UK key performance indicators and quality assurance standards for colonoscopy

Colin J Rees, Siwan Thomas Gibson, Matt D Rutter, Phil Baragwanath, Rupert Pullan, Mark Feeney, Neil Haslam, British Society of Gastroenterology, the Joint Advisory Group on GI Endoscopy, the Association of Coloproctology of Great Britain and Ireland, Colin J Rees, Siwan Thomas Gibson, Matt D Rutter, Phil Baragwanath, Rupert Pullan, Mark Feeney, Neil Haslam, British Society of Gastroenterology, the Joint Advisory Group on GI Endoscopy, the Association of Coloproctology of Great Britain and Ireland

Abstract

Colonoscopy should be delivered by endoscopists performing high quality procedures. The British Society of Gastroenterology, the UK Joint Advisory Group on GI Endoscopy, and the Association of Coloproctology of Great Britain and Ireland have developed quality assurance measures and key performance indicators for the delivery of colonoscopy within the UK. This document sets minimal standards for delivery of procedures along with aspirational targets that all endoscopists should aim for.

Keywords: COLONOSCOPY; ENDOSCOPIC PROCEDURES; ENDOSCOPY.

Conflict of interest statement

Conflicts of Interest: None declared.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

References

    1. Rex DK, Cutler C, Lemmel GT, et al. . Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterol 1997;112:24–8. 10.1016/S0016-5085(97)70214-2
    1. Arora G, Mannalithara A, Singh G, et al. . Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009;69: 654–64. 10.1016/j.gie.2008.09.008
    1. Iqbal CW. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch Surg 2008;143:701–6. 10.1001/archsurg.143.7.701
    1. Korman LY, Overholt B, Box T, et al. . Perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003;58:554–7. 10.1067/S0016-5107(03)01890-X
    1. Rabeneck L, Paszat LF, Hilsden RJ, et al. . Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterol 2008;135:1899–1906.e1. 10.1053/j.gastro.2008.08.058
    1. Kaminski MF, Regula J, Kraszewska E, et al. . Quality indicators for colonoscopy and the risk of interval cancer. N Eng J Med 2010;362:1795–803. 10.1056/NEJMoa0907667
    1. Bowles CJA, Leicester R, Romaya C, et al. . A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut 2004;53:277–83.
    1. Gavin D, Valori R, Anderson JT, et al. . The National Colonoscopy Audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013;62:242–9. 10.1136/gutjnl-2011-301848
    1. Rajasekhar PT, Rutter MD, Bramble MG, et al. . Achieving high quality colonoscopy: using graphical representation to measure performance and reset standards. Colorectal Dis 2012;14:1538–45. 10.1111/j.1463-1318.2012.03057.x
    1. HES data, 2011.
    1. Atkin WS, Cook CF, Cuzick J, et al. . Single flexible sigmoidoscopy screening to prevent colorectal cancer: baseline findings of a UK multicentre randomised trial. Lancet 2002;359:1291–300. 10.1016/S0140-6736(02)08268-5
    1. Atkin WS, Edwards R, Kralj-Hans I, et al. . Once-only flexible sigmoidoscopy screening in prevention of colorectal cancer: a multicentre randomised controlled trial. Lancet 2010;375:1624–33. 10.1016/S0140-6736(10)60551-X
    1. Logan RFA, Patnick J, Nickerson C, et al. . Outcomes of the Bowel Cancer Screening Programme (BCSP) in England after the first 1 million tests. Gut 2012;61: 1439–46. 10.1136/gutjnl-2011-300843
    1. Aslinia F, Uradomo L, Steele A, et al. . Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a university hospital. Am J Gastroenterol 2006;101:721–31. 10.1111/j.1572-0241.2006.00494.x
    1. Shah HA, Paszat LF, Saskin R, et al. . Factors associated with incomplete colonoscopy: a population-based study. Gastroenterol 2007;132:2297–303. 10.1053/j.gastro.2007.03.032
    1. Brenner H, Chang-Claude J, Seiler CM, et al. . Interval cancers after negative colonoscopy: population-based case-control study. Gut 2012;61:1576–82. 10.1136/gutjnl-2011-301531
    1. Bressler B, Paszat LF, Chen Z, et al. . Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterol 2007;132:96–102. 10.1053/j.gastro.2006.10.027
