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Quality Improvement in Gastroenterology: A Systematic Review of Practical Interventions for Clinicians

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Abstract

Background

Quality improvement (QI) identifies practical methods to improve patient care; however, it is not always widely known which QI methods are successful. We sought to create a primer of QI in gastroenterology for the practicing clinician.

Methods

We performed a systematic review of QI literature in gastroenterology. We included search terms for inflammatory bowel disease, irritable bowel syndrome, celiac disease, gastroesophageal reflux disease, pancreatitis, liver disease, colorectal cancer screening, endoscopy, and gastrointestinal bleeding. We used general search terms for QI as well as specific terms to capture established quality metrics for each GI disease area.

Results

We found 33 studies that met our definitions for QI. There were 17 studies of endoscopy including screening colonoscopy, six on liver disease, four on IBD, two on GERD, three on GI bleeding, and one on celiac disease. Education was the most common intervention, although most successful studies combined education with another intervention. Other effective interventions included retraining sessions to reach ADR goals in colonoscopy, nursing protocols to increase HCC screening, and EMR decision support tools to prompt reassessment of PPI therapy. Many studies showed improved compliance to metrics, but few were able to show differences in length of stay, readmissions, or mortality.

Conclusions

Our review of quality improvement literature in gastroenterology revealed common themes of successful programs: Education was frequently used but often insufficient, the EMR may be underutilized in guiding decision making, and patient-reported outcomes were infrequently assessed. Further research may be needed to compare QI strategies directly.

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References

  1. OECD Health Statistics 2017. June 30th, 2017. Organization for Economic Co-operation and Development. http://www.oecd.org/els/health-systems/health-data.htm. Accessed August, 15, 2017.

  2. Morgan L. US healthcare annual spending estimated to rise by 58% on average through 2024. Am Health Drug Benefits. 2015;8:272.

    PubMed  PubMed Central  Google Scholar 

  3. MacDorman MF, Mathews TJ, Mohangoo AD et al. International comparisons of infant mortality and related factors: United States and Europe. Natl Cent Health Stat. 2014;63(5):1–6.

    Google Scholar 

  4. Robeznieks A. US has the highest maternal death rate among developed countries. Modern Healthcare, May 6th, 2015. http://www.modernhealthcare.com/article/20150506/NEWS/150509941. Accessed August 15, 2017.

  5. Xu J, Murphy SL, Kochanek KD et al. Mortality in the United States, 2015. NCHS Data Brief. 2016; No. 267.

  6. Readmissions Reduction Program. Centers for Medicare and Medicaid Services. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed August 15, 2017.

  7. Fonarow GC, Stevenson LW, Walden JA, et al. Impact of a comprehensive heart failure management program on hospital readmission and functional status of patients with advanced heart failure. J Am Coll Cardiol. 1997;30:725–732.

    Article  CAS  PubMed  Google Scholar 

  8. Krumholz HM, Amatruda J, Smith GL, et al. Randomized trial of an education and support intervention to prevent readmission of patients with heart failure. J Am Coll Cardiol. 2002;39:83–89.

    Article  PubMed  Google Scholar 

  9. Amarasingham R, Patel PC, Toto K, et al. Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective controlled study. BMJ Qual Saf. 2013;22912:998–1005.

    Article  Google Scholar 

  10. Ong MK, Romano PS, Edington S, et al. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the better effectiveness after transition–heart failure (BEAT-HF) randomized clinical trial. JAMA Intern Med. 2016;22(12):310–318.

    Article  Google Scholar 

  11. Hale TM, Jethwani K, Kandola MS, et al. A remote medication monitoring system for chronic heart failure patients to reduce readmissions: a two-arm randomized pilot study. J Med Internet Res. 2016;18:e91.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Atkinson S, Ingham J, Cheshire M, et al. Defining quality and quality improvement. Clin Med (Lond). 2010;10:537–539.

    Article  Google Scholar 

  13. Choosing Wisely: An Initiative of the ABIM Foundation. American Gastroenterology Association. http://www.choosingwisely.org/societies/american-gastroenterological-association/. Accessed January 5, 2018.

  14. Physician Quality Reporting System 2015. American Gastroenterology Association. https://www.gastro.org/practice/quality-initiatives/performance-measures/400-1708901-MHC-AGA_PQRS-IBD-Flashcard.pdf. Accessed January 5, 2018.

