Colonoscopy quality: metrics and implementation

Consensus quality indicators for monitoring multiple sclerosis

Multiple sclerosis (MS) as a chronic, degenerative autoimmune disease of the central nervous system has a longitudinal and heterogeneous course with increasing treatment options and risk profiles requiring constant monitoring of a growing number of parameters. Despite treatment guidelines, there is a lack of strategic and individualised monitoring pathways, including respective quality indicators (QIs). To address this, we systematically developed transparent, traceable, and measurable QIs for MS monitoring. Through literature review, expert discussions, and consensus-building, existing QIs were identified and refined. In a two-stage online Delphi process involving MS specialists (on average 53 years old and with 25 years of professional experience), the QIs were evaluated for content, clarity, and intelligibility, resulting in a set of 24 QIs and checklists to assess the quality of care. The final QIs provide a structured approach to document, monitor, and enhance the quality of care for people with MS across their treatment journey.

A Framework for the Evaluation of Human Machine Interfaces of Robot-Assisted Colonoscopy

The Human Machine Interface (HMI) of intraluminal robots has a crucial impact on the clinician's performance. It increases or decreases the difficulty of the tasks, and is connected to the users' physical and mental stress.

OBJECTIVE

This article presents a framework to compare and evaluate different HMIs for robotic colonoscopy, with the objective of identifying the optimal HMI that minimises the clinician's effort and maximises the clinical outcomes.

METHODS

The framework comprises a 1) a virtual simulator (clinically validated), 2) wearable sensors measuring the cognitive load, 3) a data collection unit of metrics correlated to the clinical performance, and 4) questionnaires exploring the users' impressions and perceived stress. The framework was tested with 42 clinicians investigating the optimal device for tele-operated control of robotic colonoscopes. Two control devices were selected and compared: a haptic serial-kinematic device and a standard videogame joypad.

RESULTS

The haptic device was preferred by the endoscopists, but the joypad enabled better clinical performance and reduced cognitive and physical load.

CONCLUSION

The framework can be used to evaluate different aspects of a HMI, both hardware and software, and determine the optimal HMI that can reduce the burden on clinicians while improving the clinical outcome.

SIGNIFICANCE

The findings of this study, and of future studies performed with this framework, can inform the design and development of HMIs for intraluminal robots, leading to improved clinical performance, reduced physical and mental stress for clinicians, and ultimately better patient outcomes.

What are the priority quality indicators for colonoscopy in real-world clinical practice?

Colonoscopy is widely used as a colorectal cancer (CRC) screening tool. The effectiveness of a screening colonoscopy is associated with a decreased risk of CRC. However, colonoscopy is an operator-dependent procedure, and endoscopists' quality performance varies widely. This article reviewed the priority metrics and practices that contribute to high-quality screening colonoscopy in real-world clinical practice. With growing evidence, quality indicators have been subject to intense research and associated with reducing postcolonoscopy CRC incidence and mortality. Some quality metrics can reflect an endoscopy unit-based practice (i.e. quality of bowel preparation and withdrawal time). Other quality indicators primarily reflect individuals' skill and knowledge (i.e. cecal intubation rate, adenoma detection rate, and appropriately assigned follow-up colonoscopy interval). Measurement and improvement of priority quality indicators for colonoscopy should be made at both the endoscopist and unit levels. Substantial evidence supports the impact of high-quality colonoscopy in reducing the incidence of postcolonoscopy CRC.

Application of artificial intelligence in colorectal cancer screening by colonoscopy: Future prospects (Review)

Colorectal cancer (CRC) has become a severe global health concern, with the third‑high incidence and second‑high mortality rate of all cancers. The burden of CRC is expected to surge to 60% by 2030. Fortunately, effective early evidence‑based screening could significantly reduce the incidence and mortality of CRC. Colonoscopy is the core screening method for CRC with high popularity and accuracy. Yet, the accuracy of colonoscopy in CRC screening is related to the experience and state of operating physicians. It is challenging to maintain the high CRC diagnostic rate of colonoscopy. Artificial intelligence (AI)‑assisted colonoscopy will compensate for the above shortcomings and improve the accuracy, efficiency, and quality of colonoscopy screening. The unique advantages of AI, such as the continuous advancement of high‑performance computing capabilities and innovative deep‑learning architectures, which hugely impact the control of colorectal cancer morbidity and mortality expectancy, highlight its role in colonoscopy screening.

