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Background and study aims: The assessment of indications for follow-up colonoscopy may help to improve the allocation of available endoscopy resources. The aim of this study was to assess the timing of early follow-up colonoscopy and surveillance utilization in relation to adenoma detection rate (ADR) at follow-up. Methods: An assessment of the timing and yield of follow-up colonoscopies was performed in patients with non-inflammatory bowel disease (IBD) in a Dutch multicenter study. The primary outcome was the number of patients with a prior (index) colonoscopy. The necessity for follow-up procedures was assessed using the ADR. Results: Of 4800 consecutive patients undergoing a colonoscopy, 1249 non-IBD patients had undergone an index colonoscopy. Of these, follow-up procedures were performed within 1 year in 27% (331/1249). Excluding incomplete colonoscopy, incomplete polypectomy, or poor bowel preparation on index, the ADR on early follow-up was 4% for symptomatic and 26% for asymptomatic patients. Among the asymptomatic patients with a follow-up colonoscopy at >1 year (n=463), an ADR of 23% (108/463) was found. In 27% of these patients, the observed surveillance intervals were in accordance with American Gastroenterological Association (AGA) surveillance recommendations; 60% were classified as over-utilization and 13% as under-utilization according to the AGA. Optimal utilization follow-up colonoscopies had higher ADRs on follow-up compared with overutilized procedures (31% vs. 17%; P<0.001). Conclusions: Follow-up colonoscopy in symptomatic patients within a year has limited value in terms of adenoma detection. A considerable proportion of surveillance colonoscopies are performed too early according to current guidelines, resulting in low detection rates. Both aspects can be targeted for optimal usage in endoscopic capacity. [ABSTRACT FROM AUTHOR]

Introduction: The Global Rating Scale (GRS) is a quality assurance program that was developed in England to assess patient-centered care in endoscopy. The aim of the current studywas to evaluate patient experiences of colonoscopy using the GRS in order to compare different departments and to provide benchmarks. The study also evaluated factors associated with patient satisfaction. Methods: A GRS questionnaire was used both before and after the procedure in outpatients undergoing colonoscopy. The questionnaire assessed the processes associated with the colonoscopy, from making the appointment up until discharge. Mean values and ranges of 12 endoscopy departments were calculated together with P values in order to assess heterogeneity. Results: In total, 1904 pre-procedure and 1532 (80 %) post-procedure questionnaires were returned from 12 endoscopy departments. The mean time patients had to wait for their procedure was 4.3 weeks (range 3.1-5.8 weeks), and 54% (range 35-64%; P<0.001) reported being given a choice of appointment dates/times. Discomfort during colonoscopy was reported by 20% (range 8-40%; P<0.001). Recovery room privacywas satisfactory for 76% of patients (range 66-90%; P<0.05). The majority of patients reported being sufficiently informed about what to do in case of problems after discharge (79 %, range 43-98%; P<0.001), and 85% of individuals stated that they would be willing to repeat the colonoscopy procedure (range 72-92%; P<0.001). Factors associatedwith a decreased willingness to return were the burdensome bowel preparation (odds ratio [OR] =0.25; P<0.001), "rushing staff" attitude (OR=0.57; P<0.05), low acceptance of the procedure (OR=0.42; P<0.01), and more discomfort than expected (OR=0.54; P<0.05). Conclusion: Overall patient experiences with colonoscopywere satisfactory, but they also showed considerable variation. This study shows that use of a GRS patient questionnaire is feasible in the Dutch endoscopy setting for the assessment of patient experience. The significant variability between endoscopy units can be used to benchmark services and enable shortcomings to be identified. [ABSTRACT FROM AUTHOR]

