Colorectal cancer (CRC) is the third most commonly diagnosed cancer in men and women in the United States. There will be an estimated 151,030 new cases of CRC and 52,580 deaths from CRC in 2022 (Siegel, Miller, Fuchs, & Jemal, 2022). These death tolls have declined for several decades due to the increased use of CRC screening, removal of precancerous polyps, and diagnosis of CRC at earlier and more treatable stages (American Cancer Society [ACS], 2020). Fortunately, this disease is described as one that no one has to die from because it is "preventable, treatable, and beatable." Small polyps are slow to grow and turn to cancer, which provides time for screening and removal of the precancerous polyps so that CRC is prevented (American Society for Gastrointestinal Endoscopy, 2019). Quality colonoscopy services are essential to ensure all polyps are found and removed as the final step of CRC screening.

Three Priority Quality Indicators for Colonoscopy Services

The American Society for Gastrointestinal Endoscopy Quality Assurance in Endoscopy Committee (ASGEQAEC, 2015) developed quality indicators for colonoscopy services. The Committee applied these quality indicators to preprocedure, intraprocedure, and postprocedure, with established performance targets for each quality indicator. The Committee prioritized three quality indicators for screening colonoscopies with the goal of reducing interval cancers. Interval cancers are believed to be the result of lesions missed during colonoscopies (Smith et al., 2017) or incomplete polypectomies. The three priority quality indicators for colonoscopies are the frequency of (1) adenoma detection in asymptomatic patients at average risk; (2) adherence to the surveillance intervals for postpolypectomy, postcancer resection, or the 10-year interval for the average-risk patients with good bowel preparations who had negative colonoscopies; and (3) visualization of the cecum by notation and landmark photographic documentation (ASGEQAEC, 2015).

Adenoma Detection Rate

The adenoma detection rate (ADR) refers to the percentage of screening colonoscopies in average-risk patients in whom one or more adenomas are found. The goal is a minimum of 25% for men and women (aged 50 years or older) combined or 30% for men and 20% for women when it is desired to calculate the gender rates separately. The studies performed to determine these targets were conducted on patients 50 years or older. However, the ACS (Wolf et al., 2018), American College of Gastroenterologists ([ACG]; Shaukat et al., 2021), and the U.S. Preventive Services Task Force (USPSTF, 2021) have all dropped the recommended screening age for patients at average risk to 45 years. The target ADR for these younger patients is as yet unknown.

The ADR is considered a significant quality indicator of the endoscopist's performance because a higher ADR has been correlated with fewer interval cancers (Smith et al., 2017). The ADRs for some endoscopists exceed 50%. Because the ADR is the primary measure of mucosal inspection quality, the ADR is the most important measure. Every endoscopist should have his or her ADR calculated, and those with ADRs below 25% must implement strategies to improve their performances (ASGEQAEC, 2015).

One strategy to ensure sufficient ADR is to measure the withdrawal time from the cecum for every colonoscopy; the target is 98% of all colonoscopies (screening and diagnostic, combined) should have this reported measure. A sufficient withdrawal time allows the detection of more lesions. The recommended time for screening colonoscopies in average-risk individuals with intact colons and normal results is 6 minutes or more. The average withdrawal time for screening colonoscopies may be useful feedback for endoscopists with ADRs under target. It is important to note the average withdrawal time is used because it is possible to do a quality examination in less than 6 minutes on a well-prepared patient with a shorter colon and less prominent haustra (ASGEQAEC, 2015).

Surveillance Intervals

The ADR is directly linked to the recommended intervals for screening and surveillance. Those endoscopists with high ADRs remove more polyps and bring those patients back sooner as that is the recommendation when precancerous polyps are found. On the contrary, endoscopists with low ADRs miss those precancerous polyps and utilize inappropriate, longer intervals between colonoscopies, therefore inadequately protecting those patients (ASGEQAEC, 2015).

