ACG, ASGE release first quality indicators for capsule endoscopy, deep enteroscopy
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The ACG and ASGE have released a joint guideline on comprehensive quality indicators for capsule endoscopy and deep enteroscopy in the diagnosis and management of small-bowel disease.
“Small-bowel capsule endoscopy (CE) and deep enteroscopy (DE) are both relatively new procedures that enable evaluation of the entire small bowel,” Jonathan A. Leighton, MD, FACG, a gastroenterologist at Mayo Clinic in Scottsdale, Arizona, and colleagues wrote in The American Journal of Gastroenterology and Gastrointestinal Endoscopy. “CE has revolutionized small-bowel assessment, particularly for suspected small-bowel bleeding. Currently, CE is a purely diagnostic test. DE is more invasive and complements CE with important therapeutic capabilities.”
While both tests “have an important positive impact on the diagnosis and management of small-bowel diseases,” the authors wrote, “comprehensive quality indicators for CE and DE performance have been lacking, despite previous efforts to create individual quality metrics.”
Leighton and colleagues conducted a literature review and developed a list of proposed quality indicators applicable to preprocedure, intraprocedure and postprocedure periods for CE and DE using a modified RAND/University of California Los Angeles Appropriateness Method. Based on this method, an indicator was deemed appropriate when benefits outweigh any potential risk, regardless of cost.
The task force identified 13 quality indicators for CE/DE use, which are highlighted below.
Quality indicators for CE
During the preprocedure period, quality indicators include frequency of demonstrating competency, frequency of obtaining informed consent with specific discussion of associated risks and frequency of performing CE in a timely manner following an episode of overt, suspected small-bowel bleeding.
The quality indicator during the intraprocedure period is frequency of performing CE placement for patients with contraindications to swallowing the capsule or for patients at risk for gastric retention.
Postprocedure quality indicators include the frequency of performing photo documentation and documenting small-bowel transit time, the frequency of recommending an appropriate management plan based on CE findings, and the frequency of generating a complete report for all patients undergoing CE.
Quality indicators for DE
Like CE, frequency of demonstrating competency was also cited as a quality indicator in the preprocedure period of DE. Additional indicators during this time include frequency of performing DE for an indication that is documented and included in a standard list of appropriate indications, and frequency of discussing the management of anticoagulation and documenting the periprocedural anticoagulation plan.
During the intraprocedure period, quality indicators include frequency of marking the most distal point of advancement when indicated and frequency of characterizing and treating clinically significant lesions.
Frequency of generating a complete report and frequency of tracking DE complications and appropriate management are postprocedure quality indicators.
“The task force hoped to improve the quality performance of these relatively new small-bowel diagnostic techniques by compiling comprehensive recommendations of quality indicators for CE and DE procedures,” Leighton and colleagues concluded. “Incorporating the measures into clinical practice will improve standardization of these procedures, further increasing quality.”
Perspective
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Matthew Kroh, MD, FACS, FASGE, FASMBS
Capsule endoscopy and deep enteroscopy are important diagnostic and interventional techniques that are relatively new and focus on evaluating and treating diseases of the small intestine. These modalities have resulted in new applications and have changed the practice of gastroenterology and endoscopy. Data previously has been reported on both techniques.
The key takeaway from this report — from a panel of experts with major national society support — is agreement and consensus on proposed indications, with particular attention to quality improvement and overall patient care in the areas of preoperative selection, intraprocedural performance and postoperative reporting. The differences between the techniques were emphasized, but the overall theme of comprehensive quality indicators for both techniques and procedures is important moving forward.
In addition, the task force identified quality indicators that can be incorporated into clinical practice so practitioners and centers performing these procedures will have benchmarks for evaluation. The panel also addressed existing knowledge gaps and posed research questions.
As capsule endoscopy and deep enteroscopy continue to increase the number of applications they have, identifying knowledge gaps and research questions will help us better advance these technologies, improve quality reporting for better applications in the future and continue to advance patient care.
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