Quality Improvement in Gastroenterology Clinical Practice

Rakhi Kheraj; Sumeet K. Tewani; Gyanprakash Ketwaroo; Daniel A. Leffler


Clin Gastroenterol Hepatol. 2012;10(12):1305-1314. 

In This Article

Diagnosis of Irritable Bowel Syndrome

The prevalence of irritable bowel syndrome (IBS) is about 7% in North America;[44] it is one of the most frequent complaints among patients at outpatient gastroenterology practices. The care of patients with IBS is estimated to cost about $20 billion.[44] QI in IBS care can therefore have a significant impact on patient care and healthcare resources.

Patients suspected of having IBS are routinely tested to exclude alternative organic disorders. The 2009 ACG IBS Task Force argues against the diagnosis of IBS by exclusion.[44] Instead, the ACG states patients who meet the definition of IBS (abdominal pain or discomfort associated with a change in bowel habits during a period of at least 3 months) without alarm symptoms need few, if any, formal tests. Alarm symptoms such as weight loss, anemia, family history of colorectal cancer, IBD, or celiac sprue are at high risk for organic disease; the absence of these would be consistent with a diagnosis of IBS. For patients older than 50 years or with alarm symptoms, the ACG recommends colonoscopy examination (grade C*). In patients younger than 50 with no alarm symptoms, the ACG recommends against routine colonoscopy because of the low probability that these patients have IBD or colorectal neoplasia[44] (grade B*). In patients with diarrhea-predominant or mixed IBS, the 2009 ACG Task Force recommends testing for celiac disease (grade B*). Glucose or lactulose breath tests can be considered, although there are no recommendations for small intestinal bacterial overgrowth tests because of insufficient evidence. Likewise, routine tests for food allergies and exclusion diets are not recommended in major society guidelines.

QI projects in IBS could focus on ensuring adequate adherence to consensus guidelines to reduce costly and invasive tests. Similar to BMD testing in IBD, a QI project for IBS could be designed as follows: (1) development of an evidence-based practice standard for appropriate initial evaluation of patients with suspected IBS; (2) retrospective evaluation of the appropriately tested patients; (3) development or enhancement of a mechanism to ensure adherence to appropriate testing; (4) prospective audit of IBS patients to assess rates of appropriate invasive diagnostic procedures; and (5) evaluations of any potential shortcomings of the system. The physician should then return to step 3.

Colorectal Cancer Screening

The overall goal of colorectal cancer screening and surveillance is to reduce mortality by removing colorectal cancer precursor lesions and detecting cancer at an early stage to enable more effective treatment. Guidelines for whom and when to screen, which are based on risk factors, have been outlined by several gastroenterology professional organizations.[45]

Quality measures in endoscopy are diverse and beyond the scope of this review.[46–48] However, quality colorectal cancer screening does not end with the colonoscopy report. A continuation of the inroads made against colorectal cancer in the coming years will require aggressive interventions to endorse proper screening and surveillance throughout the population.[49] Electronic reminders can help patients return on time for follow-up examinations.[12] Sint Nicolaas et al[50] recently identified patient awareness of colonoscopy results and surveillance recommendations as important areas for improvement. Although in this study patient communication did not correlate to improved attendance, higher rates of follow-up were noted in the departments with follow-up communication systems in place. It is common for patients to return for reexamination at shorter intervals than the major society guidelines recommend,[51] which increases risks and costs. For instance, in a study of 3627 patients undergoing colorectal cancer screening, 49% were reexamined within 7 years (median, 3.1 years) of the index colonoscopy, and 38% of those with fewer than 3 small adenomas received follow-up colonoscopies within 4 years.[52,53]

Successful colorectal cancer screening QI projects may target adherence to consensus guidelines, with the goal of reducing the proportion of patients who return too early or too late for follow-up examinations. An appropriate practice-based QI initiative could include the following. (1) Evaluation of rates of surveillance colonoscopies would be based on retrospective review. Shortcomings in surveillance could be improved by a combination of methods. For example, automatically generated reminder letters could help to recall patients who miss recommended appointments. (2) Computer-based software that creates endoscopy records could incorporate automatic recommendations for surveillance intervals, which are based on endoscopy findings. If final surveillance intervals differ from these algorithm-based recommendations, a specific reason would be documented. (3) This QI intervention could then be prospectively evaluated to identify potential shortcomings or further ways of improvement.