Morbidity and Mortality Conferences in the Gastrointestinal Department and Endoscopist Behaviors: Timeless Tradition or Effective Tool for Change?

Abstract

There are limited data on how morbidity and mortality (M+M) conferences impact physician behaviors. These conferences are present at all major teaching hospitals, however, it is unclear what impact they have on physician behavior. At a tertiary care center, a patient underwent 2 esophagogastroduodenoscopies (EGDs) and high-resolution manometry for dysphagia and voice hoarseness. A third EGD revealed a mass in the hypopharynx that had been missed on the previous 2 EGDs. The mass was resected and found to be a poorly differentiated squamous cell carcinoma. This case was presented at the gastrointestinal department M+M/quality improvement conference as an opportunity to discuss the role of EGD in diagnosing hypopharyngeal pathology. After the conference, physician endoscopic behaviors were tracked and compared to historical controls to see if the conference changed the way they performed/documented EGDs. All EGDs performed in the month after the M+M presentation were reviewed for text or image documentation of a hypopharynx examination. Data from the same month but 1-year prior were used as a historical control. After the initial month, the electronic medical record (EMR) was updated to include a text prompt for hypopharynx documentation. Data were collected in the subsequent month and compared to the historical control. Data were divided based on attendance at the initial M+M conference with the primary outcome of hypopharynx documentation compared between attendees of the conferences and those who did not attend. There was a significant increase in hypopharynx documentation after M+M conference and EMR update compared to historical control (Table 1). No significant difference in documentation rate between post-M+M and post-EMR update. No aspiration events were noted in any EGDs where hypopharynx documentation occurred. Four cases (of 564 EGDs) of hypopharyngeal pathology were identified. Attending participation at M+M conference was associated with a significant increase in hypopharynx documentation in June 2017 and August 2017 data (Table 2). The addition of the EMR prompt did not significantly increase rate of documentation in cases where no provider attended the M+M conference. After the presentation of a missed hypopharynx cancer at an M+M conference, providers adjusted their endoscopic and documentation behaviors to note the appearance of the hypopharynx more often. The addition of the EMR prompt in the following month did not significantly increase the overall documentation rate or the rate in procedures where no provider attended the M+M conference. It is possible that the EMR prompt helped with retention of the behavior change. Further data will be collected to determine long-term retention and overall rate of hypopharynx pathology seen on EGD to determine whether routine examination of the hypopharynx should be performed during upper endoscopy.Table 1Hypopharynx Documentation During Upper EndoscopyData set% of any mentionEGDs, nAny mention of hypopharynx, nOnly photo of hypopharynx, nOnly text mention of hypopharynx, nBoth text and photo, nCases with pathology found in the hypopharynx, nP valueJune 20168.23763128210NAJune 2017 (month after M+M)3230698813143<.0001August 2017 (month after EMR update; 2 mo after M+M)36.4258943120431<.0001 compared to June 2016; .2723 compared to June 2017NA, not available. Open table in a new tab Table 2August 2017 SubgroupsAugust 2017 subgroups% of EGDs with hypopharynx documentationTotal number of EGDs performedAny form of hypopharynx documentation, nOnly text documentation of hypopharynx exam, nBoth picture and text documentation, nP valuesAttending physician attended M+M conference44.1145641726.0036Attending physician did not attend M+M conference26.511330317—Either attending or fellow attended M+M conference48.3172831840<.0001 comparing either attending/fellow with neither attending/fellow; .0331 comparing both attending/fellow attending M+M to neither attending.Neither attending or fellow attended M+M conference12.8861123Both attending and fellow attended M+M conference70.4271909 Open table in a new tab