Annual primary production data for the western Dutch Wadden Sea between the mid 1960s and 1986 have more than tripled, when compared with1950, the increase appears more than tenfold. There are indications that the increase in primary production of the phytoplankton over that period has been fuelled by the phosphate loading from Lake IJssel, a Rhine tributary. This also suggests that, on an annual basis, the primary production in the western Dutch Wadden Sea over the period 1950 to 1986 was mainly limited by phosphate. Despite a significant decrease in the phosphorus loads since the early 1980s, the primary production in recent years remained higher than expected based on the emission reduction. This unexpectedly high primary production of phytoplankton might have been caused by a series of other changes in inputs, including the influence of the influx from the English Channel. Clearconclusions, however, are at present not possible due to the complexinfluence of nutrients, irradiance, mixing and water circulation on the phytoplankton dynamics. [ABSTRACT FROM AUTHOR]

From February 1992 until June 1993, the distribution of dissolved and particulate phosphorus and nitrogen was investigated in the Ems estuary at approximately monthly intervals. Nutrient import was quantified from the 'river load. Nutrient export to sea was quantified from river discharge and from the salinity nutrient gradient in the outer estuary. In addition, sediment cores were taken from four sites along the main axis of the estuary in October 1992. On the basis of these data a nitrogen and phosphorus budget was made. On an annual basis, 45x 106 mol P and 2,360 x 106 mol N are importedinto the Ems estuary. Freshwater runoff is the main source of input,accounting for about 92% of the nitrogen input and 71% of the phosphorus input. Import of particulate phosphorus from the sea is important in the phosphorus budget (27%). Seventy-five percent of the nitrogen input is transported to the North Sea. Denitrification is the majorloss factor (19% of the nitrogen input), and burial explains 6%. Of the phosphorus input, 60% is transported to the North Sea and 40% accumulates in the sediment. Nitrogen import during summer explains about one third of the annual primary production, indicating that nitrogen turn over is about three times. Phosphorus import during summer explains less than 16% of the annual primary production. We suggest that trapping of particulate P and adsorption onto Fe(oxy)hydroxides during the entire year and the release of Fe-bound P during summer afterreduction of Fe(oxy)hydroxides is instrumental in sustaining high primary production, which could not be sustained if it depended only onP imported during the growing season. [ABSTRACT FROM AUTHOR]

Background: Data on variation in outcomes and costs of the treatment of inflammatory bowel disease (IBD) can be used to identify areas for cost and quality improvement. It can also help healthcare providers learn from each other and strive for equity in care. We aimed to assess the variation in outcomes and costs of IBD care between hospitals., Methods: We conducted a 12-month cohort study in 8 hospitals in the Netherlands. Patients with IBD who were treated with biologics and new small molecules were included. The percentage of variation in outcomes (following the International Consortium for Health Outcomes Measurement standard set) and costs attributable to the treating hospital were analyzed with intraclass correlation coefficients (ICCs) from case mix-adjusted (generalized) linear mixed models., Results: We included 1010 patients (median age 45 years, 55% female). Clinicians reported high remission rates (83%), while patient-reported rates were lower (40%). During the 12-month follow-up, 5.2% of patients used prednisolone for more than 3 months. Hospital costs (outpatient, inpatient, and medication costs) were substantial (median: €8323 per 6 months), mainly attributed to advanced therapies (€6611). Most of the variation in outcomes and costs among patients could not be attributed to the treating hospitals, with ICCs typically between 0% and 2%. Instead, patient-level characteristics, often with ICCs above 50%, accounted for these variations., Conclusions: Variation in outcomes and costs cannot be used to differentiate between hospitals for quality of care. Future quality improvement initiatives should look at differences in structure and process measures of care and implement patient-level interventions to improve quality of IBD care., Trial Registration Number: NL8276., (© 2024 Crohn’s & Colitis Foundation. Published by Oxford University Press on behalf of Crohn’s & Colitis Foundation.)

