Seven gastroenterologists from across the United States share how they are using benchmarking to improve colonoscopy quality.
Ask a Gastroenterologist is a weekly series of questions posed to gastroenterologists around the country on business and clinical issues affecting the field of gastroenterology. We invite all GI physicians to submit responses. Next week's question: What is your approach to leadership in the gastroenterology field?
Question: How are you using benchmarking to improve colonoscopy quality?
Brett Bernstein, MD, Director of East Side Endoscopy, Manhattan, N.Y.: Benchmarking is not just for quality improvement, it is a necessary competitive strategy that can set your group apart from others. Over the last two years, we have created a clinically integrated endoscopy network of over 80 gastroenterologists performing over 50,000 annual colonoscopies. All of our physicians are participating in GIQuIC, which is a national registry that allows physicians to compare their performance on key performance metrics such as adenoma detection rates and preparation quality to their local peers and nationally. The transparency and powerful nature of this comparative data has already led to improvements in the performance of our physicians.
Glenn M. Eisen, MD, MPH, FASGE, Vice President, GI Quality Improvement Consortium, West Hills Gastroenterology, Portland, Ore.: The concept of benchmarking has taken hold in the past eight years since the co- publication of endoscopy related quality metrics by the ASGE and ACG. Colonoscopy in particular has been amenable to validating measures which ensure quality. The adenoma detection rate is strongly linked to the prevention of interval colon cancers – those found between colon examinations. Other measures including cecal intubation rates, prep quality and appropriate indications can be collected by endoscopists and thresholds for high quality colonoscopy have been developed.
Benchmarking is critical in that it enables physicians to compare themselves locally as well as nationally and even internationally to their peers. No longer is it acceptable to practice in a vacuum, not knowing your own rates for these measures, as well as how one compares to accepted standards.
All endoscopists wish to perform high quality exams on their patients and the knowledge of these metrics and benchmarking has been shown to lead to improved examinations. Those individuals with the knowledge that their data is below benchmarks now have the information to help improve their examinations. GIQuIC, which was developed in 2010, has been at the forefront in gastrointestinal endoscopy in collecting these measures and fostering benchmarking. There are now more than half a million colonoscopy records in the database and EGD is now included with other procedures and measures to come.
David Greenwald, MD, Director, Einstein/Montefiore Gastroenterology Fellowship Program, New York: Benchmarking really changes the game in terms of colonoscopy quality. Without a benchmark or target, endoscopists may assume they are doing an excellent job, but really have no way to know that. However, having a known target or benchmark to reach for or attain gives the endoscopist or the facility a way to compare their performance against a local or national standard. It reassures those who meet or exceed the threshold that they are providing high quality care in that metric, and allows for those who fall below the benchmark to reassess what they are doing and form a plan to meet the benchmark.
We use benchmarking through GIQuIC, a national registry for gastroenterology jointly developed by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology. We send data in from every colonoscopy we perform in our ambulatory endoscopy center, and then have the ability to generate reports on a wide variety of metrics such as bowel preparation quality, cecal intubation rate and adenoma detection rate. We can generate reports for each individual provider or for our center as a whole, and those reports contain the established benchmarks for each measure right on the report. It's therefore very easy to see "how we are doing" both individually and as a group comparing ourselves to nationally recognized benchmarks. It's a very powerful tool to help provide high quality colonoscopy, which is clearly a crucial goal.
Rajeev Jain, MD, AGAF, American Gastroenterological Association, Practice Management & Economics Committee, Partner, Texas Digestive Disease Consultants, Dallas: Physicians are inherently competitive and want to provide high value care. By benchmarking or comparing themselves to their partners and/or national averages, gastroenterologists can assess their performance on various quality metrics.
In colonoscopy, process measures such as cecal intubation, withdrawal time and procedural documentation are commonly benchmarked as these measures are easily exported from endoscopy report writers. In the future, outcome measures, such as the development of interval colon cancers in a screened population, will be tracked. For the time being, adenoma detection rate serves as a reasonable surrogate marker for high quality colonoscopy and colon cancer prevention. Finally, gastroenterologists should be monitoring procedural complications such as perforation, post-polypectomy bleeding and adverse events related to anesthesia.
The AGA offers the Digestive Health Recognition ProgramTM, which allows gastroenterologists to meet CMS Physician Quality Reporting System requirements and avoid penalties, compare performance to national benchmarks and submit data to complete an American Board of Internal Medicine self-directed performance improvement module. A program for colorectal cancer prevention and surveillance is scheduled for late spring 2014.
