Evaluation of the quality of colonoscopies performed by Alberta North Zone surgeons, family physicians and internists: a quality improvement initiative

Michael R. Kolber; Peter J. Miles; Marcus D. Shaw; Hilgard Goosen; Dereck C.M. Mok

doi:10.9778/cmajo.20210237

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Figure 1:
Record flow.

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Table 1:

Characteristics of study endoscopists

Characteristic	No. (%) of participants n = 16
Specialty
General surgeon	9 (56)
Family physician	5 (31)
General internist	2 (12)
Endoscopist sex
Female	4 (25)
Male	12 (75)
No. of years performing endoscopy
< 5	5 (31)
6–10	4 (25)
11–15	2 (12)
> 15	5 (31)
Estimated no. of colonoscopies performed annually
< 150	3 (19)
150–250	4 (25)
251–400	2 (12)
> 401	7 (44)

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Table 2:

Characteristics of study patients

Characteristic	No. (%) of patients^* n = 6212
Sex
Female	3071 (49.4)
Male	3141 (50.6)
Age, yr, mean (range)	56.9 (13–92)
Patient’s first colonoscopy occurred in study^†
Yes	2568 (41.3)
No	3643 (58.7)
Predominant indication category for colonoscopy^‡^§
CRC screening	1757 (28.3)
(FIT positive)	1058 (17.0)
Symptom investigation	2345 (37.7)
Surveillance	1634 (26.3)
Other	474 (7.6)
Location of colonoscopy
Grande Prairie	3364 (54.2)
Hinton	1325 (21.3)
Peace River	721 (11.6)
Whitecourt	398 (6.4)
High Level	234 (3.8)
McLennan	170 (2.7)

Note: CRC = colorectal cancer, FIT = fecal immunochemical test.
↵* Unless stated otherwise.
↵† Missing 1 patient’s first colonoscopy result.
↵‡ Missing 2 patients’ indication results.
↵§ Definitions of indication categories: CRC screening: FIT positive, family history of CRC, Lynch syndrome or familial adenomatous polyposis, average risk screen. Symptom investigation: abdominal pain, diarrhea, constipation, rectal bleeding, anemia. Surveillance: follow-up colonoscopies for inflammatory bowel disease, CRC or polyps. Although individual patients may have had more than 1 indication for their colonoscopy, the endoscopy team chose the predominant indication.

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Table 3:

Individual and overall results — 6 key performance indicators

Physician	Colonoscopies performed, n	Inadequate bowel preparations, no. (%)	Successful cecal intubations, no. (%) [95% CI]	Males ≥ 50 yr with ≥ 1 polyp, no. (%) [95% CI]	Females ≥ 50 yr with ≥ 1 polyp, no. (%) [95% CI]	Moderate or severe discomfort, no. (%)	Withdrawal time (no lesions detected), min, mean ± SD
1	224	8 (3.6)	214 (95.5) [92.8–98.2]	20/27 (74.1) [57.5–90.6]	8/11 (72.7) [46.4–99.0]	6 (2.7)	7.7 ± 2.3
2	376	13 (3.5)	368 (98.1) [96.8–99.5]	32/48 (66.7) [53.3–80.0]	26/41 (63.4) [48.7–78.2]	26 (6.9)	6.1 ± 3.6
3	484	47 (9.7)	469 (96.9) [95.4–98.4]	42/59 (71.2) [59.6–82.7]	30/59 (50.9) [38.1–63.6]	22 (4.5)	6.4 ± 2.5
4	689	29 (4.2)	667 (96.9) [95.7–98.2]	71/103 (68.9) [60.0–77.9]	39/81 (48.1) [37.3–59.0]	58 (8.4)	7.2 ± 2.7
5	816	35 (4.3)	788 (96.6) [95.3–97.8]	65/117 (55.6) [46.6–64.6]	49/106 (46.2) [36.7–55.7)	56 (6.9)	7.7 ± 2.2
6	153	3 (2.0)	150 (98.0) [95.8–100]	25/40 (62.5) [47.5–77.5]	14/28 (50.0) [31.5–68.5]	11 (7.2)	9.8 ± 3.8
7	388	25 (6.4)	381 (98.2) [96.9–99.5]	28/46 (60.9) [46.8–75.0]	19/52 (36.5) [23.5–49.6]	2 (0.5)	11.0 ± 3.8
8	937	38 (4.1)	923 (98.5) [97.7–99.3]	121/152 (79.6) [73.2–86.0]	46/77 (59.7) [48.8–70.7]	5 (0.5)	6.8 ± 2.4
9	298	11 (3.7)	295 (99.0) [97.9–100]	47/63 (74.6) [63.9–85.4]	29/49 (59.2) [45.4–72.9]	33 (11.1)	6.8 ± 4.5
10	471	24 (5.1)	436 (92.6) [90.2–94.9]	11/20 (55.0) [33.2–76.8]	5/18 (27.8) [7.1–48.5]	55 (11.7)	5.7 ± 2.8
11	390	17 (4.4)	374 (95.9) [93.9–97.9]	38/62 (61.3) [49.2–73.4]	25/52 (48.1) [34.5–61.7]	26 (6.7)	7.2 ± 3.4
12	64	4 (6.3)	56 (88.9) [81.1–96.6]	3/13 (23.1) [0.2–46.0]	3/7 (42.9) [6.2–79.5]	6 (9.5)	8.3 ± 3.4
13	438	10 (2.3)	419 (95.7) [93.8–97.6]	25/69 (36.2) [24.9–47.6]	19/62 (30.6) [19.2–42.1]	31 (7.1)	6.2 ± 3.9
14	397	20 (5.0)	386 (97.2) [95.6–98.8]	47/61 (77.0) [66.5–87.6]	29/44 (65.9) [51.9–79.9]	10 (2.5)	8.9 ± 3.6
15	47	2 (4.3)	47 (100) [100–100]	9/9 (100) [100–100]	5/9 (55.6) [23.1–88.0]	3 (6.4)	13.4 ± 5.0
16	40	2 (5.0)	33 (82.5) [70.7–94.3]	8/9 (88.9) [68.4–100]	2/3 (66.7) [13.3–100]	7 (17.5)	7.8 ± 2.1
Totals	6212 [95% CI^*]	288/6209^† (4.6) [3.6–5.7]	6006/6209^‡ (96.7) [94.5–99.0]	592/898 (65.9) [56.4–75.4]	348/699 (49.8) [42.5–57.1]	357/6208^§ (5.8) [3.5–8.0]	7.3^¶ ± 3.4

Note: CI = confidence interval, SD = standard deviation.
↵* Since variability in endoscopist outcomes is likely due to a combination of both patient-related factors (age, sex, indications) and endoscopist performance, we performed a cluster-level analysis to correct the confidence intervals of the overall findings.
↵† Number of procedures for which inadequate bowel preparation was captured.
↵‡ Number of procedures for which cecal intubation was captured.
↵§ Number of procedures for which patient discomfort was captured.
↵¶ 3095 procedures occurred in which no lesions were detected.

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Table 4:

Key performance indicator benchmarks achieved by endoscopists

Key performance indicator	Benchmark	Overall mean, %^*	Individual endoscopist, range, %^*	No. of endoscopists achieving benchmark^†
Bowel preparation	< 10% inadequate	4.6	2.0–9.7	16
Cecal intubation	≥ 90%	96.7	82.5–100	14
Polyp detection: males	≥ 45%	66.1	36.2–88.9	15
Polyp detection: females	≥ 35%	49.8	27.8–72.7	14
Patient discomfort	≤ 10%	5.6	0.5–17.5	13
Withdrawal time	≥ 6 min	7.3	5.7–13.4	15
Additional outcomes
Sedation level of consciousness	≤ 33% unresponsive	54.9	5.4–99.2	7
Polyps per 100 scopes	NA	121.4	42.7–218.1	NA

Note: KPI = key performance indicator, NA = not applicable.
↵* Unless stated otherwise.
↵† Number of endoscopists achieving all 6 KPIs = 11. Number of endoscopists achieving 6 KPIs and sedation benchmark = 4.