Introduction: Biologics are effective for the treatment of inflammatory bowel disease (IBD). However, unwarranted variation in processes and outcomes has been reported in the treatment of IBD. A care pathway for the treatment of IBD has the potential to reduce practice variation and improve outcomes. This study aims to compare the effect of a uniform care pathway for the treatment of patients with IBD with biologics to the current situation., Methods and Analysis: IBD Value is a longitudinal multicentre non-randomised parallel cluster trial with a baseline period. The study takes place in eight centres in the Netherlands. The baseline period will run for 12 months, after which the care pathway will be implemented in 6 of the 8 participating hospitals during the implementation phase of 3 months. Hereafter, the effect of the care pathway will be assessed for 12 months. Total study period is 27 months. The primary outcome is the effect of the care pathway on disease control (IBD-Control questionnaire). Secondary outcomes are the effect of the care pathway on the other outcomes of the International Consortium of Health Outcomes Measurement IBD standard set, health-related generic quality of life, patient experiences and degree of variation; cost effectiveness of the care pathway; and the variation between hospitals in the aforementioned outcomes in the baseline period. Outcomes will be measured every 6 months. The study started on 1 December 2020 and a minimum of 200 patients will be included., Ethics and Dissemination: The study was deemed not to be subject to Dutch law (WMO; Medical Research Involving Human Subjects Act) by the Medical Ethics Committee of the Erasmus MC, the Netherlands (registration number: MEC-2020-075) and a waiver was provided. Results will be disseminated through peer-reviewed journals and presented at (inter)national conferences., Trial Registration Number: NL8276., Competing Interests: Competing interests: RCAvL, NvL, DN, EB, MS, VdJ, KEV and JAH has nothing to disclose. CJvdW reports grants from Pfizer and Janssen and personal fees from AbbVie and Celltrion outside the submitted work. DvN reports personal fees from Janssen and Takeda outside the submitted work. RLW reports personal fees from AbbVie, Janssen and Pfizer outside the submitted work., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The marine environment is a complex system formed by interactions between ecological structure and functioning, physico-chemical processes and socio-economic systems. An increase in competing marine uses and users requires a holistic approach to marine management which considers the environmental, economic and societal impacts of all activities. If managed sustainably, the marine environment will deliver a range of ecosystem services which lead to benefits for society. In order to understand the complexity of the system, the DPSIR (Driver-Pressure-State-Impact-Response) approach has long been a valuable problem-structuring framework used to assess the causes, consequences and responses to change in a holistic way. Despite DPSIR being used for a long time, there is still confusion over the definition of its terms and so to be appropriate for current marine management, we contend that this confusion needs to be addressed. Our viewpoint advocates that DPSIR should be extended to DAPSI(W)R(M) (pronounced dap-see-worm) in which Drivers of basic human needs require Activities which lead to Pressures. The Pressures are the mechanisms of State change on the natural system which then leads to Impacts (on human Welfare). Those then require Responses (as Measures). Furthermore, because of the complexity of any managed sea area in terms of multiple Activities, there is the need for a linked-DAPSI(W)R(M) framework, and then the connectivity between marine ecosystems and ecosystems in the catchment and further at sea, requires an interlinked, nested-DAPSI(W)R(M) framework to reflect the continuum between adjacent ecosystems. Finally, the unifying framework for integrated marine management is completed by encompassing ecosystem structure and functioning, ecosystem services and societal benefits. Hence, DAPSI(W)R(M) links the socio-ecological system of the effects of changes to the natural system on the human uses and benefits of the marine system. However, to deliver these sustainably in the light of human activities requires a Risk Assessment and Risk Management framework; the ISO-compliant Bow-Tie method is used here as an example. Finally, to secure ecosystem health and economic benefits such as Blue Growth, successful, adaptive and sustainable marine management Responses (as Measures) are delivered using the 10-tenets, a set of facets covering all management disciplines and approaches., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background & Aims: We investigated adenoma and colonoscopy characteristics that are associated with recurrent colorectal neoplasia based on data from community-based surveillance practice., Methods: We analyzed data of 2990 consecutive patients (55% male; mean age 61 years) newly diagnosed with adenomas from 1988 to 2002 at 10 hospitals throughout The Netherlands. Medical records were reviewed until December 1, 2008. We excluded patients with hereditary colorectal cancer (CRC) syndromes, a history of CRC, inflammatory bowel disease, or without surveillance data. We analyzed associations among adenoma number, size, grade of dysplasia, villous histology, and location with recurrence of advanced adenoma (AA) and nonadvanced adenoma (NAA). We performed a multivariable multinomial logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs)., Results: During the surveillance period, 203 (7%) patients were diagnosed with AA and 954 (32%) patients with NAA. The remaining 1833 (61%) patients had no adenomas during a median follow-up of 48 months. Factors associated with AA during the surveillance period included baseline number of adenomas (ORs ranging from 1.6 for 2 adenomas; 95% CI: 1.1-2.4 to 3.3 for ≥5 adenomas; 95% CI: 1.7-6.6), adenoma size ≥10 mm (OR = 1.7; 95% CI: 1.2-2.3), villous histology (OR = 2.0; 95% CI: 1.2-3.2), proximal location (OR = 1.6; 95% CI: 1.2-2.3), insufficient bowel preparation (OR = 3.4; 95% CI: 1.6-7.4), and only distal colonoscopy reach (OR = 3.2; 95% CI: 1.2-8.5). Adenoma number had the greatest association with NAA. High-grade dysplasia was not associated with AA or NAA., Conclusions: Large size and number, villous histology, proximal location of adenomas, insufficient bowel preparation, and poor colonoscopy reach were associated with detection of AA during surveillance based on data from community-based practice. These characteristics should be used jointly to develop surveillance policies for adenoma patients., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload., Objective: To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC., Methods: Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval., Results: A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared., Conclusion: Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.

