rate of adenoma detection. The authors report an overall rate of adenoma detection of 23.5%, with advanced adenomas (defined as adenomas with a diameter of at least 10 mm or with villous histologic features, high-grade dysplasia, or invasive cancer) in 5.2%, which is very similar to the percentages seen in previous work.3,4
The unique contribution of this study is the observation of significant variation among the 12 endoscopists in the rates of detection of any adenomas and of advanced adenomas. The variable associated with low rates of detection was colonoscopic withdrawal time of less than 6 minutes during normal examinations. Longer procedure time does not necessarily mean higher quality; the endoscopist must be able to recognize important pathologic features and have the technical skills to ensure appropriate management. However, the results of this study are intuitive — careful endoscopic examination of the colon should improve the rate of detection of adenomas, which is the important indicator of quality. The quality of the preparation of the bowel and complete examination from the cecum to the rectum are other factors that may affect the rate of detection of adenomas, though they were not important variables in the current study.
Why is the quality of colonoscopy important, and is quality a problem? New evidence shows that colonoscopies, even in the hands of experts, are not performed perfectly. Studies evaluating the use of aspirin, cyclooxygenase-2 inhibitors, calcium, or diet for chemoprevention have shown that in 0.3 to 0.9% of patients who had adenomas removed, invasive colorectal cancer developed within 3 years after a baseline colonoscopy during which all polyps were removed.11,12,13,14,15 Possible reasons for the development of these cancers include missed lesions, incomplete removal of adenomas, and new fast-growing lesions. Important missed lesions, including adenomas greater than 1 cm in diameter, have been noted in studies that compared optical colonoscopy with computed tomographic colonography.16,17,18 Diagnostic tools such as colonoscopy have inherent limitations, which may be both technical and operator-dependent. New technology may improve our ability to see some lesions. It is the operator-dependent variables that are the focus of efforts to improve quality.
Quality has an important effect on use. Lack of confidence in the baseline colonoscopy, due to an incomplete or rapid examination, may result in overuse of colonoscopy for surveillance because of concern about finding serious pathological features on subsequent examinations. There is evidence that many physicians do not follow the surveillance guidelines described by Levine and Ahnen in this issue of the Journal19 and perform examinations at shorter intervals than are recommended.20 This overuse consumes valuable colonoscopy resources, drives up health care costs, and exposes patients to unnecessary risk.
How can we improve quality? One answer is to measure it every day. A task group from the National Colorectal Cancer Roundtable is developing a reporting system for colonoscopy that could be adopted in every clinical practice. This system would capture key quality indicators (including the rate of detection of adenomas), provide benchmarking information for the endoscopist, and enable continuous quality improvement. Primary care providers would have information that they could use to refer patients to an endoscopist.
Some may argue that measuring quality is onerous and cannot be accomplished efficiently in busy clinical practices. The current study by Barclay et al. shows that the members of a private group practice can "take a look in the mirror" by asking critical questions about their daily practice and by measuring key outcomes to improve the quality of patient care. There is a lesson here for every practitioner in every specialty — research in quality improvement not only is an activity for academic centers and funded investigators, but also needs to be part of the culture of everyday clinical practice.
Finally, many persons believe that if they have a colonoscopy, their risk of developing colorectal cancer will be eliminated. This is not a realistic expectation. Colonoscopy screening performed with the highest quality can reduce, but will never eliminate, the risk of colorectal cancer. Future research may identify less invasive screening tests and risk-reduction strategies.19 Colonoscopy will continue to be the preeminent test for evaluating any positive colon-screening test. It is time for all endoscopists to routinely measure quality indicators in their practice and strive for continuous quality improvement.
No potential conflict of interest relevant to this article was reported.
Source Information
From the Division of Gastroenterology, Oregon Health and Science University, Portland Veterans Affairs Medical Center, Portland.
References
Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002;97:1296-1308.
Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873-885.
Lieberman DA, Weiss DG. One-time screening for colorectal cancer with combined fecal occult-blood testing and examination of the distal colon. N Engl J Med 2001;345:555-560.
Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med 2000;343:169-174.
Cram P, Fendrick AM, Inadomi J, Cowen ME, Carpenter D, Vijan S. The impact of a celebrity promotional campaign on the use of colon cancer screening: the Katie Couric effect. Arch Intern Med 2003;163:1601-1605.
Harewood GC, Lieberman DA. Colonoscopy practice patterns since introduction of Medicare coverage for average-risk screening. Clin Gastroenterol Hepatol 2004;2:72-77.
Lieberman DA, Holub J, Eisen G, Kraemer D, Morris CD. Utilization of colonoscopy in the United States: results from a national consortium. Gastrointest Endosc 2005;62:875-883.
Singh H, Turner D, Xue L, Targownik LE, Bernstein CN. Risk of developing colorectal cancer following a negative colonoscopy examination: evidence for a 10-year interval between colonoscopies. JAMA 2006;295:2366-2373.
Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993;329:1977-1981.
Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533-2541.
Schatzkin A, Lanza E, Corle D, et al. Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. N Engl J Med 2000;342:1149-1155.
Alberts DS, Martínez ME, Roe DJ, et al. Lack of effect of a high-fiber cereal supplement on the recurrence of colorectal adenomas. N Engl J Med 2000;342:1156-1162.
Robertson DJ, Greenberg ER, Beach M, et al. Colorectal cancer in patients under close colonoscopic surveillance. Gastroenterology 2005;129:34-41.
Bertagnolli MM, Eagle CJ, Zauber AG, et al. Celecoxib for the prevention of sporadic colorectal adenomas. N Engl J Med 2006;355:873-884.
Arber N, Eagle CJ, Spicak J, et al. Celecoxib for the prevention of colorectal adenomatous polyps. N Engl J Med 2006;355:885-895.
Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med 2003;349:2191-2200.
Cotton PB, Durkalski VL, Pineau BC, et al. Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia. JAMA 2004;291:1713-1719.
Rockey DC, Paulson E, Niedzwiecki D, et al. Analysis of air contrast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005;365:305-311.
Levine JS, Ahnen DJ. Adenomatous polyps of the colon. N Engl J Med 2006;355:2551-2557.
Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004;141:264-271.(David Lieberman, M.D.)