The recommended surveillance intervals assume (1) cecal intubation (discussed later), (2) adequate bowel preparation, and (3) a thorough examination of the colon mucosa. The quality of the bowel preparation should be documented; the criterion is whether the preparation is sufficient to identify polyps of greater than 5 mm. The documentation might be either "adequate" or "inadequate" or might involve descriptors of nonstandardized definitions such as excellent, good, fair, or poor (ASGEQAEC, 2015). There are several validated bowel preparation scores such as the Ottowa Bowel Preparation Scale, Aronchick Scale, Boston Bowel Preparation Scale, and Harefield Cleansing Scale; however, they all have limitations (Parmar, Martel, Rostom, & Barkun, 2016).

Average-risk patients, 50 years and older, without risk factors have a recommended screening interval of 10 years. Accurate intervals are determined by documenting whether the patient had a previous colonoscopy, the date of the last colonoscopy, and the histological findings of polyps removed. The recommended intervals balance the risks and costs of colonoscopy with their protective effects. These intervals are dependent upon the size, numbers, and histology of precancerous polyps.

Endoscopists with low ADRs fail to identify polyps, and their patients who need shorter surveillance intervals are put at risk. Unnecessarily shorter intervals are not cost-effective and subject patients to extra risks. It is important to determine the examination intervals and adherence to the surveillance recommendations (or an explanation regarding the variation from the guideline) in quality improvement programs. Screening or surveillance colonoscopies done at intervals shorter than recommended in the guidelines and without an explanation for the shorter interval have an inappropriate indication (ASGEQAEC, 2015).

Photographic Documentation of the Cecum

Visualization of the cecum by landmark notation and photographic documentation should be done with every procedure. Cecal intubation is the passage of the colonoscope proximal to the ileocecal valve such that the cecal caput, including the medial cecal wall between the appendiceal orifice and ileocecal valve, is visible. Cecal intubation is essential because CRC can occur there. Cecal photography is mandated, and the performance target for cecal intubation with photography for screening colonoscopies is 95% or more.

The best photographs are (1) of the appendiceal orifice at a distance showing the cecal strap fold around the appendix, (2) the cecum taken distal to the ileocecal valve, and perhaps (3) villi, lymphoid hyperplasia, and circular valvulae conniventes. Exclusions from the cecal intubation calculation include aborted cases due to severe colitis or an inadequate preparation (ASGEQAEC, 2015).

Quality Improvement: Plan-Do-Study-Act

The Institute for Healthcare Improvement (IHI) provides resources for organizational change and to enhance the quality improvement process. The Plan-Do-Study-Act cycle is recommended to guide these changes (IHI, 2021). The Institute of Medicine developed six aims for healthcare improvement, including effectiveness. This aim aligns the care provided with the best available science; the goal is to avoid ineffective care and maximize effective care (Committee on Quality of Health Care in America, Institute of Medicine, 2001).

The American Society for Gastrointestinal Endoscopy is a physicians' professional organization dedicated to improving endoscopy through analysis of data to make the best recommendations regarding patient care. Its Quality Assurance in Endoscopy Committee developed quality indicators and benchmarks for colonoscopy services. Benchmarks are the intended performance targets for those various indicators (ASGEQAEC, 2015). Gastroenterology nurses, endoscopists, and the quality management team can work together to affect organizational changes using Plan-Do-Study-Act cycles to achieve the best recommendations on the three priority quality indicators for colonoscopy services.

Conclusion

The Plan-Do-Study-Act process can be used by gastroenterology nurses, endoscopists, and the quality management team to meet the established performance targets for the three priority quality indicators for screening colonoscopies and reduce interval cancers in patients. Periodic spot checks are helpful to ensure these targets continue to be met. Once these routines are well established, the gastroenterology team might then advance to the proposed quality indicators common to all endoscopic procedures, including those specific to the preprocedure, intraprocedure, and postprocedure processes.

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