Quality Indicators for Colonoscopy

Abstract

Colonoscopy is the cornerstone of colorectal cancer (CRC) prevention worldwide and in the United States (1–4). In the United States, colonoscopy is commonly used for primary CRC screening and is the first and preferred colorectal imaging test in patients presenting with symptoms, with positive screening tests other than colonoscopy (1–4), undergoing surveillance after resection of CRC or precancerous polyps (5,6), with a strong family history of CRC or advanced precancerous lesions (1), and undergoing dysplasia surveillance in ulcerative colitis (UC) and Crohn's colitis (7). Evidence indicates colonoscopy reduces the incidence of CRC and prevents CRC mortality (8–23) (Table 1). Reduction in incidence and mortality of CRC with colonoscopy is greater in the left-sided colon than the right-sided colon (24). In the first randomized controlled trial comparing colonoscopy with no screening, patients who complied with and underwent colonoscopy (per-protocol analysis) had a 31% reduction in CRC incidence and a 50% reduction in CRC mortality (25). Several factors, including earlier than planned reporting of trial results, absence of stage shift in CRCs detected in the colonoscopy arm (suggesting symptomatic patients were enrolled in the colonoscopy arm), and lower than expected cecal intubation and adenoma detection, indicate the study may have underestimated the benefits of colonoscopy (25). Table 1. - Evidence indicates that colonoscopy is able to reduce the incidence of CRC and prevent CRC mortality (8–23) • Incidence of CRC is lower in patients undergoing screening fecal blood tests • Incidence of right-sided colon cancer is lower in patients undergoing screening flexible sigmoidoscopy with liberal rules for performing colonoscopy based on flexible sigmoidoscopy findings • CRC incidence and mortality are reduced in adenoma cohorts compared with reference populations • CRC incidence in screening cohorts is reduced compared with reference populations • Case-control studies in screening and nonscreening populations show reduction in incidence and mortality • Case-control studies show reductions in right-sided CRC incidence and mortality in screening and nonscreening populations • Evidence from US population trends • Studies show variable prevention between endoscopists with different detection skills CRC, colorectal cancer. The impact of colonoscopy on CRC and other outcomes (e.g., polyp detection, assignment of screening, and surveillance intervals) is highly operator-dependent. Detection of precancerous colorectal lesions is highly variable (26–28) and is associated with the risk of developing post colonoscopy CRC (PCCRC) (21,22). In response to evidence of inconsistent performance, professional gastroenterology and endoscopy societies began an organized movement 2 decades ago to improve the quality of technical performance and reduce the operator-dependence of colonoscopy (29). This document represents the latest update of recommendations from the American College of Gastroenterology (ACG)/American Society for Gastrointestinal Endoscopy (ASGE) Quality Task Force. Previous recommendations from this task force were published in 2006 (30) and 2015 (31). This update reflects new evidence published since 2015. High-quality colonoscopy includes adequate bowel preparation, safe colonoscope insertion to the proximal extent of the colon, detailed examination with identification of all precancerous lesions, and complete and curative resection of these lesions. The process is completed by thorough and accurate documentation of findings and assignment of any appropriate screening or surveillance follow-up at cost-effective intervals based on recommendations from the US Multi-Society Task Force (MSTF) on CRC (32). High-quality performance in 1 aspect of colonoscopy does not ensure adequate performance in others. For example, colonoscopists may be effective at detection but not resection of precancerous lesions or vice versa (33). Understanding deficiencies in performance is generally gained only through quality measurement. Given the impact of inadequate performance on critical outcomes including cancer development, failure to measure performance is unacceptable. This document presents many quality indicators related to the technical performance of colonoscopy. Practicing colonoscopists are encouraged to make quality measurements related to all indicators, but this may not be feasible from a time, staffing, or cost perspective. Therefore, the document recommends priority quality indicators (Table 2). These indicators were chosen based on clinical relevance, evidence of variable performance, and feasibility of measurement. Measurement of priority indicators is considered essential. Table 2. - Priority quality indicators for colonoscopy • Adenoma detection rate • Sessile serrated lesion detection ratea • Rate of using recommended screening and surveillance intervals • Bowel preparation adequacy ratea • Cecal intubation rateb aDesignates a new priority indicator.bShould be measured for all colonoscopists but can be measured intermittently or not at all if consistent high-level performance has been demonstrated. METHODOLOGY The first version of this document was published by the ACG/ASGE Task Force on Quality in Endoscopy in 2006 (30) and was revised in 2015 (31). This current revision integrates new data relevant to existing quality indicators and introduces new indicators based on interval progress in