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Performance Measures for Upper Gastrointestinal Endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

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Performance Measures for Upper Gastrointestinal Endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative Guideline Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative Authors Raf Bisschops1, Miguel Areia2,3, Emmanuel Coron4, Daniela Dobru5, Bernd Kaskas6, Roman Kuvaev7, Oliver Pech8, Krish Ragunath9, Bas Weusten10, Pietro Familiari11, Dirk Domagk12, Roland Valori13, Michal F. Kaminski14, 15, Cristiano Spada11, Michael Bretthauer14, 16, Cathy Bennett17, Carlo Senore18, Mário Dinis-Ribeiro3,19, Matthew D. Rutter20,21 Institutions Institutions are listed at end of article. Bibliography Abbreviations rate, and interval cancers, among others) have DOI http://dx.doi.org/ ! been identified over the last decade [2,3]. Follow- 10.1055/s-0042-113128 CI confidence interval ing the Quality in UGI Endoscopy meeting held in Published online: 22.8.2016 EAC early adenocarcinoma Lisbon in 2013, it was clear that there was a need Endoscopy 2016; 48: 843–864 © Georg Thieme Verlag KG EMR endoscopic mucosal resection to identify performance measures for the UGI Stuttgart · New York ENT ear, nose, and throat tract, and that quality standards could be identi- ISSN 0013-726X ESGE European Society of Gastrointestinal fied although there is a paucity of evidence. This Endoscopy lack of evidence helps however to identify re- Corresponding author Raf Bisschops FAP familial adenomatous polyposis search priorities for the development of clinical Department of GAVE gastric antral vascular ectasia trials that will further validate and substantiate Gastroenterology and HGD high grade dysplasia the implementation of performance measures. Hepatology LGD low grade dysplasia The aim therefore of the UGI working group was University Hospital Leuven, KU MAPS Management of precancerous condi- twofold: (1) to identify performance measures Leuven tions and lesions in the stomach for UGI endoscopy; (2) to identify the evidence Herestraat 49 OLGA Operative Link for Gastritis Assessment or absence of evidence that would develop the re- 3000 Leuven, OLGIM Operative Link on Gastric Intestinal search priorities in this field. Belgium Fax: +32-16-344225 Metaplasia We used an innovative methodology to facilitate [email protected] OR odds ratio the quality initiative process, which combined a PEG percutaneous endoscopic gastrostomy thorough search and standardized evaluation of PICO population/patient; intervention/indi- the available evidence for each clinical question, This article is published cator; comparator/control; outcome followed by a Delphi process (http://is.njit.edu/ simultaneously in the journals PPI proton pump inhibitor pubs/delphibook/delphibook.pdf. Accessed: July Endoscopy and the United QIC Quality improvement committee 2016) using an online platform [4,5]. This online European Gastroenterology SCC squamous cell cancer platform permitted iterative rounds of modifica- Journal. Copyright 2016 © Georg Thieme Verlag KG UEG United European Gastroenterology tion and comment by all members of the UGI and © by the United European UGI upper gastrointestinal tract working group until agreement was reached on Gastroenterology the performance measure. We now report these newly identified performance measures. Introduction ! The European Society of Gastrointestinal Endos- Methodology copy (ESGE) and United European Gastroenterol- ! ogy (UEG) have identified quality of endoscopy as We previously described the multistep process for a major priority and we described our rationale the methodology to develop performance meas- for this in a first manuscript that also addressed ures [1]. Briefly, following the Lisbon meeting in the methodology of the quality initiative process 2013, a list of 56 possible performance measures [1]. was distributed to all of the working group mem- The identification of upper gastrointestinal (UGI) bers for comments, suggestions, and shortcomings performance measures presents a considerable in September 2014. Every participant was requir- challenge, in contrast to the situation with colo- ed to comment on all of the proposed performance noscopy for instance, where several performance measures during teleconferences that took place measures (inspection time, adenoma detection between October 1st and December 18th 2014. Bisschops Raf et al. Performance measures for UGI endoscopy… Endoscopy 2016; 48 Guideline All possible performance measures that were identified by this able evidence, along with details of how the score should be process were structured using the PICO framework (where P measured and the desired threshold. stands for Population/Patient; I for Intervention/Indicator; C for During the Delphi process, the Quality Improvement Committee