Abstract
Objectives: Appropriate documentation of the colonoscopy procedure is an important component of patient care and one measure of quality. However, direct evaluation of colonoscopy reporting has been minimal. The aim of this study was to assess the quality of colonoscopy reporting.
Methods: We retrospectively collected data from 110 colonoscopy reports, where at least one polyp was noted. These reports were completed by 110 endoscopists from 2005-2006 through a statewide colorectal cancer screening program in Maryland, representing a variety of reporting formats from endoscopists throughout the state. We evaluated 25 key data elements recommended by the Standardized Colonoscopy Reporting and Data System (CO-RADS), including procedure indications, risk and comorbidity assessments, procedure technical descriptions, colonoscopy findings, and specimen retrieval and submission for pathology.
Results: All 110 reports stated an indication for the endoscopy, 36% included patient's medical comorbidities, 73% documented the bowel preparation quality, and 82% documented specific cecal landmarks. For the 177 individual polyps identified, information on size and morphology was documented for 87% and 53%, respectively. For these key data elements, ambiguous descriptors were sometimes used.
Conclusions: There was considerable variation among these colonoscopy reports. The absence of key data elements may impact the ability to make recommendations for recall intervals for colorectal cancer screening. Measurement of quality indicators in colonoscopy practice can identify areas for quality improvement.
Citation Information: Cancer Prev Res 2010;3(12 Suppl):A97.
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