the field. This document focuses on quality indicators unique to colonoscopy (Table 3). The indicators common to all gastrointestinal (GI) endoscopic procedures are presented in detail in a separate article (34) and are, for completeness, also listed in Table 4. Indicators common to all GI endoscopic procedures are not addressed in this document, except in some instances where discussion specific to colonoscopy is required. Table 3. - Quality indicators for colonoscopy Quality of colonoscopy quality indicators 1. with colonoscopy is for an appropriate and the is 2. Rate of bowel preparation of patients undergoing colonoscopy with adequate bowel preparation, Bowel in of colon or by of the preparation or The recommended screening or surveillance interval be consistent with US Multi-Society Task Force recommendations 3. Cecal intubation ratea of patients undergoing colonoscopy with who have intubation of the with documentation of cecal Detection indicators for colonoscopy 4. Adenoma detection ratea of patients undergoing colonoscopy for screening, or other than positive screening tests (e.g., fecal tests or who have detected and by with positive screening cancer (e.g., or undergoing colonoscopy for of are from the of patients with positive fecal screening tests blood or with and by of detected colonoscopy in patients with of screening, or of with positive screening cancer (e.g., or undergoing colonoscopy for of are from the Sessile serrated lesion detection ratea of patients undergoing screening, or colonoscopy for with serrated lesions and by with positive screening cancer (e.g., or undergoing colonoscopy for of are from the in or in undergoing screening, or colonoscopy. with positive screening cancer (e.g., or undergoing colonoscopy for of are from the indicators of polyp for the the lesion and of resection of to lesions that are using a of appropriate screening and surveillance with recommended and resection surveillance intervals and of intervals between screening in risk patients who have examination and adequate bowel of and associated with colonoscopy that are and by a quality to for and clinical of Quality indicators for colonoscopy in colonoscopy indicators of for the of ulcerative colitis in a of extent and of or of is of for the of Crohn's in a of or in Crohn's or is quality indicators of appropriate for a follow-up surveillance colonoscopy interval for ulcerative colitis patients undergoing dysplasia screening dysplasia detected bowel priority Table 4. - Quality indicators common to all endoscopic procedures with associated performance Quality of 1. with endoscopy is for an that is in a published of appropriate and the is 2. with is and 3. with history and examination are and 4. with a that includes risk for is is with are for appropriate with of is and the with a is and with endoscopy is or by an who is and to that with documentation is with is and with and of is with endoscopic is and with from the endoscopy to is with are with endoscopic results, and follow-up recommendations are to the and appropriate with a complete is with are with with data are not in the indicators that have clinical are associated with in and and have been in clinical data were indicators of clinical were chosen by have progress in feasibility and The task force a of highly relevant but not quality indicators are and quality is an or process are in quality of but can be to measure in clinical of data and may be by other In process indicators are of endoscopic The of a process on the evidence with a relevant and process are The in this document to endoscopic The quality of is by factors, including related to endoscopy These are in a separate article to quality For this the task force existing quality indicators based on factors, including and of new quality indicators were if were by based on For relevant were by the through a of of of from of the update of this through The for a of in and were the and reference of relevant were by with in on this revised the of for was to a used (Table this the of quality was a from a strong quality that can be to clinical to a quality of a of evidence The of for was with of the Table - of recommendations of of evidence can be to clinical with results, to to evidence from studies can to in studies may evidence is may on or or with results, may be some studies are to be some only to data from from evidence to to the The process and in this document are to a performance and measure is considered a quality The task force performance based on published by In the absence of considered the failure to a quality a failure to the performance was only in the quality not be Quality indicators are to a for quality The quality indicators and associated performance not the of or and is a to any of the quality indicators in this document The 2006 and 2015 ACG/ASGE quality many indicators for quality in the technical performance of colonoscopy Quality is new and The 2015 document priority indicators that endoscopy to This current revision also priority indicators (Table 2). Priority indicators the with are to colonoscopy prevention of cancer and cancer the feasibility of in clinical evidence for in performance, and the of the a or of technical performance of colonoscopy. The for of priority indicators in this document (Table is presented in the discussion of indicators that quality on indicators and progress to other indicators is that endoscopists are performing recommended at or after The cecal intubation rate a quality for colonoscopy in this was a priority in 2015 a priority has been in this update (Table 2). are associated with prevention of CRC and intubation to and associated with imaging and at colonoscopy. to of evidence indicates that recommended and Therefore, a of may not be an effective of in where is no evidence of inadequate priority indicators are by in Table 2. of these is adequacy of bowel preparation, is to cost-effective colonoscopy. The is the serrated lesion detection rate is based on evidence to cancer prevention indicators for colonoscopy 1. with colonoscopy is for an appropriate and the is of process for colonoscopy are listed in Table an or an if the is considered and findings from (e.g., advanced lesions, or that the current colonoscopy be with the Table - for colonoscopy 1. of GI with GI of fecal blood 2. 