Evaluating colonoscopy screening intervals in patients with Lynch syndrome from a large Canadian registry

BACKGROUND

Lynch syndrome (LS) screening guidelines originally recommended colonoscopy every 1 to 2 years, beginning between the ages of 20 and 25 years. Recent studies have questioned the benefits of these short screening intervals in preventing colorectal cancer (CRC). Our goal is to determine how colonoscopy screening intervals impact CRC in patients with LS.

METHODS

We analyzed the demographics, screening practices, and outcomes of patients with LS identified through the clinic based Familial Gastrointestinal Cancer Registry at the Zane Cohen Centre, Sinai Health System, Toronto, Canada.

RESULTS

A total of 429 patients with LS were identified with median follow-up of 9.2 years; 44 developed CRC. We found a positive trend between shorter screening intervals and the number of adenomas detected during colonoscopy. Any new adenoma detected at screening decreased 10-year CRC incidence by 11.3%. For MLH1 carriers, a screening interval of 1-2 years vs 2-3 years led to a 20-year cumulative CRC risk reduction of 28% and 14% in females and males, respectively. For MSH2 carriers, this risk reduction was 29% and 17%, respectively, and for male MSH6 carriers 18%. Individuals without any adenomas detected (53.4% of LS carriers) had an increased 20-year CRC risk of 25.7% and 57.2% for women and men, respectively, compared with those diagnosed with adenomas at screening.

CONCLUSIONS

The recommended colonoscopy screening interval of 1-2 years is efficient at detecting adenomas and reducing CRC risk. The observation that 53.4% of LS patients never had an adenoma warrants further investigation about a possible adenoma-free pathway.

MicroRNA panels as diagnostic biomarkers for colorectal cancer: A systematic review and meta-analysis

Background

Circulating microRNAs (miRNA) have emerged as promising diagnostic biomarkers for several diseases, including cancer. However, the diagnostic accuracy of miRNA panels in colorectal cancer (CRC) remains inconsistent and there is still lack of meta-analyses to determine whether miRNA panels can serve as robust biomarkers for CRC diagnosis.

Methods

This study performed a systematic review and meta-analysis to evaluate the clinical utility of miRNA panels as potential biomarkers for the diagnosis of CRC. The investigation systematically searched PubMed, Medline, Web of Science, Cochrane Library, and Google Scholar (21-year span, between 2000 and 2021) to retrieve articles reporting the diagnostic role of miRNA panels in detecting CRC. Diagnostic meta-analysis of miRNA panels used diverse evaluation indicators, including sensitivity, specificity, Positive Likelihood Ratio (PLR), Negative Likelihood Ratio (NLR), Diagnostic Odds Ratio (DOR), and the area under the curve (AUC) values.

Results

Among the 313 articles identified, 20 studies met the inclusion criteria. The pooled estimates of miRNA panels for the diagnosis of CRC were 0.85 (95% CI: 0.84-0.86), 0.79 (95% CI: 0.78-0.80), 4.06 (95% CI: 3.89-4.23), 0.20 (95% CI: 0.19-0.20), 22.50 (95% CI: 20.81-24.32) for sensitivity, specificity, PLR, NLR, and DOR, respectively. Moreover, the summary receiver operating characteristics (SROC) curve revealed an AUC value of 0.915 (95% CI: 0.914-0.916), suggesting an outstanding diagnostic accuracy for overall miRNA panels. Subgroup and meta-regression analyses demonstrated that miRNA panels have the highest diagnostic accuracy within serum samples, rather than in other sample-types - with a sensitivity, specificity, PLR, NLR, DOR, and AUC of 0.87, 0.86, 7.33, 0.13, 55.29, and 0.943, respectively. Sensitivity analysis revealed that DOR values did not differ markedly, which indicates that the meta-analysis had strong reliability. Furthermore, this study demonstrated no proof of publication bias for DOR values analyzed using Egger's regression test (P > 0.05) and funnel plot. Interestingly, miR-15b, miR-21 and miR-31 presented the best diagnostic accuracy values for CRC with sensitivity, specificity, PLR, NLR, DOR, and AUC values of 0.95, 0.94, 17.19, 0.05, 324.81, and 0.948, respectively.

Conclusion

This study's findings indicated that miRNA panels, particularly serum-derived miRNA panels, can serve as powerful and promising biomarkers for early CRC screening.

Systematic review registration

[www.crd.york.ac.uk/prospero], identifier [CRD42021268172].

Do Gastroenterologists Have a "Weak" Day? Impact of Day of the Week on the Quality of Outpatient Screening Colonoscopies

GOAL

The goal of this study is to determine the significance of day of the work week and its contribution to endoscopist performance using adenoma detection rate (ADR) and proposed surrogate quality measures.

