7 minute read
Gastrointestinal Endoscopy version 2
GASTROINTESTINAL ENDYGASTROINTESTINAL ENDOSCOPY
Advertisement
GENERAL COMMENTS
Associate Professor William Tam Gastroenterological Society of Australia Chair, ACHS Gastrointestinal Endoscopy Working Party Version 3
Optimal bowel preparation is a necessary first step to performing high-quality diagnostic and therapeutic colonoscopy. While there is no worrisome trend in the proportion of patients in whom colonoscopy was unsuccessful due to poor bowel preparation (CI 1.1), subset analysis has revealed variation between public and private HCOs, and across states. The outlier records further indicate there is room for further education and promotion of this key component of high-yield colonoscopy (discussed specifically below).
Failure to achieve caecal intubation due to bowel pathology (CI 1.2) has slightly improved over the time period, while failure due to instrumental failure has convincingly improved. Tasmania did record a higher incomplete colonoscopy rate due to diseased colon in 2018, although the absolute number was small.
Both post-polypectomy and post-colonoscopy perforation (CI 2.1 and 2.2) have declined over the assessment period. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. In 2018, the number of patients requiring treatment for polypectomyrelated perforation reduced by about a third. This is reassuring and may be reflective of the increased emphasis on training and education by GESA, colleges and the hospital environment.
Post-polypectomy bleeding (CI 2.3) has steadily fallen over the assessment period. The rate change was 0.083 per 100 colonoscopies with polypectomy. This is more impressive given the increasing proportion of patients who are on anticoagulants and anti-platelet medication and may be due to the adoption of endoscopic techniques which can reduce post-polypectomy bleeding (e.g. use of cold-snaring and haemostatic clips). The number of patients diagnosed with a colorectal malignancy who have received a colonoscopy within the previous five years (CI 3.2) has decreased between 2013 and 2018. This trend was also significant after allowing for the changing composition of HCOs contributing over the period. The rate change was 9.3 per 100 patients. Interestingly, there was no variation between HCOs and there were no outlier HCOs in 2018.
Oesophageal dilatation with possible perforation (CI 4.1) has increased in the assessed time period. In 2018, there were 72 records from 40 HCOs. The annual rate was 0.22 per 100 patients. The reasons for this observation are not immediately obvious. It is not related to outlier data. It may be related to changes in disease prevalence (acid-peptic, inflammatory or motility disorders) or treatment modalities (bouginage versus balloon dilatation). This is a clinical area which requires ongoing monitoring.
Aspiration following GI endoscopy (CI 5.1) has increased in the assessment period. The fitted rate deteriorated from 0.022 to 0.035, a change of 0.013 per 100 patients. In 2014, ANZCA released the PS09 professional standard background paper which discussed important aspects of anaesthesia during endoscopy and in the peri-procedural period. The importance of adequate training of anaesthetic staff, particularly in regard to use of the anaesthetic drug propofol, is a key issue of this discussion. In recognition of the important links between sedation, airway management and risks of aspiration, a new indicator, "Sedation Practice" has been introduced in the third version of the ACHS Gastrointestinal Endoscopy Clinical Indicators released in 2019 to underscore safe procedural sedation during endoscopy. The use of reversal agents for sedation recovery following endoscopy is selected as the indicator to measure the appropriate use of sedation.
