Quality of colonoscopy reporting in community practice

Background: Quality endoscopy reporting is essential when community endoscopists perform colonoscopies for veterans who cannot be scheduled at a Veterans Administration (VA) facility. Objective: To examine the quality of colonoscopy reports received from community practices and to determine factors associated with more complete reporting, by using national documentation guidelines. Design: Cross-sectional analysis. Setting: Reports submitted to the Durham VA Medical Center, Durham, North Carolina, from 2007 to 2008. Patients: Subjects who underwent fee-basis colonoscopy. Main Outcome Measurements: Scores created by comparing community reports with published documentation guidelines. Three scores were created, one for each category of information: Universal Elements (found on all endoscopy reports), Indication Elements (specific to the procedure indication), and Finding Elements (specific to examination findings). Results: For the 135 included reports, the summary scores were Universal Elements, 57.6% (95% confidence interval [CI], 55%-60%); Indication Elements, 73.7% (95% CI, 69%-78%); and Finding Elements, 75.8% (95% CI, 73%-79%). Examples of poor reporting included patient history (20.7%), last colonoscopy date (18.0%), average versus high risk screening (32.0%), withdrawal time (5.9%), and cecal landmark photographs (45.2%). Only the use of automated reporting software was associated with more thorough reporting. Limitations: Modest sample size, mostly male participants, frequent pathologic findings, limited geography, and lack of complete reporting by a minority of providers. Conclusions: The overall completeness of colonoscopy reports was low, possibly reflecting a lack of knowledge of reporting guidelines or a lack of agreement regarding important colonoscopy reporting elements. Automated endoscopy software may improve reporting compliance but may not completely standardize reporting quality. (Gastrointest Endosc 2010;72:321-7.)