Sustained colonoscopy quality improvement using a simple intervention bundle

Abstract

Background Unacceptable variation in colonoscopy quality exists. The Quality Improvement in Colonoscopy (QIC) study in 2011 improved quality by introducing an evidence-based “bundle” of measures into routine colonoscopy practice. The QIC bundle included: minimal cecal withdrawal time of ≥ 6 minutes; hyoscine butylbromide use; supine patient position for transverse colon examination; rectal retroflexion. Colonoscopy quality was measured by adenoma detection rate (ADR). The current study measured whether these effects led to a sustained change in practice 3 years following implementation.

Methods This observational study collected data from eight hospital trusts (sites) in the United Kingdom for a 6-month period, 3 years following QIC bundle implementation. Use of the antispasmodic, hyoscine butylbromide, was measured as a marker of bundle uptake. Bundle effectiveness was measured by ADR change. Comparisons were made between data before and immediately after implementation of the bundle.

Results 28 615 colonoscopies by 188 colonoscopists were studied. Hyoscine butylbromide use increased from 15.8 % pre-implementation to 47.4 % in the sustainability phase (P < 0.01) indicating sustained engagement with QIC measures. ADR was higher in the sustainability period compared with pre-intervention, but only reached statistical significance among the poorest-performing colonoscopists.

Conclusions The introduction of a simple, inexpensive, pragmatic intervention significantly changed practice over a sustained period, improving colonoscopy quality as measured by ADR, particularly in poorer performers. QIC demonstrates that an easy-to-implement quality improvement approach can deliver a sustained change in practice for many years post intervention.

