The Quality Improvement in Colonoscopy (QIC) Study: Improving Adenoma Detection Rates and Reducing Variation between Colonoscopists

Abstract

Introduction
Adenoma detection rate (ADR) is an established quality marker in colonoscopy. Significant variability in ADR exists. Withdrawal time of ≥ 6 minutes; Buscopan use; position change and rectal retroflexion have been shown to improve lesion detection. We evaluated the feasibility and clinical outcome of implementing these measures, as a ‘bundle’, into routine practice to improve ADR. Factors influencing uptake were evaluated in a qualitative study.

Methodology
Twelve units participated. All nominated a lead colonoscopist and nurse. Implementation combined central training, local leadership, feedback and continuous central support. The 3 months prior to implementation was compared to a 9 month period after. Colonoscopists performing ≥ 25 procedures during the baseline period were ranked in quartiles by ADR. Buscopan use was used as a surrogate marker for uptake. Changes were evaluated using a corrected Chi Squared test. For the qualitative study, units and individuals were purposively sampled to ensure a range of units were included. Semi-structured interviews were conducted until saturation was reached. Data were evaluated using thematic analysis.

Results
Global and quartile analyses comprised data from 118 and 68 colonoscopists performing 17, 508 and 14,193 procedures respectively. There was a significant increase in Buscopan use globally (15.8% vs. 54.4%, p<0.001) and in each quartile. The ADR also increased significantly globally (16.0% vs. 18.1%, p=0.002), with a significant reduction in variation. Interviews were conducted with 8 lead and 3 non-lead colonoscopists and 1 lead nurse. Increased emphasis on examination time, awareness of ADR as a quality marker and empowerment of endoscopy nurses to encourage the use of quality measures were positive outcomes of the intervention. Challenges included difficulty in arranging set up meetings and engaging certain speciality groups.

Discussion
This evidence based educational intervention resulted in a significant change in behaviour, evidenced by increased Buscopan use. A significant increase in the global ADR and reduction in variation between quartiles was observed. Other positive outcomes included increased awareness of colonoscopy quality and empowerment of endoscopy nurses to promote quality measures. This study demonstrates that simple interventions can significantly change practice and improve quality. The timing of meetings and strategies to engage speciality groups are important.