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      9 Quality Assurance in Endoscopy

       Matthew D. Rutter

      9.1 The Importance of Quality

      In recent years, the publication of several key studies has brought the importance of quality in health care services into sharp focus. For example, a study from the United States in 2000 indicated that as many as 98,000 people were dying each year as a result of medical errors.¹ In endoscopy, which is a pivotal investigation in the diagnosis and management of gastrointestinal (GI) pathology, the quality agenda has been advanced further by the introduction of organized colorectal cancer screening programs. High-quality endoscopy delivers better health outcomes and better patient experience,² yet it is widely recognized that significant variation exists in the performance of endoscopists and of endoscopy units,^3,4,5,6,7 and as tens of millions endoscopic procedures are performed every year across the world, the potential health impact of suboptimal endoscopic quality is large.

      The current variation in endoscopic quality between services and between individuals is best evidenced in colonoscopy. For example, a recent United Kingdom study demonstrated a fourfold variation in postcolonoscopy colorectal cancer (PCCRC) rates between hospitals.⁸ It is known that the majority of PCCRCs arise from missed cancers, missed premalignant polyps, or incomplete polypectomy.^9,10 Back-to-back colonoscopy studies show that there is a three- to sixfold variation in adenoma detection rates (ADRs) between endoscopists, and even greater variation in serrated polyp detection rates.^11,12 Even when polyps are found, removal may be incomplete: the CARE study concluded that 10% of nonpedunculated polyps of 5 to 20 mm, 23% of nonpedunculated polyps of 15 to 20 mm, and 48% of serrated polyps of 10 to 20 mm were incompletely resected.¹³

      Quality variation is not limited to colonoscopy. In endoscopic retrograde cholangiopancreatography (ERCP), which is one of the most complex and high-risk commonly performed endoscopic procedure, a wide variation is seen in procedure completion and in complication rates.^{14,15,16,17,18,19,20,21} Gastric cancers and precursor lesions are also frequently missed in the upper GI tract—in one series, 7.2% of patients diagnosed with gastric cancer had had a negative gastroscopy within the preceding year, of which around three-quarters were due to endoscopist error.²²

      9.2 Performance Measures

      Differences in endoscopic quality will only come to light if performance is measured. Services and individuals are unlikely to improve, nor can support be provided, unless they are aware of their performance and how it compares with benchmark standards. Such comparison can be a powerful motivator for individuals and services to improve, diminishing the variation in quality between endoscopists and services.