Background: The Global Rating Scale is an endoscopy quality assurance programme, successfully implemented in England. It remains uncertain whether it is applicable in another health care setting., Aim: To assess the applicability of the Global Rating Scale as benchmark tool in an international context., Methods: Eleven Dutch endoscopy departments were included for a Global Rating Scale-census, performed as a cross-sectional evaluation, July 2010. Two Global Rating Scale-dimensions - 'clinical quality' and 'patient experience' - were assessed across six items using a range of levels: from level-D (basic) to level-A (excellent). Construct validity was assessed by comparing department-specific colonoscopy audit data to GRS-levels., Results: For 'clinical quality', variable scores were achieved in items 'safety' (9%=B, 27%=C, 64%=D) and 'communication' (46%=A, 18%=C, 36%=D). All departments achieved a basic score in 'quality' (100%=D). For 'patient experience', variable scores were achieved in 'timeliness' (18%=A, 9%=B, 73%=D) and 'booking-choice' (36%=B, 46%=C, 18%=D). All departments achieved basic scores in 'equality' (100%=D). Departments obtaining level-C or above in 'information', 'comfort', 'communication', 'timeliness' and 'aftercare', achieved significantly better audit outcomes compared to those obtaining level-D (p<0.05)., Conclusion: The Global Rating Scale is appropriate to use outside England. There was significant variance across departments in dimensions. Most Global Rating Scale-levels were in line with departments' audit outcomes, indicating construct validity., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. All rights reserved.)