Publikationsverlauf

Eingereicht: 11. September 2018

Angenommen: 16. Dezember 2019

Artikel online veröffentlicht:
02. März 2020

• References

• 1 Shenbagaraj L, Thomas-Gibson S, Stebbing J. et al. Endoscopy in 2017: a national survey of practice in the UK. Frontline Gastroenterol 2019; 10: 7-15
• 2 Joseph DA, Meester RG, Zauber AG. et al. Colorectal cancer screening: estimated future colonoscopy need and current volume and capacity. Cancer 2016; 122: 2479-2486
• 3 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: 277-283
• 4 Gavin DR, Valori RM, Anderson JT. et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
• 5 Rees CJ, Gibson ST, Rutter MD. et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut 2016; 65: 1923-1929
• 6 Rees CJ, Bevan R, Zimmermann-Fraedrich K. et al. Expert opinions and scientific evidence for colonoscopy key performance indicators. Gut 2016; 65: 2045-2060
• 7 Rex DK, Petrini JL, Baron TH. et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006; 101: 873-885
• 8 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 9 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
• 10 Kaminski M, Wieszczy P, Rupinski M. et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology 2017; 153: 98-105
• 11 Corley DA, Jensen CD, Marks AR. Can we improve adenoma detection rates? A systematic review of intervention studies. Gastrointest Endosc 2011; 74: 656-665
• 12 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: 1091-1098
• 13 Wallace MB, Crook JE, Thomas CS. et al. Effect of an endoscopic quality improvement program on adenoma detection rates: a multicenter cluster-randomized controlled trial in a clinical practice setting (EQUIP-3). Gastrointest Endosc 2017; 85: 538-545.e4
• 14 Rajasekhar PT, Rees CJ, Nixon C. et al. Factors influencing change in clinical practice: a qualitative evaluation of the implementation of the quality improvement in colonoscopy study. Int J Health Care Qual Assur 2016; 29: 5-15
• 15 Pronovost P, Needham D, Berenholtz S. et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355: 2725-2732
• 16 Rajasekhar PT, Rees CJ, Bramble MG. et al. A multicenter pragmatic study of an evidence-based intervention to improve adenoma detection: the Quality Improvement in Colonoscopy (QIC) study. Endoscopy 2015; 47: 217-224
• 17 Rajasekhar P, Rees C, Rutter M. et al. Developing a clinical research network: The Northern Region Endoscopy Group experience. Clin Med (Lond) 2014; 14: 107-112
• 18 East J, Saunders B, Burling D. et al. Mechanisms of hyoscine butylbromide to improve adenoma detection: a case–control study of surface visualization at simulated colonoscope withdrawal. Endosc Int Open 2015; 03: E636-641
• 19 Madhoun MF, Ali T, Tierney WM. et al. Effect of hyoscine N-butylbromide on adenoma detection rate: meta-analysis of randomized clinical trials. Dig Endosc 2015; 27: 354-360
• 20 MHRA safety alert: hyoscine butylbromide (Buscopan) injection. Drug Ther Bull 2017; 55: 51
• 21 Fuccio L, Frazzoni L, Hassan C. et al. Water exchange colonoscopy increases adenoma detection rate: a systematic review with network meta-analysis of randomized controlled studies. Gastrointest Endosc 2018; 88: 589-597.e11
• 22 Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol 2014; 109: 1714-1723
• 23 Cheng YL, Huang KW, Liao WC. et al. Same-day versus split-dose bowel preparation before colonoscopy. J Clin Gastroenterol 2018; 52: 392-400
• 24 Gkolfakis P, Tziatzios G, Dimitriadis GD. et al. New endoscopes and add-on devices to improve colonoscopy performance. World J Gastroenterol 2017; 23: 3784-3796
• 25 Hassan C, Senore C, Radaelli F. et al. Full-spectrum (FUSE) versus standard forward-viewing colonoscopy in an organised colorectal cancer screening programme. Gut 2016; 66: 1949-1955
• 26 Ratone JP, Bories E, Caillol F. et al. Impact of Full Spectrum Endoscopy^® (Fuse^®, EndoChoice^®) on adenoma detection: a prospective French pilot study. Ann Gastroenterol 2017; 30: 512-517
• 27 Facciorusso A, Del Prete V, Buccino V. et al. Full-spectrum versus standard colonoscopy for improving polyp detection rate: a systematic review and meta-analysis. J Gastroenterol Hepatol 2018; 33: 340-346
• 28 Bevan R, Ngu WS, Saunders BP. et al. The ADENOMA Study. Accuracy of detection using Endocuff Vision™ optimization of mucosal abnormalities: study protocol for randomized controlled trial. Endosc Int open 2016; 4: E205-212
• 29 Ngu WS, Bevan R, Tsiamoulos ZP. et al. Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial. Gut 2019; 68: 280-288
• 30 Tsiamoulos ZP, Misra R, Rameshshanker R. et al. Impact of a new distal attachment on colonoscopy performance in an academic screening center. Gastrointest Endosc 2018; 87: 280-287
• 31 Kahi CJ, Ballard D, Shah AS. et al. Impact of a quarterly report card on colonoscopy quality measures. Gastrointest Endosc 2013; 77: 925-931
• 32 Nielsen AB, Nielsen OH, Hendel J. Impact of feedback and monitoring on colonoscopy withdrawal times and polyp detection rates. BMJ Open Gastroenterol 2017; 4: e000142
• 33 Gurudu SR, Boroff ES, Crowell MD. et al. Impact of feedback on adenoma detection rates: outcomes of quality improvement program. J Gastroenterol Hepatol 2018; 33: 645-649
• 34 Abdul-Baki H, Schoen RE, Dean K. et al. Public reporting of colonoscopy quality is associated with an increase in endoscopist adenoma detection rate. Gastrointest Endosc 2015; 82: 676-682
• 35 Kaminski MF, Anderson J, Valori R. et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomised trial. Gut 2016; 65: 616-624
• 36 Coe SG, Crook JE, Diehl NN. et al. An endoscopic quality improvement program improves detection of colorectal adenomas. Am J Gastroenterol 2013; 108: 219-226
• 37 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: 489-496
• 38 Pronovost PJ, Goeschel CA, Colantuoni E. et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010; 340: c309