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Gastrointest Endosc. Author manuscript; available in PMC 2017 October 04. Published in final edited form as: Gastrointest Endosc. 2016 January ; 83(1): 179–181. doi:10.1016/j.gie.2015.06.052.

What makes a “good” colonoscopy quality indicator? Jeffrey K. Lee, MD, MAS and Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA

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Douglas A. Corley, MD, PhD Department of Medicine, Division of Gastroenterology, University of California San Francisco, San Francisco, California, Division of Research, Kaiser Permanente Northern California, Oakland, California, USA Colorectal cancer (CRC) is the second-leading cause of cancer-related deaths in the United States.1 In 2014, approximately 136,830 new cases of CRC were diagnosed in the United States, and 50,310 patients will die of this disease.2 Observational studies have shown that colonoscopy reduces CRC incidence and mortality through the detection and removal of adenomatous polyps.3–5

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However, growing evidence suggests that colonoscopy examination quality affects colonoscopy’s effectiveness in reducing CRC incidence and mortality.6,7 The fact that endoscopists miss adenomas has been well documented by tandem colonoscopy studies and CT colonography studies.8 Even endoscopists within the same practice group report up to a sevenfold variation in their adenoma detection rates (ADRs).7 Not surprisingly, most experts presume that at least some interval CRCs are attributable to missed adenomas at the time of the initial colonoscopy.

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The American Society for Gastrointestinal Endoscopy (ASGE) and American College of Gastroenterology (ACG) Task Force on Quality in Endoscopy first published colonoscopy quality indicators in 2006 to potentially improve colonoscopy quality, establish minimum competency standards in performing colonoscopy, and recommend 14 colonoscopy quality indicators for the different phases of the colonoscopy procedure (ie, preprocedure, intraprocedure, and postprocedure).8 Recently, the ASGE/ACG Task Force further increased the number of recommended colonoscopy quality indicators to 15.9 Unfortunately, the proliferation of quality indicators, of unknown marginal benefit, can result in unanticipated consequences. For example, providers and organizations may overinvest measurement resources and improvement dollars in capturing and improving performance on quality indicators linked to reimbursement and bonuses to the detriment of indicators that may be more tightly linked to improved patient outcomes. In anticipation of the continued growth of required quality indicators, establishing guidelines for the development of future quality indicators is critical for patients, physicians, and payers.

DISCLOSURE This work was supported by the American Gastroenterological Association Research Scholar Award (J.K.L.) and grant U54 CA163262 (D.A.C.) from the National Cancer Institute. All authors disclosed no financial relationships relevant to this article.

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The National Quality Forum (NQF), a leading organization for quality indicator endorsement, developed 4 factors that identify a good quality metric: importance, scientific acceptability, feasibility, and usability.10 The first criterion, importance, denotes whether an indicator addresses a critical component in care, affects outcomes, and has room for improvement. The quality indicator must be relevant to a large number of patients, involve a high-risk condition (eg, myocardial infarction or CRC), or in some other way represent a large opportunity for improvement. Scientific acceptability includes the concepts of reliability and validity. Reliability means the indicator gives the same result on repeated measures, and validity implies that the indicator measures what it is intended to measure. The third criterion, feasibility, measures whether quality data can be obtained without undue burden. Difficult-to-obtain data, such as those requiring extensive manual data collection from medical records, must be extremely valuable; otherwise, they will result in misspent resources. Last, usability refers to how the results of the quality indicator can be applied to improve care. Data from any quality indicator must be understood by the intended audience (eg, patients, providers, and payers).

