Using audit and feedback to improve colonic polyp detection, qualitative studies within the national endoscopy database automated performance reports to improve quality outcomes trial (NED APRIQOT)

M.D ThesisColorectal cancer (CRC) arises from polyps, and polyp detection and resection at colonoscopy is pivotal in preventing CRC. Colonoscopists with a low polyp detection rate have a higher rate of CRC after colonoscopy. The National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial (NED-APRIQOT) is a randomised cluster control trial of electronic audit and feedback (A&F) in English endoscopy centres. This MD aimed to (1) assess the acceptability of colonoscopy key performance indicators (KPIs); (2) develop an evidence-based and theoretically informed behaviour change intervention (BCI), an A&F endoscopist performance report, for implementation in the trial; and (3) explore pre-trial experiences of endoscopy A&F. A narrative review of A&F and KPIs in the colonoscopy literature was undertaken. This informed selection of KPIs for a Delphi consensus, to determine the clinical acceptability of KPIs available through the NED. A panel of UK experts in colonoscopy, reflecting the varied professional backgrounds performing endoscopy, undertook three rounds rating statements and provided free-text comments. A case-mix adjusted mean number of polyps (MNP) was chosen for the trial. An A&F behavioural theory review informed the design of a draft BCI. Interviews were undertaken with 19 endoscopists from six English NHS endoscopy centres, purposively sampled for clinical background and professional experience. The BCI was iteratively refined through rounds of cognitive interviews in which participants interacted with and ‘talked aloud’ about the BCI. The finalised BCI was implemented in the NED-APRIQOT. These participants also undertook semi-structured interviews exploring current colonoscopy A&F practices. A framework thematic analysis mapped themes to Feedback Intervention Theory (FIT) and the Theory of Planned Behaviour. A FIT-based model described A&F’s intended and paradoxical effects on endoscopist behaviour. Detection and patient safety were dependent on coaching, team behaviours and unit-leads managing underperformance. Future endoscopy A&F interventions should consider targeting behaviours using theoretical models

Infection frequently triggers thrombotic microangiopathy in patients with preexisting risk factors : a single-institution experience

Thrombotic microangiopathies are rare conditions characterized by microangiopathic hemolytic anemia, microthrombi, and multiorgan insult. The disorders, which include hemolytic uremic syndrome and thrombotic thrombocytopenic purpura, are often acute and life threatening. We report a retrospective analysis of 65 patients presenting to our institution from 1997 to 2008 with all forms of thrombotic microangiopathy. Therapeutic plasma exchange was a requirement for analysis and 65 patients were referred to our institution; 66% of patients were female and median age at presentation was 52 years. Bacterial infection was the most commonly identified etiologic factor and in the multivariate model was the only significant variable associated with survival outcome (odds ratio 5.1, 95% confidence interval, 1.2-21.7). As infection can be considered a common trigger event for thrombotic microangiopathy, patients with hepatobiliary sepsis may benefit from elective cholecystectomy. We conclude that bacterial infection frequently triggers TTP and other thrombotic microangiopathies in patients with preexisting risk factors and propose a model for the development of these syndromes

Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy

Background Audit and feedback (A&F) interventions improve patient care but may result in unintended consequences. To evaluate plausible harms and maximise benefits, theorisation using logic models can be useful. We aimed to explore the adverse effects of colonoscopy A&F using a feedback intervention theory (FIT) dark logic model before the National Endoscopy Database Automated Performance Reports to Improve Quality Outcomes Trial study. Methods We undertook a qualitative study exploring A&F practices in colonoscopy. Interviews were undertaken with endoscopists from six English National Health Service endoscopy centres, purposively sampled for professional background and experience. A thematic framework analysis was performed, mapping paradoxical effects and harms using FIT and the theory of planned behaviour. Results Data saturation was achieved on the 19th participant, with participants from nursing, surgical and medical backgrounds and a median of 7 years’ experience. When performance was below aspirational targets participants were falsely reassured by social comparisons. Participants described confidence as a requirement for colonoscopy. Negative feedback without a plan to improve risked reducing confidence and impeding performance (cognitive interference). Unmet targets increased anxiety and prompted participants to question messages’ motives and consider gaming. Participants described inaccurate documentation of subjective measures, including patient comfort, to achieve targets perceived as important. Participants described causing harm from persevering to complete procedures despite patient discomfort and removing insignificant polyps to improve detection rates without benefiting the patient. Conclusion Our dark logic model highlighted that A&F interventions may create both desired and adverse effects. Without a priori theorisation evaluations may disregard potential harms. In colonoscopy, improved patient experience measures may reduce harm. To address cognitive interference the motivation of feedback to support improvement should always be clear, with plans targeting specific behaviours and offering face-to-face support for confidence