Objectives: Colonoscopy is the gold standard for visualization of the colon. It is generally accepted as a safe procedure and major adverse events occur at a low rate. However, few data are available on structured assessment of (minor) post-procedural adverse events., Methods: Consecutive outpatients undergoing colonoscopy were asked for permission to be called 30 days after their procedure. A standard telephone interview was developed to assess the occurrence of (i) major adverse events (hospital visit required), (ii) minor adverse events, and (iii) days missed from work. Adverse events were further categorized in definite-, possible-, and unrelated adverse events. Patients were contacted between January 2010 and September 2010., Results: Out of a total of 1,528 patients who underwent colonoscopy and gave permission for a telephone call, 1,144 patients were contacted (response: 75%), 49% were male, the mean age was 59 years (s.d.: 14). Thirty-four patients (3%) reported major adverse events. These were definite-related in nine (1%) patients, possible-related in 6 (1%), and unrelated in 19 patients (2%). Minor adverse events were reported by 466 patients (41%). These were definite-related in 336 patients (29%), possible-related in 36 (3%), and unrelated in the remaining 94 patients (8%). Female gender (odds ratio (OR): 1.5), age <50 years (OR: 1.5), colonoscopy for colorectal cancer screening/surveillance (OR: 1.6), and fellow-endoscopy (OR: 1.7) were risk factors for the occurrence of any definite-related adverse event. Patients who reported definite-related adverse events were significantly less often willing to return for colonoscopy (81 vs. 88%, P<0.01) and were less often positive about the entire colonoscopy experience (84 vs. 89%, P=0.04)., Conclusions: Structured assessment of post-colonoscopy adverse events shows that these are more common than generally reported. Close to one-third of patients report definite-related adverse events, which are major in close to 1 in 100 patients. The occurrence of adverse events does have an impact on the willingness to return for colonoscopy.

Background & Aims: The efficacy of colorectal cancer screening programs depends on the rate of attendance at surveillance colonoscopy examinations. Increasing patients' awareness about the importance of surveillance might improve attendance, but it is not clear how much they know about their follow-up recommendations. We assessed the awareness of patients with adenomas about their surveillance recommendations., Methods: Ten endoscopy departments provided access to their colonoscopy database for quality assurance; 2 datasets were obtained. We analyzed data from 4000 colonoscopies (400 per department) performed on patients with adenomas. All the patients were mailed a survey to determine how much information they had about their colonoscopy results and their follow-up recommendations. Data from 549 patients were included in the analysis. We also assessed surveillance attendance among 500 patients (50 per department) who had adenomas removed., Results: Of the patients analyzed, 85% recalled retrieval of polyps during their colonoscopy, and 85% recalled whether they needed surveillance or not. The indication for surveillance was recalled by 69% of patients (range between departments, 55%-83%; P < .01). Factors that were associated with awareness of recommendations were younger age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.06-1.09), treatment by a gastroenterologist (OR, 5.53; 95% CI, 3.28-9.32), and presence of 3 or more adenomas (OR, 2.97; 95% CI, 1.29-6.85). Attendance among patients with adenomas varied among departments, from 60% to 89% (P < .01), and was not associated with awareness of patients about their recommendations per department (P = .59)., Conclusions: Not enough patients (only 85%) who receive colonoscopies are aware of their results or surveillance recommendations. Although awareness of findings and recommendations did not correlate with follow-up attendance, patients should be better informed about findings and their need for surveillance., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: Due to the increasing demand for colonoscopy, adherence to postpolypectomy surveillance guidelines is important. Suboptimal compliance can lead to unnecessary risks and ineffective use of resources., Objective: To determine the awareness of and adherence to postpolypectomy surveillance guidelines among members of the Canadian Association of Gastroenterology (CAG)., Methods: A survey describing 14 clinical cases was mailed to all physician members (n=411) of the CAG. Respondents were required to recommend a surveillance interval and a reason for his or her choice., Results: A total of 150 colonoscopists (37%) completed the survey. Adherence to the guidelines varied from 23% to 96% per clinical scenario (median 63%). Recommended surveillance intervals were too short in 0% to 60% of the different cases (median 8%). The recommended interval was most often (60%) too short for a patient with one tubular adenoma with high-grade dysplasia. Surveillance intervals were too long in 4% to 75% of the cases (median 9%). The recommended interval was most often too long in a patient with a villous adenoma 15 mm in size and removed piecemeal (75%). Most often, recommendations were reported to be based on guidelines (median 74%; range 31% to 94%). However, in nine of 14 cases, more than 10% (median 18%; range 12% to 38%) of the respondents stated that their recommendation was based on guidelines, but did not provide the appropriate surveillance interval., Conclusions: Compliance to colonoscopy surveillance guidelines is suboptimal and reflects both overuse and underuse. The results show that awareness about the content of guidelines needs to be raised and strategies implemented to increase adherence.

