Quality care is a subject matter that should be taken to heart by all physicians, no matter what background or specialty one may hail from. Nonetheless, the issue of quality morphs and takes different shapes depending on the specialty a physician may practice. Ralph McKibbin, MD, FACP, medical director of Allegheny Regional Endoscopy Center, an American Society of Gastrointestinal Endoscopy Unit Recognition Program honoree, explains the state of quality in the field of gastroenterology.
Q: How does quality currently fit into gastroenterology?
Dr. Ralph McKibbin: While there are several quality directives a GI physician could look at, GI doesn't have a long history of [collecting data on] quality. There is some firm data on certain subjects, such as pathology specimens and the number of biopsies needed to determine cancer, but in general the field doesn't have a good handle on quality data. I believe the laboratory specialties have the longest tradition of quality, and there is such a good understanding of how to get reliable and reproducible results that many tasks are now automated. Procedural specialties, such as gastroenterology, have to struggle with both patient and provider variation, and it is often difficult to say exactly what constitutes a quality examination. Traditionally, we have defined quality more as a low rate of complications rather than by positive patient outcomes. In my opinion, that's not really understanding what quality is. A physician can't just go on a government website and find the definition of a quality endoscopy.
Q: What does the field have a handle on in terms of quality?
RM: In terms of nursing, OR procedures and other procedural issues, the field is very sophisticated. We know how to handle and clean instruments and how to monitor such things as never reusing syringes. There are occasional instances where people don't follow established rules, but there is a large and solid body of knowledge on these subjects.
Q: What new GI-related quality parameters are beginning to take shape?
RM: Outcome-based measurements are starting to emerge. A practice in Illinois did an internal study looking at scope withdrawal time during colonoscopy and found that an average scope withdrawal time of six minutes on a negative screening examination was clearly correlated with a higher adenoma detection rate. This is a surrogate marker that needs to be validated for individual practices but is a fine example of outcome-based quality measures. Another example is the rate of going completely around the colon, which is measured by the cecal intubation rate. In addition, quality examinations don't mean anything if the results are not clearly communicated so colonoscopy reports are starting to be scrutinized for details, such as polyp description and location and preparation quality, which helps to determine the adequacy of the examination.
Q: What can GI physicians do to contribute to the collection of quality data?
RM: It is important to understand that quality is here to stay. Insurance carriers and patients both expect us to perform at a high level. Competition for shrinking healthcare dollars is also a factor. It won’t be enough to just be very good at what you do; you will also have to provide the data to prove it. I would suggest initially doing some practice improvement studies such as those required for board re-certification and evaluating the quality programs that are being unveiled by the specialty societies. Every practice is different so the outcomes that are most important will vary, but because many will be shared a benchmarking group or program can be very helpful.
Learn more about Allegheny Regional Endoscopy Center.
Q: How does quality currently fit into gastroenterology?
Dr. Ralph McKibbin: While there are several quality directives a GI physician could look at, GI doesn't have a long history of [collecting data on] quality. There is some firm data on certain subjects, such as pathology specimens and the number of biopsies needed to determine cancer, but in general the field doesn't have a good handle on quality data. I believe the laboratory specialties have the longest tradition of quality, and there is such a good understanding of how to get reliable and reproducible results that many tasks are now automated. Procedural specialties, such as gastroenterology, have to struggle with both patient and provider variation, and it is often difficult to say exactly what constitutes a quality examination. Traditionally, we have defined quality more as a low rate of complications rather than by positive patient outcomes. In my opinion, that's not really understanding what quality is. A physician can't just go on a government website and find the definition of a quality endoscopy.
Q: What does the field have a handle on in terms of quality?
RM: In terms of nursing, OR procedures and other procedural issues, the field is very sophisticated. We know how to handle and clean instruments and how to monitor such things as never reusing syringes. There are occasional instances where people don't follow established rules, but there is a large and solid body of knowledge on these subjects.
Q: What new GI-related quality parameters are beginning to take shape?
RM: Outcome-based measurements are starting to emerge. A practice in Illinois did an internal study looking at scope withdrawal time during colonoscopy and found that an average scope withdrawal time of six minutes on a negative screening examination was clearly correlated with a higher adenoma detection rate. This is a surrogate marker that needs to be validated for individual practices but is a fine example of outcome-based quality measures. Another example is the rate of going completely around the colon, which is measured by the cecal intubation rate. In addition, quality examinations don't mean anything if the results are not clearly communicated so colonoscopy reports are starting to be scrutinized for details, such as polyp description and location and preparation quality, which helps to determine the adequacy of the examination.
Q: What can GI physicians do to contribute to the collection of quality data?
RM: It is important to understand that quality is here to stay. Insurance carriers and patients both expect us to perform at a high level. Competition for shrinking healthcare dollars is also a factor. It won’t be enough to just be very good at what you do; you will also have to provide the data to prove it. I would suggest initially doing some practice improvement studies such as those required for board re-certification and evaluating the quality programs that are being unveiled by the specialty societies. Every practice is different so the outcomes that are most important will vary, but because many will be shared a benchmarking group or program can be very helpful.
Learn more about Allegheny Regional Endoscopy Center.