In this study, we looked at 110 colonoscopy reports sampled from endoscopists in 22 of Maryland's 24 jurisdictions, for a time period of 3 to 4 years after publication of the MSTF-CRC recommendations but before the publication of CO-RADS. We found that certain key quality indicators were not consistently well documented by endoscopists in their colonoscopy reports prior to the publication of CO-RADS including patient risk and comorbidity, quality of the bowel preparation, and polyp size and morphology.
CO-RADS recommends use of the ASA classification to document risk and comorbidity [20
]. For patients with an ASA class 3 or higher, colonoscopy should be performed in a hospital or a setting with full capacity for resuscitation and support [20
]. In our study, almost two thirds of reports lacked any comorbidity documentation. Only 15% of reports provided the ASA class. While most patients were seen for a prescreening or complete physical exam prior to the endoscopy, where the endoscopist reviews the patient's prior history and documents it in the office record, this information was not always included in the colonoscopy report.
It has been reported that interval cancers within 1 to 4 years of screening colonoscopy could result from missed lesions or incomplete adenoma removal [24
]. In fact, computed tomographic colonography studies have shown that optical colonoscopy missed 2%–12% of polyps larger than 10
]. Missing lesions may be attributed to inadequate bowel preparation, an incomplete procedure, or failure to identify a lesion due to inadequate time spent examining the colonic mucosa. Inadequate bowel preparation not only limits the visibility of the mucosa and prolongs cecal intubation time and withdrawal time, but it also leads to a shorter interval for the next exam [12
]. Our results revealed that about 25% of reports lacked any mention of bowel preparation quality and another 20% of reports used ambiguous terms to describe the quality. We have heard anecdotally from some programs that some endoscopists “chart by exception”, meaning they only mention the quality of the bowel preparation when it is inadequate. However, CO-RADS recommends that endoscopists explicitly document whether they believe bowel preparation was adequate to allow the detection of lesions larger than 5
Ensuring complete examination of the colon helps reduce the possibility of missing lesions. All colonoscopy reports in our study mentioned the extent of the examination; however, 18% did not provide information on specific cecal landmarks. Short withdrawal time may be associated with detecting fewer adenomas [28
]. We found only one report that documented the withdrawal time. However, our study period predated the publication of the association between withdrawal time and adenoma detection rates and the subsequent recommendation to document the withdrawal time in colonoscopy reports.
Polyp characteristics are important factors in assessing risk for malignancy and recurrence of advanced lesions, and in determining the follow-up interval [29
]. In this study, size information was absent for 13% of individual polyps. In up to one third of individual polyps, size was described solely with qualitative terms such as “small” or “large.” Moreover, different endoscopists used different qualitative terms to describe same-sized polyps. CO-RADS recommends reporting polyp size in millimeters. This facilitates determination of the appropriate interval for follow-up exams and clear communication between the endoscopist and the referring physician and patient. While exact measurement of polyp size during the endoscopy may be difficult—given that the endoscope contains no measuring device—many endoscopists use the open biopsy forceps to estimate polyp size. According to CO-RADS, polyp morphology should be documented as pedunculated, sessile, or flat. In our study these specific morphologic descriptions were absent for almost half of the identified individual polyps, though other descriptors were often used. It may be that some endoscopists only include morphologic descriptions for larger polyps where the morphology was clearly sessile, flat, or pedunculated. Indication of whether a polyp was completely removed is a key factor to predict the risk for recurrence of an adenoma and the risk for CRC, and to set the recall interval. CO-RADS recommends including this information in the colonoscopy report. However, this was not always clear in our study. Although “removed” probably meant “completely removed” in many places, we recommend that endoscopists assess the completeness of removal of each polyp (or lack thereof) and clearly state this in the colonoscopy report.
To our knowledge, only a few studies have directly evaluated quality in colonoscopy reporting [17
]. In 2002, Robertson et al. assessed quality of colonoscopy reporting by reviewing a single colonoscopy report from 122 independent endoscopy centers across the nation [17
]. Overall, the quality of colonoscopy reporting in Robertson's study was poorer than what we found in our study. In Robertson's study, all colonoscopy procedures were performed on colorectal cancer patients to detect cancer recurrence [17
]. The study claimed that local customs and template sharing may result in less variation within and across healthcare facilities [17
]. For our study, we used data from colonoscopies performed throughout a statewide colorectal cancer screening program. This program routinely collects available information on extent of examination, quality of bowel preparation, and number, size, and type of polyps. LHD may have emphasized the need for these data elements for program-patient management over the years. Recently, Lieberman et al. evaluated the quality of colonoscopy reports in 73 U.S. gastroenterology practice sites that used a structured computerized endoscopy report generator. In our study, we analyzed all types of reports, not just those from computerized report generators. Because of the standard use of a computerized report generator among the centers in the consortium, Lieberman's study was biased toward finding high rates of completion of quality indicators [19
The findings of our study are subject to the following limitations. First, our study was not population based in that it did not include every endoscopist in Maryland; it did, however, include 110 gastroenterologists and surgeons from throughout Maryland who were contracted in the CRC screening program. Second, inclusion of only one report per endoscopist may not adequately represent his/her reporting quality or the change in quality over time.
Many endoscopists use a reporting tool to generate their reports. The format and choices in such tools may not follow CO-RADS and may thus limit the ability of endoscopists to easily include all the CO-RADS elements. Also, the lower reporting rate of certain quality indicators on the colonoscopy report may reflect the fact that these items were routinely recorded in the other parts of the medical record and not duplicated in the colonoscopy report. The colonoscopy team includes the endoscopist, anesthetist or anesthesiologist, and nurses and technicians providing care to the patient. The patient's medical history is reviewed by the endoscopist and anesthesiologist and probably recorded elsewhere. If an anesthesiologist is administering the sedation, he or she will keep a separate record for the patient's chart. Nurses and technicians working in the endoscopy suite maintain records concerning the documentation of informed consent, type and upkeep of the endoscope, as well as specimens that are retrieved and sent to pathology. Nevertheless, the American Society for Gastrointestinal Endoscopy (ASGE) guideline published in 1999 suggested these elements should be included in a single colonoscopy report [17