3.4 KPI Definitions by procedure type 3.5 Colonoscopy KPI Abbreviation Definition Required data fields Output format Relevant outcome source Minimum Standard/ Target Discussion points Colonoscopy Procedure count Core KPI COLProcNum Number of diagnostic or therapeutic colonoscopies performed by an endoscopist or site in a stated period of time {procedureName}=[COLON] By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Integer GRS JETS NED None set Provide number of therapies as a Attribute to Endoscopist 1, Trainee (if assisted or was observed, Endoscopist 2 if assisted or was observed) Caecal intubation rate Core KPI COLCIR Percentage of colonoscopies where caecum or anastomosis reached by a stated endoscopist or at a stated site in a stated period Numerator: {procedureName}=[COLON], {ExtentTypeEnum}=[Caecum] or [terminal ileum] or [anastomosis] or anastomosis] or [neo-terminal ileum] Denominator: {procedureName}=[COLON] Levels: By {site}=[x] or Percentage JETS NED Minimum standard 90%, aspirational target 95% Note- anastomosis counts if most proximal extent of colon. Note- photo documentation not assessed by NED. Attribute to Endoscopist 1, Trainee (if assisted or was observed,
By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Endoscopist 2 if assisted or was observed. Terminal ileum intubation rate 2nd Tier KPI COLTIIR Percentage of colonoscopies terminal ileum reached Numerator: {ExtentTypeEnum}= [terminal ileum] or [neo-terminal ileum] Denominator: {procedureName}=[COLON] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Percentage JETS None set Attribute to Endoscopist 1, Trainee (if assisted or was observed, Endoscopist 2 if assisted or was observed. Rectal retroversion Core KPI COLRRR Percentage of colonoscopies where rectal retroversion is recorded as having been performed by a stated endoscopist or at a stated site in a stated period Numerator: {procedureName}=[COLON], {rectal retroversion}=[Yes] Denominator: {procedureName}=[COLON] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] percentage JETS NED BSG Minimum Standard 90% (BSG) No rectal retroversion field in Business management document (J manoeuvre in colonoscopy) Attribute to Endoscopist 1, Trainee (if assisted or was observed,
Endoscopist 2 if assisted or was observed. Colonoscopy Withdrawal time Core KPI COLNCCWT Mean withdrawal time for all negative, complete colonoscopies performed by a stated endoscopist in a stated period Numerator: Sum of {withdrawal time} where no procedure performed and no polyps detected (normal colonoscopy). Denominator: where no procedure performed AND no polyps detected (normal colonoscopy) AND {ExtentTypeEnum}=[Caecum] or [terminal ileum] or [anastomosis] or anastomosis] or [neo-terminal ileum] Levels: By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] minutes NED BSG Minimum standard – mean of ≥6mins Aspirational target- mean of ≥10 mins (BSG) Include procedures where pathology such as diverticular disease found. No exclusions for pathology such as cancer (likely to have biopsies taken or be incomplete anyway). Exclude procedures where therapy delivered, biopsies taken or polyps detected. Permissible (accept procedure if outwith range but exclude value from KPI calculations Attribute to Endoscopist 1, Trainee (if assisted or was observed,
Endoscopist 2 if assisted or was observed. detection rate Core KPI COLPDR Percentage of colonoscopies performed by a stated endoscopist or at a stated site in a stated period at one or more polyps were detected Numerator: {procedureName}=[COLON], {DiagnosisEnum}=[Polyp/s] Denominator: {procedureName}=[COLON] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Only include complete procedures: {ExtentTypeEnum}=[Caecum] or [terminal ileum] or [anastomosis] or anastomosis] or [neo-terminal ileum] percentage NED BSG Minimun standard 15% Aspirational target 20% Decision taken at OG meeting (2/3/16) to only include complete procedures in calculation of PDR. Polyps should be counted toward PDR even if they are not removed. retrieval success- percentage 2nd Tier KPI COLPRGT Percentage of polyps successfully retrieved by a stated endoscopist or at a stated site in a stated period. Numerator: {procedureName}=[COLON], {Therapeutic Type}= [polypectomy]=[successful], percentage JETS Minimum standard 90% (BSG) Size cut off removed- previous KPI stated PRR of polyps>10mm in size.
