Quality and safety issues in procedural rural practice: A prospective evaluation of current quality and safety guidelines in 3000 colonoscopies

Abstract

Introduction: Colonoscopy remains the gold standard for the investigation and management of bowel pathology. A 2009 National Bowel Cancer Screening Program Quality Working Group report revealed that small rural towns in inner regional Victoria, Australia, for example Echuca (Rural and Remote Metropolitan Areas [RRMA] 4), registered 10.5 colonoscopies per 1000 population versus 18.5 per 1000 in the state capital Melbourne. Reasons for this discrepancy include lack of skilled practitioners in rural communities and travel time for patients to attend larger centres when the required bowel preparation or mobility issues limit access. Ideally, services are high quality, safe and local. This study assessed the quality and safety of a rural GP colonoscopy service. Methods: The indications, findings, caecal intubation rates, complications and completion time were recorded for 3000 serial colonoscopies performed by one rural procedural GP from 1995 to 2011 in Victorian Echuca. Quality was assessed using caecal intubation rate, polyp and colorectal carcinoma detection rates, and completion time. Safety was determined by complication rates. Results: The caecal intubation rate was 97% (excluding stenosing lesions), polypectomy detection rate was 39%, carcinoma detection rate was 2%, and the average time to completion was 17 min. Re-admission rates were 1.6/1000 for haemorrhage and 1.2/1000 for perforation. There were no deaths. Conclusions: The results from this study compare favourably with published international standards, validate Australian general practice procedural training standards, and validate the additional quality measure of 'colonoscopy completion time'. Rural GPs can provide a safe and high quality service. Extending this service model to similar settings could improve reduced access to colonoscopy for rural Australians. © J Azzopardi, DE DeWitt, 2012.