Tu1160 “HARD STOPS” TO CAPTURE ERCP QUALITY METRICS.

Abstract

A multi-society task force on endoscopic quality published a list of evidence-based quality indicators to measure endoscopic retrograde cholangiopancreatography (ERCP) outcomes in 2015. There are five high priority indicators, of which three measure intraprocedural outcomes in patients with native, non-surgically altered biliary anatomy. These include (1) frequency of native papilla cannulation; (2) Frequency of extraction of common bile duct stones <1 cm; (3) Frequency of stent placement for biliary obstruction below the bifurcation. The performance targets for each are recommended to be greater than 90%. Methods to increase compliance in capturing and documenting these measures would enable outcomes analyses and allow healthcare systems to monitor ERCP quality. We developed a method to universally capture these three intraprocedural quality indicators. In our health system, three hospitals perform the majority of ERCPs, and all share the same endoscopy reporting software (ProVationMD, ProVation Medical, Minneapolis, MN). We created “hard stops” in this software that requires the endoscopist to record an outcome of either success, failure, or not applicable (N/A) for each measure before the report can be finalized. These data can be exported to a spreadsheet for analysis. We analyzed intraprocedural ERCP quality metrics since instituting these “hard stops” at each hospital, and compared outcomes by (a) annual hospital volume- low (<100) vs high (>200), and (b) annual endoscopist volume- low (<50) vs high (>200). A total of 3395, 800, and 112 ERCPs were performed at three hospitals (2 high volume; 1 low volume) in our health system over 46, 41, and 39-month periods respectively. These procedures were performed by 12 different endoscopists (5 high volume; 7 low volume). Documentation of success, failure, or N/A for each quality indicator was captured in all ERCPs (100%). The average cannulation success rate at all sites was 95%. Cannulation success was higher for the high volume endoscopists (97% vs 90%; p=0.0001), and at high volume centers (97% vs 91%; p=0.009). Success for extracting biliary stones <1 cm was 97%, with higher success for high volume endoscopists (97% vs 93%; p=0.0441), and at high volume centers (97% vs 90%; p=0.0047). Success for stenting strictures was 98%, with higher success for high volume endoscopists (99% vs 81%; p=0.001), and at high volume centers (98% vs 76%; p=0.002). The metrics measuring stent placement were below recommended targets for low volume endoscopists and at low volume centers. Endoscopy documentation software can be formatted to force “hard stops” to prospectively capture intraprocedural quality indicators for ERCP. Implementing such methods allows for 100% collection of these outcomes, and can be used to analyze ERCP quality metrics in a health care system.