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The ADR is an excellent example of a “good” colonoscopy quality indicator based on the NQF’s 4 factors. The ADR is defined as the proportion of screening colonoscopies in which 1 or more adenoma is found.9

Importance

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A Polish group first highlighted ADR in 2010 as an important quality indicator for colonoscopy quality by showing that patients whose endoscopists had ADRs 10 times higher than patients whose endoscopists had ADRs ≥20%.6 Last year, its importance was further emphasized with a demonstration of its inverse association with interval CRC risk and mortality in a U.S. population-based cohort study: for every 1% increase in a physician’s ADR, there was a corresponding 3% and 4% decrease in their patients’ CRC risk and mortality, respectively.7

Scientific acceptability An ADR for screening examinations, particularly when an examination indication is assigned before the procedure is performed, is both a reliable and valid measure and is likely less corruptible than the polyp detection rate because it requires an independent pathologist to confirm the adenoma diagnosis.

Feasibility Author Manuscript

Although measuring the ADR may be challenging due to the need to electronically capture or manually enter pathology data post-procedure, several practice groups have demonstrated its feasibility in real-life practice. In fact, screening ADRs are now widely reported on GI practice websites nationwide. In addition, to eliminate the burden of manual chart review, 5 different groups have successfully used natural language processing or electronic algorithms to extract and calculate ADRs efficiently.11–15

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Usability The evidence for ADR is so pervasive that it has now become increasingly accepted by patients, physicians, and even payers. Just recently, a patient inquired about my ADR before her screening colonoscopy, prompting many of my colleagues to calculate their own ADRs. The Centers for Medicare and Medicaid Services have also included ADR in its list of 2014 Physician Quality Reporting System measures, resulting in financial implications for reimbursement and bonuses. Finally, to address the significant variation in endoscopists’ ADRs within the same practice groups, several studies have developed endoscopist education and training tools for colonoscopy quality improvement projects.16,17

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In this issue of Gastrointestinal Endoscopy, Sanaka and colleagues18 examined whether physicians’ ADRs from high-risk patients (ie, personal history of polyps/adenomas, family history of CRC or polyps) differed from average-risk patients. In a total population of 4141 patients, physicians’ overall and proximal ADRs for high-risk patients were higher compared with average-risk patients screened among a multispecialty group of clinicians. Moreover, the surveillance ADRs (ie, personal history of polyps/adenomas) were 37.1% for male patients and 28.5% for female patients, whereas the screening ADRs were 30.7% for male patients and 20.1% for female patients. Based on their findings, Sanaka et al concluded that defining a minimum target surveillance ADR for high-risk individuals deserves particular attention and suggested that this could serve as a new colonoscopy quality indicator. Would surveillance ADR be a “good” additional colonoscopy quality indicator? We should carefully assess surveillance ADR by using the NQF’s criteria.

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Importance Surveillance is critical for CRC prevention and is the most common indication for colonoscopy according to the Clinical Outcomes Research Initiative database.19 However, no studies to date have demonstrated a clear association between surveillance ADR and the risk of interval CRC, nor identified an optimal ADR threshold.

Scientific acceptability Similar to screening ADR, surveillance ADR is likely both reliable and valid.

Feasibility Author Manuscript

Surveillance ADR may be challenging to calculate if there are no records of previous pathology confirming the surveillance indication. As seen in this study, the authors could not confirm whether every patient with a history of polyps truly had an adenoma.

Usability Although surveillance ADR is easily understood by physicians, to justify the work of reporting surveillance ADR as an additional discrete quality metric, surveillance ADR

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should probably be shown to have an additive value independent of screening ADR. To date, surveillance ADR utility compared with screening ADR remains unclear. However, 2 studies recently showed a very strong correlation between screening ADRs and surveillance ADRs (R = 0.72–0.77).7,20 In addition, Ussui et al have shown consistent and durable improvement in both screening and surveillance ADRs of low-performing endoscopists who underwent an intense endoscopic education and training intervention.17 Therefore, given this high correlation between screening and surveillance ADRs and its likelihood of only providing a marginal benefit, measuring surveillance ADR as a separate quality indicator may not be necessary at this time.

