Screening Colonoscopy

Quality Indicators

New York City Department of Health and Mental Hygiene

New York Citywide Colon Cancer Control Coalition

About This Presentation

• Target Audience

Gastroenterologists and residents

Allied health professionals specializing in endoscopy

• Objectives

Engage physicians and staff in a conversation about

evidence-based metrics for the quality of screening

colonoscopies

Illustrate the link between evidence-based measures

and reducing colorectal cancer (CRC) mobility and

mortality

Indicators of a High Quality Screening

Colonoscopy Program

• Preparation

Adequate bowel preparation rate ≥ 85%

• Procedure

Adenoma Detection Rate (ADR) ≥ 25%

≥ 30% in men

≥ 20% in women

Cecal intubation with photography rate

≥ 95%

• Follow-up

Interval between screening

colonoscopies is 10 years after a

normal examinationRex DK, et al. Gastrointestinal Endoscopy. 81:31-53. 2015.

Colonoscopy-Specific Value-Based Payment

Quality Metrics

Centers for Medicare and Medicaid

Services. Quality Measures. 2017;

https://qpp.cms.gov/mips/quality-

measures

Importance of Adequate Bowel Preparation

Rates

• Adequate bowel prep is a quality metric.

U.S. Multi-Society Task Force-endorsed quality metric

Value-based payment metric

• Optimal preparation results in:

Better detection of small polyps, large adenomas and flat lesions

More efficient examinations

Reduced repeat colonoscopies

• Suboptimal preparation results in:

Increased cost

Loss of follow-up

Johnson DA, et al. Gastrointestinal Endoscopy. 80:543-562. 2014.

Rex DK. Nature Reviews Gastroenterology & Hepatology.11:419-425. 2014.

Optimal vs. Suboptimal Bowel Preparation

Optimal Preparation Suboptimal Preparation

Photos courtesy of Benjamin Lebwohl, MD

Adequate Bowel Preparation Rates:

Split-Dose Bowel Preparation

• Using a split-dose bowel cleansing regimen is strongly

recommended for elective colonoscopy

Strong recommendation based on high-quality evidence

• The second dose of split preparation should ideally begin four to six

hours before time of colonoscopy, with completion of last dose two

hours before procedure

Strong recommendation based on moderate-quality evidence

• Split-dose bowel cleansing is associated with greater willingness to

repeat regimen compared with the day before regimen

Strong recommendation based on high-quality evidence

Johnson DA, et al. Gastrointestinal Endoscopy. 80:543-562. 2014.

Enestvedt BK, et al. Clinical Gastroenterology and Hepatology. 10:1225-1231. 2012.

Martel M, et al. Gastroenterology. 149:79-88.

Unger RZ, et al. Digestive Diseases and Sciences. 55:2030-2034. 2010.

Split-Dose Bowel Preparation

Improves Bowel Preparation Quality

Aoun E, et al. Gastrointestinal Endoscopy. 62:213-218. 2005.

Group A – Received Whole-dose PEG-E Solution

Group B – Received Split-dose dose PEG-E Solution

Adherence With Split-Dose Bowel

Preparation

• Survey of potential colonoscopy

patients (n = 300)

Majority (85%) stated they

would be willing to get up during

the night to take the second

dose of preparation

• Observation of patients scheduled

for early morning colonoscopy

(n = 107 scheduled for 7 to 9 a.m.)

78% actually got up during the

night for the second doseUnger RZ, et al. Digestive Diseases and Sciences. 55:2030-2034. 2010.

Split-Dose Bowel Cleansing Improves

Bowel Preparation Quality

Unger RZ, et al. Digestive Diseases and Sciences. 55:2030-2034. 2010.

Adequate Bowel Preparation Rates:

Split-Dose Bowel Cleansing

“Given the level of evidence supporting split dosing, and

same-day dosing and its endorsement in screening

guidelines, in my opinion, it's reasonable to ask whether

endoscopists who continue with administering all

doses the day before colonoscopy are serious about

detecting pre-cancerous lesions during colonoscopy.”

Rex DK. Nature Reviews Gastroenterology & Hepatology. 11:419-425. 2014.

Adenoma Detection Rates

• Physician adenoma

detection rate (ADR) is

inversely related to the

risk of interval colorectal

cancer

– Each 1% increase in

physician ADR was

associated with 3%

decrease in patient CRC

risk and 4% decrease in

CRC deaths

Corley DA, et al. New England Journal of Medicine. 370:1298-1306. 2014.

Adenoma Detection Rates and CRC

Corley DA, et al. New England Journal of Medicine. 370:1298-1306. 2014.

Cecal Intubation With

Photo Documentation Rate

• Cecal intubation: the proportion of colonoscopies in

which the cecum is reached

• Benchmark is met if cecum is reached in ≥ 95% of

screening colonoscopies (or ≥ 90% of all colonoscopies)

• Lack of cecal intubation indicates that a portion of the

colon has not been examined

• Low cecal intubation rates have been associated with an

increased risk of post-colonoscopy CRC

Baxter NN, et al. Gastroenterology. 140:65-72. 2011.