  15. Huang Y, Don-Wauchope AC, Grey VL, et al. Improving serological test ordering patterns for the diagnosis of celiac disease through clinical laboratory audit of practice. Clin Biochem. 2012;45:455–459.

    Article  PubMed  Google Scholar 

  16. Tapper E, Finkelstein D, Mittleman M, et al. A quality improvement initiative decreases 30-day readmission rates for patients with cirrhosis: a prospective trial. Clin Gastroenterol Hepatol. 2016;14:753–759.

    Article  PubMed  Google Scholar 

  17. Ghaoui R, Friderici J, Desilets DJ, et al. Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis. J Hosp Med. 2015;10:236–241.

    Article  PubMed  Google Scholar 

  18. Desai AP, Satoskar R, Appannagari A, et al. Co-management between hospitalist and hepatologist improves the quality of care of inpatients with chronic liver disease. J Clin Gastroenterol. 2014;48:e30–e36.

    Article  PubMed  Google Scholar 

  19. Kennedy NA, Rodgers A, Altus R, et al. Optimisation of hepatocellular carcinoma surveillance in patients with viral hepatitis: a quality improvement study. Intern Med J.. 2013;43:772–777.

    Article  CAS  PubMed  Google Scholar 

  20. Aberra FB, Essenmacher M, Fisher N, et al. Quality improvement measures lead to higher surveillance rates for hepatocellular carcinoma in patients with cirrhosis. Dig Dis Sci. 2013;58:1157–1160. https://doi.org/10.1007/s10620-012-2461-4.

    Article  PubMed  Google Scholar 

  21. Loy V, Kwiatt J, Dodda A. Performance feedback improves compliance with quality measures. Am J Med Qual. 2016;31:118–124.

    Article  PubMed  Google Scholar 

  22. Inra J, Nayor J, Rosenblatt M, et al. Comparison of colonoscopy quality measures across various practice settings and the impact of performance scorecards. Dig Dis Sci. 2017;62:894–902. https://doi.org/10.1007/s10620-016-4410-0.

    Article  PubMed  Google Scholar 

  23. Shaukat A, Oancea C, Bond J, et al. Variation in detection of adenomas and polyps by colonoscopy and change over time with a performance improvement program. Clin Gastroenterol Hepatol. 2009;7:1335–1340.

    Article  PubMed  Google Scholar 

  24. Clayton D, Palmer W, Robison S, et al. Colonoscopy bowel preparation quality improvement for patients with decompensated cirrhosis undergoing evaluation for liver transplantation. Clin Transplant. 2016;30:1236–1241.

    Article  PubMed  Google Scholar 

  25. Kahi C, Ballard D, Shah A, et al. Impact of a quarterly report card on colonoscopy quality measures. Gastrointest Endosc. 2013;77:925–931.

    Article  PubMed  Google Scholar 

  26. Mai HD, Sanowski RA, Waring JP. Improved patient care using the A/S/G/E guidelines on quality assurance: a prospective comparative study. Gastrointest Endosc. 1991;37:597–599.

    Article  CAS  PubMed  Google Scholar 

  27. Abdul-Baki H, Schoen R, Dean K, et al. Public reporting of colonoscopy quality is associated with an increase in endoscopist adenoma detection rate. Gastrointest Endosc. 2015;82:676–682.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Ross W, Thirumurthi S, Lynch P, et al. Detection rates of premalignant polyps during screening colonoscopy: time to revise quality standards? Gastrointest Endosc. 2015;81:567–574.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Coe S, Crook J, Diehl N, et al. An endoscopic quality improvement program improves detection of colorectal adenomas. Am J Gastroenterol. 2013;108:219–226.

    Article  PubMed  Google Scholar 

  30. Ussui V, Coe S, Rizk C, et al. Stability of increased adenoma detection at colonoscopy. Follow-up of an endoscopic quality improvement program-EQUIP-II. Am J Gastroenterol. 2015;110:489–496.

    Article  PubMed  Google Scholar 

  31. Wallace MB, Crook JE, Thomas CS, et al. Effect of an endoscopic quality improvement program on adenoma detection rates: a multicenter cluster-randomized controlled trial in a clinical practice setting (EQUIP-3). Gastrointest Endosc. 2017;85:538–545.

    Article  PubMed  Google Scholar 

  32. Rajasekhar P, Rees C, Bramble M, et al. A multicenter pragmatic study of an evidence based intervention to improve adenoma detection: the Quality Improvement in Colonoscopy (QIC) study. Endoscopy. 2015;47(3):217–224.

