Recommendations for the quality of colonoscopy services are summarized in Table . The following describes the basis for these recommendations.
Elements of Quality of Colonoscopy Services with Operational Definitions
1. Elements of the Colonoscopy Report
We listed six basic descriptors of what was done and what was found during the colonoscopy based on earlier work by Task Group8
. Each of these descriptors is necessary to interpret the clinical significance of findings and plans for follow-up.
- Depth of insertion is related to the proportion of the colon examined and thus the percent of adenomas and cancers that could have been found. Confidence in a report that the cecum was reached should be supported by a clear description of anatomic landmarks (appendiceal orifice and ileocecal valve) and photo documentation if it is available.
- Quality of bowel preparation. Poor bowel preparation results in missed lesions and follow-up examinations scheduled sooner than the usually recommended interval. The quality of bowel cleansing is a subjective measure, but efforts are under way to increase reproducibility and validity by establishing a common measure across endoscopists8 and to anchor judgments in an objective phenomenon such as “adequate to detect polyps >5 mm”8.
- Patient tolerance of the procedure is important information for the clinician who coordinates the patient’s care over time. For example, syncope during the bowel preparation or procedure may signal cardiovascular risk and require evaluation; bleeding from the procedure may cause anemia, which should be diagnosed and treated.
- Description of polyps. The number, size, location, morphology (pedunculated, sessile, or flat) and histology of adenomas has been related to recurrence rate and this, plus completeness of polyp removal and biopsy results are the basis for planning surveillance intervals10.
- Pathology results for any biopsies. Recommendations for follow-up and surveillance depend on information from both the procedure itself and the pathology report. Despite logistic challenges in obtaining pathology reports promptly, referring clinicians should expect that the colonoscopist will promptly communicate findings from the procedure itself, the pathology, as well as recommendations both to them an directly to the patient.
- Recommendations for follow-up and/or surveillance need to be explicit so that referring clinician, as well as the patient, know what the endoscopist has recommended. Recent, evidence-based guidelines, relating surveillance interval to risk factors for subsequent advanced neoplasia, are summarized in Table 11. If the recommended interval differs from guidelines, the reasons should be made explicit.
Recommended Surveillance Intervals After Polypectomy in Average Risk Patients (From 11)*
Physicians in practice say they often choose shorter surveillance intervals11
than recommended in clinical practice guidelines. Because some risks and substantial costs (measured both in financial and human terms) are at stake, and the clinical benefit of short-interval colonoscopy surveillance after initial polypectomy is low for most patients12
, the surveillance interval is an important decision for everyone involved with the patient’s careFamily history information gathered at the time of screening as well as some colonoscopy findings (such as a malignancy or advanced adenomas at a young age) may suggest that other family members are at increased risk and should have earlier than usual screening with colonoscopy. In the case of Lynch Syndrome, they are at increased risk for other cancers as well. The endoscopy report should include recommendations for colorectal cancer screening in family members when appropriate. The endoscopist and the primary care clinician have a collective responsibility for encouraging patients to notify family members if they are at increased risk, and for recommending that these family members talk with their own primary care clinician about colorectal cancer screening.
2. Cecal Intubation Rate
Clinically-important adenomas and cancers occur throughout the colon and will be missed to the extent that the entire colon is not examined. Reports of consecutive screening colonoscopies have established that cecal intubation rates of over 90% are achievable13–18
, especially in patients without clinical reasons for incomplete colonoscopies such as severe colitis, poor preparation, severe diverticulosis, vital sign instability during the procedure17
. Several expert groups have set a quality target of 90% or higher for cecal intubation rate7,19
. Screening guidelines recommend that if the cecum cannot be reached other imaging procedures (computed tomographic colonography or double contrast barium enema) should be used to complete the examination1
.We concluded that an average cecal intubation rate of at least 90% was achievable after excluding examinations that were terminated for clinical reasons and those for which full colonoscopy was not the original intent. Rates are lower in some settings6,20,21,
but there is evidence that rates can be improved by quality improvement programs21
. We recommend that all endoscopists should aim to meet this target, regardless of specialty, training, or experience.
3. Adenoma Detection Rate
The prevalence of adenomas at age 50 years is estimated to be 15% in women and 25% in men, increases with age in both sexes7
, and the majority of adenomas are detected by colonoscopy22,23
. It is not feasible to measure the proportion of adenomas found for individual colonoscopists against research standards, (a second colonoscopy and computed tomographic colonography) so we chose adenoma detection rates as a crude metric for the proportion of adenomas found at colonoscopy. Adenoma detection rate during screening colonoscopy has been shown to be inversely related to the risk of interval cancers24
. We confined this quality measure to first colonoscopies because prior polypectomies can change the prevalence of adenomas, making polyp prevalence lower and detection rates more difficult to interpret.
4. Safe Setting
Colonoscopy can cause clinically-important complications such as bleeding, perforation, and cardiovascular events during bowel preparation or endoscopy. The procedure can also spread infection if equipment is improperly cleaned and disinfected. Although the great majority of colonoscopies occur without incident, complication rate is an important aspect of quality. However, we chose not to include complication rates in the quality measures because events occur too infrequently to allow stable estimates of rates for individual colonoscopists, unless he or she has performed an unusually high volume of procedures.Instead, the panel recommended that safety be assessed by a surrogate measure, characteristics of the setting in which procedures are done. Among these are adequate cleaning and disinfection of equipment, well-maintained equipment, well-trained endoscopist and staff, and the ability to react to emergencies that might arise during the procedure25
.While some states and professional societies have guidelines for safe settings and requirements for accreditation, primary care clinicians cannot always rely on external review to decide whether the colonoscopy setting is safe. At this time, there is no single, overall mechanism for credentialing that applies to all specialties that do colonoscopy and in all settings in which it is done.