The present prospective, multicentre, national program demonstrated the feasibility of point-of-care practice audit (13
), and provided baseline data on widely endorsed colonoscopy quality indicators (2
). These data will support repeat peer-comparator programs for quality improvement in gastroenterology and endoscopy allied to personal continuing professional development. The current study was smaller than the earlier study (13
); however, it represented approximately 5% of practising Canadian endoscopists (18
). The higher proportion of screening colonoscopies in the current study (37% versus 25% ) was probably due to the increase in colorectal cancer screening across Canada.
These results identify several indicators that are amenable to intervention and improvement. Only 73% of bowel preparations were rated as excellent (17
), indicating the need for improved bowel preparation strategies. The mean cecal intubation rate (94.9%) increased slightly from 92% (13
) but, although it appears acceptable (2
), 10% of participants reported a mean rate of less than 85%. Ileal intubation rates were higher (43.3%) than previously reported (29.1% ) but, unlike mucosal biopsy rates, provincial variations did not appear to be related to the reason for colonoscopy.
The mean withdrawal time of 8.8 min exceeded recommendations (longer than 6 min [8,9]), but 38.7% of participants reported shorter withdrawal times for procedures during which they did not remove polyps and this was associated, as in previous studies (8
), with lower polypectomy rates. Polypectomy, rather than adenoma confirmation or polyp detection, was used as an outcome measure to ensure documentation of clinically relevant lesions while avoiding delays needed to assure adenoma confirmation; the reported rates suggest that polypectomy is comparable with these other measures as a surrogate end point.
The nonlinear relationship between experience and withdrawal time suggests a complex interaction among clinical judgment, technical expertise and practice pressures that may be difficult to modify. Other predictors of withdrawal time, such as the choice of bowel preparation and sedation, are modifiable and should respond to an educational intervention. The identification of outcome predictors does not confirm a causal relationship, but it may indicate why practice and outcomes differ with respect to centre type, colonoscopy indication, bowel preparation adequacy and withdrawal time.
The results of the present study are open to bias because the procedures were selected by the participant and the data were self-reported. However, the outcome of the procedure was unknown when data entry began, thus limiting the participant’s ability to select favourable cases. Bias arising from self-reporting was, perhaps, lessened because data were known to be confidential; additionally, in many cases, procedural data were recorded or confirmed by an endoscopy nurse to reduce the risk of bias.
Ideally, practice audits should include data on delayed adverse events and adenoma detection rates; however, this would have required delayed data entry, including patient identifiers, which is incompatible with point-of-care data collection. Data from national registries such as the Clinical Outcomes Research Initiative (USA) (19
) suggest that 30-day complication rates for screening and surveillance colonoscopy are very low (20
); thus, the reporting requirements for delayed events are inconsistent with the present type of practice audit.
The strengths of the reported methodology are its rapidity, simplicity and ability to collect real-time data with low infrastructure costs. The questionnaire content and format were managed entirely by the investigators and the cost per completed questionnaire was less than US$1.00 (ReForm XT, GoAnyWare Solutions, USA). Questionnaire data were in a standard format, suitable for automated analysis and display at a secure, password-protected, independent website providing rapid practice audit feedback to participants.
The present study indicated that practising colonoscopists were willing and able to undertake practice audit using a flexible, low-cost, platform-independent methodology. The data do not constitute an outcomes registry such as the Clinical Outcomes Research Initiative (19
) or an epidemiological study – the case mix depends on the participating physicians and there is no independent data verification. However, the validity of the data is supported by the finding that the results were broadly similar to those of a previous national program (13
) and by the finding that shorter withdrawal times are associated with lower polyp removal rates (8
Although practice audit enables quality improvement and continuing professional development, it does pose challenges. If participants accept that their performance (eg, cecal intubation rates) is suboptimal, it is not clear who should provide, fund or evaluate their remediation. If, on the other hand, participants do not accept that their outcomes (eg, ileal intubation, mucosal biopsy and polypectomy rates) are inappropriate (21
), it is not clear who should set the appropriate standards.
Overall, performance in the present audit appeared acceptable but some individuals’ performance indicators fell below the norm. Practice audit enables these individuals to confidentially identify their own needs and to seek remedies without stigma. Practice audit also documents systematic differences in practice differences, for example, with respect to ileal intubation or sedation (13
). These needs assessments for individuals and national groups provide a basis for the development of targeted education programs and national guidelines.