Quality programs in endoscopy: for the patient, the doctor and society

Colorectal cancer (CRC) is the second most common cancer in Europe and the second leading cause of cancer-related mortality [1]. It has long been established that removal of the precursor lesions – colorectal polyps – reduces the incidence of CRC and cancer-related mortality [1] [2] [3].

The primary aim of screening is the prevention of CRC. Screening programs enable the detection and removal of precursor lesions, or the treatment of CRC, and have proven effective in reducing both the incidence and mortality related to CRC. As a result, screening programs have been initiated in many European countries. The primary screening tool differs among these countries, and includes guaiac fecal occult blood tests, fecal immunochemical tests, and colonoscopy, and all of these methods have their pros and cons. A prerequisite for all of these methods is that colonoscopy is carried out with the highest possible level of quality. Colonoscopy and polypectomy are associated with adverse events and complications [4]; thus, it goes without saying that high quality colonoscopy procedures are associated with high benefit and low adverse events. But what is the definition of high quality?

High quality is perceived very differently by patients, doctors, and society. Patients want the reassurance that they are free from cancer, and if this requires a colonoscopy, then they want to know that the colonoscopy is a safe procedure during which all polyps are found and removed, no pathology is missed, no discomfort is experienced, and that all members of the colonoscopy team are kind and respectful. Traditionally, endoscopists have focused more on the technical aspects of the colonoscopy procedure, and strive to perform at least as well as their peers when it comes to cecal intubation, and the detection and removal of all lesions. Society as a whole, and the public health services, will aim to spend the often limited resources in the most optimal fashion and this always involves a cost–benefit aspect. The aim here is not necessarily to completely eradicate CRC but to employ the strategy that is most effective in reducing the burden of CRC at a national level with the limited resources available. This means that these three different groups have very different expectations when it comes to high quality.

What can we, as endoscopists, contribute? Ideally, the perfect endoscopist always reaches the cecum, detects and completely removes all polyps, has no need for sedation but still achieves good patient comfort scores. Indeed, it has been shown that good endoscopists have high cecal intubation and polyp detection rates, use less sedation, and achieve good patient comfort scores [5]. Usually these endoscopists perform colonoscopies in high volumes, and also have lower complication rates [6]. However, we have to acknowledge the fact that not all endoscopists perform colonoscopy to an equal standard, and this is why minimal quality performance measures are being upheld in CRC screening programs.

There are two major action points that lead to increased quality in CRC screening programs. First, participating endoscopists have to demonstrate and maintain a certain level of quality, which is expressed as an annual number of colonoscopies performed that is preferably > 300 [6] with an unadjusted cecal intubation rate of > 90 %, and an adenoma detection rate (ADR) of > 20 % [7]. Endoscopists who repeatedly perform below these standards are denied participation within the screening program. Second, a mechanism must be in place for continual feedback of performance measures to individual endoscopists, endoscopy units, and screening organizations. This feedback is essential to detect weaknesses, and poor or suboptimal performance. Only with this awareness can improvement plans be created to achieve optimal performance of endoscopists and endoscopy units.

The study by Kozbial et al. [8] in this issue of Endoscopy is, in my opinion, a perfect example that the above strategy works. High quality screening was achieved by a selected group of endoscopists, regardless of specialty, who were really dedicated to performing high quality colonoscopy with high volumes, and who acted upon continual feedback of performance measures. In Austria, an annual audit is in place, and endoscopists who repeatedly miss the qualification criteria are excluded from participation in the screening program. Endoscopists who contributed fewer than 20 colonoscopies but who participated in the screening program were excluded from the Kozbial study. The results contradict a large number of studies in which the specialty of endoscopists was reported as an important factor in relation to quality of performance [9] [10] [11]. This is likely to be related to the fact that the participating endoscopists all showed the same dedication to the project by performing large numbers of colonoscopies, whereas the reported numbers of procedures per specialty in previous studies was much different or a structured feedback program was lacking. The current study does not report how exclusion from the screening program was distributed among the different specialty groups. An interesting finding was the significant difference in ADR between internists and surgeons (42.9 % vs. 59.3 % with ADRs < 20 %), and in the total percentage of adenomas and advanced adenomas detected (21.5 % vs. 18.8 % and 6.7 % vs. 5.8 %; P < 0.0001) [8]. This difference disappeared in the multivariate adjustment. Is this explained by the observation that internists scoped a different age and sex group than surgeons? One cannot help wondering whether the proportion of missed (advanced) adenomas is somewhat higher in the surgical specialty group. Ultimately, this should become apparent in a difference in interval cancers between the two groups [12].

Finally, I believe that we all benefit from high quality endoscopy: patients can be reassured that they are being treated by a member of a dedicated team of endoscopists who are subject to repeated audits, transparent outcome measures, and structured feedback as a method to improve. Society as a whole is served in the sense that resources are being utilized in the most optimal fashion from a quality point of view. The final outcome will inevitably result in a reduced burden of CRC.

• References

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