Quality indicators for colonoscopy Douglas K. Rex, MD, John L. Petrini, MD, Todd H. Baron, MD, Amitabh Chak, MD, Jonathan Cohen, MD, Stephen E. Deal, MD, Brenda Hoffman, MD, Brian C. Jacobson, MD, MPH, Klaus Mergener, MD, PhD, Bret T. Petersen, MD, Michael A. Safdi, MD, Douglas O. Faigel, MD, ASGE Co-Chair, Irving M. Pike, MD, ACG Co-Chair ASGE/ACG Taskforce on Quality in Endoscopy Colonoscopy is widely used for the diagnosis and treat- ment of colonic disorders. Properly performed, colonos- copy is generally safe, accurate, and well tolerated by most patients. Visualization of the mucosa of the entire large intestine and distal terminal ileum is usually possible at colonoscopy. In patients with chronic diarrhea, biopsy specimens can help diagnose the underlying condition. Polyps can be identified and removed during colonoscopy, thereby reducing the risk of colon cancer. Colonoscopy is the preferred method to evaluate the colon in most adult patients with bowel symptoms, iron deficiency anemia, abnormal radiographic studies of the colon, positive colo- rectal cancer screening tests, postpolypectomy and post- cancer resection surveillance, surveillance in inflammatory bowel disease, and in those with suspected masses. The use of colonoscopy has become accepted as the most effective method of screening the colon for neopla- sia in patients over the age of 50 years and in younger pa- tients at increased risk. 1 The effectiveness of colonoscopy in reducing colon cancer incidence depends on adequate visualization of the entire colon, diligence in examining the mucosa, and patient acceptance of the procedure. Preparation quality affects the ability to perform a com- plete examination, the duration the procedure, and the need to cancel or reschedule procedures. 2,3 Ineffective preparation is a major contributor to costs. 4 Longer with- drawal times have been demonstrated to improve polyp detection rates, 5-7 and conversely, rapid withdrawal may miss lesions and reduce the effectiveness of colon cancer prevention by colonoscopy. The miss rates of colonoscopy for large (R1 cm) adenomas may be higher than previ- ously thought. 8,9 Thus, careful examinations are necessary to optimize the effectiveness of recommended intervals between screening and surveillance examinations. Finally, technical expertise will help prevent complications that can offset any cost-benefit ratio gained by removing neo- plastic lesions. The following quality indicators have been selected to establish competence in performing colonoscopy and help define areas for continuous quality improvement. The levels of evidence supporting these quality indicators were graded according to Table 1. PREPROCEDURE The preprocedure period encompasses the time from first contact by the patient until administration of sedation or instrument insertion. The aspects of patient care ad- dressed in prior documents apply here as well, including timely scheduling, patient preparation, identification, history and physical examination, appropriate choice of sedation and analgesia, evaluation of bleeding risk, etc. Be- cause many examinations are currently being performed for colon cancer screening and are elective, care must be taken to be certain that all potential risks have been reduced to as low as practically achievable. The American Society for Gastrointestinal Endoscopy (ASGE) 10 and the U.S. Multi-Society Task Force on Colon Cancer have published appropriate indications for colonos- copy 11 (Tables 2 and 3). Specific quality indicators 1. Appropriate indication. The ASGE and the U.S. Multi- Society Task Force on Colon Cancer have published ap- propriate indications for colonoscopy (Tables 2 and 3). An indication should be documented for each proce- dure, and when it is a nonstandard indication it should be justified in the documentation. Discussion. The ASGE in 2000 published a list of ac- cepted indications for endoscopic procedures. 10 This list was determined by a review of published literature and ex- pert consensus. Studies have shown that when esophago- gastroduodenoscopy and colonoscopy are done for appropriate reasons significantly more clinically relevant diagnoses are made. 12-14 In these studies, which divided indications into appropriate, uncertain, and inappropriate, and looked at high-volume European centers, 21% to 39% were classified as inappropriate. It is likely that this can be improved to less than a 20% inappropriate rate. 15 The European Panel of Appropriateness of Gastrointesti- nal Endoscopy (EPAGE) Internet guideline is a useful de- cision support tool for determining the appropriateness of colonoscopy. 15 The goal is to minimize as much as pos- sible the number of inappropriate procedures. 16-19 In the average-risk population, colonoscopic screen- ing is recommended in all current guidelines at 10-year intervals. 20-22 Direct observational data to support this interval are lacking. However, in a cohort of average- risk persons who underwent an initial colonoscopy Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology 0016-5107/$32.00 doi:10.1016/j.gie.2006.02.021 S16 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 4 : 2006 www.giejournal.org