Abstract

Introduction: Colonoscopists with low polyp detection rates (PDR) have higher post colonoscopy colorectal cancer rates. Audit and feedback (A&F) interventions modestly improve performance in clinical contexts, but most interventions lack theoretical underpinnings so how they work is not understood. We aimed to develop a behaviour change intervention (BCI) giving endoscopists feedback to improve mean number of polyps (MNP) detected.

Methods: An A&F literature review will inform a draft BCI: a report on endoscopist performance. Rounds of cognitive interviews were undertaken with independent colonoscopists, purposively sampled by professional role. Participants viewed the BCI and “talked aloud” about content, followed by a semi-structured interview. The BCI was refined after each round, recruitment ceased when no new themes arose.

Results: The BCI was based on the theory of planned behaviour and feedback intervention theory. 19 endoscopists participated in 6 interview rounds. Case-mix adjusted MNP was endorsed as an acceptable performance metric after iterative refinement of explanatory text. Participants noted it would take time to adjust to MNP being higher than PDR.
Participants were motivated by social comparison, particularly to expert groups. Participants responded negatively to statements ranking their performance nationally, preferring a visual comparison with an aspirational top quartile. Expected performance is highlighted in blue, as amber elicited a fear response. Underperformance is in red and focussed attention on goals.
The BCI is programmed and emailed monthly from the National Endoscopy Database (NED). Participants noted monthly data may be variable and paid more attention to trends. The BCI was revised to emphasise a 4-month summary and plotted trend.

The BCI has a personalised action plan using targets for behaviours which influence detection, supported by information to improve knowledge. Participants believed that hyoscine butylbromide, withdrawal time, and turning the patient improved detection and were consistent with personal goals. Rectal retroversion is included in the BCI but few participants believed this improves detection.
Participants described positive experiences using nursing staff to prompt behaviours but spoke about complex social barriers to nurse empowerment. To overcome barriers, action plans encourage endoscopists to ask nursing staff to provide specific prompts.

Conclusions: This process has resulted in an evidence and theory informed BCI (video), which is being tested in the NED Automated Performance Reports Improving Quality Outcomes Trial (APRIQOT) multicentre randomised control trial. NED APRIQOT is funded by the Health Foundation.