assessing usaf primary care colonoscopy training and outcomes using quality indicators brian...

Assessing USAF Primary Care Colonoscopy Training and

Outcomes Using Quality Indicators

Brian Crownover, M.D., FAAFP Ethan Zimmerman, M.D.

Family Medicine Residency Nellis AFB, NV

Goals of QI review

Describe training experience of Family Medicine colonoscopy trainers in USAF

Use outcomes based indicators to represent quality of USAF primary care colonoscopy

Measure results against national standard quality indicators

USAF Primary Care Endoscopists

Who? ● Teaching faculty at 4 US Air Force Family

Medicine residency locations who perform colonoscopy

● NW Florida, N Calif, Las Vegas, St Louis

What? ● Type and amount of training received● Self-collected procedure log data – post training

Primary Quality Indicators

Adenoma Detection Rate

Cecal Intubation Rate● Recommended ≥ 95% for screening

colonoscopy

Primary Care Endoscopy

Why evaluate quality indicators?

● Primary care under attack from Gastroenterology

● Polypectomy reduces CRC mortality 53%● NEJM 2012; 366(8):687

● Only 65% Americans receive appropriate CRC screening

● https://healthmeasures.aspe.hhs.gov/measure/25

https://healthmeasures.aspe.hhs.gov/measure/25

Specialty differences from: Ko et al.

ADR?

Ko et al.

“Polyp detection and removal rates were significantly lower for nongastroenterologists than gastroenterologists”

ACG/AGA/ASGE – ADR Working Gp

Screening Colonoscopy Adenoma Detection Rate Measure- Draft: Public Comment (6/2012)

Numerator: Number of patients age 50‐75 with at least one adenoma detected during screening

Denominator: Patients age 50‐75 undergoing a screening colonoscopy

Exclusions: Incomplete colonoscopy Measure: The percentage of patients age 50‐75

with at least one adenoma detected Adobe Acrobat

Document

Published GI Norms (PDR Surrogate for ADR)

Screening Williams JE 2011

Number patients 2,706

Location USA - VA

Number endoscopists 15 @ 1 site

Specialty Gastroenterology

Years Experience (mean) 18

Cecal intubation rate 97

PDR / ADR – all (%) Not reported

PDR / ADR mean – male (%) 43.5 (18-66) / 29.5 (15-45)

PDR / ADR mean – female (%) 25.8 (11-43) / 12.7 (6-26)

Cancer detection rate (%) 0.36

PRs correlated well with ADRs (r(s) = 0.86, P < .001).

To attain the established benchmark ADRs for men (25%) and women (15%), endoscopists needed PDRs of 40% and 30%, respectively.

Published GI Norms

Screening Cooper 2005

Number patients 1.8 Million – all ≥ 65yo

Location US Medicare Claims data

Number endoscopists Not reported

Specialty Not reported

Years Experience mean Not reported

Cecal intubation rate Not reported

PDR / ADR mean– all (%) 35.7 / ----

PDR / ADR mean – male (%) 41.2 / ----

PDR / ADR mean – female (%) 31.5 / ----

Cancer detection rate (%) Not reported

Published GI Norms

Screening Imperiale 2009

Number patients 2664

Location Indiana, Eli Lilly Corp

Number endoscopists 25


Years Experience Not reported


PDR / ADR mean– all (%) 35 (13-82) / 19 (7-44)

PDR / ADR mean – male (%) 40 / 24

PDR / ADR mean – female (%) 28 / 13


Published GI Norms

Screening Goncalves 2011

Number patients 1545

Location Portugal


Specialty GI staff/fellows

Years Experience Not reported


PDR – all (%) 33 / ----

PDR – male (%) 44 / ----

PDR – female (%) 25 / ----


Published GI Norms

Screening Chen, Rex 2007


Location Indiana


Specialty Gastroenterology staff

Years Experience mean 9

Cecal intubation rate ≥ 93

PDR / ADR mean– all (%) ---- / (15.5-41.1)

PDR / ADR mean – male (%) ---- / 28.1

PDR / ADR mean – female (%) ----/ 19.2

Cancer detection rate (%) Not reported

Published GI Norms

Screening Lieberman 2000

Number patients 3121 VA pts (98% men)

Location 13 VA centers



Years Experience mean “Extensive”