3. for colorectal at recommended intervals in or with family 4. in in patients with at recommended intervals for colorectal cancer or precancerous lesions at recommended intervals of cancer risk in bowel of in bowel for of response of of imaging of the that precancerous lesions, or identification of a lesion not or at of lesions and of polyp or colorectal cancer of or of of or a for fecal or colorectal cancer screening test colonoscopy is used for appropriate is a of relevant for can be used to colonoscopy for Rate of bowel preparation adequacy 2. of patients undergoing colonoscopy with adequate bowel preparation, Bowel in of colon or by of the preparation or The recommended screening or surveillance interval be consistent with US of process The ACG/ASGE Task Force on Quality Indicators for Colonoscopy on the bowel preparation recommendations of the US bowel preparation is the recommended interval for screening or surveillance colonoscopy be consistent with the US recommendations a for earlier colonoscopy (e.g., an strong family or a process bowel the US patients with inadequate bowel preparation have a study 1 The US recommended in that at of be by an adequate bowel preparation The Society of Gastrointestinal Endoscopy recommended a The US recommendations are and based on evidence of of adequate preparation in clinical the ACG/ASGE Task Force recommends the bowel preparation the cost of colonoscopy and risk and for a a priority the US that the colonoscopy in the of adequate preparation of bowel preparation or or a Bowel of in all colon and of the the Bowel is the Bowel is for after of bowel is the relevant to the the recommended follow-up interval be consistent with US or resection surveillance indicators Cecal intubation rate 3. of patients undergoing colonoscopy with who have intubation of the with documentation of cecal of process a with a of Cecal intubation is of the colonoscope proximal to the and the cecal that the can be and and the of the between the and can be (31). have been associated with be with of of the colon can be by reduction of and in the insertion and of can reduce risk the colon is from or of only in patients with and associated with The risk of be in all patients with a colon, and the and using the is and the proximal colon for all are by of colonoscopists colonoscopists have measured are the recommended is and can be intermittently or not at all in the of a consistent of performance recommended evidence of variable performance for many evidence that performance is and the of reduction in for high-level Adenoma detection rate 4. of patients undergoing colonoscopy for screening, or other than positive screening tests (e.g., fecal tests or who have 1 or detected and by with positive screening cancer (e.g., or undergoing colonoscopy for of are from the of The adenoma detection rate is the relevant and quality in colonoscopy. was in in response to evidence that adenoma detection and cancer prevention were variable in clinical and was the of patients undergoing colonoscopy for other than or who had adenoma and by The was in and in and was at a the of detected at screening colonoscopy studies in In 2006 the for was to the of patients adenoma in a screening colonoscopy This that the were from screening colonoscopy studies In a screening colonoscopy study that for were colonoscopy was by colonoscopists with compared with colonoscopy by colonoscopists with In the were to in and in after a study in with in screening and new evidence to the an in CRC to the recommended to CRC screening to the consistent with the recommended to screening, that the be measured in than adenoma is related to this a in the studies adenoma in to to be only lower than in to (Table have been the and the of patients undergoing colonoscopy is compared with (Table no in the for the is for of to in the measurement. Table - in of colonoscopy performance of in patients in patients in patients in patients adenoma detection not GI Quality in the after the American Society studies the incidence of at a screening colonoscopy after an screening colonoscopy (Table Adenoma incidence at is that at an screening patients In of this that and screening can be in the for the Table - Incidence of at a screening colonoscopy after an screening colonoscopy at the first screening at the screening adenoma detection not the of surveillance for and for (29). The to the to screening was in 2006 (30) the had been based on screening In this the of a to surveillance and not for positive fecal Given the for in adenoma based on colonoscopy is that the to all surveillance and based on in the any by is expected to be In for surveillance are than for screening (Table for