Background: Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting., Objective: This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance., Design: Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department., Setting: Daily clinical practice in 12 Dutch endoscopy departments., Patients: Consecutive patients undergoing scheduled colonoscopy procedures., Main Outcome Measurements: Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR)., Results: A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurse-endoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%)., Limitations: Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist., Conclusion: Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved., (Copyright © 2012 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

This chapter aims to describe the origin and current status of quality assurance (QA) in health care and to provide a background of similar developments in other industries, which have provided a major impetus for QA initiatives in health care. The interest in quality and safety in the health care sector has rapidly risen over the past decade. Without important lessons learnt from other industries, the interest and obtained improvements would have been far less fast. Knowledge on basic principles and challenges faced by other industries like the airline, car, and nuclear energy industry, that drove quality improvement projects, is of major relevance to understand the evolutions taking place in health care. To fully appreciate the QA movement, and design or implement quality improvement projects, its basic principles need to be understood. This chapter aims to give insights in basic principles underlying QA, and to discuss historical lessons that have been learnt from other industries. Furthermore, it discusses how to implement and assure a sustainable QA program., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Quality assurance has become an important issue. Many societies are adopting quality assurance programs in order to monitor and improve quality of care., Aim: To assess the opinion of gastroenterologists towards quality assurance on the endoscopy department., Methods: A survey was sent to all gastroenterologists (n=319) in the Netherlands. It assessed their opinion on a quality assurance program for endoscopy units, including its design, logistics, and content., Results: 200 gastroenterologists (63%) completed the questionnaire. 95% had a positive opinion towards quality assurance and 67% supposed an increase in quality. 28% assumed a negative impact on the time available for patient contact by introducing a quality assurance program and 35% that the capacity would decrease. A negative attitude towards disclosure of results to insurance companies (23%) and media (53%) was reported. Female gastroenterologists were less positive to share the results with other stakeholders (p<0.05). Most important quality measurements were assessment of complications (97%), standardised reporting (96%), and adequate patient information (95%)., Conclusion: Gastroenterologists have a positive attitude towards quality assurance. However, concerns do exist about time investment and disclosure of results to others. Information provision and procedure characteristics were considered the most important aspects of quality assurance., (Copyright © 2010 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The Global Rating Scale (GRS) comprehensively evaluates the quality of an endoscopy department, providing a patient-centred framework for service improvement., Objective: To assess patient experiences during colonoscopy and identify areas that need service improvement using the GRS., Methods: Consecutive outpatients undergoing colonoscopy were asked to complete a pre- and postprocedure questionnaire. Questions were based on GRS items and a literature review. The preprocedure questionnaire addressed items such as patient characteristics and information provision. The postprocedure questionnaire contained questions regarding comfort, sedation, the attitude of endoscopy staff and aftercare., Results: The preprocedure questionnaire was completed by 1,187 patients, whereas the postprocedure part of the questionnaire was completed by 851 patients (71.9%). Fifty-four per cent of patients were first seen in the outpatient clinic. The indication for colonoscopy was explained to 85% of the patients. Sixty-five per cent of the patients stated that information about the risks of colonoscopy was provided. Sedation was used in 94% of the patients; however, 23% judged the colonoscopy to be more uncomfortable than expected. Ten per cent of patients rated the colonoscopy as (very) uncomfortable. Preliminary results of the colonoscopy were discussed with 87% of patients after the procedure. Twenty-one per cent of the patients left the hospital without knowing how to obtain their final results. Being comfortable while waiting for the procedure (OR 9.93) and a less uncomfortable procedure than expected (OR 2.99) were important determinants of the willingness to return for colonoscopy., Conclusions: The present study provided evidence supporting the GRS in identifying service gaps in the quality of patient experiences for colonoscopy in a North American setting. Assessing experiences is useful in identifying areas that need improvement such as the provision of pre- and postprocedure information.