BACKGROUND

Nearly a quarter of adenomas are missed on routine screening colonoscopy which contributes to between 50% and 60% of interval colorectal cancer.

MATERIALS AND METHODS

Adult patients who underwent outpatient screening colonoscopy between January 2015 and April 2020 were included. Measurement of ADR and proposed quality metrics were analyzed for each day of the work week. Secondary outcomes included rates of good or excellent bowel preparation, trainee fellow participation, performance quartile of individual endoscopists, and patient demographic data. A generalized linear mixed model was used to analyze predictors of ADR.

RESULTS

A total of 1884 screening procedures were included in our analysis. ADR on Friday (35.6%) was significantly lower than all other days of the work week ( P <0.001). When compared with Friday, all days were found to be independent predictors of increased ADR. Male gender [95% confidence interval (CI): 1.12-1.65, P =0.002], good rather than excellent bowel preparation (95% CI: 1.22-2.28, P =0.001) and colonoscopy withdrawal time (CWT) (95% CI: 1.02-1.03, P <0.001) were all found to be predictors of increased ADR. Proposed quality indicators were all well correlated with ADR ( r >0.811, P ≤0.001) apart from CWT ( r =0.28, P =0.379).

CONCLUSIONS

The data suggests there is a decline in endoscopist performance on Friday when compared with all other days of the work week. ADR correlates well with many proposed quality parameters, however, CWT may be of additional value as a quality metric.

Post-polypectomy follow-up recommendations by practicing academic gastroenterologists-does number of years in practice matter?

AIM

Colorectal cancer (CRC) is the third most deadly and fourth most common cancer worldwide. Early detection, resection, and appropriate surveillance of precursor polyps result in better outcomes. Colonoscopy is a safe, accurate, and effective tool for surveillance and follow-up of premalignant polyps. Recommended surveillance intervals are based on polyp, procedural, and patient-related factors. The United States Multi-Society Task Force (MSTF) on CRC publishes guidelines with periodic updates on surveillance. We sought to evaluate adherence to post-polypectomy surveillance guidelines by academic gastroenterologists at a high-volume center.

METHODS

One-year retrospective study evaluating compliance with post-polypectomy recommendations after average risk adult screening colonoscopies. Data was collected on number and size of polyps, quality of bowel prep, initial follow-up recommendations, polyp pathology, and follow-up recommendations. Correlation with the 2012 MSTF guidelines was also evaluated. Endoscopist experience was categorized as greater or less than 10 years of practice experience. Binomial regression was used to model the association between the providers' years of experience (<10 vs. >10) and the likelihood of agreement between initial assessment and post-pathology assessment.

RESULTS

There was a greater than 85% adherence to post-polypectomy surveillance guidelines, independent of endoscopist experience.

CONCLUSION

There is a high level of adherence to post-polypectomy guidelines by practicing academic gastroenterologists independent of post-fellowship clinical experience.

Software Analysis of Colonoscopy Videos Enhances Teaching and Quality Metrics

Purpose

Machine learning algorithms were hypothesized as being able to predict the quality of colonoscopy luminal images. This is to enhance training and quality indicators in endoscopy.

Methods

A separate study involving a randomized controlled trial of capped vs. un-capped colonoscopies provided the colonoscopy videos for this study. Videos were analyzed with an algorithm devised by the Australian Institute for Machine Learning. The image analysis validated focus measure, steerable filters-based metrics (SFIL), was used to assess luminal visualization quality and was compared with two independent clinician assessments (C1 and C2). Goodman and Kruskal's gamma (G) measure was used to assess rank correlation data using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY).

Results

A total of 500 random colonoscopy video clips were extracted and analyzed, 88 being excluded. SFIL scores matched with C1 in 45% and C2 in 42% of cases, respectively. There was a significant correlation between SFIL and C1 (G = 0.644, p < 0.005) and SFIL and C2 (G = 0.734, p < 0.005).

Conclusion

This study demonstrates that machine learning algorithms can recognize the quality of luminal visualization during colonoscopy. We intend to apply this in the future to enhance colonoscopy training and as a metric for quality assessment.

Important Quality Metrics and Standardization in Endoscopy

Quality metrics and standardization has become critical as the Affordable Care Act mandates that the Center for Medicare and Medicaid Services change reimbursement from volume to a value-based system. While the most commonly used quality indicators are related to that of colonoscopy, quality metrics for other procedures and endoscopy units have been developed mainly by the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy. Data to show that these quality metrics, especially in the field of advanced endoscopy as well as in the era of COVID-19 pandemic, can improve patient outcomes, are anticipated.