Cecal intubation rate 97.7

PDR / ADR mean– all (%) ---- / ----

PDR / ADR mean – male (%) 53.8 / 37.5

PDR / ADR mean – female (%) ---- / ----


Published GI Norms

Screening Heitman 2009 Meta-Analysis

Number patients 18 pooled studies Avg Risk Pts

Location Various





PDR / ADR mean– all (%) ---- / 30.2 (random effects model)

PDR / ADR mean – male (%) ---- / ----



Published GI Norms

Screening Cotton 2003


Location 7 Academic Centers N. America

Number endoscopists 69 using GI-TRAC software


Years Experience mean All > 50 cases


PDR / ADR mean– all (%) ---- / ---- (none reported)

PDR / ADR mean – male (%) ---- / ----


Cancer detection rate (%) ----

Data reported in arbitrary group thresholds, not comparable to other published data

Published FM Norms

Screening Kolber 2009

Number patients 1178 (1/4 c/o bleeding)

Location Rural Canadian practice


Specialty Family Med

Years Experience mean Covered 0-8 yrs post trng


PDR / ADR mean– all (%) ---- / 23.0

PDR / ADR mean – male (%) ---- / 29.8

PDR / ADR mean – female (%) ---- / 18.0


Published FM Norms

Screening Kolber 2010

Number patients 577 over 2 months

Location Multisite Canada


Specialty Family Med – 8, Internal Med - 2



PDR / ADR mean– all (%) ---- / ----

PDR / ADR mean – male (%) ---- / 46.4


Cancer detection rate (%) ----

Published FM Norms

Screening Eckert 2009

Number patients 660 – all Asx > 50yo

Location US Army base

Number endoscopists 1 (newly credentialed)

Specialty Family Med

Years Experience mean First 4 yrs post training (residency)


PDR / ADR mean– all (%) ---- / 27.1

PDR / ADR mean – male (%) ---- / 33.7



Published FM Norms

Screening Wilkins 2009


Location Misc: Meta-analysis


Specialty Primary Care – mostly Family Med


Cecal intubation rate 89.2 (92.0 if only include sedated cases)

PDR / ADR mean– all (%) ---- / 28.9

PDR / ADR mean – male (%) ---- / ----



Published Norms

Screening Denis 2011

Number patients 5852 (all were FOBT +)

Location France



Years Experience mean “Extensive”


PDR / ADR mean– all (%) 43 / 35.6 (14.3-53.4)

PDR / ADR mean – male (%) 52 / 45.2

PDR / ADR mean – female (%) 33 / 26.3


So what did we find???

Descriptive Statistics

Location Number of Teaching Faculty

Eglin AFB (NW Florida) 5

Nellis AFB (Las Vegas) 4

Scott AFB (St Louis) 2

Travis AFB (N. California) 3

14 total

Descriptive Statistics prior to independent practice

Preceptor for training cases Mean % (sd)

General Surgeon 6 (16)

Gastroenterologist 32 (33)

Family Physician 62 (31)

Descriptive Statistics prior to independent practice

Additional Training N (%)

Fellowship 0 (0)

Simulator 8 (57)

CME conference (NPI, State chapter) 6 (43)


Experience in training Mean (sd)

Cases prior to independent practice

117 (60)

Years of practice post training 2.6 (1.3)

Post training cases - all 207 (191)

- males 101 (91)

- females 83 (87)


Performance Mean (sd)

Withdrawal time w/o trainee 22 (7) minutes

Withdrawal time with trainee 26 (4) minutes

Cecal intubation rate 97 (3) percent

Adenoma detection rate (ADR)

- ALL 27.8 (9.3)

- MALES 33.7 (10.7)

- FEMALES 21.6 (9.8)

Cancer detection rate 0.74 (0.69) cases per 100 patients

Specialty Comparison

Gastroenterology Family Medicine

USAF GME FM Faculty

ADR – total 19, 32, 15.5-41.1 23, 27.1, 28.9 27.8

ADR – male 24, 28, 29.5, 37.5 29.8, 33.7, 46.4 33.7

ADR – female 12.7, 13, 19.2 18, 21.6, 30.2 21.6

Cecal intubation rate 88, 91, 97, 98 89, 92, 97, 98.6 97

Cancer detection 0.3, 0.36, 1.0 0.75, 1.7, 2.1 0.74


Indication for colonoscopy N (%) Mean (sd) per faculty

Average Risk 1819 (82) 165 (152)

High Risk (prior polyps, +Fam hx) 359 (16) 33 (36)

