Endoscopic Retrograde Cholangiopancreatography Quality Research Articles

Recording ERCP Fluoroscopy Metrics Using a Multinational Quality Network: Establishing Benchmarks and Examining Time-Related Improvements

We aimed to establish benchmarks for fluoroscopy time (FT) in endoscopic retrograde cholangiopancreatography (ERCP) and assess the effect of physician practice networking on time trends. Data from the ERCP Quality Network were used to assess practice variability in FT and establish case- and provider-level benchmarks of the first 200 cases for providers entering more than 100 cases. Trends in FT and high FT, by 50-patient groupings, were assessed by multilevel multivariate linear and logistic regression models. Median FT was 2.9 minutes, averaging 16% of procedure time. Ninetieth percentiles for the 57 eligible providers were 10 minutes and 22% (n = 9, 185 ERCP). Every 50 cases entered was associated with lower FT. In multivariate analysis, more cases entered, higher lifetime and annual volumes, lower difficulty grade, and manometry had lower FTs; academics, trainee involvement, various therapeutics, and failed cannulation had higher FTs. FT is highly variable, and many provider and case factors predict FT. FT benchmarks are now available. Self-review of one's case FT might decrease FT.

Improving ERCP quality and decreasing risk to patients and providers

Endoscopic retrograde cholangiopancreatography (ERCP) continues to be one of the most complex gastrointestinal procedures and carries the highest risk of complications. Optimizing the outcome of ERCP requires a fine balance between the risk and the benefit of every maneuver performed. This fine balance has to include an analysis of the indication for the procedure, the optimal timing, the setting where the procedure is performed, the endoscopist and staff training and expertise, availability of surgical and interventional radiology support, the risk of every maneuver and ways to minimize this risk. As in any other procedure, it is very important to know one’s limitations and have a plan for failed procedures including consulting a colleague or referring the patient to a center with more expertise. In addition, a process of quality improvement is integral to every endoscopy center to address areas of underperformance, improve patient care and decrease liability.

Intraprocedural Quality in Endoscopic Retrograde Cholangiopancreatography: A Meta-Analysis

In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation. A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator. A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement). ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Quality evaluation through self-assessment: a novel method to gain insight into ERCP performance

BackgroundThe American Society for Gastrointestinal Endoscopy Committee on Outcomes Research has recommended monitoring nine endoscopic retrograde cholangiopancreatography (ERCP)-specific quality indicators for quality assurance in ERCP. With the development of a...

The ERCP Quality Network

There is increasing interest in the quality of endoscopic practice and in documenting it. Endoscopic retrograde cholangiopancreatography (ERCP) is the most complex and risky procedure performed regularly by gastroenterologists. The goal was to test the acceptability and functioning of a voluntary system for individual endoscopists to report details of their ERCP cases and to compare them with unidentified peers. Participants were compared by site of practice, procedure complexity, volumes, durations, and selected technical success rates. There was no independent audit. A total of 63 endoscopists in the United States entered data on 18 182 procedures over 3 years. Results in academic and community practices were similar, but there were significant and expected differences in the complexity of practice and key quality metrics between endoscopists performing more than and fewer than 100 cases per year. The study provided useful data on variations in ERCP practice in the United States and will assist in planning the development of national projects in this field.

The ERCP quality network benchmarking project: a preliminary comparison of practice in UK and USA

ObjectiveThe Endoscopic retrograde cholangiopancreatography (ERCP) Quality Network is a voluntary system for submission of data to generate individual report cards and benchmarking. The aim of this study was to compare...

PWE-016 The Endoscopic Retrograde Cholangiopancreatography Quality Network: a tool for improving standards: a preliminary comparison of UK and US practice: Abstract PWE-016

Introduction There is increasing interest in documenting the performance of individual endoscopists for their own education and to safeguard quality standards.1 What has hitherto been lacking is an infrastructure to facilitate collection and analysis of data to allow practioners to easily compile a “report card” of their own practice or benchmark themselves against their peers. Methods The Endoscopic Retrograde Cholangiopancreatography Quality Network (ERCP N) is a web-based tool that started as a voluntary reporting system in the US.2 Anonymised key data points (indications, sedation/anaesthesia, therapies, successes and adverse events) on each case are uploaded through a web-based interface onto a central server. 73 American endoscopists have uploaded data on 11 015 ERCP procedures. Eight British endoscopists enrolled more recently and have reported so far on 1007 procedures. Individual report cards or benchmark reports against the average of all users can be user-generated online. Result The table shows some of the areas (mean values) where practice differed between countries. All numbers (except the total) are percentage, and all differences are statistically significant. These data do not purport to reflect average UK and US practice, as participants are self-selected and not necessarily representative. UK endoscopists in this study performed less complex procedures as judged by the accepted complexity grade3 with lower (but acceptable) technical success rates. There were no significant differences in average procedure and fluoroscopy times or the proportion of cases involving trainees (Abstract 016). Conclusion UK users have found it quick and easy to enter data and that it provides very useful information. Collection of this level of data about one9s own practice is likely to become mandatory in the near future. We hope that these very preliminary data will encourage other UK endoscopists to participate.

Endoscopic biliopancreatic investigations and therapy

The management of most biliopancreatic diseases benefits from endoscopic treatment. Forty years after the first endoscopic cannulation of the ampulla of Vater, the overall effectiveness and safety of endoscopic retrograde cholangiopancreatography (ERCP) can be evaluated using the quality assurance programs that have recently been developed for gastrointestinal endoscopy, including ERCP. Such evaluation does not mean simply reporting therapeutic success and complication rates; rather, it involves a complex analysis of the entire gastrointestinal unit, of the medical practises, and of patient satisfaction. The overall quality of ERCP has been analysed and many quality deficits identified, even in referral centres. Training for such a specialised procedure is difficult and expensive. Competence in ERCP requires as many as 200 ERCP procedures. Quality assurance programs can help to improve the overall quality of endoscopic practise, including training of young endoscopists.

Quality in Endoscopic Retrograde Cholangiopancreatography

Purpose: In an effort to adopt a uniform system of quality performance measurement, a task force formed by the ASGE and ACG recently published a list of quality indicators (QI) for the pre-procedure, intra-procedure and post-procedure phases of each endoscopic procedure. It is unclear what the level of compliance is for these quality indicators, if they have influenced the practice, and if complying with these indicators improves patient care. We assessed if pre-, intra-, and post-procedure quality indicators are measurable within our ERCP practice with the aim of defining adherence to them before and after their publication. Methods: We performed a retrospective chart review of patients who have undergone an ERCP procedure at our institution. We reviewed 150 consecutive cases since the publication of the quality indicators (post) and compared them to 150 cases performed prior to their publication (pre). The study was approved by the IRB. All procedures were performed by 2 experienced endoscopists. No specific steps were undertaken to adhere to the quality indicators. Results: Comparing procedures performed prior to the publication of quality indicators to those performed after their publication, mean age was 59 vs 58, and males made up 52% vs 51%. Table 1 compares adherence rates to the quality indicators between procedures performed pre- and post-publication. In the 2 patients that developed cholangitis, antibiotics were indicated and given.Table: Adherence rates to quality indicators before (pre) and after (post) their publication.Conclusion: Our adherence rate to quality indicators has not changed significantly since their publication. Whether documenting the procedure difficulty preprocedurally will impact success rate or patient outcome has yet to be studied.

ASGE Technology Status Evaluation Report: radiographic contrast media used in ERCP

ASGE Technology Status Evaluation Report: radiographic contrast media used in ERCP