The National Endoscopy Database (NED) automated performance reports to improve quality outcomes trial (APRIQOT) randomized controlled trial design

© 2020 The Authors. Published by Thieme Open. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: https://www.thieme-connect.de/products/ejournals/html/10.1055/a-1261-3151Background and study aims Colonoscopists with low polyp detection have higher post colonoscopy colorectal cancer incidence and mortality rates. The United Kingdom’s National Endoscopy Database (NED) automatically captures patient level data in real time and provides endoscopy key performance indicators (KPI) at a national, endoscopy center, and individual level. Using an electronic behavior change intervention, the primary objective of this study is to assess if automated feedback of endoscopist and endoscopy center-level optimal procedure-adjusted detection KPI (opadKPI) improves polyp detection performance. Methods This multicenter, prospective, cluster-randomized controlled trial is randomizing NHS endoscopy centres to either intervention or control. The intervention is targeted at independent colonoscopists and each center’s endoscopy lead. The intervention reports are evidence-based from endoscopist qualitative interviews and informed by psychological theories of behavior. NED automatically creates monthly reports providing an opadKPI, using mean number of polyps, and an action plan. The primary outcome is opadKPI comparing endoscopists in intervention and control centers at 9 months. Secondary outcomes include other KPI and proximal detection measures at 9 and 12 months. A nested histological validation study will correlate opadKPI to adenoma detection rate at the center level. A cost-effectiveness and budget impact analysis will be undertaken. Conclusion If the intervention is efficacious and cost-effective, we will showcase the potential of this learning health system, which can be implemented at local and national levels to improve colonoscopy quality, and demonstrate that an automated system that collects, analyses, and disseminates real-time clinical data can deliver evidence- and theory-informed feedback.Published versio

Power of big data to improve patient care in gastroenterology

Big data is defined as being large, varied or frequently updated, and usually generated from real-world interaction. With the unprecedented availability of big data, comes an obligation to maximise its potential for healthcare improvements in treatment effectiveness, disease prevention and healthcare delivery. We review the opportunities and challenges that big data brings to gastroenterology. We review its sources for healthcare improvement in gastroenterology, including electronic medical records, patient registries and patient-generated data. Big data can complement traditional research methods in hypothesis generation, supporting studies and disseminating findings; and in some cases holds distinct advantages where traditional trials are unfeasible. There is great potential power in patient-level linkage of datasets to help quantify inequalities, identify best practice and improve patient outcomes. We exemplify this with the UK colorectal cancer repository and the potential of linkage using the National Endoscopy Database, the inflammatory bowel disease registry and the National Health Service bowel cancer screening programme. Artificial intelligence and machine learning are increasingly being used to improve diagnostics in gastroenterology, with image analysis entering clinical practice, and the potential of machine learning to improve outcome prediction and diagnostics in other clinical areas. Big data brings issues with large sample sizes, real-world biases, data curation, keeping clinical context at analysis and General Data Protection Regulation compliance. There is a tension between our obligation to use data for the common good and protecting individual patient’s data. We emphasise the importance of engaging with our patients to enable them to understand their data usage as fully as they wish

Decision making in the management of adults with malignant colorectal polyps: An exploration of the experiences of patients and clinicians

From Crossref journal articles via Jisc Publications RouterHistory: received 2020-12-19, accepted 2021-04-12, epub 2021-06-16, issued 2021-06-16, published 2021-06-16Article version: VoRPublication status: PublishedAbstractAimA diagnosis of colorectal polyp cancer presents a treatment dilemma. The decision between segmental resection versus endoscopic surveillance is difficult due to a lack of good quality clinical evidence for either option. The aim of this study was to understand the decision making experiences of both clinicians and patients when faced with such a diagnosis.MethodsQualitative, semi‐structured interviews were undertaken with 10 clinicians involved in the care of patients diagnosed with polyp cancer and five patients who had experience of a diagnosis of polyp cancer. All clinicians and patients were from four hospital trusts across the north of England. Interviews were audio‐recorded, transcribed verbatim and analysed using the principles of interpretative phenomenological analysis.ResultsAnalysis of the interview transcripts evidenced that clinicians and patients were supportive of a shared approach to treatment decision making in the context of a diagnosis of colorectal polyp cancer. Uncertainty, influences and information were among the themes identified to be preventing this happening at present. This study identified themes which were common to both groups. These were complexity of the risk information, lack of patient information resources, and system factors and time.ConclusionThis research study has evidenced several factors such as uncertainty, complexity of risk information and influences on decisions which are preventing patients being involved in treatment decisions following a diagnosis of colorectal polyp cancer. Recommendations for improvements in practice, including a framework to assist treatment decision making in the future, are highlighted

