Quality Indicators Common to All GI Endoscopic Procedures

Abstract

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (1). The American Society for Gastrointestinal Endoscopy (ASGE), the American College of Gastroenterology (ACG), and the American Gastroenterological Association (AGA) have continually promoted the ideal that all patients have access to high-quality GI endoscopy services. A high-quality endoscopy is an examination in which patients receive an indicated procedure, correct and relevant diagnoses are recognized or excluded, any therapy provided is appropriate, and all steps that minimize risk have been taken. The quality of health care can be measured by comparing the performance of an individual or a group of individuals with an ideal or benchmark (1). The particular parameter that is being used for comparison is termed a quality indicator. A quality indicator is often reported as a ratio between the incidence of correct performance and the opportunity for correct performance or as the proportion of interventions that achieve a predefined goal (2). Quality indicators can be divided into three categories: (1) structural measures—these assess characteristics of the entire health care environment (e.g., availability and maintenance of endoscopy equipment at a hospital), (2) process measures—these assess performance during the delivery of care (e.g., proportion of patients who undergo biopsies when Barrett's Esophagus was suspected), and (3) outcome measures—these assess the results of the care that was provided (e.g., proportions of patients diagnosed with colon cancer within five years of a screening colonoscopy). METHODOLOGY In 2006, the ASGE/ACG Task Force on Quality in Endoscopy published the first version of quality indicators common to all endoscopic procedures (3). The present update integrates new data pertaining to previously proposed quality indicators and new quality indicators common to all endoscopic procedures. For the current report, we prioritized indicators that had wide-ranging clinical application, were associated with variation in practice and outcomes, and were validated in clinical studies. Clinical studies were identified through a computerized search of Medline followed by review of the bibliographies of all relevant articles. When such studies were absent, indicators were chosen by expert consensus. Although feasibility of measurement was a consideration, we hope that inclusion of highly relevant, but not yet easily measurable, indicators will promote their eventual adoption. Although a comprehensive list of quality indicators is proposed, we recognize that, ultimately, only a small subset might be widely used for continuous quality improvement, benchmarking, or quality reporting. As in 2006, the current task force concentrated its attention on parameters related solely to endoscopic procedures (Table 1). Although the quality of care delivered to patients is clearly influenced by many factors related to the facilities in which endoscopy is performed, characterization of unit-related quality indicators was not included in the scope of this effort.Table 1: Composition of the task forceThe resultant quality indicators were graded on the strength of the supporting evidence (Table 2) (4). Each quality indicator was classified as an outcome or a process measure. Although outcome quality indicators are preferred, some can be difficult to measure in routine clinical practice, because they need analysis of large amounts of data and long-term follow-up and may be confounded by other factors. In such cases, the task force deemed it reasonable to use process indicators as surrogate measures of high-quality endoscopy. The relative value of a process indicator hinges on the evidence that supports its association with a clinically relevant outcome, and such process measures were emphasized.Table 2: Grades of recommendationaThe quality indicators for this update were written in a manner that lends them to be developed as measures. Although they remain quality indicators and not measures, this document also contains a list of performance targets for each quality indicator. The task force selected performance targets from benchmarking data in the literature when available. When data were unavailable to support establishing a performance target level, “N/A” (not available) was listed. However, when expert consensus considered failure to perform a given quality indicator a “never event,” such as monitoring vital signs during sedation, then the performance target was listed as >98%. It is important to emphasize that the performance targets listed do not necessarily reflect the standard of care but rather serve as specific goals to direct quality improvement efforts (Table 3).Table 3: Summary of proposed quality indicators common to all endoscopic proceduresQuality indicators were divided into 3 time periods: preprocedure, intraprocedure, and postprocedure. For each category, key relevant research questions were identified. In order to guide continuous quality improvement efforts, the task force also recommended a high-priority subset of the indicators described, based on their clinical relevance and importance, on evidence that performance of the indicator varies significantly in clinical practice, and feasibility of measurement (a function of the number of procedures needed to obtain an accurate measurement with narrow confidence intervals and the ease of measurement). A useful approach for individual endoscopists is to first measure their performances with regard to these priority indicators. Quality improvement efforts would then move to different quality indicators if endoscopists are performing above recommended thresholds, or the employer and/or teaching center could institute corrective measures and remeasure performance of low-level performers. Preprocedure quality indicators The preprocedure period includes all contact between members of the endoscopy team with the patient before the administration of sedation or insertion of the endoscope. Common issues for all endoscopic procedures during this period include: appropriate indication, informed consent, risk assessment, formulation of a sedation plan, management of prophylactic antibiotics and antithrombotic drugs, and timeliness of the procedure. 1. Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications, and the indication is documented (priority indicator) Level of evidence: 1C+ Performance target: >80% Type of measure: process Standard indications for endoscopy are listed in the ASGE Appropriate Use of GI Endoscopy guideline (5). An appropriate indication should be documented for each procedure, and, when it is not a standard indication listed in the current ASGE Appropriate Use of GI Endoscopy guideline, it should be justified in the documentation. Discussion: In general, endoscopy is indicated when the information gained or the therapy provided will improve patient outcomes and is not indicated when the risks of the procedure outweigh any possible benefit to the patient. ASGE published a list of accepted indications for endoscopic procedures in 2000 (6). This list was determined by a review of published literature and expert consensus and was updated in 2012 (5). There was little substantial change with regard to indications for EGD and colonoscopy in the update. Facilitation of cholangioscopy and pancreatoscopy were added as accepted indications for ERCP. Additional EUS indications were included, such as placement of fiducial markers, treatment of symptomatic pseudocysts, drug delivery, provision of access to the bile or pancreatic ducts, evaluation for chronic pancreatitis, perianal and perirectal disease, and screening patients at increased risk of pancreatic cancer. Studies have shown that when EGD and colonoscopy are done for appropriate indications, significantly more clinically relevant diagnoses are made (7, 8, 9, 10). A quality improvement goal is to minimize the number of procedures without appropriate indications. Open access patients for endoscopy without with the is widely studies have shown that access are done for appropriate indications A quality improvement goal is to that for to with regard to of quality goals that are relevant to access endoscopy include: availability of information the procedure to patients in of the procedure, availability of clinical information to the in of the procedure, of endoscopic and to the and of appropriate Frequency with which informed is and documented Level of evidence: 3 Performance target: Type of measure: process should be and documented for the procedure, in of or should a of the sedation and risks associated with sedation, indication for the procedure, of the procedure, common to the procedure, and patient if treatment is sedation for the procedure is provided by an then a by that may be Discussion: informed patient It a process patient and It the patient to receive the relevant information the proposed procedure and to an informed or not to with the recommended of it the patient the opportunity to patient and confidence in the health care ASGE on informed in endoscopy the to obtain may be by and and by information provided by and other A for a particular procedure that contains all the of may a with the patient. may be useful for and procedures. The quality of informed been an important in a of procedures that in The and informed is is not Frequency with which preprocedure and examination are performed and documented Level of evidence: 3 Performance target: Type of measure: process sedation, a preprocedure and examination should be performed and Discussion: ASGE and the American Society of a preprocedure that includes a health and examination that are performed before the patient is and before endoscopy The for and some may not for of a current patient and examination to be solely on the endoscopy and, may be The should on indications for the procedure as as that may the performance and of the procedure. The also should emphasize issues (1) of (2) with sedation or (3) current and and of or use or The should the and of the Although are data on the of on the risk of patients are to before sedation and endoscopy. to practice patients should not for for a for or a with or for before sedation with and may a period of to minimize risk of The of should be into before period of may before endoscopic procedures. A of colonoscopy patients that of in the was and patients the or all of the on the before the procedure Frequency with which risk for is and documented before sedation is Level of evidence: 3 Performance target: Type of measure: process sedation is a risk for is performed and of patients by such as the the risk of This information should be used for with regard to or the procedure or the procedure and sedation Discussion: The used for risk before endoscopic procedures are the and the The and patients on a to and to and at substantial risk of within studies that used endoscopy have shown that during that are related to The a to assess the An with in This not been validated as a risk for endoscopic but it gained clinical relevance with use of sedation and, possible need for Frequency with which prophylactic antibiotics are for appropriate indication (priority indicator) Level of evidence: varies by individual Performance target: Type of measure: process antibiotics are only for selected for which they are Discussion: For endoscopic prophylactic antibiotics are not indicated for of ASGE updated its for the use of antibiotics before endoscopic procedures in from in that GI endoscopy is considered to be a risk for antibiotics to are not for patients who are at risk for are not recommended for patients or other any endoscopic procedure of in the of with of the GI of and any endoscopic procedure of antibiotics are recommended in the (1) in patients in is (e.g., of (2) in patients with pancreatic that with the pancreatic (e.g., of (3) in patients with of in patients with the GI of any endoscopic procedure in patients with and GI of and placement in all patients of may be indicated for if clinical them at risk of (e.g., There are data to for for patients with the GI The American Association with ASGE and, in prophylactic antibiotics for the first for patients who have ASGE from the of the American of which that should be given to patients with before any procedure to However, the its for patients with and that the might the practice of prophylactic antibiotics ASGE do not patients but the Society for and that the be of before colonoscopy with Frequency with which a sedation is documented Level of evidence: varies by individual Performance target: Type of measure: process sedation is the of sedation is as sedation, sedation, sedation, sedation, or Discussion: sedation is a during which patients to Although function and may be and and are sedation is a of during which patients to or by interventions are to a and is function is sedation is a of during which patients be easily but or The to function may be may in a and may be function is is a of during which patients be by The to function is often often in a and may be because of or of function may be The that because sedation is a it may not be possible