Tu1111 EFFECT OF A QUALITY IMPROVEMENT INITIATIVE ON INAPPROPRIATE FORCEPS POLYPECTOMY FOR NON-DIMINUTIVE POLYPS

Abstract

Forceps polypectomy of non-diminutive colorectal polyps is associated with higher rates of incomplete polyp resection compared to snare polypectomy, and for this reason the ESGE and others recommend snare polypectomy for non-diminutive polyps. However, there are a paucity of data on the rate of inappropriate use of forceps for polypectomy, and no data on efforts to improve this rate. We sought to quantify the incidence and predictors of inappropriate forceps use and to measure the effect of a quality improvement initiative to encourage snare polypectomy for non-diminutive polyps. We performed a retrospective study of all colonoscopies with polypectomies performed at two U.S. health systems (an academic tertiary care hospital and safety-net health system) between 10/1/2017 and 9/30/2019. The primary outcome was colonoscopies with an inappropriate forceps polypectomy, i.e. use of forceps polypectomy for any polyp ≥5mm. We measured the prevalence of inappropriate forceps polypectomy and used multivariate logistic regression to identify factors associated with inappropriate forceps polypectomy. We examined the effect of a quality improvement initiative, implemented 11/15/2019, in which avoidance of inappropriate forceps polypectomy was included as a quality metric tied to a modest financial incentive for the gastroenterology division. We identified 10118 colonoscopies with polypectomies. Overall, 1940 (18.9%) included inappropriate forceps polypectomy, including 20.8% of colonoscopies at the tertiary care hospital and 18.5% at the safety-net health system. Implementation of the quality improvement initiative was associated with a reduction in inappropriate forceps polypectomy (27.0% vs. 14.7%; OR 0.45, 95%CI 0.40 – 0.51) in adjusted analysis (Figure 1). In multivariate analysis, an adequate bowel preparation (OR 0.78, 95%CI 0.66 – 0.91) and fellow involvement in the procedure (OR 0.62, 95%CI 0.55 – 0.71) were associated with decreased odds of inappropriate forceps polypectomy, while number of polyps (OR 2.27, 95%CI 1.98 – 2.60 for 3-9 polyps; OR 4.65, 95%CI 3.57 – 6.05 for 10 or more polyps) and polyps in the right and left colon (OR 1.44, 95%CI 1.23 – 1.69) were associated with increased inappropriate forceps use. Among colonoscopies that employed forceps polypectomy for non-diminutive polyps, 41% included forceps polypectomy for polyps 6mm or larger. Nearly 1 in 5 colonoscopies had inappropriate forceps polypectomy for non-diminutive polyps, with higher proportions in those with inadequate bowel prep, higher number of polyps, and the presence of polyps in both the right and left colon. A simple quality improvement initiative significantly reduced use of inappropriate forceps polypectomy.