Average dose of Pethidine ≥70 2nd Tier KPI COLPGT70 Median dose of pethidine administered when used for colonoscopy by a stated endoscopist or at a stated site in a stated period in patients 70 years of age or older. {procedureName}=[COL], {pethidine}=[number] Conditions: Exclude where{pethidine}=[null] {age}≥[70] Exclude values from median calculation outwith range 12.5-200mg Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Median dose (mg) NED Auditable Outcome (BSG) Median total dose ≤25mg Average dose of Midazolam <70 2nd Tier KPI COLMLT70 Median dose of midazolam administered when used for colonsocopy by a stated endoscopist or at a stated site in a stated period in patients less than 70 years of age. {procedureName}=[COL], {midazolam}=[number] Conditions: Exclude where{pethidine}=[null] {age}<[70] Exclude values from median calculation outwith 0.5-10mg Median dose (mg) NED Auditable Outcome (BSG) Median total dose ≤5 mg
Average dose of Fentanyl <70 2nd Tier KPI COLFLT70 Median dose of fentanyl administered when used for colonoscopy by a stated endoscopist or at a stated site in a stated period in patients less than 70 years of age. {procedureName}=[COL], {fentanyl}=[number] Conditions: Exclude where{pethidine}=[null] {age}<[70] Exclude values from median calculation outwith range 12.5-200mcg Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Median dose (mcg) NED Auditable Outcome (BSG) Median total dose ≤100mcg Average dose of Fentanyl ≥70 2nd Tier KPI COLFGT70 Median dose of fentanyl administered when used for colonoscopy by a stated endoscopist or at a stated site in a stated period in patients 70 years of age or older. {procedureName}=[COL], {fentanyl}=[number] Conditions: Exclude where{pethidine}=[null] {age}≥ [70] Exclude values from median calculation outwith range 12.5-200mcg Median dose (mcg) NED Auditable Outcome (BSG) Median dose ≤50 mcg
Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Unsedated procedures 2nd Tier KPI COLUS Percentage of colonoscopy performed by a stated endoscopist or at a stated site in a stated period the no midazolam, fentanyl or pethidine was administered. {procedureName}=[COL], {pethidine}=[null], {midazolam}=[null], {fentanyl}=[null] Denominator: {procedureName}=[COL] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Percentage JETS NED Not set Notes- include procedures in numerator where Entonox given. Exclude procedures where general anaesthetic given (if this data field available. Sedation greater than recommended dose COLGTRD Percentage of colonosocpy performed by a stated endoscopist or at a stated site in a stated period where the dose of midazolam exceeded 5mg in patients aged <70 and 2.5mg in patients aged ≥70 OR the dose of fentanyl exceeded 100 mcg in patients aged <70 and 50mcg in {procedureName}=[COL] Age <70 {pethidine}>50mg {midazolam}>5mg {fentanyl}>100mcg Percentage JETS NED Auditable outcome As per BSG safe sedation guidelines Removed from this phase.
patients aged ≥70 OR where the dose of pethidine exceeded 50 mg in patients aged <70 and 25 mg in patients aged ≥70 Age ≥70 {pethidine}>25mg {midazolam}>2.5mg {fentanyl}>50mcg Colonoscopy Comfort Score Core KPI COLCOM34 Percentage of colonoscopies performed by a stated endoscopist or at a stated site in a stated period where the comfort level is recorded as moderate or severe discomfort. {procedureName}=[COL], Numerator: {DiscomfortEnum}= [moderate] or [severe] Denominator: {procedureName}=[COL] Percentage where comfort score is moderate or severe JETS NED Auditable outcome Aim to have less than 10 % of patients with moderate or severe discomfort. (BSG) All ERS should adopt modified Gloucester system: Minimal- 1 or 2 episodes of mild discomfort with no distress Mild- More than 2 episodes of discomfort without distress Moderate- Significant discomfort experienced several times with some distress Severe- Frequent discomfort with significant distress Bowel preparation quality COLBPQ Proportion of colonoscopies where bowel prep inadequate Numerator: Number of procedure where bowel prep quality= inadequate Percentage NED BSG/JAG GRS Bowel preparation of sufficient diagnostic quality to not warrant repeat or - For BSG KPI- map to levels bowel prep not of sufficient quality to require repeat or alternative test.