Cecal Intubation and CRC

Baxter NN, et al. Gastroenterology. 140:65-72. 2011.

Colonoscopy Follow-Up Intervals

• High-quality colon cancer prevention requires that

colonoscopies are implemented appropriately

• Colonoscopies can be overused:

Recommending a repeat colonoscopy in < 10 years in

average-risk individuals after a normal examination

• Colonoscopies can be underused:

Low screening rates in uninsured populations

Lack of timely surveillance examinations in high-risk

individuals

Sheffield KM, et al. JAMA Internal Medicine. 173:542-550. 2013.

Schoen RE, et al. Gastroenterology. 138:73-81. 2010.

Overuse of Screening Colonoscopies

Sheffield KM, et al. JAMA Internal Medicine. 173:542-550. 2013.

Underuse of Surveillance Colonoscopies

Schoen RE, et al. Gastroenterology. 138:73-81. 2010.

Conclusions

• Adequate bowel preparation is

critical for high-quality colonoscopy.

Split-dose preparation preferred

• Higher adenoma detection rate is

associated with protection against

colon cancer.

• Cecal intubation is required for full

colonoscopic evaluation.

• Evidence-based follow-up intervals

are important.

References

1. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy.

Gastrointestinal Endoscopy. 2015;81(1):31-53.

2. Centers for Medicare and Medicaid Services. Quality Measures. 2017;

https://qpp.cms.gov/mips/quality-measures.

3. Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing

for colonoscopy: recommendations from the U.S. multi-society task force on

colorectal cancer. Gastrointestinal Endoscopy. 2014;80(4):543-562.

4. Rex DK. Optimal bowel preparation--a practical guide for clinicians. Nature Reviews

Gastroenterology & Hepatology. 2014;11(7):419-425.

5. Enestvedt BK, Tofani C, Laine LA, Tierney A, Fennerty MB. 4-Liter split-dose

polyethylene glycol is superior to other bowel preparations, based on systematic

review and meta-analysis. Clinical Gastroenterology and Hepatology.

2012;10(11):1225-1231.

6. Martel M, Barkun AN, Menard C, Restellini S, Kherad O, Vanasse A. Split-Dose

Preparations Are Superior to Day-Before Bowel Cleansing Regimens: A Meta-

analysis. Gastroenterology.149(1):79-88.

References

7. Unger RZ, Amstutz SP, Seo DH, Huffman M, Rex DK. Willingness to undergo split-

dose bowel preparation for colonoscopy and compliance with split-dose instructions.

Digestive Diseases and Sciences. 2010;55(7):2030-2034.

8. Aoun E, Abdul-Baki H, Azar C, et al. A randomized single-blind trial of split-dose PEG-

electrolyte solution without dietary restriction compared with whole dose PEG-

electrolyte solution with dietary restriction for colonoscopy preparation.

Gastrointestinal Endoscopy. 2005;62(2):213-218.

9. Corley DA, Jensen CD, Marks AR, et al. Adenoma Detection Rate and Risk of

Colorectal Cancer and Death. New England Journal of Medicine. 2014;370(14):1298-

1306.

10. Baxter NN, Sutradhar R, Forbes SS, Paszat LF, Saskin R, Rabeneck L. Analysis of

Administrative Data Finds Endoscopist Quality Measures Associated With

Postcolonoscopy Colorectal Cancer. Gastroenterology. 2011;140(1):65-72.

11. Sheffield KM, Han Y, Kuo Y, Riall TS, Goodwin JS. Potentially inappropriate screening

colonoscopy in Medicare patients: Variation by physician and geographic region.

JAMA Internal Medicine. 2013;173(7):542-550.

12. Schoen RE, Pinsky PF, Weissfeld JL, et al. Utilization of surveillance colonoscopy in

community practice. Gastroenterology. 2010;138(1):73-81.

Additional Readings

1. Goodwin JS, Singh A, Reddy N, Riall TS, Kuo YF. Overuse of screening colonoscopy

in the Medicare population. Archives of internal medicine. 2011;171(15):1335-1343.

2. Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR.

Guidelines for colonoscopy surveillance after screening and polypectomy: a

consensus update by the US Multi-Society Task Force on Colorectal Cancer.

Gastroenterology. 2012;143(3):844-857.

3. Saini SD, Nayak RS, Kuhn L, Schoenfeld P. Why don't gastroenterologists follow

colon polyp surveillance guidelines?: results of a national survey. Journal of Clinical

Gastroenterology. 2009;43(6):554-558.

4. Stock C, Holleczek B, Hoffmeister M, Stolz T, Stegmaier C, Brenner H. Adherence to

Physician Recommendations for Surveillance in Opportunistic Colorectal Cancer

Screening: The Necessity of Organized Surveillance. PLOS ONE.

2013;8(12):e82676.