Assessment of the Quality of Colonoscopy Dictation Reports

C Marcoux, D Pace, M Borgaonkar, M Lougheed, B Evans, D Boone, J McGrath. Memorial University

Introduction: The Canadian Association of Gastroenterology (CAG) has released consensus guidelines on safety and quality indicators in endoscopy, including required endoscopy report elements.  Our aim was to examine the quality of endoscopy reports based on CAG guidelines at two academic hospitals in Canada. 

Methods: A retrospective cohort study was performed on 3235 patients who underwent colonoscopy in St. John’s, NL in the year 2012.  Data were obtained from procedure reports dictated by the endoscopist in the electronic medical record (EMR).  Based on CAG guidelines, the following report elements were examined: consent, type and quality of bowel preparation, type and dose of sedation, maximum insertion, completeness of colonoscopy based on intent of procedure, polyp description and size, polypectomy technique, post-procedure diagnosis, withdrawal time, and recommendation for follow-up. Consent was determined by reviewing the endoscopy report. Quality of bowel preparation and maximum insertion were defined as that reported by the endoscopist.  Completeness of endoscopy was reported as determined by the investigator.  Appropriateness of recommendations were determined by comparing recommendations in the endoscopy report to current CAG guidelines.  Statistics for all variables were determined solely by reviewing endoscopy reports and calculated using SPSS software. 

Results: Documentation of consent was reported in 53% of cases. Type of bowel preparation was reported in 46% of cases, while quality of bowel preparation was reported in 52% of cases. Type and dose of sedation was reported in 46% of cases.  Maximum insertion was reported in 100% of cases.  Whether the colonoscopy was complete or incomplete based on the intent of the procedure was reported in 80% of cases. Of the 1162 patients in which polyps were found, polyp description and size was reported in 73% and 44% of cases, respectively, while 77% of reports described the polypectomy technique used.  Post-procedure diagnosis was reported in 70% of patients. Withdrawal time was reported in 24% of patients. Recommendations were made regarding follow-up in 77% of reports, and 84% of those recommendations were appropriate based on current Canadian Association of Gastroenterology (CAG) guidelines.

Conclusion:  Of the required endoscopy report elements as defined in the CAG guidelines, only maximum insertion was regularly reported.  Type and quality of bowel preparation, type and dose of sedation, maximum insertion, completeness of colonoscopy, polyp description and size, polypectomy technique, post-procedure diagnosis, withdrawal time, and recommendations for follow-up were not consistently reported.