English national root-cause analysis of post-colonoscopy colorectal cancers

Introduction Post-colonoscopy colorectal cancers (PCCRCs) represent missed opportunities to diagnose colorectal cancer or prevent it altogether. Up to 89% of PCCRCs are avoidable [1] but identifying PCCRCs for root-cause analysis is difficult, especially when the cancer is diagnosed in a different hospital to the original colonoscopy. The aim of this study was to create a process for identifying PCCRCs for all English National Health Service (NHS) hospitals, introduce a template to identify the most plausible explanation for the PCCRC, and use the evidence captured to inform recommendations to reduce PCCRC rates. Methods PCCRCs occurring 6–48 months after a colonoscopy (PCCRC-4yr) were identified by linking datasets (cancer registry and hospital episode statistics) and uploaded into a secure portal with an audit template based on World Endoscopy Organisation (WEO) recommendations and a previously published case review [1]. This method was tested in 10 pilot sites, refined and then rolled out nationally for review between 01/09/2021 and 10/05/2022. A maximum of 25 PCCRCs were uploaded for each of 126 hospital sites. Results 2,722 PCCRCs were uploaded into the portal and 122 of 126 sites participated in the audit. 539 PCCRC were not reviewed before the audit deadline. After review, 459 cases were excluded. A complete audit dataset was available for 1724 PCCRCs. In 294 of 1724 (17%) PCCRCs the colonoscopy was performed in a different organisation to where the cancer was diagnosed. Overall, 1190 (70%) were potentially avoidable (4% definitely, 13% probably, and 53% possibly). 16% of PCCRCs were judged to have led to major harm or premature death consequent to the delay in diagnosis. Photographic evidence of completion and rectal retroflexion was absent or inadequate in >50% of cases where it was deemed important. WEO categorisation of cases is shown in figure 1. Patient factors were involved in 10%, clinical factors in 10%, and administrative factors in 5% of cases. Conclusions This analysis of 1724 PCCRCs in the English NHS provides the largest dataset of aggregated data on PCCRCs and the only one for an entire country. The process for identifying PCCRCs has shown 17% are diagnosed at a different hospital to the original colonoscopy. In these cases, the hospital would be unaware of a subsequent cancer. The root-cause analysis confirms the majority of PCCRCs are not just avoidable, but the delay leads to moderate to severe harm and even premature death in a large proportion of patients. Unlike multivariate analyses of large datasets, it provides detailed information of what leads to delays in diagnosis and what needs to be done to reduce PCCRCs. Large dataset analyses are important to highlight potential variation in colonoscopy performance, but detailed case reviews are needed to find the aetiology of PCCRC, provide a mechanism to feedback to colonoscopists and patients, and to formulate improvement plans.

Citation

Burr, N., Beaton, D., Trudgill, N., Rutter, M., Morris, E., & Valori, R. (2023). English national root-cause analysis of post-colonoscopy colorectal cancers. Gut, 72(Suppl 2), A14–A15. DOI: 10.1136/gutjnl-2023-BSG.26

DOI

10.1136/gutjnl-2023-BSG.26

URI

https://hdl.handle.net/20.500.14709/529