Comparator/Control; and O for Outcome) to inform searches for (QIC) chairs distinguished key performance measures from minor available evidence to support the performance measures. This performance measures to assist service providers with decisions process resulted in 67 possible performance measures and 108 about the implementation of performance measures in their PICOs. endoscopy services. Reasons to qualify a performance measure as Because of the timeframe for this first initiative and the wide minor included the measure being very disease specific (e.g. de- range of pathology in the UGI tract, the working group had to tection of neoplasia during surveillance of Barrett’s esophagus or prioritize general UGI endoscopy topics within the abundance of gastric intestinal metaplasia) or that its implementation might be proposed performance measures and PICOs. As part of this prior- relatively difficult and dependent on the availability of adequate itization, PICOs that were concerned with areas where guidelines software for auditing of the performance measures. The division were already available or under development were omitted. We and allocation of performance measures to key and minor per- also excluded PICOs that focused on: the assessment of effective- formance measures was agreed by the UGI working group in an ness, or comparative effectiveness, of specific treatments (e.g. ad- additional face-to-face meeting in April 2016. ministration of proton pump inhibitors [PPIs] before endoscopy The number of cases that need to be audited to adequately assess for acute bleeding, percentage of patients undergoing endoscopic if the threshold for a certain performance measure is reached can resection in Barrett’s esophagus with high grade dysplasia [HGD] be calculated by estimating the 95 % confidence intervals (CI) for before ablation); legal or local regulation (informed consent); a predefined threshold and variable sample size (see Appendix 1). histopathology (e.g. the need for confirmation/revision of a diag- For reasons of practicality and feasibility when implementing an nosis of dysplasia by an independent pathologist); and service audit, the working group agreed that 100 procedures (or all, if< working group issues (e.g. adequate management of anticoagu- 100 procedures had been performed) should be measured to as- lants, sedation, etc.). sess the performance measure. Ideally this should be done at an The initial priority list was developed during a face-to-face meet- individual procedure level but, as this requires robust and sophis- ing on February 14th 2015. In total, 44 PICOs were retained as the ticated software, we suggest that the assessment is first per- basis for literature searches. Several disease-specific performance formed at a service level. If problems are detected at a service lev- measures were also developed (Barrett’s esophagus, intestinal el, further analysis at an individual level is then required to iden- metaplasia in the stomach, and squamous cell cancer [SCC] in tify possible targets for improvement. the esophagus). The PICOs and the clinical statements derived from these, which were organized into eight domains on the basis of their clinical Performance measures for upper gastrointestinal applications, were adapted and/or excluded during the iterative endoscopy rounds of comments and suggestions from the working group ! members during the Delphi process. The evolution and adapta- In the first round of development, the working group accepted 11 tion of the different PICOs and clinical statements during the Del- performance measures in total, after a total of four voting rounds phi process can be reviewed in Supporting Information. In total, in the modified Delphi process. The evidence quality (assessed working group members participated in four rounds of voting to using the GRADE criteria [6]) for most of these performance agree on the performance measures in predefined domains and measures is low; however, this does not indicate that a perform- their respective thresholds, which are discussed below. The ance measure is not important. agreement that is given for the different statements refers to the Taking into account both the feasibility of implementation and last voting round in the Delphi process. A statement was accep- the possible impact on diagnostic quality and patient outcome, ted if at least 80% agreement was reached after a minimum of we identified six key and five minor performance measures two voting rounds. (●" Table 1;●" Fig.1). Nevertheless, all the performance measures The performance measures are displayed in boxes under the rel- were deemed valuable by the working group members and were evant domain. Each box describes the performance measure and obtained after a rigorous process, as described above. From a the rationale behind its adoption, the agreement
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