High quality colonoscopy: using textbook process as a composite quality measure

Abstract

BACKGROUND : High quality colonoscopy is fundamental to good patient outcomes. "Textbook outcome" has proven to be a feasible multidimensional measure for quality assurance between surgical centers. In this study, we sought to establish the "textbook process" (TP) as a new composite measure for the optimal colonoscopy process and assessed how frequently TP was attained in clinical practice and the variation in TP between endoscopists. METHODS : To reach consensus on the definition of TP, international expert endoscopists completed a modified Delphi consensus process. The achievement of TP was then applied to clinical practice. Prospectively collected data in two endoscopy services were retrospectively evaluated. Data on colonoscopies performed for symptoms or surveillance between 1 January 2018 and 1 August 2021 were analyzed. RESULTS : The Delphi consensus process was completed by 20 of 27 invited experts (74.1 %). TP was defined as a colonoscopy fulfilling the following items: explicit colonoscopy indication; successful cecal intubation; adequate bowel preparation; adequate withdrawal time; acceptable patient comfort score; provision of post-polypectomy surveillance recommendations in line with guidelines; and the absence of the use of reversal agents, early adverse events, readmission, and mortality. In the two endoscopy services studied, TP was achieved in 5962/8227 colonoscopies (72.5 %). Of 48 endoscopists performing colonoscopy, attainment of TP varied significantly, ranging per endoscopist from 41.0 % to 89.1 %. CONCLUSION : This study proposes a new composite measure for colonoscopy, namely "textbook process." TP gives a comprehensive summary of performance and demonstrates significant variation between endoscopists, illustrating the potential benefit of TP as a measure in future quality assessment programs.

Fig. 1

Rates for achievement of each individual item of the textbook process (TP) and cumulative rate for achievement of TP.

Fig. 2

Combination of the textbook process items that were not achieved. The first column represents the first item that was not achieved; when more than one item was not achieved, the different combinations of items not achieved are shown in the remaining columns (groups of n < 50 are not shown in this figure).

Fig. 3

Variation in textbook process (TP) rates per endoscopist and relationship to number of colonoscopies performed, with benchmark (dotted line) and 95 %CIs (solid lines) shown.

Fig. 4

Correlation between the textbook process (TP) rate and the adenoma detection rate (ADR) per endoscopist (Spearman rank correlation coefficient, r  = 0.48; P  < 0.001).