    1. Lee TWJ, Rutter MD, Blanks RG, et al. . Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012;61:1050–7. 10.1136/gutjnl-2011-300651
    1. Corley DA, Jensen CD, Marks AR, et al. . Adenoma detection rate and risk of colorectal cancer and death. N Eng J Med 2014;370:1298–306. 10.1056/NEJMoa1309086
    1. Francis DL, Rodriguez-Correa DT, Buchner A, et al. . Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. Gastrointest Endosc 2011;73:493–7. 10.1016/j.gie.2011.01.005
    1. Patel NC, Islam RS, Wu Q, et al. . Measurement of polypectomy rate by using administrative claims data with validation against the adenoma detection rate. Gastrointest Endosc 2013;77:390–4. 10.1016/j.gie.2012.09.032
    1. Rajasekhar PT, Lee TJ, Rutter MD, et al. . Using a ‘conversion factor’ to estimate adenoma detection rate. Endoscopy 2012;61(Suppl 3):A371.
    1. Rembacken B, Hassan C, Riemann J, et al. . Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012;44:957–68. 10.1055/s-0032-1325686
    1. Connor A, Tolan D, Hughes S, et al. . Consensus guidelines for the safe prescription and administration of oral bowel-cleansing agents. Gut 2012;61:1525–32. 10.1136/gutjnl-2011-300861
    1. Gerard DP, Foster DB, Raiser MW, et al. . Validation of a new bowel preparation scale for measuring colon cleansing for colonoscopy: the Chicago bowel preparation scale. Clin Transl Gastroenterol 2013;4:e43 10.1038/ctg.2013.16
    1. Aronchick CA, Lipshutz WH, Wright SH, et al. . Validation of an instrument to assess colon cleansing. Am J Gastroenterol 1999;94:2667.
    1. Rostom A, Jolicoeur E. Validation of a new scale for the assessment of bowel preparation quality. Gastrointest Endosc 2004;59:482–6. 10.1016/S0016-5107(03)02875-X
    1. Halphen M, Heresbach D, Gruss H-J, et al. . Validation of the Harefield Cleansing Scale: a tool for the evaluation of bowel cleansing quality in both research and clinical practice. Gastrointest Endosc 2013;78:121–31. 10.1016/j.gie.2013.02.009
    1. Lai EJ, Calderwood AH, Doros G, et al. . The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009;69:620–5. 10.1016/j.gie.2008.05.057
    1. Chilton A, Rutter MD. Quality assurance guidelines for colonoscopy. NHS Cancer Screening Programmes, 2011.
    1. Cotton PB, Williams CB. Chapter 9. In: Cotton PB, Williams CB, Haycock A, et al. eds. Practical gastrointestinal endoscopy. Wiley-Blackwell, 1996:218–20.
    1. El Younis CM. Correlation of preprocedure digital rectal examination and rectal retroflexion during colonoscopy of asymptomatic patients. Gastroenterol Hepatol 2009;5:201–4.
    1. Grobe JL, Kozarek RA, Sanowski RA. Colonoscopic retroflexion in the evaluation of rectal disease. Am J Gastroenterol 1982;77:856–8.
    1. Cutler AF, Pop A. Fifteen years later: colonoscopic retroflexion revisited. Am J Gastroenterol 1999;94:1537–8. 10.1111/j.1572-0241.1999.01140.x
    1. Hanson JM, Atkin WS, Cunliffe WJ, et al. . Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination. Dis Colon Rectum 2001;44:1706–8. 10.1007/BF02234394
    1. Saad A, Rex DK. Routine rectal retroflexion during colonoscopy has a low yield for neoplasia. World J Gastroenterol 2008;14:6503–5. 10.3748/wjg.14.6503
    1. Varadarajulu S, Ramsey WH. Utility of retroflexion in lower gastrointestinal endoscopy. J Clin Gastroenterol 2001;32:235–7. 10.1097/00004836-200103000-00012
    1. Reddy AB, Palardy LG, Reddy KB. The utility of rectal retroflexion. Am J Gastroenterol 2011;106:1008–11. 10.1038/ajg.2010.498
    1. Katsinelos P, Kountouras J, Chatzimavroudis G, et al. . Endoscopic closure of a large iatrogenic rectal perforation using endoloop/clips technique. Acta Gastroenterol Belg 2009;72:357–9.
    1. Sullivan JL, Maxwell PJ IV, Kastenberg DM, et al. . Rectal perforation by retroflexion of the colonoscope managed by endoclip closure. Am Surg 2010;76:108–10.
    1. Quallick MR, Brown WR. Rectal perforation during colonoscopic retroflexion: a large, prospective experience in an academic center. Gastrointest Endosc 2009;69:960–3. 10.1016/j.gie.2008.11.011
