Pediatric Colonoscopy Quality Indicators

See “A Single-center Review of Pediatric Colonoscopy Quality Indicators” by Pasquarella et al on page 648. The assurance that a high-quality colonoscopy is being performed is an increasingly expected standard. Quality indicators are required for use by endoscopists and endoscopy units to monitor and improve the overall quality of endoscopic care (1). Although cecal intubation rate and adenoma detection rate are considered standard quality metrics for adult colonoscopy, neither is ideal for children. Indications for pediatric colonoscopy are quite different, with the most common indication in children being the exclusion of inflammatory bowel disease, which requires terminal ileal (TI) intubation. Complete ileocolonoscopy is essential to optimize diagnostic yield (2,3). TI intubation rate is, therefore, a key quality indicator for pediatric colonoscopy. In this issue, Pasquarella et al (4) report on quality indicators for nearly 400 colonoscopies at a single center and attempt to evaluate reasons for failed TI intubation. This study demonstrates a nearly 95% cecal intubation rate and 91% TI intubation rate. Approximately 3% of failed TI intubations were attributed to disease severity; a factor, which is difficult to mitigate as the examination must often be limited in severe disease to prevent complications. An additional 1.4% were because of inadequate bowel preparation. Although bowel preparation quality can be improved through proper measurement, preparation optimization, and quality improvement initiatives, there will always be some inadequate preparations. Meanwhile, approximately 5% of incomplete procedures were likely related to technical difficulties. These results demonstrate that high rates of cecal and ileal intubation are achievable in pediatric colonoscopy. We suggest that attainment of high-quality standards is only possible through transparency in quality measurement and teamwork. TRANSPARENCY Quality in endoscopy can only be improved through transparency regarding quality indicators used to assess performance and how these indicators are being monitored to provide feedback. Endoscopic providers and users can only know whether high-quality care is being delivered if it is measured. Quality indicators provide a framework and benchmarks against which endoscopists and endoscopy units can assess their service. A NASPGHAN clinical report on quality in endoscopy suggested a target standard of 90% for TI intubation rate (5). A recent consensus conference was held by the Pediatric Endoscopy Quality Improvement Network (PEnQuIN), a joint NASPGHAN and ESPGHAN initiative, to define quality and safety standards and indicators tailored to pediatric endoscopic practice. These performance measures will help to create the basis for accountability and quality improvement and increase transparency about patient care processes and outcomes, with the ultimate goal of improving the quality and efficiency of patient and family-centered care. Setting minimum and target standards for quality metrics, such as TI intubation rate, and monitoring performance incentivizes improvement; when endoscopists see their own data, it is likely to result in centers across the country matching the intubation rates presented in this study. We suggest that endoscopy directors and institutions monitor quality metrics, such as TI intubation rate and provide direct feedback to providers on their own personal data to foster improvement in endoscopic care. Ultimately, the goal is not meeting quality targets, but to deliver the highest quality healthcare possible. The study by Pasquarella et al (4) demonstrates that cecal and TI intubation rate quality indicators are attainable in clinical practice, and being transparent of the goal rate is the first step towards meeting indicators. In addition, the study demonstrates that the mean colonoscopy duration is approximately 40 minutes and that the addition of a trainee adds approximately 8 minutes to a procedure. These data are important as time can be considered another quality metric. TEAMWORK We suggest the study by Pasquarella et al (4) provides an ideal strategy to meet quality indicator goals: teamwork. Perhaps the most striking finding of the study by Pasquarella et al (4) is the sharp contrast in TI intubation rates between the operating room and the endoscopy suite (78.6% vs 96.0%). Although one would postulate that disease severity is the primary driver, the authors found that technical difficulties and miscellaneous factors accounted for this significant variation. Interestingly, the only difference between sites was that colleagues and/or the endoscopy director were typically available to assist in the endoscopy suite but not the operating room. Or, to state this in another manner, teamwork amongst colleagues was the primary difference between sites and likely the primary driver for improved quality and completion rates. Although teamwork in endoscopy has traditionally referred to interprofessionals within