By David A. Johnson MD, FACG, FASGE
Traditional benchmarking has focused on cost and efficiency. Downward pricing pressure will drive continuation of such activities, but there will be an intense and ever-increasing focus on quality direction for value-based purchasing. Furthermore, the rising consumerism related to health care consumption will force defensive benchmarking with an eye to how the data will be perceived by an external audience.
Defensive benchmarking will evaluate the confluence of quality measures, patient satisfaction and price, in light of how these will be evaluated by the patient as well as the insurers. Traditional benchmarking can provide cost data to support pricing decisions, but well-defined and broadly accepted quality measures that can transcend single episodes of care and are applicable to complex patient care across specialties have yet to be developed.
Endoscopy has become enormously popular throughout the world because of its proven value in the diagnosis and treatment of digestive diseases. A major, perhaps limiting, problem is that the benefits are maximized only when procedures are performed at an optimal level of quality and safety, which is not always the case. Technical failures and adverse events can occur even in the best of hands, but are more likely when procedures are performed by endoscopists with inadequate training and experience. Practitioners, patients and payers should all be interested in enhancing the quality of endoscopy and documenting it. Furthermore, gastrointestinal professional organizations have increasingly embraced the quality improvement paradigm that is advancing through medicine.
Recognition and Measure Excellence of Endoscopists
There are some features of an endoscopist that make a good experience more likely. Formal endoscopic training and extensive experience do not guarantee quality practice, but they certainly make it more likely. Thus, documentation of these and related elements should be a part of any assessment of endoscopic performance. Appropriate metrics could include:
• Specialty training and certification (place and dates)
• Training and maintenance of competence in life support and sedation
• Evidence for continuing education in endoscopy
• For each procedure—lifetime numbers, total last year and spectrum of practice
The proof of quality comes from documentation of performance. There is no substitute for collecting relevant data. Trainees are now expected to maintain logbooks of their procedural activity during training, and many authorities have recommended that endoscopists should continue to collect data prospectively on their endoscopic practice and performance. This translates into “endoscopy report cards.”
The assurance that high-quality endoscopic procedures are performed has taken increased importance. A high-quality endoscopy ensures that the patient receives an indicated procedure, that correct and clinically relevant diagnoses are made (or excluded), therapy is properly performed, and all of these are accomplished with minimum risk. The motivation for developing quality indicators for endoscopy begins with the desire to provide patients with the best possible care. These indicators may then be used in programs to
improve the overall quality of endoscopic services.
In 2006, the ACG and ASGE Quality Task Force developed and published quality benchmarks intended to create rational quality indicators that any well-trained endoscopist committed to patient care should and would follow and exceed minimum frequency thresholds. These benchmarks, weighted by scientific evidence, were developed to identify poorly-trained individuals doing a disservice to their patients and the medical profession.