By benchmarking these and other colonoscopy related metrics, gastroenterologists can assess the quality of the colonoscopies they are performing and identify deficiencies. The use of dashboards or report cards to show individual performance with comparison to others can influence physician behavior. Practices will need physician champions and leaders to create and promote a culture of quality measurement and performance improvement. When deficiencies are identified, they should be addressed and a plan for improvement with closer monitoring instituted. Additionally, CMS, private payers and patients are demanding transparency with objective measurement of quality such that reimbursement is tied to high value care.
Joyann Kroser, MD, FACP, FACG, AGAF, Chair, Crozer-Keystone Endoscopy Quality Committee, Upland, Pa.: The physicians of Crozer Gastroenterology Associates aim to demonstrate to our patients, to ourselves and, increasingly, to payers, the quality of our performance with reliable and relevant measures of endoscopic quality that give our physicians meaningful information they can use to improve patient care.
Today, informed patients want to know about the quality of care being provided. They frequently ask the questions, "What is your adenoma detection rate?" and, "What is your complication rate?" We are dedicated to providing ongoing, peer-based performance evaluation and continuous quality improvement by auditing our colonoscopy practices across the Crozer-Keystone Health System.
We then compare our data to the currently accepted published quality data. We then provide these benchmarking reports to the physicians who perform colonoscopy in our hospital outpatient endoscopy units and in our outpatient ambulatory endoscopy facilities to support quality improvement initiatives. This allows us to identify gaps in care and develop quality indicators to address gaps.
We feel that we improve clinical and patient outcomes through higher quality procedural services. Currently we track withdrawal times, adenoma detection rates and preparation quality among other metrics. We have a peer-review endoscopy quality committee that reviews the data and addresses any concerns. We hope to begin using an external benchmarking registry soon.
Irving M. Pike, MD, FACG, FASGE, President of GI Quality Improvement Consortium, CMO of John Muir Health, Walnut Creek, Calif.: There has been a concerted effort by gastroenterologists since 2006 to measure and improve the quality of the colonoscopies they perform. The opportunity to do this was brought about by a joint task force of the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The task force developed the quality indicators for colonoscopy as well as for other gastrointestinal endoscopic procedures. These indicators were simultaneously published in Gastrointestinal Endoscopy and the American Journal of Gastroenterology in April 2006.
Upon the publication of these quality indicators, gastroenterologists, health systems software vendors and others interested in offering the best possible colonoscopies for colon cancer prevention, as well as for establishing diagnosis and providing therapy, set out to devise a way to collect data to measure performance of quality endoscopy. This interest and effort led to the establishment of GIQuIC, in 2010. Today this registry that receives data electronically from 10 certified Endoscopy Report Writers, as well as having a manual entry option, and has over a half million colonoscopies in the database.
There are more than 100 data fields for each procedure. In addition to being a benchmarking tool for improving and maintaining quality, the registry is available for clinical research. We now have evidence that increasing adenoma detection rate of the endoscopist increases protection against interval colon cancer. Specific key measures for colonoscopy such as adenoma detection rate, cecal intubation rate and appropriate use of screening and surveillance intervals are available in GIQuIC.
Additional standard colonoscopy measures, esophagogastroduodenoscopy measures and the ability to create custom measures exist. Facilities are able to measure their ability to reach and exceed established benchmarks as well as compare themselves to a national cohort. If individuals or facilities find themselves below benchmarks or what they aspire to achieve, there is the opportunity to seek additional instruction and improve what they are doing.
I first was convinced that measuring one's performance was meaningful when I asked a participant in the pilot that led to the establishment of GIQuIC if participating in measuring and benchmarking the quality of her colonoscopy was worth the effort. Her reply was, "Absolutely, now when I perform a colonoscopy I am focused on the quality of the exam I am performing for the patient rather than completing the procedure."
Pankaj Vashi, MD, Lead National Medical Director, National Clinical Director of Gastroenterology/Nutrition, Metabolic Support and Gastroenterology, Midwestern Regional Medical Center, Zion, Ill.: Benchmarking as a means to improve colonoscopy quality plays a vital role in being able to deliver the most current and reliable information and modes of care to all of the key audiences, including patients, accrediting organizations and licensing bodies.
The best benchmarks for colonoscopy quality are adenoma detection rate and cecal intubation rate. ADR is defined as the average percent of patients with polyps who have been screened through colonoscopy over the age of 50. The rate has to be greater than 25 percent in males and greater than 15 percent for females. The other quality measured is the cecal intubation rate. This is the time the colonoscope is withdrawn back through the colon, carefully examining the lining from cecum to rectum. The current benchmark for this is a minimum of six minutes. At Cancer Treatment Centers of America®, we use cecal intubation rate as a quality measure. We benchmark this by documenting the number of patients in whom cecum was reached during colonoscopy.
The future of medicine will continue to challenge us to document quality of care so that all parties that use this information are kept well informed. But most important of all is the benefit it will have for the patients that we serve.
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