NED not currently capable of capturing interval cancer data- this would require linkage with other registries. 3.6 Combined Colonoscopy and Flexible Sigmoidoscopy KPI Abbreviation Definition Required data fields Output format Relevant outcome source Minimum standard/ target Discussion points Colonoscopy + Flexi Sig Digital rectal examination 2nd Tier KPI CFSDRE Percentage of colonoscopies where a digital rectal examination is recorded as having been performed by a stated Numerator: {procedureName}=[COLON] or [Flexi], {Digitalrectal exam}=[Yes] percentage JETS NED BSG Rectal examination or omission should be recorded in BSG target is ‘documentation of rectal exam’. NED will record whether rectal
endoscopist or at a stated site in a stated period Denominator: {procedureName}=[COLON] or [Flexi] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] 100% of cases (BSG) exam is perfomed. Attribute to Endoscopist 1 Trainee (if assisted or was observed,) Tattoo of Cancers and polyps ≥20mm Core KPI CFSTATCAP Proportion of suspected cancers or polyps ≥20mm (not in the caecum or rectum) a tattoo is placed {procedureName}=[COL] or [FLEXI] Numerator: polyp≥20mm or cancer and tattoo placed [or previous tattoo] not in rectum or caecum Denominator: number of polyps ≥20mm or cancers not in rectum or caecum Percentage BSG Not specified BSG Minimum standard 100% for polyps ≥20mm Diagnostic biopsies for unexplained diarrhoea 2nd Tier KPI COLRCB Proportion of procedures chronic diarrhoea is the indication and a minimum of 2 left colonic and 2 right colonic biopsies are obtained {procedureName}=[COL] or [FLEXI] Numerator:biopsiy taken Denominator: {procedureName}=[COL], {IndicationsEnum}=[Diarrhoea-chronic or Diarrhoea- chronic with blood] Percentage BSG GRS Minimum standard- Rectal biopsies taken in 100% of cases Aspirational target- minimum of 2 and 2 left biopsies In phase 2 develop ability to include location of biopsies
3.7 Flexi Sig KPI Abbreviation Definition Required data fields Output format Relevant outcome source Minumum standard/target Discussion points Flexi Sig Procedure count Core KPI FSProcNum Number of diagnostic or therapeutic flexible sigmoidoscopies performed by an endoscopist or site in a stated period of time {procedureName}=[FLEXI] By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Integer GRS JETS NED Provide number of therapies as a Rectal retroversion 2nd Tier KPI FSRRR Percentage of flexible sigmoidoscopy where rectal retroversion is recorded as having been performed by a stated endoscopist or at a stated site in a stated period Numerator: {procedureName}=[FLEXI], {rectal retroversion}=[Yes] Denominator: {procedureName}=[FLEXI] Levels: percentage JETS NED BSG
By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Polyp detection rate 2nd Tier KPI Percentage of flexible sigmoidoscopy performed by a stated endoscopist or at a stated site in a stated period at which one or more polyps were detected Numerator: {procedureName}=[FLEXI], {DiagnosisEnum}=[Polyp/s] Denominator: {procedureName}=[FLEXI] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] percentage NED BSG Numerator be based on therapeutic field=polypectomy retrieval success- percentage 2nd Tier KPI FSPRGT Percentage of polyps successfully removed and retrieved by a stated endoscopist or at a stated site in a stated period. Numerator: {Therapeutic Type}= [polypectomy]=[successful], [retrieval]=[successful], [polypSize]>=10mm Denominator= : {procedureName}=[Flexi], {Therapeutic Type}= [polypectomy]=[successful] percentage JETS Minimum standard 90% (BSG) Size cut off removed- previous KPI stated PRR of polyps>10mm in size.
