Mejora en la calidad de la fase diagnóstica del programa de cribado del cáncer colorrectal del Área VI del Servicio Murciano de Salud

Zusammenfassung

There is a great variability in the performance of colonoscopy as a method of screening for colorectal carcinoma. During the last years, criteria or indicators of quality with the objective have seted out to standardize and to improve this technique. OBJECTIVES The general mission of our study is to improve the quality of the colonoscopy procedures in the Program of Screening of the Colorrectal Cancer, carried out in the Area VI of the Murrcian System of Health by the Hospital General Universitario José María Morales Meseguer. The specific objectives are: to evaluate the quality of these procedures; to identify, to select and to define indicators of quality for its evaluation; to design a set of activities to improve the quality and; finally, to evaluate the effectiveness of the improvement measures. METHODS This is a before-and-after study, using the methodology of a quality improvement cycle. The measuring instrument is a set of quality indicators of the Screening Program. Firs, a process of identification, selection is carried out by a work group, and later, a definition of the terms of the indicators of quality to evaluate. An observational, descriptive, retrospective and single-center study is carried out to analyze the degree of compliance with the selected quality indicators. The possible causes that have influenced the observed results are analyzed, using quality tools and methods: analysis of the force fields; cause-effect diagram and a Pareto diagram. The identified causal categories are classified according to the capacity to act that we can exercise. Finally, the activities to achieve the improvement are represented in an Affinity Diagram. The second evaluation is developed as an observational, descriptive, prospective post-intervention and single-center substudy about the same indicators. RESULTS 20 indicators of quality to evaluate the screening colonoscopies had been selected and defined. In the first evaluation, 110 of 665 colonoscopies were randomly selected, except for indicators 3.3, 3.4, 3.6 and 3.7, where the sample size was greater. The established standars of quality in 10 of the 20 indicators of quality were not fulfilled. In no case was the withdrawal time recorded, with very poor compliance with the colonic cleaning rate, as well as the rate of cecal intubation, which in both cases, was less than 90 %. The detection rate of adenomas was 63.81 %. After the design and implementation of the activities for improvement, in the second evaluation, 110 of 298 colonoscopies were selected, complying with the quality standards established in all indicators, except three. It was possible to improve the completion of all quality indicators, except: adenoma detection rate, which was 63.6 %; polyp recovery rate ≥ 5 mm; post-polypectomy bleeding rate; and the rate of complications requiring re-entry in ≤ 7 days. CONCLUSIONS A group of indicators representative of the quality o the colorectal carcinoma screening colonoscopy process has been defined. Globally considered, the quality of colonoscopies is high, complying with the quality standards proposed by the main scientific societies except for three of the indicators evaluated, mainly due to a poor record of activity. Following the analysis of the situation and the results obtained, a plan has been designed and implemented to improve the quality of the screening colonoscopy. The results of the quality indicators has been significantly improved in most of the indicators, with less improvement in those that started with good results in the first evaluation.