title: The Quality of Colonoscopy Reporting in Usual Practice: Are Endoscopists Reporting Key Data Elements?
abstract: Background. High quality reporting of endoscopic procedures is critical to the implementation of colonoscopy quality assurance programs. Objective. The aim of our research was to (1) determine the quality of colonoscopy (CS) reporting in "usual practice," (2) identify factors associated with good quality reporting, and (3) compare CS reporting in open-access and non-open-access procedures. Methods. 557 CS reports were randomly selected and assigned a score based on the number of mandatory data elements included in the report. Reports documenting greater than 70% of the mandatory data elements were considered to be of good quality. Physician and procedure factors associated with good quality CS reporting were identified. Results. Variables that were consistently well documented included date of the procedure (99.6%), procedure indication (88.9%), a description of the most proximal anatomical segment reached (98.6%), and documentation of polyp location (97.8%). Approximately 79.4% of the reports were considered to be of good quality. Gastroenterology specialty, lower annual CS volume, and fewer years in practice were associated with good quality reporting. Discussion. CS reporting in usual practice in Ontario lacks quality in several areas. Almost 1 in 5 reports was of poor quality in our study. Conclusions. Targeted interventions and/or use of mandatory fields in synoptic reports should be considered to improve CS reporting.
authors: Montfort Hospital, Gastroenterology, Ottawa, ON, Canada K1K 0T2.
authors: S D
authors: 0000-0003-1873-8479
authors: SD
authors: Hadlock
authors: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada M4N 3M5.
authors: N
authors: 0000-0001-9215-475X
authors: N
authors: Liu
authors: Sunnybrook Health Sciences Centre, Toronto, ON, Canada M4N 3M5.
authors: M
authors: M
authors: Bernstein
authors: Toronto Digestive Disease Associates Inc, Toronto, ON, Canada L4L 4Y7.
authors: M
authors: 0000-0003-2784-9576
authors: M
authors: Gould
authors: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada M4N 3M5; Cancer Care Ontario, Toronto, ON, Canada M5G 2L7; Department of Medicine, University of Toronto, Toronto, ON, Canada M5S 1A8; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada M5T 3M6; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada M5T 3M7.
authors: L
authors: 0000-0002-2375-0758
authors: L
authors: Rabeneck
authors: Sunnybrook Health Sciences Centre, Toronto, ON, Canada M4N 3M5.
authors: A
authors: 0000-0002-0221-5836
authors: A
authors: Ruco
authors: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada M4N 3M5; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada M5T 3M7.
authors: R
authors: 0000-0002-0320-6042
authors: R
authors: Sutradhar
authors: Institute for Clinical Evaluative Sciences, Toronto, ON, Canada M4N 3M5; Sunnybrook Health Sciences Centre, Toronto, ON, Canada M4N 3M5; Cancer Care Ontario, Toronto, ON, Canada M5G 2L7; Department of Medicine, University of Toronto, Toronto, ON, Canada M5S 1A8; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada M5T 3M6.
authors: J M
authors: 0000-0002-0264-2176
authors: JM
authors: Tinmouth
mesh_terms: D002983:Clinical Competence; D003111:Colonic Polyps / Q000175:diagnosis; D003113:Colonoscopy / Q000592:standards* / Q000706:statistics & numerical data; D004282:Documentation / Q000592:standards*; D005762:Gastroenterology; D006801:Humans; D009864:Ontario; D011785:Quality Assurance, Health Care; D019984:Quality Indicators, Health Care; D013997:Time Factors