Nuclear factor κB predicts poor outcome in patients with hormone-naive prostate cancer with high nuclear androgen receptor

Despite recent advances in prostate cancer treatments, disease recurrence is common and associated with significant morbidity and mortality. The need for more effective antitumor agents has led researchers to target signaling pathways that drive tumorigenesis by modulating or bypassing androgen receptor signaling--attenuation or blockade of which current treatments aim to effect. The transcription factor nuclear factor κB/p65 has been implicated in prostate cancer progression; however, few studies have examined the involvement of nuclear factor κB in hormone-naive disease. We used immunohistochemistry to investigate expression of p65, androgen receptor, Ki-67, and phosphorylation status of p65 at serine 536, in 154 tumor samples taken from patients before hormone ablation or radical treatment. Nuclear p65 expression was significantly associated with disease-specific mortality: P = .005; hazard ratio, 2.2. When patients were stratified according to androgen receptor status, this relationship was abolished in low androgen receptor-expressing patients and potentiated in high androgen receptor-expressing patients: P = .002; hazard ratio, 3.1. Ki-67 expression was also prognostic of shorter disease-specific mortality: P = .001; hazard ratio, 2.3. When the cohort was stratified according to androgen receptor status, this relationship held for high androgen receptor expressers but not low expressers: P = .0003; hazard ratio, 3.5. Neither androgen receptor nor p65 phosphorylated at S536 were significantly prognostic when considered individually. These data suggest that future prostate cancer treatments that target nuclear factor κB signaling should be assigned primarily to patients with concomitant high nuclear p65 and androgen receptor expression

Nationally Automated Colonoscopy Performance Feedback Increases Polyp Detection: The National Endoscopy Database – Automated Performance Reports to Improve Quality Outcomes Trial (NED-APRIQOT) a Cluster Randomised Controlled Trial.

Background and Aims Post-colonoscopy colorectal cancer incidence and mortality rates are higher for endoscopists with low polyp detection rates. Using the UK’s National Endoscopy Database (NED), which automatically captures real-time data, we assessed if providing feedback of case-mix-adjusted Mean Number of Polyps (aMNP), as a key performance indicator, improved endoscopists’ performance. Feedback was delivered via a theory-informed evidence-based audit and feedback intervention. Methods This multicentre, prospective, NED Automated Performance Reports to Improve Quality Outcomes Trial (NED-APRIQOT) randomised NHS endoscopy centres to intervention or control. Intervention-arm endoscopists were emailed tailored monthly reports automatically generated within NED, informed by qualitative interviews and behaviour change theory. The primary outcome was endoscopists’ aMNP during the 9-month intervention. Results From November 2020-July 2021, 541 endoscopists across 36 centres (19 intervention; 17 control) performed 54,770 procedures during the intervention, and 15,960 procedures during the 3-months post-intervention period. Comparing intervention-arm to control-arm endoscopists during the intervention period: aMNP was non-significantly higher (7%, 95% confidence interval (CI) -1% to 14%; p=0·08). Unadjusted MNP (10%, 95%CI 1-20%) and polyp detection rate (PDR) (10%, 95%CI 4-16%) were significantly higher. Differences were not maintained in the post-intervention period. In the intervention-arm, endoscopists accessing NED-APRIQOT webpages had higher aMNP than those who did not (118 vs 102 aMNP, p=0.03). Conclusion Although our automated feedback intervention did not increase aMNP significantly in the intervention period; MNP and PDR did significantly improve. Engaged endoscopists benefited most and improvements were not maintained post-intervention; future work should address engagement in feedback and consider the effectiveness of continuous feedback. www.isrctn.org ISRCTN1112692