Betting on quality indicators to improve inflammatory bowel disease surveillance outcome: All-in or one to pick?

Inflammatory bowel disease (IBD) has a well-known increased risk of colorectal cancer (CRC).1 Therefore, guidelines recommend meticulous endoscopic surveillance, aiming for a reduction in CRC-related death by detecting and treating lesions in a premalignant state. All guidelines currently suggest the use of chromoendoscopy with targeted biopsies (European Society of Gastrointestinal Endoscopy [ESGE] and European Crohn’s and Colitis Organisation [ECCO])2, 3 or with random biopsies every 10 centimeter (Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations [SCENIC], ESGE and ECCO).2-4 Although several quality criteria have been defined for colorectal cancer screening programs, and for colonoscopy specifically,2 there is still a need for validated quality indicators that should be met when carrying out IBD surveillance endoscopy. The current lack of clear quality indicators has led to a wide variation in clinical practice and low penetration of guidelines. Therefore, the current publication of Smith et al. can be rewarded for their attempt to implement potential quality indicators in clinical practice. They showed a significant increase in adoption of chromoendoscopy from 54.2% to 76%, which was associated with an increase in targeted biopsies (called “lesions”) from 24.9% to 33.1% and increased quality in reporting (use of Paris classification and Kudo pattern).5 However, we have to keep in mind this only applies for well-trained endoscopists, as carrying out a qualitative colonoscopy requires a certain learning curve based on indicators such as quantity, cecal intubation rate and time.

Their quality improvement initiative relied on two major pillars. First of all, education: every quality measurement starts with educating and training of staff, who are often not aware of the paramount importance of the recommendations in what sometimes is perceived as a forest of guideline recommendations. It was shown by the authors that education with a simple PowerPoint (Microsoft Corp. Redmond, WA, USA) presentation including the concept of dye-based chromoendoscopy (DCE), and examples of lesions to target and correct terminology, resulted in an adoption of the technique and use of correct terminology. Without the necessary know-how, any attempt of quality improvement is unlikely to touch base. As shown in their results, the DCE-trained endoscopists performed significantly better in intubation of the terminal ileum, dye spraying, scoring disease activity, allocating Kudo pit pattern and the Paris classification, and lesion detection.5 Although medical education is a nationally driven matter, improvement starts there and needs to be updated in line with progressing insights. Nonetheless, quality improvement in endoscopy is also driven by large scientific societies, such as recently ESGE, American Society for Gastrointestinal Endoscopy (ASGE) and ECCO. In essence, quality should not differ between countries within one continent.

The second pillar is standardization. Development of a standardized protocol for a medical procedure has been shown to be effective in other branches of medicine (e.g. time-out/sign-out-protocol).6 Standardized protocols have a potential beneficial effect on quality improvement as they leave little space for interpretation and personal differences when followed, thereby reducing the error rate. By implementing DCE as standard practice for IBD surveillance colonoscopy, the overall experience will increase and the results will improve as shown by the study by Smith et al.5 Other standardization measures within their protocol were the use of a foot pedal-operated pump-jet for cleaning and dying, implementing a timeframe of 45 min and standardization of reporting with established scoring systems.5

We were also left with some remaining questions after reading the article of Smith et al. What quality indicator(s) should one select to assess performance of colonoscopy in IBD? Do we need to include this as a quality indicator of a colonoscopy service, of the overall management of IBD, or should we only assess quality of colonoscopy in IBD patients with multiple performance measures? Indeed, one has to admit that other diseases except polyps have been neglected in assessing quality in colonoscopy. The ESGE performance measures for colonoscopy do not refer to IBD at all.2 However, a new movement has been made. It has been shown that standardized reporting of disease activity in IBD can improve the quality of the endoscopic report and impact on the outcome of clinical trials if this is done through central reading.7 Now, it seems, after including DCE in guidelines and the clear effect on auditable outcomes, that future standardized reading and reporting of disease activity in IBD should also be included. Another prerequisite of a key quality indicator is that it should also be simple to measure with a clear effect on the desired outcome. Based on the data provided in the study by Smith et al., just measuring the use of DCE might already be enough. Or can we use the number of targeted sites, such as TDR (target detection rate) or even TDRP (target detection rate per patient) to better assess performance in IBD surveillance? All of these seem to significantly improve endoscopic practice in IBD surveillance when it comes to assessing, detecting and characterizing colonic lesions, which indirectly may improve survival. There is nothing against the effort that was taken by Smith et al. to improve their IBD surveillance practice by implementing all measures at the same time, but maybe it is not realistic to expect such a thorough exercise in every endoscopy practice. In this respect, it would be interesting if the major endoscopy societies could join forces to univocally select one or several key performance measures to include IBD surveillance in the different domains of quality assessment for colonoscopy. Japan Gastroenterological Endoscopy Society (JGES), ESGE and ASGE could collaborate to come up with an easy-to-measure key quality indicator to add to the currently existing performance measures for colonoscopy. In particular, the scientific organizations should try to determine a target for the performance measure that is realistic in a real-world practice in order to increase acceptance by their members. As the article in this issue of Digestive Endoscopy provides real-world data, it can shed some light on realistic targets and selection of performance measures. However, preferably, this needs to be confirmed in a Delphi process to look for a common ground of acceptance.

Interestingly, Smith et al.5 used a PowerPoint presentation for training. It would be interesting to see whether application of the same presentation could facilitate implementation in different centers and in less experienced endoscopists. Therefore, ESGE is currently developing curricula of postgraduate training for optical diagnosis, which hopefully might become validated as future training and get DCE implemented in colitis surveillance.8

In view of more recent evidence, it should also be decided as to whether DCE is mandatory or whether it can be replaced by virtual chromoendoscopy (VCE). The most recent ESGE guidelines recommended the use of either DCE or VCE in view of recent evidence that showed no clear difference between the two modalities.9, 10

In conclusion, quality improvement by adoption of guideline recommendations for IBD surveillance colonoscopy clearly affects measurable patient outcomes. However, there is still some margin for improvement and a consensus on the matter is needed on short notice as current guidelines do not clearly define performance measures or aspirational targets. Key points are thorough education and standardization of protocol with application not only on an institutional level but also on individual and (inter) national levels. Further training and education will improve adjustment of these quality indicators, as will international consensus on IBD surveillance. As clinicians may see this at first hand as a burden on their clinical practice, the study by Smith et al. can help to convince them of the bigger picture, which remains high-level, uniform and qualitative medicine for all our patients.

Authors declare no conflicts of interest for this article.