Polyp Surveillance Measures

The AGA Center for Quality in Practice selected colon polyp surveillance for internal measure development using the AGA Institute Performance Measures Process. Colonoscopic polypectomy and surveillance has been shown to reduce subsequent colorectal cancer incidence. Post-polypectomy surveillance is a significant component of endoscopic practice. Measures to assess the appropriate utilization of polyp surveillance are both timely and salient.

Methods

Panel Membership

Members of the AGA Polyp Surveillance Performance Measures Technical Expert Panel (TEP) were nominated to participate based on their expertise and representation of one or more important areas in polyp surveillance care. The panelists were:

TEP Participant

Role

John Allen, MD, MBA

Community Gastroenterologist, large group practice

Jennifer Crockford, FNP

Gastroenterology nurse practitioner

Robert Fletcher, MD

Guideline developer/author

Thomas Gage, MD

Community Gastroenterologist, small group practice

David Lieberman, MD

Guideline developer/author & academic gastroenterologist

Doug Rex, MD

Guideline developer/author & academic gastroenterologist

Anthony Senagore, MD

Academic Colorectal Surgeon

Michael Weinstein, MD

Community Gastroenterologist, mid-size group practice

Sidney Winawer, MD

Guideline developer/author & academic gastroenterologist

Evidence Base

The colon polyp surveillance measures are based on recommendations contained in the AGA Institute's 2003 colorectal cancer screening and surveillance guidelines1; joint guidelines on post-polypectomy surveillance issued in 2006 by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society2; and the AGA Task Force’s recommendations for quality in the technical performance of colonoscopy3.

Process

The Polyp Surveillance Performance Measures TEP commenced its efforts in January 2006, facilitated by a consultant with expertise in methodology and measures development. After an initial teleconference, the TEP met in February 2006 to develop draft measures. Over the following months, the draft measures were refined, and then presented to the CQIP Advisory Group and the AGA Clinical Practice & Economics Committee for review and approval. The final measures were submitted to the AGA Institute Governing Board, which approved them in May 2006.

Pilot Testing and Results

Drafting data collection form and instructions

The technical consultant identified the data items necessary to create each of the performance measures, and drafted a data collection form and instructions. TEP members were consulted with particular questions during instrument development. A subset of the Panel reviewed the draft instruments and provided detailed feedback.

Recruiting pilot test sites

The goal of pilot testing was to test the data collection tools under a range of conditions, including practice size, type and documentation system (e.g., commercial packages for colonoscopy reports, electronic and paper-based documentation systems, computerized results monitoring versus paper log). Six practice sites participated in the pilot test.

Pilot site training

Each pilot test site identified participants to test the tools — typically a clinician (e.g., NP) or practice administrator. Each attended a one-hour training teleconference session. Each site then completed a review over a two-week period for patients who had undergone colonoscopy with polyp retrieval. Sites were instructed to select a range of patients and clinicians to test the tool under a variety of conditions.

Pilot test feedback

After the sites completed the pilot reviews, they were queried about the data collection process and tools. The feedback was positive and confirmed the measures are useable in a variety of practice settings. Pilot test participants reported the data collection tool was easy to use, and all sites could easily identify eligible patients using their existing administrative systems. The testers made recommendations to improve the tool (e.g., revising the order of the response options so that the most commonly-found were first) and identified items for which further instructions or revisions were necessary.

Further tool revision by TEP

Based on the pilot test, questions were discussed with the TEP, and the tools were further refined.

Data Collection Form and Instructions

The AGA Institute Polyp Surveillance Data Collection Form and Instructions are now available. Based on this instrument, measure descriptions and measure calculation numerator and denominator statements were constructed for each performance measure after review and refinement by the TEP.

Use of Measures

Measures 1-8 are founded on multi-society evidence-based guidelines. Measures regarding communication support principles of quality improvement and transparency necessary for providing excellent health care. The goal is to use all the measures for quality improvement purposes.

Measures 1-8 should be utilized as a set. Measures 1-7, related to adequacy of prep, reaching the cecum, complete removal of lesions, and pathology reports, are the quality indicators / characteristics intricately associated with the ability to confidently follow the intervals for follow-up surveillance, as described in measure 8.

To calculate a specific measure or indicator:

  • Complete a data collection form for each eligible patient to be include in measurement population.
  • Apply the responses to the measure's numerator and denominator as described in the measures table.
  • Calculate rate.

The measures were submitted in November 2006 to the National Quality Forum (NQF) for endorsement consideration.

Contact the Center

Deborah P. Robin, MSN, RN, CHCQM
Senior Director for Quality
Phone: (301) 941-2615
E-Mail: drobin@gastro.org

References

  1. Winawer S, Fletcher R, Rex D, Bond J, Burt R, Ferrucci J , Ganiats T, Levin T, Woolf S, Johnson D, Kirk L, Litin S, Simmang C; Gastrointestinal Consortium Panel. Colorectal cancer screening and surveillance: clinical guidelines and rationale-Update based on new evidence. Gastroenterology. 2003;124(2):544-60.
  2. Winawer S, Zauber A, Fletcher R, Stillman J, O’Brien M, Levin B, Smith, R, Lieberman D, Burt R, Levin T, Bond J, Rex D. Post-polypectomy surveillance: A consensus update by the U.S. Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; 56:143-159 .
  3. Rex DK, Bond JH, Winawer S, Levin TR, Burt RW, Johnson DA, Kirk LM, Litlin S, Lieberman DA, Waye JD, Church J, Marshall JB, Riddell RH; U.S. Multi-Society Task Force on Colorectal Cancer. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2002;97(6):1296-308.
  4. Using clinical practice guidelines to evaluate quality of care. Volume 2: Methods. USHHS, AHCPR Pub. No. 95-0046, March 1995
  5. Mainz J. Developing evidence-based clinical indicators: A state of the art methods primer. International Journal for Quality in Health Care. 2003;15:i5-i11
  6. McGlynn EA, Asch SM. Developing a clinical performance measure. Am J Prov Med 1998; 14:14–21
  7. Mysliwiec PA, Brown ML, Klabunde CN, Ransohoff DF. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med. 2004:17;141(4):I22.