FEATURE CLINICAL INDICATOR
CI 1.1 Failure to reach caecum due to inadequate bowel preparation Adequacy of bowel preparation is fundamental for optimal bowel examination during colonoscopy. There was no detectable trend between 2011 and 2018 in the annual rate of incomplete colonoscopies due to incomplete bowel preparation, with a reported rate of 0.42 per 100 colonoscopies in 2018. However, subset analysis in 2018 showed a four-fold difference between the rate seen in the 39 private health care organisations (HCOs) compared with the 12 public HCOs, in favour of the private sector. There was also a two-fold difference between the best and worst performing Australian state (0.37 versus 0.78 per 100 colonoscopies). Furthermore, there were 10 outlier HCO records in 2018 with an overall rate of 1.6 per 100 colonoscopies. The reasons for these observations are outside the scope of this report and were not specifically assessed. It may be related to the number and type (free-standing or integrated) of HCOs, patient factors (e.g. comorbidities and ASA class) and the demographic variation across Australian states. The report indicates that there is room for improvement. Clinicians, patients and HCOs can all play important roles in optimising bowel preparation as a necessary first step in performing quality colonoscopy. This is particularly relevant with the increasing emphasis on achieving high quality endoscopy, and this is reflected in the adoption of adenoma detection rate as a clinical indicator in the third version of the ACHS Gastrointestinal Endoscopy Clinical Indicators1 . The Colonoscopy Clinical Care Standard2 published by the Australian Commission on Safety and Quality in Health Care in 2018 also underscores the importance of policies and procedures which support best practice for bowel preparation. There are ample data in the literature to suggest that better bowel cleansing is achieved with a split-dose regimen and with a short ‘runway time’3,4. Clinicians and HCOs can further support patients by enabling access to clear, written instructions, telephone hot-line for inquiries, interpreter services and translated materials.
REFERENCES 1. Australian Council on Healthcare Standards. Gastrointestinal Clinical Indicator User Manual Version 3. Sydney: ACHS; 2018. 2. Australian Commission on Safety and Quality in Health Care. Colonoscopy Clinical Care Standard. Sydney: ACSQHC; 2018 [Available from: https://www.safetyandquality.gov.au/our-work/clinical-care-standards/colonoscopy-clinical-care-standard] 3. Siddiqui AA, Yang K, Spechler SJ, Cryer B, Davila R, Cipher D, Harford WV. Duration of the Interval Between the Completion of Bowel
Preparation and the Start of Colonoscopy Predicts Bowel-Preparation Quality. Gastrointestinal Endoscopy. 2009 Mar;69(3 Pt 2):700-6. 4. Bucci C, Rotondano G, Hassan C, Rea M, Bianco MA, Cipolletta L, Ciacci C, Marmo R. Optimal Bowel Cleansing for Colonoscopy: Split the
Dose! A Series of Meta-analyses of Controlled Studies. Gastrointestinal Endoscopy. 2014 Oct 1;80(4):566-576.
SUMMARY OF RESULTS
In 2018 there were 865 submissions from 77 HCOs for 11 CIs. Ten were analysed for trend, 6 of which improved, 2 deteriorated and the remainder showed no evidence of trend. In 2018, significant stratum variation was observed in 2 CIs. Five CIs showed greater systematic variation, with centile gains in excess of 50% of all events. Outlier gains in excess of 25% of all events were observed in 3 CIs. See Summary of Indicator Results below.
Summary of Indicator Results
Indicator HCOs Aggregate rate %
Best Stratum Outlier HCOS (%)* Outlier Gains (%)+ Centile Gains (%)+ Events# Trend
Failure to reach caecum 1.1 Failure to reach caecum due to inadequate bowel preparation (L) 51 0.421 1.2 Failure to reach caecum due to diseased colon (L) 44 0.219 8 (16%) 113 (25%) 280 (62%) 452 6 (14%) 44 (22%) 127 (63%) 202
1.3 Failure to reach caecum due to instrument failure (L) 1.4 Failure to reach caecum for any other reason (L) 43 0.0011 1
43 0.240 Private 8 (19%) 96 (43%) 190 (86%) 221 Adverse outcomes - colonoscopy / polypectomy 2.1 Treatment for possible perforation post-polypectomy (L) 59 0.0226 2.2 Treatment for possible perforation post-colonoscopy (L) 56 0.0213
2.3 Post-polypectomy haemorrhage (L) 52 0.106
Colorectal cancer 3.1 Malignancies diagnosed at colonoscopy (N) 3.2 Malignancies not detected at another colonoscopy within past 5 years (L) Oesophageal dilatation - perforation 4.1 Oesophageal dilatation - possible perforation (L) Aspiration following GI endoscopy 5.1 Aspiration following endoscopy (L) 28 0.786
12 6.341
40 0.218
48 0.022 Metropolitan 16
6 (40%) 15
2 (4%) 17 (26%) 49 (74%) 66
3 (23%) 13
3 (50%) 6
10 (48%) 21
# Number of undesirable or non-compliant events + % of events that contribute to outlier/centile gains * % of outlier HCOs