to an individual patient will to a given of sedation should be to patients of sedation sedation should be to patients who a of sedation, sedation should be to patients who a of Frequency with which management of antithrombotic therapy is and documented before the procedure (priority indicator) Level of evidence: 3 Performance target: Type of measure: process use by the patient is and a management of antithrombotic is documented and to the patient and health care Discussion: ASGE the management of patients antithrombotic endoscopy were updated in In general, endoscopic procedures are considered risk for and do not of antithrombotic endoscopic procedures are considered risk for and of some antithrombotic at risk for may of or with a associated with other or a of within a or endoscopic procedures can be performed without In the of antithrombotic may be In patients who have endoscopic the of to be into the of endoscopic therapy performed and the risk of A quality improvement goal is to and document a to antithrombotic for all patients these Frequency with which a team is and documented Level of evidence: 3 Performance target: Type of measure: process administration of sedation or insertion of the the endoscopy team to patient and of procedure. This should be Discussion: A team to as before any procedure sedation or is by the for and The of this is to that the correct patient is the desired procedure. the may for of any or data that may the performance or of the endoscopic procedure. It also may an opportunity for the to team members of the procedure and the for interventions or from practice that would Frequency with which endoscopy is performed by an individual who is and to perform that particular procedure Level of evidence: 3 Performance Type of measure: process A quality endoscopy procedure is performed by an who measures for Discussion: the desired and the quality of an endoscopic procedure. There is evidence that colonoscopy performed by a is associated with an increased risk of and The ASGE published and that of and these should be to the process GI endoscopy is important in this regard (1) measures of performance and not number of procedures performed in should be used to (2) measures of when are should be and not by (3) in procedure should not necessarily in and in a given endoscopic procedure should that the be to perform specific to that procedure (e.g., standard in colonoscopy and placement for in Preprocedure research questions often are procedures performed for indications in clinical is the for performance of such that can minimize such such as or patient of the procedure during the new preprocedure risk that are specific for GI endoscopy need to be developed and and endoscopists new is the and use of sedation for GI sedation endoscopists endoscopy outcomes, or patient are the risks of antithrombotic for small colon be in patients antithrombotic are the of a team for is the use of proposed and this process improve patient quality indicators The period from the administration of sedation, or insertion of the when sedation is the is This period includes all the of the procedure of the examination and of Common to endoscopic procedures is the provision of sedation and need for patient Frequency with which is performed Level of evidence: 3 Performance target: Type of measure: process of important and should be Discussion: Although the of endoscopic is to be in clinical its use current practice and should be of may patient of the with other and for during procedures. This also may information the quality and of evaluation when patients present at a with GI of are in of the is an of the quality indicator and is included in the for Performance Endoscopy and of the is the and of that a colonoscopy been It is recommended that key the with and the with be the or the the of or of for other endoscopic procedures are not as but are Frequency with which patient monitoring during sedation is performed and documented Level of evidence: 3 Performance target: Type of measure: process endoscopic procedures the parameters are with and and should be at intervals Discussion: It is accepted that patient monitoring of the proposed monitoring parameters have been shown to improve outcome in studies. monitoring for and are included in published by ASGE and and a to in a during sedation Although monitoring been shown to be associated with in patients endoscopy sedation with are data yet to support the use of monitoring in sedation Frequency with which the and of administration of all used during the procedure are documented Level of evidence: 3 Performance target: Type of measure: process Frequency with which use of is documented Level of evidence: 3 Performance target: Type of measure: process The use of (e.g., should be This should be reported as the of such of all procedures the sedation (e.g., the of time was used for sedation when was used as a Discussion: As a surrogate to some health care have chosen to use the administration of for an or procedure. The use of this indicator be because it may for use of these The task force that any use of this be in a manner as not to the use of Although of used should be standard and such it should be considered within the of process improvement and not as an measure of Frequency with which procedure and because of issues is documented Level of evidence: 3 Performance target: process management that and of the procedure should be Discussion: Clinical in which the is the risks and of the endoscopic procedure are the of clinical care and are to be an endoscopic procedure should not be considered an should be in a manner within the of continuous quality When the of procedure is related to or this should be As more outcomes are for the outcome measure in the may by procedure and of sedation research questions monitoring such as during routine endoscopic procedures and sedation improve of with any on patient is the for with regard to management and is the sedation for the of the patients with and patients classified as or monitoring administration as a quality indicator their use and patient quality indicators The period from the time the is to to the of the procedure, and of with and patient Frequency with which from the endoscopy to is documented Level of evidence: 3 Performance target: process is that the patient before from the endoscopy Discussion: endoscopy should have a written the patient before from the that the patient these should be Frequency with which patient are provided Level of evidence: 3 Performance target: process should be provided in with ASGE Discussion: written should be