Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics

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<ul><li><p> 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY</p><p> Letters to the Editor 1089</p><p>Harvard Medical School , Boston , Massachusetts , USA . Correspondence: Joseph Feuerstein, MD , Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School , 330 Brookline Avenue E / Dana 501 , Boston, Massachusetts 02215 , USA . E-mail: Jfeuerst@bidmc.harvard.edu </p><p> Terminal Ileitis Found Upon Imaging: Is It Always Crohn s Disease? </p><p> Teresa Pinto Pais , MD 1 , S nia Fernandes , MD 1 , Carlos Fernandes , MD 1 , Iolanda Ribeiro , MD 1 and Jo o Carvalho , MD 1 </p><p> doi:10.1038/ajg.2014.114 </p><p> To the Editor: Terminal ileitis (TI), defi ned as infl ammation of the terminal ileum, is a common condition in clinical practice and is classically associated with Crohn s disease (CD). However, a wide variety of diseases may be associated with ileitis ( 1,2 ). Diagnosis of the specifi c cause of ileitis is of paramount importance because misdiagnosis may result in critical delays or errors in patient management ( 3 5 ). None-theless, distinguishing between the various forms of ileitis remains a test of clinical acu-men. Accurate diagnosis is suggested by a detailed history and physical examination, by laboratory testing, and by ileocolonos-copy and / or radiological evaluation. </p><p> To study the diff erent entities associated with TI in clinical practice, we reviewed all patients with confi rmed imaging of TI on ultrasound admitted to our depart-ment over four consecutive years. An observational, descriptive, longitudinal study was performed, with a retrospective review of demographics, clinical presenta-tion, laboratory data, treatment, and fol-low-up. Abdominal ultrasonography was performed in all patients and was comple-mented with computed tomography when necessary. Sonographic features compati-ble with TI included hypoechogenic mural thickening of the terminal ileum and hyp-oechoic enlarged mesenteric lymph nodes ( 6 ). Th e diagnosis of ileal CD was based on clinical, endoscopic, and histopathological data. Acid-fast bacilli smear and culture </p><p>were performed in ileal biopsy specimens. An infectious etiology was presumed when there was clinical, analytical, and imag-ing remission aft er empirical antibiotic therapy, or when confi rmed by isolation of pathogenic microorganisms in stool cultures. </p><p> Th is study assessed 62 patients with a median age of 38.2 years (18 82), with a slight predominance of females (56.4 % ). Th e main form of presentation was abdom-inal pain (93.5 % ) and diarrhea (67.7 % ). All patients presented with ultrasonographic features of TI, which were corroborated by computed tomography in 62.9 % . In this study, infectious etiology was confi rmed in 62.9 % ( n = 39) of patients, CD was diagnosed in 32.2 % ( n = 20), and ileum cancer in 4.9 % (ileal lymphoma 2, ade-nocarcinoma 1). Fecal pathogens were identifi ed in 7 patients: Campylobacter 3, Yersinia 2, and Salmonella 2. No para-sitic or tuberculosis infection was identifi ed. On comparing the groups with confi rmed CD and infectious ileitis, we found in the fi rst group higher median values of serum infl ammatory parameters (C-reactive pro-tein: 9.8 vs. 7.4 mg / dl; leukocyte count: 16.650 vs. 11.170 / l), lower hemoglobin levels (10.45 vs. 13.5 g / dl, t- test, P =0.03), and a longer inpatient period (10 vs. 5 days). Patients diagnosed with CD maintain long-term follow-up in our outpatient clinic. </p><p> In the current study, the diagnosis of CD of the ileum was confi rmed histopatholog-ically in 32.2 % of patients with imaging of TI. We highlight that infl ammation of the terminal ileum is not always CD, and infec-tious etiology is a common cause (62.9 % in our study). Th e diff erential diagnosis of TI found on imaging, although sometimes diffi cult, is of critical importance to avoid further unnecessary diagnostic workup and inappropriate treatment. </p><p> CONFLICT OF INTEREST Guarantor of the article: Teresa Pinto Pais, MD. Specifi c author contributions: Teresa Pinto Pais was involved in planning and conduct-ing the study, collecting and interpret-ing data, and writing the paper. She has approved the fi nal draft submitted. S nia Fernandes was involved in planning the study, interpreting data, and draft ing the </p><p>manuscript. She has approved the fi nal draft submitted. Carlos Fernandes was involved in collecting and interpreting data. He has approved the fi nal draft submitted. Iolanda Ribeiro was involved in