Average dose of Pethidine <70 2nd Tier KPI FSPLT70 Average dose of pethidine administered when used for flexible sigmoidoscopy by a stated endoscopist or at a stated site in a stated period in patients less than 70 of age. Numerator: {pethidine}=[number] Denominator: {procedureName}=[FLEXI] colonoscopy Conditions: Exclude where{pethidine}=[null] {age}<[70] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Average dose (mg) JETS NED Exclude from median value calculation if value outwith the range 12-5-200mg Average dose of Pethidine ≥70 2nd Tier KPI FSPGT70 Average dose of pethidine administered when used for flexible sigmoidoscopyby a stated endoscopist or at a stated site in a stated period in patients 70 of age or older. {pethidine}=[number] Denominator: Conditions: Exclude where{pethidine}=[null] {age}≥[70] Average dose (mg) NED Exclude from median value calculation if value outwith the range 12-5-200mg
Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Average dose of Midazolam <70 2nd Tier KPI FSMLT70 Average dose of midazolam administered when used for flexible sigmoidoscopyby a stated endoscopist or at a stated site in a stated period in patients less than 70 years of age. {procedureName}=[FLEXI], {midazolam}=[number] Denominator: Conditions: Exclude where{pethidine}=[null] {age}<[70] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Average dose (mg) NED Exclude from median value calculation if value outwith the range 0.5-10mg Average dose of Midazolam ≥70 FSMGT70 Average dose of midazolam administered when used for flexible sigmoidoscopy by a stated endoscopist or at a stated site in a {procedureName}=[FLEXI], {midazolam}=[number] Denominator: {procedureName}=[FLEXI] Average dose (mg) NED Exclude from median calculation if value outwith the range 0.5-10mg
Core KPI Denominator: {procedureName}=[OGD] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Exclude procedures where indication =Barretts oesophagus or varices surveillance/screening J manoeuvre rate Core KPI OGDJR Percentage of OGD performed by a stated endoscopist /site in a stated period J manoeuvre successfully performed Numerator: {procedureName}=[OGD], {jManoeuve}=[Yes] Denominator: {procedureName}=[OGD] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] percentage JETS NED Median dose of Pethidine<70 OGDPLT70 Median dose of pethidine administered when used for OGD by a stated endoscopist or at a stated Numerator: Median dose (mg) JETS NED Exclude from median calculation if value
2nd tier KPI site in a stated period in patients less than 70 years of age. {procedureName}=[OGD], {pethidine}=[number] Denominator: {procedureName}=[OGD] Conditions: Exclude where{pethidine}=[null] {age}<[70] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] outwith the range Median dose of Pethidine ≥70 2nd tier KPI OGDPGT70 Median dose of pethidine administered when used for OGD by a stated endoscopist or at a stated site in a stated period in patients 70 years of age or older. {procedureName}=[OGD], {pethidine}=[number] Denominator: {procedureName}=[OGD] Conditions: Exclude where{pethidine}=[null] {age}≥[70] Median dose (mg) NED Exclude from median value calculation if value outwith the range 12-5-200mg
3.9 ERCP Current BSG document on ERCP quality indicators is in development. It is planned that NED KPIs will reflect the BSG proposed standards. The BSG standards include variables in the indicators to reflect the competence of the endoscopist and the difficulty of the procedure. Thes variable may be difficult to account for when generating KPIs within the confines of the NED data schema. KPI Abbreviation Definition Required data fields Output format Relevant outcome source Standards Discussion points ERCP Procedure count ERCPProcNum Number of diagnostic or therapeutic colonoscopies performed by an endoscopist or site in a stated period of time {procedureName}=[ERCP] By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Integer JETS BSG Cannulation rate for accessible virgin main papilla Brushings rate for histologically undiagnosed strictures Successful clearance rate for Stones < 10mm Successful duct decompression for stones > 10mm
In time period {Ukdatetype}= [x]to[y] Median dose of Pethidine ≥70 Numerator: {procedureName}=[ERCP], {pethidine}=[number] Denominator: {procedureName}=[ERCP] Conditions: Exclude {age}<[70] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Exclude from median value calculation if value outwith the range 12-5-200mg Median dose of Midazolam <70 Numerator: {procedureName}=[ERCP], {midazolam}=[number] Denominator: {procedureName}=[ERCP] Conditions: Exclude from median calculation if value outwith the range
Exclude where{ midazolam }=[null] {age}<[70] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Median dose of Midazolam ≥70 Numerator: {procedureName}=[ERCP], { midazolam }=[number] Denominator: {procedureName}=[ERCP] Conditions: Exclude where{midazolam}=[null] {age}<[70] Levels: By {site}=[x] or By {professionalbodycode}=[x] In time period {Ukdatetype}= [x]to[y] Exclude from median value calculation if value outwith the range 0.5-10mg Median dose of Numerator: Exclude from median value calculation if