that not of positive fecal tests are lower than for screening colonoscopy. a including screening, and test is to a screening study that a endoscopists and the screening a of Table - of and colonoscopy of colonoscopy screening or 2015 and 2015 adenoma detection not from the are for positive fecal the is of in patients with positive fecal blood tests the at an in patients with positive fecal tests Therefore, positive fecal tests are from other The of fecal and in the United States, and the of for positive fecal blood tests is expected to In where the of for a positive fecal test is in organized screening and are can be in the of the for of of endoscopists of positive fecal tests in the of US and with Therefore, that in patients be measured if detection performance is measured in is to patients from and all other detection the not be expected to polyp resection (e.g., colonoscopy for lower GI or indicate have the In a screening in US gastroenterology had to by In a the risk of and were to by and for in the In a this between and was to the interval from to were generally and the to the for colonoscopy for nonscreening in in US gastroenterology the on quality the 2 decades the of Given the that screening, and colonoscopy but of a positive screening test (e.g., fecal blood and procedures for resection or of cancer (e.g., and recommendations for in patients with positive fecal screening tests are in the that have in screening populations and that of surveillance procedures may by a extent for some a of for the in and in that the of chosen the the of endoscopists who are the chosen an but the this with are recommended to to improve and to is evidence that risk to also that all colonoscopists to the recommended of and can in the has and the in a of a of the a of the interval is and performance is for endoscopists The evidence that the risk of after nonscreening and also in patients with positive fecal blood tests of the performance a of colonoscopy to the to and results, if the process is data this but is not For all related to lesion detection, feasible and in the of where the is insertion of inadequate preparation or the examination is complete to the but is 1 In documentation of preparation to the for also procedures that are to the or an of (e.g., or and in patients with positive fecal screening tests of patients with positive fecal screening tests blood or with 1 or and by of to of for positive fecal screening tests from the This is the of for positive fecal screening tests The is in US where screening is and can be in with organized screening and the is in these of positive fecal screening tests from of the In some the of for positive fecal screening tests is to of the this in the population risk The of in patients is and can The is the of of for a positive test is the primary screening adenoma in with a positive is than In the United States, a of of is used in on the an of 50% in and in in populations where with a of of are is evidence the expected in patients with a positive test evidence is the for in patients for colonoscopy of detected colonoscopy in patients with of screening, or of with positive screening cancer (e.g., or undergoing colonoscopy for of are from the of The has and a quality are a colon measure in the of from lesions in the serrated by is generally with a of of the is that does not detection of after the first adenoma has been and and many patients have This has to colonoscopy detection and resection of the has been associated with a lower risk of In the between and is this instances have been in an adequate has been associated with in of endoscopists For example, in 1 of endoscopists in the of performance had of the endoscopists in the of performance had on these that can be considered an to in where are generally and endoscopists are that can and In this a for of is recommended but are may not the is The of is the for a to separate separate for a and is not recommended to improve the of is to the of detected in the The to the of in the colonoscopy This be used an of or with a and In the absence of a and can be used to document the of that in separate is Sessile serrated lesion detection rate of patients undergoing screening, or colonoscopy for with 1 or serrated lesions and by with positive screening cancer (e.g., or undergoing colonoscopy for of are from the of The ACG/ASGE Quality Task Force on Colonoscopy considered and at to a detection serrated lesions. that many US endoscopists are not a separate for detection of serrated lesions an and for endoscopists and endoscopy unique are associated with the of any serrated indicators that are not relevant to the in the of polyps This is not an in the of (31). a serrated the identification and resection of colon are generally considered not to be precancerous an that on colonoscopy be to and in some of serrated detection have used polyp These measurements be to and in these studies that is a detection In 2 and serrated lesion detection were in of endoscopists of endoscopists had and serrated In the between and serrated detection was a of serrated detection indicators has been the considered serrated proximal serrated and of with in studies and the the quality of the precancerous serrated lesion of and is not to (Table Table - for serrated lesion detection Rate to detection data serrated detection rate and associated with risk for serrated polyp detection rate only associated with risk for Sessile serrated lesion detection rate only by associated with risk for