Extreme Risk (genetic syndrome, IBD, CA) 2 (0) 0 (1)

Diagnosis of symptoms (bleeding, pain) 43 (2) 3 (8)

Total (indication tracked) 2223

TOTAL CASES DONE 2893

*Small % Diagnostic cases d/t GI input into referral mgt process


Complications N (mean per 100 cases)

Nausea/Vomiting 27 (1.2)

Rescue (need assist to complete) 25 (2.0)

Hypotension 17 (1.1)

Bradycardia 13 (0.8)

Inability to biopsy/remove polyps 7 (0.6)

Agitation 5 (0.3)

Bleeding endoscopic cautery req 3 (0.1)

Bleeding admitted postop 2 (0.1)

Perforation 1 (0.1)

Post-polypectomy Syndrome 0

OVERALL 100 (3.9)

Correlations

Training experience to ADR

● No correlation to receipt of simulator training Fisher's Exact Test (two-sided) p-value = 0.083

● No correlation to CME conference attendance Fisher's Exact Test (two-sided) p-value = 0.4755

Correlations with ADR

Quality factor R2 correlation coefficient

Training by Surgery 0.008

Training by GI 0.192

Training by Family Med 0.242

Cases done prior to independence 0.090

Cases done as independent faculty 0.001

Years experience 0.149

Bottom line: No significant correlation with independent factors and ADR

Take home points

Recently trained faculty working with residents achieve high quality ADR rates (27.8%) comparable to published GI and FM numbers● Mean 2.6 years experience, 207 cases post training

(117 cases in training)

Complications rates were low No correlations were found between training

experience variables and ADR

Questions?

Biblio

Rex DK, Petrini JL, Baron TH, et al. Quality Indicators for Colonoscopy. Am J Gastroenterol 2006;101:873–885

Kaminski MF, Regula J, Kraszewska E, et al. Quality Indicators for Colonoscopy and the Risk of Interval Cancer. N Engl J Med 2010; 362: 1795‐803.

Biblio

Cooper GS, Chak A, Koroukian S. The polyp detection rate of colonoscopy: A national study of Medicare beneficiaries. American Journal of Medicine 2005; 118, 1413.e11‐1413.

Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. NEJM 2000; 343: 162-8.

Biblio

Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012 Feb 23;366(8):687-96.

Imperiale TF, Glowinski EA, Juliar BE, et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc.2009 Jun;69(7):1288–95

Biblio

Williams JE, Le TD, Faigel DO. Polypectomy rate as a quality measure for colonoscopy. Gastrointest Endosc 2011;73(3):498–506.

Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007;102(4):856-61.

Biblio

Goncalves AR, Ferreira C, Marques A, et al. Assessment of quality in screening colonoscopy for colorectal cancer. Clin Experimental Gastroenterology 2011;4: 277–281.

Denis B, Sauleau EA, Gendre I, et al. Measurement of adenoma detection and discrimination during colonoscopy in routine practice: an exploratory study. Gastrointest Endosc. 2011;74(6):1325-36.

Biblio

Ko CW, Dominitz JA, Green P, et al. Specialty differences in polyp detection, removal, and biopsy during colonoscopy. Am J Med 2010;123 (6): 528–35.

Kolber M, Szafran O, Suwal J, et al. Outcomes of 1949 endoscopic procedures. Can Fam Physician 2009; 55(2): 170–175.

Biblio

Kolber M. Prospective Study of the Quality of Colonoscopies performed by Primary Care Physicians in Alberta, Canada – The Alberta Primary Care Endoscopy (APC –Endo) Study. ClinicalTrials.gov Identifier: NCT01320826. Publication pending

Eckert LD, Short MW, Domagalski JE, et al. Assessing Colonoscopy Training Outcomes Using Quality Indicators. J Grad Med Educ 2009;1(1):89-92.

Biblio

Wilkins T, LeClair B, Smolkin M, et al. Screening colonoscopies by primary care physicians: a meta-analysis. Ann Fam Med 2009;7(1):56-62.

Cotton PB, Connor P, McGee D, et al. Colonoscopy: practice variation among 69 hospital-based endoscopists. Gastrointest Endosc 2003;57(3):352-357.

Biblio

Heitman SJ, Ronksley PE, Hilsden RJ, et al. Prevalence of adenomas and colorectal cancer in average risk individuals: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2009 Dec;7(12):1272-8.

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