Gut Online First, published on October 8, 2016 as 10.1136/gutjnl-2016-312043 Recent advances in clinical practice Expert opinions and scientific evidence for colonoscopy key performance indicators Gut: first published as 10.1136/gutjnl-2016-312043 on 8 October 2016. Downloaded from Colin J Rees,1 Roisin Bevan,2 Katharina Zimmermann-Fraedrich,3 Matthew D Rutter,2 Douglas Rex,4 Evelien Dekker,5 Thierry Ponchon,6 Michael Bretthauer,7 Jaroslaw Regula,8 Brian Saunders,9 Cesare Hassan,10 Michael J Bourke,11 Thomas Rösch3 ▸ Additional material is ABSTRACT While colonoscopy can detect CRC and prevent it published online only. To view Colonoscopy is a widely performed procedure with by removal of adenomas,12 it can also lead to please visit the journal online procedural volumes increasing annually throughout the serious complications and quality measures should (http://dx.doi.org/10.1136/ 13–16 gutjnl-2016-312043). world. Many procedures are now performed as part of ensure that these are minimised. Additionally, fi colorectal cancer screening programmes. Colonoscopy poor quality colonoscopy is associated with For numbered af liations see 17 18 end of article. should be of high quality and measures of this quality increased rates of interval cancers. A major should be evidence based. New UK key performance challenge is to deliver high quality colonoscopy in Correspondence to indicators and quality assurance standards have been the setting of ever-increasing demand and activity. Professor Colin J Rees, developed by a working group with consensus England has seen a 20% increase in colonoscopy Department of agreement on each standard reached. This paper reviews activity over the last 5 years with 360 000 proce- Gastroenterology, South 19 Tyneside District Hospital, the scientific basis for each of the quality measures dures performed annually. In the USA, 14 million South Shields NE34 0PL, UK; published in the UK standards. colonoscopies are performed per year,20 with a sig- [email protected] nificant percentage being primary screening colon- oscopies as opposed to colonoscopies performed Received 12 April 2016 Revised 8 September 2016 INTRODUCTION after positive FOBT screening in countries such as Accepted 11 September 2016 Colonoscopy is a widely performed procedure for in the UK. Added pressures of new screening pro- fi patients with lower GI symptoms and is an integral grammes have involved a signi cant increase in part of all colorectal cancer (CRC) screening pro- workload in the UK and throughout the 12122 grammes, either primarily or secondarily following world. positive stool tests or other colonic imaging. There A major variable for assessing quality of all col- is evidence from randomised trials that faecal onoscopy is the rate of interval cancers. For screen- occult blood tests (guaiac faecal occult blood ing colonoscopy this is the most important marker – http://gut.bmj.com/ testing (FOBT)) and sigmoidoscopy1 4 reduce CRC of quality. Interval cancers may occur in individuals mortality in screening, but there is currently no evi- screened by another modality such as FOBT, there- dence from randomised trials for screening colon- fore in order to differentiate interval cancers in – oscopy.5 7 Results from trials are expected in the patients who have undergone colonoscopy and 2020s. those screened by another means, the term postco- It is fundamentally important that colonoscopy lonoscopy colorectal cancer (PCCRC) has been 23 procedures are of the highest possible quality and developed. PCCRC rates will become the gold on September 29, 2021 by guest. Protected copyright. that measures of quality are based upon evidence. standard in studies assessing surrogate quality vari- Widely used quality measures include caecal intub- ables such as ADR (the rate of procedures where at ation and adenoma detection rates (ADR) and these least one adenoma was detected). The term should be evaluated alongside other measures of PCCRC has been used in this review where that is quality. New UK key performance indicators (KPI) the measure reported in a study but the term inter- and quality assurance (QA) standards for colonos- val cancer has been used where the data do not fi copy have been developed by the British Society speci cally report postprocedural cancers. of Gastroenterology (BSG), the Joint Advisory Group for GI Endoscopy and the Association of METHODS Coloproctology of Great Britain and Ireland and In this paper, we review the importance of each of are published in this edition of Gut.8 The evidence the UK KPI and QA standards and the evidence presented in this review paper is taken from the behind them. The aim of this paper is to provide development of these guidelines and from data supporting evidence for these new indicators and review performed for the recently published standards, and to demonstrate the value and German guidelines on quality standards in GI importance of each of the measures. Each measure endoscopy.9 While colonoscopy is crucial in the is addressed in turn including caecal intubation rate detection and prevention of CRC, this will only be (CIR), ADR, bowel preparation, rectal retroflexion, the case if procedures are performed to high stan- withdrawal time, sedation practice and comfort To cite: Rees CJ, Bevan R, dards. In the UK, a 2012 national audit10 demon- levels, annual procedure volumes, polyp retrieval Zimmermann-Fraedrich K, fi et al. Gut Published Online strated a signi cant improvement in colonoscopy rate (PRR), management of suspected malignant First: [please include Day completion rates when compared with a previous lesions including tattooing of lesions, follow-up Month Year] doi:10.1136/ 1999 audit, it also showed that wide variation still recommendations and adherence, diagnostic biopsy gutjnl-2016-312043 existed between centres and endoscopists.10 11 rate, PCCRC rate and adverse event rates. Rees CJ, et al. Gut 2016;0:1–16. doi:10.1136/gutjnl-2016-312043 1 Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& BSG) under licence. Recent advances in clinical practice It should be borne in mind that much of the data on colonos- large series demonstrate that caecal intubation rates >90% can copy quality have been derived from the screening setting, and be readily achieved. The American Society for GI Endoscopy Gut: first published as 10.1136/gutjnl-2016-312043 on 8 October 2016. Downloaded from may not be automatically transferrable to diagnostic colonoscopy. (ASGE)/American College of Gastroenterology (ACG) taskforce The UK standards8 were developed by a working group where for colonoscopy sets a similar standard for diagnostic proce- individuals were tasked with reviewing evidence in each area and dures.28 A CIR of 95% is recommended by the European then standards agreed by consensus of all working group stake- Society of GI Endoscopy (ESGE) and the ASGE/ACG for screen- holders. The balance was often struck between available evidence ing colonoscopies.28 39 Reporting of caecal intubation rates may and expert opinion and pragmatism. The German standards9 be presented in a non-adjusted form based upon CIR in all were also developed by a working group forming a consensus on patients where the intention was to reach the caecum, or be the standards. adjusted for factors such as impassable strictures and poor It is important that a systematic approach is developed bowel preparation. Different studies adjust for different factors regarding the implementation and monitoring of standards. and this must be borne in mind when comparing different – Endoscopy programmes and units have the responsibility for studies (see online supplementary table S2).31 32 40 46 It may be QA and they should develop QA strategies for investigating and assumed that in the screening setting (as opposed to the symp- monitoring potential underperformance. Graphical representa- tomatic service), a lower rate of poorly prepared colons and tion, for example in the form of funnel plots,24 allows evalu- strictures will be found, therefore the recommended higher rate ation of performance around a mean and helps measure for screening versus diagnostic colonoscopy (95% vs 90%) performance where the numbers of procedures vary and where seems to be justified. The European Union (EU) guidelines on some individuals may be performing low numbers of proce- the quality of colonoscopy as part of CRC screening demand a dures. Where performance appears to fall below agreed stan- minimum CIR of at least 90%, and suggest a rate of 95% is dards then investigation should ensure that confounders such as desirable.23 case mix, age and gender of patients are taken into consider- Regarding documentation of caecal intubation, the EU guide- ation. In addition, the nature of procedures should be consid- lines47 recommend ‘auditable photodocumentation of comple- ered, for example, complications maybe higher where advanced tion’, as do American guidelines,26 but reported practice varies therapy is undertaken. Monitoring of quality should be a con- from 50% in the UK10 to 70%–99% in other parts of tinuous process and early identification of deteriorating per- Europe.48 49 The reliability of photodocumentation of the formance prior to individuals falling below lower confidence caecum in demonstrating completion has been questioned with limits is preferable. Where true underperformance is identified, ileal photodocumentation advocated as more accurate.50 Biopsy however, strategies to address this should be put in place. of the ileum may additionally be useful in confirming comple- tion but can be technically difficult, comes with extra costs and THE STANDARDS has some associated risks, so it is not recommended as a stand- – Caecal intubation rate ard of practice.51 53 CIR is the most frequently used indicator of colonoscopy – quality.25 28 It is self-evident that complete examination of the Adenoma detection rate large bowel is essential to detect abnormalities,29 30 however, Most CRCs develop through the adenoma-carcinoma sequence.54 http://gut.bmj.com/ CIR varies as demonstrated in a number of studies.11 31 32 Detection and removal of these adenomas therefore reduces CRC Although CRCs are more commonly found in the distal colon risk.