the endoscopy suite working to achieve a common goal (6), we suggest teamwork also encompasses collaboration amongst colleagues to provide assistance whenever required. Data regarding the number of endoscopies that required assistance from a colleague are not reported in this study; however, one could postulate that up to 15% of colonoscopies required some assistance, given the difference in TI intubation rates across settings. Recent adult data suggest that upwards of 300 colonoscopies are necessary to achieve a 90% cecal intubation rate and meet competency benchmarks on the Assessment of Competency in Endoscopy (ACE) assessment tool (7). Meanwhile, NASPGHAN Training Guidelines only recommend 120 colonoscopies by the end of training (8). The aforementioned adult study reports a mean cecal intubation rate of approximately 80% after 120 colonoscopies, further suggesting that new pediatric graduates may need assistance with 15% to 20% of their procedures. Additionally, a recently published abstract outlining data from 12 North American pediatric centers (154 practicing endoscopists and 5765 colonoscopies) found that practicing pediatric endoscopists perform a median of 31.5 (interquartile range [IQR]: 17–53) colonoscopies per year (9). Given these data, one can postulate that up to 6 years of practice may be necessary for new graduates to accumulate 300 colonoscopies. Therefore, one would suggest that requiring assistance in up to 15% to 20% of cases should be the norm for the first 3 to 6 years in practice, and even thereafter, a smaller percentage of colonoscopies will likely need assistance. Teamwork to provide assistance for technically difficult procedures requires available expertise and a culture that supports asking for help. Endoscopy directors and senior providers typically have the expertise. However, with increasing demands on time, pressures to maximize productivity and more satellite or split campuses at many institutions, the availability of expert colleagues has decreased. Assistance with colonoscopy by the endoscopy director is a core component of the job; however, it is often not recognized or valued by institutions in the age of deliverables. The blueprint provided by this study starts with protecting time for the endoscopy director and/or senior providers to assist with technically difficult procedures and providing increased protected time when new endoscopists are hired to ensure they feel supported. It is important for endoscopic services to ensure a backup system is in place. Having clear protocols in place would help to ensure easier access to support whenever required and help to prevent unsafe and uncomfortable situations from arising. Finally, in an era where asking for help can be viewed as a sign of weakness and threaten ones credibility, practices should strive to create a culture whereby help-seeking behavior is not only encouraged but is considered a requirement. Research outside of healthcare field suggests that the majority of what people learn at work is learned informally on-the-job from their colleagues (10). It is essential to ensure the accessibility of expertise and to foster a work environment in which individuals trust and respect each other (11). Availability of colleagues may also facilitate proctoring and competency assessment to help identify target areas for improvement. It is important for institutions to foster an open, nonjudgmental, dialogue about endoscopic competence among faculty from all levels of practice. This will help to cultivate a positive culture that encourages or even incentivizes retraining and upskilling to ensure maintenance of competence. SUMMARY In summary, high-quality endoscopic care improves both patient outcomes and patient experience. The path to quality starts with an effort to define key pediatric quality indicators that impact the quality and safety of care. Transparency regarding key quality metrics, minimum and target standards, and monitoring and feedback processes are necessary to take the next steps towards being measured by quality of care rather than volume of care. These quality indicators include TI intubate rate and the study by Pasquarella et al (4) demonstrates that a 90% TI intubation rate is achievable. We highlight the fact that high-quality care is only attainable within a culture of teamwork, whereby expertise is available and providers are encouraged to ask for assistance. As medicine moves towards outcome measures for payment rather than volume measures, pediatric gastroenterologists have a golden opportunity to demonstrate the ability to meet benchmarks for quality indicators in endoscopy. More importantly, the pediatric gastroenterology community should not wait for changes in healthcare reimbursement. Instead, by defining and monitoring quality indicators, developing a culture of teamwork, and providing feedback to providers we can not only improve the quality of endoscopic care but also stay ahead of healthcare changes.

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