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)

Abstract

Colorectal 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.