collecting and interpreting data. She has approved the fi nal draft submitted. Jo o Carvalho was involved in planning the study, interpreting data, and draft ing the manuscript. He has approved the fi nal draft submitted. Financial support: None. Potential competing interests: None. </p><p> REFERENCES 1 . Dilauro S , Crum-Cianfl one NF . Ileitis: when it </p><p>is not Crohns disease . Curr Gastroenterol Rep 2010 ; 12 : 249 58 . </p><p> 2 . Greaves ML , Pochapin M . Asymptomatic ileitis: past, present, and future . J Clin Gastroenterol 2006 ; 40 : 281 5 . </p><p> 3 . Lee YJ , Yang SK , Byeon JS et al. Analysis of colonoscopic fi ndings in the diff erential diagno-sis between intestinal tuberculosis and Crohns disease . Endoscopy 2006 ; 38 : 592 7 . </p><p> 4 . Jeong SH , Lee KJ , Kim YB et al. Diagnostic value of terminal ileum intubation during colonoscopy . J Gastroenterol Hepatol 2008 ; 23 : 51 5 . </p><p> 5 . Chang HS , Lee D , Kim JC et al. Isolated termi-nal ileal ulcerations in asymptomatic individu-als: natural course and clinical signifi cance . Gastrointest Endosc 2010 ; 72 : 1226 32 . </p><p> 6 . Ledermann HP , B rner N , Strunk H et al. Bowel wall thickening on transabdominal sonography . Am J Roentgenol 2000 ; 174 : 107 17 . </p><p> 1 Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia / Espinho , Vila Nova de Gaia , Portugal . Correspondence: Teresa Pinto Pais, MD , Department of Gastroenterology and Hepatology, Centro Hospitalar de Gaia / Espinho, Rua Concei o Fernandes , 4434-502 Vila Nova de Gaia , Portugal . E-mail: teresapintopais@gmail.com </p><p> Patient Satisfaction Does Not Correlate With Established Colonoscopy Quality Metrics </p><p> Rena Yadlapati , MD 1 , Andrew Gawron , MD 1 , 2 and Rajesh N. Keswani , MD 1 </p><p> doi:10.1038/ajg.2014.115 </p><p> To the Editor: Quality metrics for colonos-copy are increasingly being measured and reported, as procedure quality correlates </p></li><li><p>The American Journal of GASTROENTEROLOGY VOLUME 109 | JULY 2014 www.amjgastro.com</p><p>1090 Letters to the Editor </p><p>with its eff ectiveness in reducing colorec-tal cancer incidence and mortality ( 1,2 ). Patient satisfaction ratings (PSRs) are also publicly reported and may be eventually tied to reimbursement in clinical practice. PSRs are additionally being utilized in con-cert with other measures to determine pro-vider performance and health-care quality ( 3 6 ). However, previous studies have failed to validate a relationship between PSRs and surgical procedure quality ( 4 ). As a result, we sought to investigate whether patient satisfaction correlates with estab-lished indicators of colonoscopy quality, an area that has not been studied previously. </p><p> We performed a retrospective review of PSRs and colonoscopy quality for endo-scopists at a single-center tertiary care teaching institution from September 2012 to August 2013. Endoscopists were included if they were attending gastroenterologists and performed more than 50 colonoscop-ies over 1 year. Th is study was approved by the Institutional Review Board. </p><p> All patients undergoing endoscopic procedures at our institution are asked to complete an 11-question outpatient vali-dated survey developed by Press Ganey Associates (South Bend, IN) assessing their procedure experience ( 6 ). Th e PSR is measured by calculating the percent-age of responses with a score of 5 (rep-</p><p>resenting very good ) on a scale of 1 5. Physician quality indicators for screening colonoscopies including adenoma detec-tion rate (ADR), withdrawal time (WT) in normal screening colonoscopies, and cecal intubation rate are also measured. Th e relationship between patient satisfac-tion and quality indicators was determined using Spearman s rank-order correlation. Statistical analyses were performed using STATA 12.0 (College Station, TX). </p><p> During the 1-year period 1,688 patient satisfaction surveys were collected and 6,761 screening colonoscopies were performed. Th e mean screening colonoscopy volume per physician was 687 (229 1179) 301. Twenty-one endoscopists (5F:16M) were included in this study: 48 % were in private practice and 52 % were in academic practice. Th ere was no signifi cant diff erence in PSRs and practice type. Median time in clinical practice aft er training was 15 years (inter-quartile range = 22), and did not correlate with patient satisfaction ( r = 0.11). </p><p> Th e overall mean PSR was 75.6 % (64 84 % ) 5.5 % . Th e mean ADR, WT, and cecal intubation rate were 29 % (12 51 % ) 10.8 % , 10.5 (3.1 19.2) 4.5 min, and 98.6 % (96.3 100 % ) 1.2 % , respectively. Th