Knowledge Check
The quality improvement initiative described by Alhaidari S et al. reduced the rate of inappropriate biliary stent placement after ERCP from ____% to ____%.
Reducing Unnecessary Post-ERCP Biliary Stent Placement Using a Structured Quality Improvement Initiative
Rajesh N. Keswani, MD, MS, reviewing Alhaidari S, et al. BMJ Open Gastroenterol 2024 Aug 21.
In general, biliary stents are required after ERCP only when extraction of all the stone disease fails or a stricture is present. However, many ERCP specialists still place biliary stents after complete stone clearance—a practice not supported by guidelines. Placement of an unnecessary biliary stent results in the need for a second procedure, with attendant costs and risks.
According to this report of a prospective quality improvement (QI) initiative, the initial goal was to reduce the rate of potentially unnecessary biliary stent placement after ERCP. The interventions included reporting baseline data to the ERCP group, an associated educational session, and ongoing monthly audits and feedback. The authors report a baseline rate of 28% for inappropriate stent placement, which decreased to 7% (P < .0001) after the QI initiative began. Patients with choledocholithiasis experienced a similar significant reduction in unnecessary stent placement (from 16% to 2%). As expected, significant cost savings were associated with the reduced rate of unnecessary repeat ERCP.
COMMENT
The authors present the results of a successful initiative to reduce inappropriate stent usage after ERCP. Although their approach is similar to that described for many other QI issues in endoscopy, it is uncommon to see it successfully applied for procedures like ERCP. This detailed report can be utilized in other endoscopy units attempting to achieve similar results.
Rajesh N. Keswani, MD, MS
CITATION
Alhaidari S, Alzahrani I, Alhanaee M, et al. Optimising the indications for biliary stent placement during endoscopic retrograde cholangiopancreatography: a quality improvement initiative to enhance patient care and reduce healthcare resource utilisation. BMJ Open Gastroenterol 2024;11:e001375. (https://doi.org/10.1136/bmjgast-2024-001375)
COMMENT
This study affirms important principles for FIT screening. First, cancers detected by FIT remain in an early stage during subsequent screening rounds. Further, increasing the cutoff level of hemoglobin for positive test results reduces sensitivity but does not shift the fraction of detected cancers substantially toward later-stage CRC. Thus, programs can adjust the cutoff to levels appropriate for their colonoscopy resources, and the detected cancers will be in an early stage across a range of hemoglobin thresholds for positive tests.