This chapter explores the concept of quality assurance of colorectal cancer screening. It argues that effective quality assurance is critical to ensure that the benefits of screening outweigh the harms. The three key steps of quality assurance, definition of standards, measurement of standards and enforcement of standards, are explained. Quality is viewed from the perspective of the patient and illustrated by following the path of patients accessing endoscopy within screening services. The chapter discusses the pros and cons of programmatic versus non-programmatic screening and argues that quality assurance of screening can and should benefit symptomatic services. Finally, the chapter emphasises the importance of a culture of excellence underpinned by continuous quality improvement and effective service leadership., (Copyright © 2010. Published by Elsevier Ltd.)

Large-scale losses of seagrass beds have been reported for decades and lead to numerous restoration programs. From worldwide scientific literature and 20 years of seagrass restoration research in the Wadden Sea, we review and evaluate the traditional guidelines and propose new guidelines for seagrass restoration. Habitat and donor selection are crucial: large differences in survival were found among habitats and among donor populations. The need to preferably transplant in historically confirmed seagrass habitats, and to collect donor material from comparable habitats, were underlined by our results. The importance of sufficient genetic variation of donor material and prevention of genetic isolation by distance was reviewed. The spreading of risks among transplantation sites, which differed in habitat characteristics (or among replicate sites), was positively evaluated. The importance of ecosystem engineering was shown in two ways: seagrass self-facilitation and facilitation by shellfish reefs. Seagrass self-facilitative properties may require a large transplantation scale or additional measures.

The main goal of the EU Water Framework Directive (WFD) is to achieve good ecological status across European surface waters by 2015 and as such, it offers the opportunity and thus the challenge to improve the protection of our coastal systems. It is the main example for Europe's increasing desire to conserve aquatic ecosystems. Ironically, since c. 1975 the increasing adoption of EU directives has been accompanied by a decreasing interest of, for example, the Dutch government to assess the quality of its coastal and marine ecosystems. The surveillance and monitoring started in NL in 1971 has declined since the 1980s resulting in a 35% reduction of sampling stations. Given this and interruptions the remaining data series is considered to be insufficient for purposes other than trend analysis and compliance. The Dutch marine managers have apparently chosen a minimal (cost-effective) approach despite the WFD implicitly requiring the incorporation of the system's 'ecological complexity' in indices used to evaluate the ecological status of highly variable systems such as transitional and coastal waters. These indices should include both the community structure and system functioning and to make this really cost-effective a new monitoring strategy is required with a tailor-made programme. Since the adoption of the WFD in 2000 and the launching of the European Marine Strategy in 2002 (and the recently proposed Marine Framework Directive) we suggest reviewing national monitoring programmes in order to integrate water quality monitoring and biological monitoring and change from 'station oriented monitoring' to 'basin or system oriented monitoring' in combination with specific 'cause-effect' studies for highly dynamic coastal systems. Progress will be made if the collected information is integrated and aggregated in valuable tools such as structure- and functioning-oriented computer simulation models and Decision Support Systems. The development of ecological indices integrating community structure and system functioning, such as in Ecological Network Analysis, are proposed to meet a cost-effective approach at the national level and full assessment of the ecosystem status at the EU level. The WFD offers the opportunity to re-consider and re-invest in environmental research and monitoring. Using examples from the Netherlands and, to a lesser extent, the United Kingdom, the present paper therefore reviews marine monitoring and marine environmental research in combination and in the light of such major policy initiatives such as the WFD.