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一种支持质量保证的新型结肠镜检查报告系统。

A novel colonoscopy reporting system enabling quality assurance.

作者信息

van Doorn Sascha C, van Vliet Joost, Fockens Paul, Dekker Evelien

机构信息

Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands.

Olympus Nederland B.V., Zoeterwoude, The Netherlands.

出版信息

Endoscopy. 2014 Mar;46(3):181-7. doi: 10.1055/s-0034-1364877. Epub 2014 Feb 5.

Abstract

BACKGROUND AND STUDY AIMS

The quality of colonoscopy can only be measured if colonoscopy reports include all key quality indicators. In daily practice, reporting is often incomplete and not standardized. This study describes a novel, structured colonoscopy reporting system, which aims to generate standardized and complete reports and to facilitate the automatic analysis of colonoscopy quality indicators.

METHODS

A new colonoscopy reporting system (EndoALPHA) was developed. The system reports all colonoscopy quality indicators, as well as pathological findings, in a systematic manner using structured terminology. All essential items carry specific codes, which enables statistical analysis and the automatic generation of reports of all quality indicators. The EndoALPHA reporting system was tested with regard to completeness of reporting and evaluation of quality indicators both for individual endoscopists and the endoscopy unit.

RESULTS

In 2012, all 810 colonoscopies performed at one colonoscopy center were documented using EndoALPHA. Overall, 94 % of performed colonoscopies were reported completely using the encoded terminology. Individual unadjusted cecal intubation rates were above 90 % for all endoscopists (mean 96.7 %), and the adenoma detection rate was above 20 % for all endoscopists (35.4 % for the unit).

CONCLUSION

The novel EndoALPHA reporting system enables automatic quality assessment on two levels: the completeness of reporting can be evaluated, and if this is adequate, the quality of the colonoscopies can also be assessed. Integrated with feedback, benchmarking and training, the reporting system may facilitate quality improvement for colonoscopy services.

摘要

背景与研究目的

只有当结肠镜检查报告包含所有关键质量指标时,才能对结肠镜检查质量进行评估。在日常实践中,报告往往不完整且不规范。本研究描述了一种新型的结构化结肠镜检查报告系统,其目的是生成标准化且完整的报告,并便于对结肠镜检查质量指标进行自动分析。

方法

开发了一种新的结肠镜检查报告系统(EndoALPHA)。该系统使用结构化术语系统地报告所有结肠镜检查质量指标以及病理结果。所有基本项目都带有特定代码,这使得能够进行统计分析并自动生成所有质量指标的报告。EndoALPHA报告系统针对个体内镜医师和内镜检查科室在报告完整性和质量指标评估方面进行了测试。

结果

2012年,一家结肠镜检查中心进行的所有810例结肠镜检查均使用EndoALPHA进行了记录。总体而言,94%的结肠镜检查使用编码术语进行了完整报告。所有内镜医师的个体未调整盲肠插管率均高于90%(平均96.7%),所有内镜医师的腺瘤检出率均高于20%(该科室为35.4%)。

结论

新型的EndoALPHA报告系统能够在两个层面上进行自动质量评估:可以评估报告的完整性,如果报告完整,则还可以评估结肠镜检查的质量。与反馈、基准比较和培训相结合,该报告系统可能有助于提高结肠镜检查服务的质量。

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