Sample A
Prevalence of missed adenomas and variations in physician recommended repeat colonoscopy
intervals in patients with inadequate bowel preparation on screening colonoscopy
Define: The gap in quality of care that we studied is the lack of a standard recommended time for
repeating a colonoscopy in patients who present for colon cancer screening but have inadequate bowel
prep. We aimed to determine the incidence of adenomas detected in that population on the next
colonoscopy and we attempted to define the optimum interval that should be recommended for a
repeat colonoscopy in patient with inadequate bowel prep on their first examination.
Measure: We used our electronic endoscopy report database to identify all patients who presented for
screening colonoscopy who had inadequate preps. WE then reviewed the reports and recorded the
recommended interval for repeat colonoscopy as determined by the attending physician. Adenoma miss
rates were assessed on a per-adenoma and per-patient basis. Per-adenoma miss rates were calculated
by dividing the number of adenomas found on repeat examination by the sum of the number of
adenomas found on initial and repeat examination. We looked at the percentage of patients in whom
clinical recommendations would have been different had all lesions been found on initial colonoscopy.
Mean time between colonoscopies was calculated for each patient who underwent repeat examination.
Baseline performance ranges from 1 day to 10 years.
Analyze: Our adenoma detection rate for all screening exams in the study time period was 32.8%.
Inadequate prep patients had an initial ADR of 25.7% and on follow up colonoscopy had an ADR of
33.8%. We assumed all polyps detected were present at the first colonoscopy but missed resulting in 45
patients with missed lesions. WE also learned that only 35.7% of the patients actually kept the
recommended follow up appointment within 1 year. The recommendations for follow up interval varied
from one day to 10 years despite the inadequate prep.
Improve: We informed all physicians and staff of the results of our audit and encouraged them to
recommend repeat colonoscopy the next day or soon as possible after the first appointment. We have
audited our performance over the past 3 months (3-2013 to 5-2013) and found the following. 31
inadequate preps were found. 28/31 (90%) were rescheduled within 1 year and 82% of that population
was rescheduled the next day or with a two day prep at the next available visit (within 6 weeks). The 3
physicians that did not recommend follow up within 1 year for an inadequate prep have been contacted
and made aware of the situation. They have all stated that they would be compliant with the
recommendation of a follow up within 1 year in the future.
Control: We learned that physician recommendations for repeat colon examinations after colonoscopy
with an inadequate prep varied greatly (1 day to 10 years). Patients often did not keep the follow up
recommendation especially if it was 6 months or longer after the initial colonoscopy. We also found that
the adenoma miss rate was higher than expected in this population. We now recommend that patients
with inadequate preps are suggested to have repeat colonoscopy at the next available visit.
The new society recommendations suggest that the exam should be repeated within 1 year of the
inadequate exam. Our physicians’ compliance with this recommendation has improved dramatically
with 90% compliance. We still need to continue to educate our physicians and nursing staff (planned for
QA meeting and GI grand rounds this year). The results of the data collection stage of our project were
published in Gastrointestinal Endoscopy 2012; 75:1197-203.
Sample B
Remediation Program to Improve Quality in Colonoscopy
I. All endoscopists using the Gastrointestinal Endoscopy Unit at Cottage Hospital for screening
colonoscopy will have 25 randomly chosen screening colonoscopies evaluated annually for
adenoma detection rates (ADRs).
II. Endoscopist(s) who have ADRs falling below 30% for males and/or 20% for females will be
identified. 25 additional cases from the endoscopist(s) in question will be evaluated to
increase the power of the endoscopist’s ADR data. If the ADR continues to fall below the
standard of 30% for males and/or 20% for females, the following remediation program will
be initiated:
- The indications for colorectal cancer screening will be evaluated to ensure the
procedures are appropriate.
- The endoscopist’s colonic preparation technique will be evaluated and ensure he/she is
using a small volume, split-dose preparation.
- Colonic preparation instructions will be reviewed to ensure they are appropriate, clear,
concise, and easy to follow.
- d. Cecal intubation rates will be calculated evidenced by two landmark pictures to confirm
cecal intubation. Acceptable landmarks include but are not limited to: the appendiceal
orifice, the Ileocecal Valve, and the terminal Ileum.
- Withdrawal times will be measured and will be required to be in excess of 6 minutes.
III. After 3 months in the remediation program, 50 subsequent colonoscopic screening cases
will be evaluated. If the ADR falls below the standard of 30% for males and/or 20% for
females, Proctoring from an approved endoscopist(s) will be recommended for 10 cases to
assess endoscopic technique and offer recommendations to improve the quality of the
colonoscopic examination.
IV. Once proctoring has been performed, 50 subsequent screening colonoscopies will be
evaluated for the ADR. If this continues to fall below the standard of 30% for males and or
20% for females, the endoscopist will be formally reviewed at the monthly GI department
conference to discuss the appropriateness of performing screening colonoscopies in the
Gastrointestinal Endoscopy Unit.