A root cause analysis system to establish the most plausible explanation for post-endoscopy upper gastrointestinal cancer

Abstract

Background Missing upper gastrointestinal cancer (UGIC) at endoscopy may prevent curative treatment. We have developed a root cause analysis system for potentially missed UGICs at endoscopy (post-endoscopy UGIC [PEUGIC]) to establish the most plausible explanations. Methods The electronic records of patients with UGIC at two National Health Service providers were examined. PEUGICs were defined as UGICs diagnosed 6–36 months after an endoscopy that did not diagnose cancer. An algorithm based on the World Endoscopy Organization post-colonoscopy colorectal cancer algorithm was developed to categorize and identify potentially avoidable PEUGICs. Results Of 1327 UGICs studied, 89 (6.7 %) were PEUGICs (patient median [IQR] age at endoscopy 73.5 (63.5–81.0); 60.7 % men). Of the PEUGICs, 40 % were diagnosed in patients with Barrett’s esophagus. PEUGICs were categorized as: A – lesion detected, adequate assessment and decision-making, but PEUGIC occurred (16.9 %); B – lesion detected, inadequate assessment or decision-making (34.8 %); C – possible missed lesion, endoscopy and decision-making adequate (8.9 %); D – possible missed lesion, endoscopy or decision-making inadequate (33.7 %); E – deviated from management pathway but appropriate (5.6 %); F – deviated inappropriately from management pathway (3.4 %). The majority of PEUGICs (71 %) were potentially avoidable and in 45 % the cancer outcome could have been different if it had been diagnosed on the initial endoscopy. There was a negative correlation between endoscopists’ mean annual number of endoscopies and the technically attributable PEUGIC rate (correlation coefficient −0.57; P = 0.004). Conclusion Missed opportunities to avoid PEUGIC were identified in 71 % of cases. Root cause analysis can standardize future investigation of PEUGIC and guide quality improvement efforts.

Road map to small bowel endoscopy quality indicators

“…Total enteroscopy was achieved in 51% (95% CI, 30-72) of cases when attempted, a major advantage over balloon-assisted enteroscopy. The pooled rate of adverse events reported in these studies was 17% (95% CI, [13][14][15][16][17][18][19][20][21]. Most of these incidences were reported as 'minor' adverse events [39].…”

“…Interval cancers are not limited to the colon but also occur in approximately 10% of patients with upper gastrointestinal cancer who underwent an unremarkable upper GI endoscopy within 3 years before diagnosis [16]. Most of these upper GI cancers are preventable and related to shortcomings in the quality of the index examination [17]. Factors such the endoscopist's annual number of procedures and the length of inspection time have been shown to influence the detection of gastric and oesophageal cancers [17][18][19].…”

“…Most of these upper GI cancers are preventable and related to shortcomings in the quality of the index examination [17]. Factors such the endoscopist's annual number of procedures and the length of inspection time have been shown to influence the detection of gastric and oesophageal cancers [17][18][19]. Quality indicators have also been proposed for ERCP and EUS, which are associated with higher risk of adverse events [20].…”

Post-endoscopy upper gastrointestinal cancer – identifying, understanding, and improving

“…The British Society of Gastroenterology, in their 2017 quality standards position statement, recommended that a root cause analysis be performed to identify contributing factors in cases of PEUGIC [4]. The Kamran et al study is the first to report the results of such an analysis of unselected patients with PEUGIC in the setting of a large endoscopy service [5]. The study findings and root cause analysis system used in the study need to be validated in other settings and populations.…”

“…The study of quality in UGI endoscopy has not developed at the same rate as it has in colonoscopy. In this edition of Endoscopy , Kamran et al make an important contribution to this area 5 . They report their findings from a retrospective study of patients with post-endoscopy UGI cancer (PEUGIC) in two NHS providers in the UK from 2010 to 2020.…”