serrated detection serrated lesion serrated or serrated or any serrated lesion proximal to the proximal serrated polyp detection of with serrated polyps serrated or serrated proximal to the serrated lesion detection of with serrated colorectal cancer. that the is to and related to in of from polyps the may performance and than performance in some instances This is a in endoscopy detection evidence that detection is with and that of this reflects and of identification of the a detection endoscopists to with to improve identification of any serrated detection for the for a data on and the of detection with and a of The of between and the in the United States was to be evidence of is with and to the study from the United States than and endoscopists that the of in to in the of by detection is may not with and that data from a quality study from the in patients that the proximal serrated polyp detection rate and the had with prevention of In a study from the of mortality reduction was for in and but the on mortality reduction not for are than proximal serrated polyps greater is an for a detection measure compared with but of that of patients with serrated polyps have only in the colon to with from the Colonoscopy also that detection of The of were and with of and of endoscopists had adequate but with the is that the of is lower than that of that be for some to with if detection is adequate or This the of but does not the of measurement. to the to with the that the interval the with measurement. and reporting of performance than used for the may be on a current for the of This is expected to be revised evidence of detection evidence is that an in patients of recommended for the in a population is is evidence that serrated lesions, and data on the of serrated lesions in positive patients does some serrated lesions based on in the but an appropriate for in this population is study a of in patients that of endoscopists using the the of the endoscopy to are the in the of adequate a of with endoscopists is in or in undergoing screening, or colonoscopy. with positive screening cancer (e.g., or undergoing colonoscopy for of are from the of process The recommended in or reflects the evidence the colonoscopists to and detailed of the colon, from the to of in the The first for in recommended an of in based on the of 2 in a rate study who had of and the endoscopists in the study In the for was to (30) on the of a study that in a of performing of in was associated with between and but since evidence has that detection at in (Table This evidence includes data that prevention of is at of at studies that detection of is at or (Table is detection of serrated lesions randomized trial comparing with to be for detection a randomized study comparing adenoma at Table - associated with detection at colonoscopy of patients 2006 is controlled controlled adenoma detection rate to by is not an adequate measure of detection performance or the primary of detection performance are and for or be measured and in clinical and if or are an inadequate to improve and on an examination of to the proximal to and in the adequate of the and to by or The is that of an of at is some evidence that can examination detection study of this is The that the be at in not be to that or the of that the other if are the recommended and by an of this be evidence of an inadequate by a be considered an to and the indicators of lesion and resection of polyp for the the lesion and of of process of for to lesions of to lesions that are using a of process The US on CRC and the Society of Gastrointestinal Endoscopy have detailed recommendations for the resection of colorectal These recommendations the and resection of the of colorectal including and of of resection and for on quality measurement. The considered a of quality indicators for resection and recommends 2 indicators that are by feasibility of evidence of variable endoscopists have clinical The first that colonoscopists for all polyps in the colon by in from the for left-sided colon and the of that no in colorectal resection except for or the of a polyp in the of a or a is an to The of is is and polyps in be with a of a and and the polyp polyps can be using the or by the of the of the polyp in the colorectal can be with a of and (e.g., and polyps in by be polyps are from the and by the with may be in the any of that advanced or endoscopic of cancer or based on or be for and not in the polyps from different to polyp the is recommended of the and is also the of of the is between and the that the for between these in of from lesions is and by is the of from of polyps for these the of many lesions and the for of the lesions, the colon for can be by specific accurate of with colorectal can resection be identification of polyp resection at is is or and is to serrated the resection is essential. in the and of in also in of and with associated with resection of lesions and for in to or prevent is associated with at the follow-up examination can be from polyp by imaging but of a is by an accurate of all of lesion resection be in the including all specific and resection used The quality of resection recommended is the of lesions in by The first the resection of lesions in this is the risk of has in The of resection is the of and for a of lesions that are to patients in the the of is than the risk of CRC, that patients with cancer. This is an for lesions with a risk of resection is associated with a resection than resection may

Topics & Concepts