Gastroenterological Endoscopy. Группа авторов
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Название: Gastroenterological Endoscopy
Автор: Группа авторов
Издательство: Ingram
Жанр: Медицина
isbn: 9783131470133
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Fig. 9.3 American Society for Gastrointestinal Endoscopy (ASGE) performance measures for ERCP.34
9.3 Practicalities of Measurement
PMs should enable assessors to identify specific deficits in the service, permitting them to be addressed and thus resulting in better patient outcomes. Several different attributes should be considered when constructing PMs:
9.3.1 Clinical Importance
As described earlier, PMs should correlate with important health outcomes. Measures should be as evidence-based as possible. However, current evidence for most endoscopic PMs (and particularly for minimum standards) is low—further research is required, but in the meantime, expert consensus opinion is an appropriate interim approach to ensure that PMs are clinically meaningful for their target audience.
9.3.2 Standardization
The standardization of PM definitions and methodology of measurement is important to permit meaningful comparison between individuals and services. PMs should be as objective (such as using an unadjusted cecal intubation rate—unadjusted for strictures or poor bowel preparation) and reproducible as possible. Current endoscopic PM definitions and methodology calculations are poorly described and inconsistent, although there is welcome movement to correct this by producing international standards.27 Another component that requires standardization is in the robustness of the methodology for capturing complications—otherwise, a perverse situation arises where poor services may appear to perform better, simply because they have not identified the complications that have occurred.
Different PMs lend themselves to different methodologies. PMs based on common events such as cannulation of the intended duct at ERCP, or adenoma detection at colonoscopy, are suited to quantitative analysis. However, rarer events, such as missed cancer or endoscopic perforation, may be best examined by qualitative review of each adverse event (root cause analysis). Rarer events can also be examined at an endoscopy unit level rather than endoscopist level, although this methodology can sometimes overlook poorly performing individuals.
9.3.3 Practicality
The trade-off of all PMs is the practicality of capturing and analyzing the data. While a multitude of highly complex PMs may be justifiable on quality grounds, it may be unrealistic or impossible to implement such measures in a busy service. Considerations include the number of PMs, the number of data sources required to calculate the PM (e.g., ADR requires both pathology and endoscopy data, whereas polypectomy rate does not), and whether data are stored electronically or not—electronic endoscopy reporting systems are an important component in allowing timely data collection and automated, standardized PM reporting.
9.3.4 Governance Infrastructure
The practicality and objectivity of quality assurance (QA) is influenced greatly by the governance infrastructure. QA requires political will and strong leadership at all levels. For programs to succeed, they need to be organized and embedded in the routine activities of an endoscopy service. Locally, support is required from hospital management. However, commitment from regional or national authorities is also desirable—the best current QA systems have arisen from colorectal cancer screening programs, where instituted (
The best programs are those where the QA process is mandatory and are overseen by those who have authority to act on the findings. If a scheme is voluntary, those whose performance is suboptimal may simply not participate to the ongoing detriment of patient care. Where it is not possible to mandate participation, some success has been achieved with schemes that incentivize participation—this has happened in both the United Kingdom and the United States, where participation or nonparticipation may result in financial reward or penalty.28
9.3.5 Negative Aspects
PMs are designed to measure and improve quality. However, there can be unintended consequences. Perhaps, the best described is the concept of “gaming”—that is, the endoscopist may either inappropriately adjust his/her practice simply to chase the PM target, or may adjust his/her reporting to make his/her figures appear better than they actually are (e.g., claiming that a failed colonoscopy was actually a flexible sigmoidoscopy so that it does not count against their cecal intubation rate). Clearly, this is an issue of integrity. Centralizing the process and using robust and objective measures less susceptible to gaming helps mitigate this risk, although it does not remove the risk altogether.
Another potential negative aspect of PMs relates to how data are published. Open publication of PMs, either among the wider health care service or to the public, permits users and commissioners of the service to assess quality for themselves. This can be very powerful in incentivizing improvements in quality. However, it can also have unintended consequences if data are open to misinterpretation or inappropriate comparison. This may lead to a defensive endoscopic culture, where endoscopists are unwilling to take on more complex cases where outcomes are likely to be worse. Strategies to address these issues include clear descriptions about the limitations of each PM, using procedure complexity adjustment, and carefully defining exclusions when calculating PMs. The pros and cons both of open publication of data and of using named or anonymized reporting of PM data should also be considered, particularly when programs are being investigated—the initial use of a degree of data anonymity can give individuals greater confidence that the process is a supportive one.
Fig. 9.4 An example of automated output from the English Bowel Cancer Screening Programme.35
9.4 Quality Improvement
Measuring quality is only one component of the broader concept of quality improvement. Quality improvement also requires the creation of a supportive culture within endoscopic services, including training, accreditation, and management of underperformance.
In recent years, the quality of endoscopy training has become increasingly sophisticated and structured, incorporating virtual reality simulators, cadaveric models (particularly for therapeutic procedures) and programs involving evidence-based one-to-one training, bespoke courses with trainers with expertise not only in endoscopy but also in teaching methodology, and formative training assessments (
Formal accreditation (credentialing) of endoscopy trainees prior to independent practice is increasingly common and undoubtedly adds a СКАЧАТЬ