    Article  PubMed  Google Scholar 

  33. Imperiali G, Minoli G, Meucci M, et al. Effectiveness of a continuous quality improvement program on colonoscopy practice. Endoscopy. 2007;39:314–318.

    Article  CAS  PubMed  Google Scholar 

  34. Barclay R, Vicari J, Greenlaw R, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091–1098.

    Article  PubMed  Google Scholar 

  35. Hayat U, Lee P, Lopez R, et al. Online educational video improves bowel preparation and reduces the need for repeat colonoscopy within three years. Am J Med. 2016;129:1219.

    Article  PubMed  Google Scholar 

  36. Park J, Kim M, Kim H, et al. A randomized controlled trial of an educational video to improve quality of bowel preparation for colonoscopy. BMC Gastroenterol. 2016;16:64.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hseuh F, Wang H, Sun C, et al. The effect of different patient education methods on quality of bowel cleanliness in outpatients receiving colonoscopy examination. App Nurs Res. 2014;27:e1–e5.

    Article  Google Scholar 

  38. Grassini M, Verna C, Battaglia E, et al. Education improves colonoscopy appropriateness. Gastroinest Endosc. 2008;67:88–93.

    Article  Google Scholar 

  39. Player MS, Gill JM, Mainous AG, et al. An electronic medical record-based intervention to improve quality of care for gastro-esophageal reflux disease (GERD) and atypical presentations of GERD. Qual Prim Care. 2010;18:223–229.

    PubMed  Google Scholar 

  40. Walsh K, Kwan D, Marr P, et al. Deprescribing in a family health team: a study of chronic proton pump inhibitor use. J Prim Health Care. 2016;8:164–171.

    Article  PubMed  Google Scholar 

  41. Loftus TJ, Go KL, Hughes SJ, et al. Improved outcomes following implementation of an acute gastrointestinal bleeding multidisciplinary protocol. J Trauma Acute Care Surg. 2017;83:41–46.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Johnson EA, Spier BJ, Leff JA, et al. Optimising the care of patients with cirrhosis and gastrointestinal haemorrhage: a quality improvement study. Aliment Pharmacol Ther. 2011;34:76–82.

    Article  CAS  PubMed  Google Scholar 

  43. Pfau P, Cooper G, Carlson M, et al. Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding. Am J Gastroenterol. 2004;99:425–431.

    Article  PubMed  Google Scholar 

  44. 2015 National Healthcare Quality and Disparities Report and 5th Anniversary Update on the National Quality Strategy. Agency for Healthcare Research and Quality. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/priorities.html. Accessed January 5, 2018.

  45. Sapir T, Moreo K, Carter JD, et al. Continuing medical education improves gastroenterologists’ compliance with inflammatory bowel disease quality measures. Dig Dis Sci. 2016;61:1862–1869. https://doi.org/10.1007/s10620-016-4061-1.

    Article  PubMed  Google Scholar 

  46. Greene L, Moreo K. Quality improvement education to improve performance on ulcerative colitis quality measures and care processes aligned with National Quality Strategy priorities. BMJ Qual Improv Rep. 2015;4:u208829-w3554.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Greene L, Sapir T, Moreo K, et al. Impact of quality improvement educational interventions on documented adherence to quality measures for adults with Crohn’s disease. Inflamm Bowel Dis. 2015;21:2165–2171.

    Article  PubMed  Google Scholar 

  48. Walsh AJ, Wetlman M, Burger D, et al. Implementing guidelines on the prevention of opportunistic infections in inflammatory bowel disease. J Crohns Colitis. 2013;7:e449–e456.

    Article  CAS  PubMed  Google Scholar 

  49. Baysari MT, Tarig A, Day RO. Alert override as a habitual behavior—a new perspective on a persistent problem. J Am Med Inform Assoc. 2017;24:409–412.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, 10945 Le Conte Ave, Suite 2338, Los Angeles, CA, 90095, USA

    Courtney Reynolds, Eric Esrailian & Daniel Hommes

  2. Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, 200 Medical Plaza Driveway, Los Angeles, CA, 90024, USA

    Eric Esrailian

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  1. Courtney Reynolds
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Correspondence to Courtney Reynolds.

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Reynolds, C., Esrailian, E. & Hommes, D. Quality Improvement in Gastroenterology: A Systematic Review of Practical Interventions for Clinicians. Dig Dis Sci 63, 2507–2518 (2018). https://doi.org/10.1007/s10620-018-5198-x

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