    1. Overholt BF, Brooks-Belli L, Grace M, et al. . Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment. J Clin Gastroenterol 2010;44:e80–6. 10.1097/MCG.0b013e3181bf9b02
    1. Simmons DT, Harewood GC, Baron TH, et al. . Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time. Aliment Pharmacol Ther 2006;24:965–71. 10.1111/j.1365-2036.2006.03080.x
    1. Barclay RL, Vicari JJ, Greenlaw RL. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol 2008;6:1091–8. 10.1016/j.cgh.2008.04.018
    1. Gromski MA, Miller CA, Lee S-H, et al. . Trainees’ adenoma detection rate is higher if ≥10 minutes is spent on withdrawal during colonoscopy. Surg Endosc 2012;26:1337–42. 10.1007/s00464-011-2033-2
    1. Lee RH, Tang RS, Muthusamy VR, et al. . Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos). Gastrointest Endosc 2011;74:128–34. 10.1016/j.gie.2011.03.003
    1. Moritz V, Bretthauer M, Ruud H, et al. . Withdrawal time as a quality indicator for colonoscopy—a nationwide analysis. Surg Endosc 2012;44:476–81. 10.1055/s-0032-1306898
    1. Sawhney MS, Cury MS, Neeman N, et al. . Effect of institution-wide policy of colonoscopy withdrawal time ≥7 minutes on polyp detection. Gastroenterol 2008;135:1892–8. 10.1053/j.gastro.2008.08.024
    1. British Society of Gastroenterology Safety and sedation during endoscopic procedures, 2003.
    1. Rajasekhar PT, Clifford GM, Lee TJW, et al. . Bowel cancer screening is safe, detects earlier stage cancer and adenomas in 50% of cases: experience of the prevalent round of screening from two first wave centres in the North East of England. Frontline Gastroenterol 2012;3:10–15. 10.1136/flgastro-2011-100004
    1. Ward ST, Mohammed MA, Walt R, et al. . An analysis of the learning curve to achieve competency at colonoscopy using the JETS database. Gut 2014;63:1746–54. 10.1136/gutjnl-2013-305973
    1. Spier BJ, Benson M, Pfau PR, et al. . Colonoscopy training in gastroenterology fellowships: determining competence. Gastrointest Endosc 2010;71:319–24. 10.1016/j.gie.2009.05.012
    1. Sedlack RE. Training to competency in colonoscopy: assessing and defining competency standards. Gastrointest Endosc 2011;74:355–366.e1–2. 10.1016/j.gie.2011.02.019
    1. Park HJ, Hong JH, Kim HS, et al. . Predictive factors affecting cecal intubation failure in colonoscopy trainees. BMC Med Educ 2013;13:5 10.1186/1472-6920-13-5
    1. Wexner SD, Garbus JE, Singh JJ. A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines. Surg Endosc 2001;15:251–61.
    1. Harewood GC. Relationship of colonoscopy completion rates and endoscopist features. Dig Dis Sci 2005;50:47–51.
    1. Adler A, Wegscheider K, Lieberman D, et al. . Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12 134 examinations (Berlin colonoscopy project 3, BECOP-3). Gut 2013;62:236–41. 10.1136/gutjnl-2011-300167
    1. Ponsky JL, King JF. Endoscopic marking of colonic lesions. Gastrointest Endosc 1975;22:42–3.
    1. Mcarthur CS, Roayaie S, Waye JD. Safety of preoperation endoscopic tattoo with India ink for identification of colonic lesions. Surg Endosc 1999;13:543–6.
    1. Bowel Cancer Screening Programme. BCSP Tattooing Policy, 2012.
    1. Fine KD, Seidel RH, Do K. The prevalence, anatomic distribution, and diagnosis of colonic causes of chronic diarrhoea. Gastrointest Endosc 2000;51:318 10.1016/S0016-5107(00)70362-2
    1. Williams JJ, Beck PL, Andrews CN, et al. . Microscopic colitis—a common cause of diarrhoea in older adults. Age Ageing 2010;39:162–8. 10.1093/ageing/afp243
    1. Pardi DS, Loftus EV, Smyrk TC, et al. . The epidemiology of microscopic colitis: a population based study in Olmsted County, Minnesota. Gut 2007;56:504–8. 10.1136/gut.2006.105890
    1. Carpenter HA, Tremaine WJ, Batts KP, et al. . Sequential histologic evaluations in collagenous colitis. Correlations with disease behavior and sampling strategy. Dig Dis Sci 1992;37:1903–9.
    1. Tanaka M, Mazzoleni G, Riddell RH. Distribution of collagenous colitis: utility of flexible sigmoidoscopy. Gut 1992;33:65–70. 10.1136/gut.33.1.65
    1. Shen B, Khan K, Ikenberry SO, et al. . The role of endoscopy in the management of patients with diarrhea. Gastrointest Endosc 2010;71:887–92. 10.1016/j.gie.2009.11.025