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In summary, the study by Sanaka et al18 provides important knowledge on surveillance ADRs compared with screening ADRs, but raises questions regarding when to include something as a separate quality metric. Given the high level of correlation between screening and surveillance ADRs, efforts that improve one may be likely to improve the other and perhaps influence interval CRC rates. Colonoscopy quality indicators are important for providing better care and value to our patients and the health care system, but we should justify the effort required for each new metric. Factors such as importance, validity, feasibility, and usability should guide decisions about indicator selection. The current article18 provides important information for researchers and clinicians regarding the expected values for ADR among surveillance patients, but further work is needed to determine whether ADR for surveillance colonoscopy is needed as an additional quality metric.

Abbreviations Author Manuscript

ACG

American College of Gastroenterology

ADR

adenoma detection rate

ASGE

American Society for Gastrointestinal Endoscopy

CRC

colorectal cancer

NQF

National Quality Forum

References

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1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013; 63:11–30. [PubMed: 23335087] 2. American Cancer Society. Cancer facts & figures 2014. Atlanta (Ga): American Cancer Society; 2014. 3. Zauber AG, Winawer SJ, O’Brien, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012; 366:687–96. [PubMed: 22356322] 4. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993; 329:1977–81. [PubMed: 8247072] 5. Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal cancer incidence and mortality after lower endoscopy. N Engl J Med. 2013; 369:1095–105. [PubMed: 24047059] 6. Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010; 362:1795–803. [PubMed: 20463339]

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7. Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014; 370:1298–306. [PubMed: 24693890] 8. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2006; 63:S16–28. [PubMed: 16564908] 9. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc. 2015; 81:31–53. [PubMed: 25480100] 10. National Quality Forum. [Accessed June 10, 2015] 2013 National Quality Forum Measure Evaluation Criteria. 2013. Available at: http://www.qualityforum.org 11. Mehrotra A, Dellon ES, Schoen RE, et al. Applying a natural language processing tool to electronic health records to assess performance on colonoscopy quality measures. Gastrointest Endosc. 2012; 75:1233–9. [PubMed: 22482913] 12. Imler TD, Morea J, Kahi C, et al. Multi-center colonoscopy quality measurement utilizing natural language processing. Am J Gastroenterol. 2015; 110:543–52. [PubMed: 25756240] 13. Raju GS, Lum PJ, Slack RS, et al. Natural language processing as an alternative to manual reporting of colonoscopy quality metrics. Gastrointest Endosc. 2015; 82:512–9. [PubMed: 25910665] 14. Gawron AJ, Thompson WK, Keswani RN, et al. Anatomic and advanced adenoma detection rates as quality metrics determined via natural language processing. Am J Gastroenterol. 2014; 109:1844–9. [PubMed: 24935271] 15. Lee JK, Jensen CD, Lee A, et al. Development and validation of an algorithm for classifying colonoscopy indication. Gastrointest Endosc. 2015; 81:575–82. [PubMed: 25577596] 16. Coe SG, Crook JE, Diehl NN, et al. An endoscopic quality improvement program improves detection of colorectal adenomas. Am J Gastroenterol. 2013; 108:219–26. [PubMed: 23295274] 17. Ussui V, Coe S, Rizk C, et al. Stability of increased adenoma detection at colonoscopy. Follow-up of an endoscopic quality improvement program-EQUIP-II. Am J Gastroenterol. 2015; 110:489–96. [PubMed: 25267326] 18. Sanaka MR, Rai T, Navaneethan U, et al. Adenoma detection rate in high-risk patients differs from that in average-risk patients. Gastrointest Endosc. 2016; 83:172–8. [PubMed: 26024584] 19. Lieberman DA, Holub J, Eisen G, et al. Utilization of colonoscopy in the United States from a national consortium. Gastrointest Endosc. 2005; 62:875–83. [PubMed: 16301030] 20. Kahi CJ, Vemulapalli KC, Johnson CS, et al. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience. Gastrointest Endosc. 2014; 79:448–54. [PubMed: 24246797]

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What makes a "good" colonoscopy quality indicator?

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