The quality of colonoscopy reporting in usual practice: are endoscopists reporting key data elements?

Background — High quality reporting of endoscopic procedures is critical to the implementation of colonoscopy quality assurance programs.

Objective — The aim of our research was to (1) determine the quality of colonoscopy (CS) reporting in “usual practice,” (2) identify factors associated with good quality reporting, and (3) compare CS reporting in open-access and non-open-access procedures.

Methods — 557 CS reports were randomly selected and assigned a score based on the number of mandatory data elements included in the report. Reports documenting greater than 70% of the mandatory data elements were considered to be of good quality. Physician and procedure factors associated with good quality CS reporting were identified.

Results — Variables that were consistently well documented included date of the procedure (99.6%), procedure indication (88.9%), a description of the most proximal anatomical segment reached (98.6%), and documentation of polyp location (97.8%). Approximately 79.4% of the reports were considered to be of good quality. Gastroenterology specialty, lower annual CS volume, and fewer years in practice were associated with good quality reporting.

Discussion — CS reporting in usual practice in Ontario lacks quality in several areas. Almost 1 in 5 reports was of poor quality in our study.

Conclusions — Targeted interventions and/or use of mandatory fields in synoptic reports should be considered to improve CS reporting.