Quality audit of colonoscopy reports amongst patients screened or surveilled for colorectal neoplasia

Table 1 Colonoscopy quality indicators

Patient demographics and history
Age
Sex
MRN
Management plans
Informed consent documentation
Previous GI procedures: documented date (yes/no)
Documentation of ASA classification
Indications for procedure
Average risk
Increased risk
Incomplete colonoscopy
Post adenoma resection
Procedure: Technical description
Date and time
Sedation
Level of difficulty of the procedure
Bowel preparation
Type and dosage
Quality
Actual extent of examination
Cecal intubation (yes/no)
Documentation of cecal landmarks
Appendiceal orifice
Ileocecal valve
Total and withdrawal time recorded (yes/no)
Colonoscopic findings
Colonic polyp(s):
Number
Size
Morphology
Morphology anatomic location
Method of removal
Completeness of removal (yes/no)
Retrieved (yes/no)
Sent to pathology (yes/no)
Interventions/unplanned events
Unplanned interventions and complications
Documentation of discharge plans (info to patient, info to referring MD)
Pathology
Documentation of pathology results to the patient and the physician
Adenoma detection (yes/no)
Cancer detection (yes/no)

MRN: Medical record number; ASA: American Society of Anesthesiology; GI: Gastrointestinal.

Table 2 Patient population and endoscopists description n (%)

	Patients (n = 250)endoscopists (n = 11)
Mean age (yr)	63.2 ± 10.5
Sex
Women	107 (42.8)
Men	143 (57.2)
Procedure indications
Average risk	85 (38.5)
Past personal history	90 (43.3)
Past family history	42 (20.2)
HNPCC	1 (1.4)
FAP	1 (1.4)
Specialty of endoscopists
Surgical	3 (27.3)
GI	8 (72.7)
Average years of endoscopists practice (yr)	17.1 ± 8.5

HNPCC: Hereditary nonpolyposis colorectal cancer syndrome; FAP: Familial adenomatous polyposis; GI: Gastrointestinal.

Table 3 Pre-procedure indicators n (%)

Quality indicator sought in the report	(n = 250)
Consent documentation	250 (100.0)
Management plan for anticoagulation1	1 (0.5; 95% CI: 0.0-1.5)
Previous GI colonoscopy date1	24 (14.0; 95% CI: 8.7-19.2)
ASA classification	0 (0)
Previous polyp resection	20 (12.7; 95% CI: 7.4-17.9)
Details available	5 (25.0; 95% CI: 4.2-45.8)
1-2 tubular adenoma < 1 cm	2 (33.3; 95% CI: 0.0-87.5)
3-10 tubular adenoma > 1 cm	1 (16.7; 95% CI: 0.0-59.9)
10 adenomas	1 (16.7; 95% CI: 0.0-59.9)
Sessile adenoma > 2 cm	1 (16.7; 95% CI: 0.0-59.9)

¹Usually documented elsewhere, but not in the endoscopy report. ASA: American Society of Anesthesiology; GI: Gastrointestinal.

Table 4 Procedural indicators and colonoscopic findings n (%)

Procedural indicators
Quality indicator sought in the report	n = 250
Date of exam	246 (98.4, 95% CI: 96.8-100.0)
Medications with dosage	248 (99.2, 95% CI: 98.1-100.0)
Level of difficulty	247 (98.8, 95% CI: 97.4-100.0)
Bowel preparation quality
Poor	10 (4.0, 95% CI: 1.6-6.5)
Fair	27 (10.8, 95% CI: 7.0-14.7)
Good	212 (85.1, 95% CI: 80.7-89.6)
Actual extent of examination
Cecum	236 (94.4, 95% CI: 91.7-97.3)
Ascending colon	6 (2.4, 95% CI: 0.5-4.3)
Transverse colon	2 (0.8, 95% CI: 0.0-1.9)
Descending colon	2 (0.8, 95% CI: 0.0-1.9)
Recto sigmoid	4 (1.6, 95% CI: 0.0-3.2)
Cecal intubation	236 (94.4, 95% CI: 91.5-97.3)
Photodocumentation	186 (74.4, 95% CI: 69.0-79.8)
Documentation of cecal landmarks
Appendiceal orifice	168 (67.2, 95% CI: 61.2-73.2)
Ileocecal valve	103 (41.2, 95% CI: 35.1-73.1)
Retroflexion in rectum	177 (70.8, 95% CI: 65.1-76.5)
Withdrawal time	0 (0)
Total time	0 (0)
Intra-procedural complications	1 (0.4, 95% CI: 0.0-1.2)
Colonoscopic findings: polyps
Polyp findings	111 (44.4, 95% CI: 38.2-50.6)
Mean polyp number	2.2 ± 2.5
Polyp size documented	73 (65.8, 95% CI: 56.8-74.7)
Mean polyp size (mm)	17.6 ± 33.1
Morphology
Documented	69 (62.2, 95% CI: 53.0-71.3)
Pedunculated	17 (23.9, 95% CI: 13.8-34.1)
Sessile	56 (80.0, 95% CI: 70.4-89.6)
Anatomic location documented	110 (99.1, 95% CI: 97.3-100.0)
Method of removal
Cold biopsy	28 (25.2, 95% CI: 17.0-33.4)
Cold snare	20 (18.0, 95% CI: 10.8-25.3)
Snare cautery	35 (31.5, 95% CI: 22.8-40.3)
Not mentioned	23 (20.7, 95% CI: 13.1-28.4)
Retrieved	72 (84.7, 95% CI: 76.9-92.5)
Sent to pathology	85 (76.5, 95% CI: 67.3-85.7)

Table 5 Comparison between national United States study and the current audit

	%	Current audit (%)
Patient characteristics
Women	49	42.8, 95% CI: 36.6-49.0
Men	51	57.2, 95% CI: 51.0-63.4
Average risk	29.6	38.5, 95% CI: 32.0-44.9
Past family history	13.4	20.2, 95% CI: 14.7-25.7
Past personal history	19	43.3, 95% CI: 36.5-50.1
Presence of recorded variables
ASA classification	89.9	0
Bowel preparation quality	86.1	99.6, 95% CI: 98.8-100.0
Previous GI colonoscopy date	33.9	14.0, 95% CI: 8.7-19.2
Cecal landmarks	85.9	67.2, 95% CI: 61.3-73.1
Polyp size	90	65.8, 95% CI: 56.8-74.7
Polyp morphology	85.3	62.2, 95% CI: 53.0-71.3
Polyp retrieval	95.5	84.7, 95% CI: 76.9-92.5
Endoscopic outcomes
Cecal intubation	96.3	94.4, 95% CI: 91.5-97.3
Polyp findings	36.3	44.4, 95% CI: 38.2-50.6

ASA: American Society of Anesthesiology; GI: Gastrointestinal.