    1. Imperiale TF, Glowinski EA, Lin-Cooper C, et al. . Five-year risk of colorectal neoplasia after negative screening colonoscopy. N Eng J Med 2008;359:1218–24. 10.1056/NEJMoa0803597
    1. Baxter NN, Sutradhar R, Forbes SS, et al. . Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterol 2011;140:65–72. 10.1053/j.gastro.2010.09.006
    1. Morris EJ, Rutter MD, Finan PJ, et al. . Post-colonoscopy colorectal cancer (PCCRC) rates vary considerably depending on the method used to calculate them: a retrospective observational population-based study of PCCRC in the English National Health Service. Gut 2015;64:1248–56.
    1. Singh H, Nugent Z, Demers AA, et al. . Rates and predictors of early/missed colorectal cancers after colonoscopy in Manitoba: a population-based study. Am J Gastroenterol 2010;105:2588–96. 10.1038/ajg.2010.390
    1. Pabby A, Schoen RE, Weissfeld JL, et al. . Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary polyp prevention trial. Gastrointest Endosc 2005;61:385–91. 10.1016/S0016-5107(04)02765-8
    1. Robertson DJ, Lieberman D, Winawer SJ, et al. . Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014;63:949–56. 10.1136/gutjnl-2012-303796
    1. Farrar WD, Sawhney MS, Nelson DB, et al. . Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006;4:1259–64. 10.1016/j.cgh.2006.07.012
    1. Rondagh EJA, Bouwens MWE, Riedl RG, et al. . Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention. Gastrointest Endosc 2012;75:1218–25. 10.1016/j.gie.2012.02.010
    1. Kahi CJ, Imperiale TF, Juliar BE, et al. . Effect of screening colonoscopy on colorectal cancer incidence and mortality. Clin Gastroenterol Hepatol 2009;7:770–5. 10.1016/j.cgh.2008.12.030
    1. Panteris V, Haringsma J, Kuipers EJ. Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy. Endoscopy 2009;41:941–51. 10.1055/s-0029-1215179
    1. Nelson DB, Mcquaid KR, Bond JH, et al. . Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc 2002;55:307–14. 10.1067/mge.2002.121883
    1. Silvis SE, Nebel O, Rogers G, et al. . Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy Survey. JAMA 1976;235:928–30.
    1. Rutter MD, Nickerson C, Rees C, et al. . Risk factors for adverse events related to polypectomy in the English Bowel Cancer Screening Programme. Endoscopy 2014;46:90–7. 10.1055/s-0033-1344987
    1. Gondal G, Grotmol T, Hofstad B, et al. . The Norwegian Colorectal Cancer Prevention (NORCCAP) Screening Study: baseline findings and implementations for clinical work-up in age groups 50–64 years. Scand J Gastroenterol 2003;38:635–42. 10.1080/00365520310003002
    1. Heldwein W, Dollhopf M, Rösch T, et al. . The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies. Endoscopy 2005;37:1116–22. 10.1055/s-2005-870512
    1. Levin TR. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006;145:880–6. 10.7326/0003-4819-145-12-200612190-00004
    1. Sieg A, Hachmoeller-Eisenbach U, Eisenbach T. Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists. Gastrointest Endosc 2001;53:620–7. 10.1067/mge.2001.114422
    1. Kim HS, Kim TI, Kim WH, et al. . Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. Am J Gastroenterol 2006;101:1333–41. 10.1111/j.1572-0241.2006.00638.x
    1. Rosen L, Bub DS, Reed JF, et al. . Hemorrhage following colonoscopic polypectomy. Dis Colon Rectum 1993;36:1126–31. 10.1007/BF02052261
    1. Saraya T, Ikematsu H, Fu KI, et al. . Evaluation of complications related to therapeutic colonoscopy using the bipolar snare. Surg Endosc 2012;26:533–40. 10.1007/s00464-011-1914-8
    1. Buddingh KT, Herngreen T, Haringsma J, et al. . Location in the right hemi-colon is an independent risk factor for delayed post-polypectomy hemorrhage: a multi-center case-control study. Am J Gastroenterol 2011;106:1119–24. 10.1038/ajg.2010.507
    1. Rutter MD, Chilton A. Quality Assurance Guidelines for Colonoscopy. NHS BCSP Publication, 2011;6:24.
    1. Cotton PB, Eisen GM, Aabakken L, et al. . A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010;71:446–54. 10.1016/j.gie.2009.10.027

Source: PubMed

3
Sottoscrivi