provided to the patient before should include: or change in antithrombotic of to such as and contact information should an or should be informed of signs and of to the procedure performed that should a to the should be they will be informed of relevant follow-up or of need for such should be Frequency with which the for follow-up is and documented Level of evidence: 3 Performance target: process When have been the management for the patient and of this to the should be Discussion: The results or management (e.g., of need for of results into the care that the patient and the be of these and their may be by by or during a follow-up the or other should be of The with which patient and receive results and that these were into a care is a more quality indicator of a use and of measurement of such more indicators may be possible in the Frequency with which a procedure is Level of evidence: 3 Performance target: process are for endoscopic procedure and should be and in a Discussion: and of endoscopic and patient care The task force that the procedure be yet the inclusion of (e.g., of during screening from relevant of the and of endoscopic may improve between performance improvement research and and computerized endoscopic may in this Quality and for that on the of data benefit from such such is the standard for proposed by the of Endoscopy This document the for by standard of to be used in the of endoscopic The Quality Task of the also developed a and data that is specific for colonoscopy The goal of this is to endoscopists with a quality improvement and to with a colonoscopy that standard and follow-up The are the of an endoscopy of procedure data and in procedure of relevant patient and examination not of informed procedure and performed are Type of endoscopic of examination of examination or of for care Frequency with which are documented Level of evidence: 3 Performance target: process should be classified to their of of to the endoscopic procedure, and degree of to the and this should be Discussion: the of endoscopy is a goal of the and and is consistent with efforts by the of There is evidence that may be to 3 previously documented and reported An ASGE task force proposed and of in an to data and An is that of the procedure or results in to the of procedure sedation and/or or can be based on as preprocedure, the administration of sedation, or insertion of the when sedation is the is to and time A of of to the endoscopic procedure as or should be of should be graded by the degree of to the patient and any in the of care as or Preprocedure and that are on of endoscopy should be in the endoscopy that are recognized also should be this should be to the endoscopy as an Frequency with which Level of evidence: 3 Performance target: outcome Discussion: from to The of in studies is between and risk factors for disease, or and an increased of to for the of during colonoscopy is In general, during screening or for all should as to are the of the with from to and management of a have been shown to associated and Although often endoscopic may be appropriate in individuals is often associated with but can with or without or When associated with may or can be for the procedure A number of large studies have reported of to colonoscopy For routine clinical practice, for should be A by that the of GI was significantly different with or without procedures as screening without and for procedures as without with for any procedures with Frequency with which and and are documented Level of evidence: 3 Performance target: outcome should be made to contact patients endoscopy to any had from the endoscopy and these were to the procedure. Discussion: The task force the of and data on and from endoscopy. emphasize the of and and this is as a quality indicator. The added and use of to perform follow-up remain an of is ideal because to of or This task force also that endoscopy these data to be included as an to the endoscopy When of any is by direct patient such information should be added that to this quality indicator will more easily with of health practice management and endoscopy which will data to Frequency with which patient data are Level of evidence: 3 Performance target: process on patient is by use of a validated and Discussion: in its and outcomes in the use of a validated of patient for use endoscopic procedures For it may be reasonable to to all in other a may be It is that these results will be within a continuous quality improvement As of patients and as for patient are outcome indicators of patient may Frequency with which with is documented Level of evidence: 3 Performance target: process The results of the endoscopic procedure and follow-up be to the or care and this should be Discussion: of of endoscopic results with other care may in patient It is the of the to results and and follow-up to the or other relevant health care This may be done by or In patients with or need of for and research questions often do patients with on of patients being given a of the procedure to the patient patient or with follow-up the use of improve and with the practice of to quality indicators improve the of data from the computerized for benchmarking and quality factors improve patient with quality indicators The recommended priority indicators that are common to all endoscopic procedures are (1) appropriate performed for an appropriate indication, (2) prophylactic antibiotics only for selected in which they are and (3) antithrombotic use by the patient and a management of antithrombotic in (Table For each of these the recommended performance target is considered associated with important clinical indicators can be measured in a number of quality indicators common to all GI endoscopic Quality and are a vital in health care to clinical and by and that clinical outcomes will improve health care For to between and clinical these and quality indicators. practice and The of to measurement of it is that endoscopists and their remain in the of these quality indicators. goal is to a and of for quality indicator. The benchmark will be such that to patient care will be to them without However, the will need to be to who may benefit from It is that endoscopy will a subset of these indicators appropriate for their indicators should then be measured and the associated with these indicators are being then of indicators should be chosen to the process of continuous quality performance the then should be developed and should be to the of such American of American College of American Gastroenterological American Society of American Society for Gastrointestinal Endoscopy