ere was weak or no correlation between PSRs and ADR ( r = 0.22), WT ( r = 0.02), and cecal intu-bation rate ( r = 0.24). We found a strong </p><p>positive correlation between ADR and WT ( r = 0.60; Table 1 ). </p><p> Th ere was a moderate, statistically sig-nifi cant, inverse correlation between PSR and physician sex ( r = 0.57, P &lt; 0.01). However, there was no signifi cant diff er-ence when comparing female with male physician ADR, WT, or cecal intubation rate ( Table 2 ). In addition, female endo-scopists saw a disproportionately greater number of female patients compared with male endoscopists (75 % vs. 55 % , P &lt; 0.01). </p><p> Th is is the fi rst study to suggest that patient satisfaction is not related to estab-lished colonoscopy quality indicators. Our analyses did, however, reproduce a correla-tion between widely accepted quality indi-cators such as ADR and WT ( 7 ). Although PSRs may refl ect an institution s ability to provide good service as part of the patient experience, our study challenges their role as a measure of colonoscopy quality. </p><p> Patient satisfaction is likely infl uenced by several factors that are unrelated to pro-cedure quality. For instance, it is possible that polyp detection and removal results in longer procedure time and emotional dis-tress, which could negatively aff ect patient satisfaction. Th is study also suggests a cor-relation between PSRs and physician gen-der. Th ese are interesting areas that require further investigation. </p><p> In conclusion, this analysis demon-strates that patient satisfaction is not a reliable metric of colonoscopy quality, and further work should be carried out before patient satisfaction is promoted as a surrogate measure for colonoscopy quality. </p><p> CONFLICT OF INTEREST Guarantor of the article: Rena Yadlapati, MD. Specifi c author contributions: Rena Yadlapati and Andrew Gawron: study concept and design, acquisition of data, analysis and interpretation of data, draft ing of manu-script, approval of fi nal draft submitted; Raj Keswani: Principal Investigator, study super-vision, study concept and design, acquisition of data, analysis and interpretation of data, draft ing of manuscript, approval of fi nal draft submitted. Financial support: None. Potential competing interests: None. </p><p> Table 1 . Colonoscopy variables and their correlation with PSRs </p><p> Variable Mean (range) s.d. Correlation with PSRs ( r ) </p><p> ADR 29.2 (11.5 51.2) 10.7 0.17 </p><p> WT (min) 10.5 (3.1 19.2) 4.5 0.88 </p><p> Cecal intubation ( % ) 98.6 (96.0 99.0) 1.18 0.26 </p><p> ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time. </p><p> Table 2 . Colonoscopy quality indicators and PSRs for male and female endoscopists </p><p> Male endoscopists ( n =16) Female endoscopists ( n =5) P value </p><p> ADR, mean 29.8 (11.6 51.2) 11.8 27.6 (20.0 37.4) 6.9 0.69 </p><p> WT, mean 10.1 (3.1 19.2) 4.6 11.8 (7.7 19.0) 4.3 0.46 </p><p> Cecal intubation rate, mean 98.7 (96.3 99.9) 1.3 98.4 (97.9 99.3) 0.6 0.68 </p><p> PSR, mean 77 (71 84) 4.5 70 (64 76) 4.5 &lt; 0.01 </p><p> ADR, adenoma detection rate; PSR, patient satisfaction rating; WT, withdrawal time. </p></li><li><p> 2014 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY</p><p> Letters to the Editor 1091</p><p> REFERENCES 1 . Zauber AG WS , O Brien MJ , Lansdorp-</p><p>Vogelaar I et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths . N Engl J Med 2012 ; 366 : 687 96 . </p><p> 2 . Lieberman DA , Weiss DG , Bond JH et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Aff airs Cooperative Study Group 380 . N Engl J Med 2000 ; 343 : 162 8 . </p><p> 3 . Centers for Medicare &amp; Medicaid Services . Medicare program: hospital inpatient value-based purchasing program . Fed Regist 2011 ; 76 : 2454 91 . </p><p> 4 . Lyu H , Wick EC , Housman M et al. Patient satisfaction as a possible indicator of quality surgical care . JAMA Surg 2013 ; 148 : 362 7 . </p><p> 5 . Pascoe GC . Patient satisfaction in primary health care: a literature review and analysis . Eval Program Plann 1983 ; 6 : 185 210 . </p><p> 6 . Hospital Consumer Assessment of Healthcare Providers and Systems 2013 (Accessed 29 December 2013, at http://www.hcahpsonline.org/home.aspx ) . </p><p> 7 . Barclay RL , Vicari JJ , Doughty AS et al. Colonoscopic withdrawal times and adenoma </p><p>detection during screening colonoscopy . N Engl J Med 2006 ; 355 : 2533 41 . </p><p> 1 Divisions of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University , Chicago , Illinois , USA ; 2 Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University...</p></li></ul>