Quality in Endoscopy

Quality improvement is a dynamic process that requires continuously monitoring quality indicators and benchmarking these with national and professional standards. Endoscopists have formed societal task forces to propose quality indicators and performance goals. Institutions are now incentivized by payers and value-based reimbursement agreements to have processes in place to measure, report, and act on these quality metrics. Nationwide registries, such as the Gastrointestinal Quality Improvement Consortium, are used to report quality data to these merit-based incentive payment systems. Quality improvement processes such as these are instrumental to improve patient safety, health, and satisfaction while decreasing costs and medical errors.

State of the Science on Quality Indicators for Colonoscopy and How to Achieve Them

Colonoscopy is a safe and effective tool, but operator dependent. Room for improvement in the quality of colonoscopy is the impetus for the development and measurement of colonoscopy quality indicators and the focus of many efforts to improve colonoscopy quality indicator prevention and control in provider practices and health systems. We present the preprocedural, intraprocedural, and postprocedural quality indicators and benchmarks for colonoscopy. Every provider and practice must make a commitment to performing high-quality colonoscopy and implement and monitor quality metrics. There are a variety of tools available to assist in improving quality indicators that range from distal attachment devices to education and feedback. Although technology can help, it is not a substitute for proper technique. The commitment also requires provider feedback through audits and report cards. The impact of these efforts on patient outcomes is an important area of further research.

Measuring the value of endoscopic retrograde cholangiopancreatography activity: an opportunity to stratify endoscopists on the basis of their value

INTRODUCTION

As finite healthcare resources come under pressure, the value of physician activity is assuming increasing importance. The value in healthcare can be defined as patient health outcomes achieved per monetary unit spent. Even though some attempts have been made to quantify the value of clinician activity, there is little in the medical literature describing the importance of endoscopists' activity. This study aimed to characterize the value of endoscopic retrograde cholangiopancreatography (ERCP) performance of five gastroenterologists.

PATIENTS AND METHODS

We carried out a retrospective-prospective cohort study using the databases of patients undergoing ERCP between September 2014 and March 2017. We collected data from 1070 patients who underwent ERCP comparing value among the ERCPists at index ERCP. Procedure value was calculated using the formula Q/(T/C), where Q is the quality of procedure, T is the duration of procedure and C is the adjusted for complexity level. Quality and complexity were derived on a 1-4 Likert scale on the basis of American Society for Gastrointestinal Endoscopy criteria; time was recorded (in min) from intubation to extubation. Endoscopist time calculated from procedure time was considered a surrogate marker of cost as individual components of procedure cost were not itemized.

RESULTS

In total, 590 procedures were analysed: 465 retrospectively over 24 months and 125 prospectively over 6 months. There was a 32% variation in the value of endoscopist activity in a more substantial retrospective cohort, with an even more considerable 73% variation in a smaller prospective arm.

CONCLUSION

In an analysis of greater than 1000 ERCPs by a small cohort of experienced ERCPists, there was a wide variation in the value of endoscopist activity. Although the precision of estimating procedural costs needs further refinement, these findings show the ability to stratify ERCPists on the basis of the value their activity. As healthcare costs are scrutinized more closely, such value measurements are likely to become more relevant.

Less Is More: A Minimalist Approach to Endoscopy

A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.

Adenoma Detection Rate Falls at the End of the Day in a Large Multi-site Sample

BACKGROUND

There is concern that mental and physical fatigue among endoscopists over the course of the day will lead to lower adenoma detection rate (ADR). There are mixed findings in the prior literature on whether such an association exists.

AIMS

The aim of this study was to measure the association between the number of colonoscopies performed in a day and ADR and withdrawal time.

METHODS

We analyzed 86,624 colonoscopy and associated pathology reports between October 2013 and September 2015 from 131 physicians at two medical centers. A previously validated natural language processing program was used to abstract relevant data. We identified the order of colonoscopies performed in the physicians' schedule and calculated the ADR and withdrawal time for each colonoscopy position.

RESULTS

The ADR for our overall sample was 29.9 (CI 29.6-30.2). The ADR for colonoscopies performed at the 9th + position was significantly lower than those at the 1st-4th or 5th-8th position, 27.2 (CI 25.8-28.6) versus 29.9 (CI 29.5-30.3), 30.2 (CI 29.6-30.9), respectively. Withdrawal time steadily decreased by colonoscopy position going from 11.6 (CI 11.4-11.9) min for the 1st colonoscopy to 9.6 (8.9-10.3) min for the 9th colonoscopy.

CONCLUSION

In our study population, ADR and withdrawal time decrease by roughly 7 and 20%, respectively, by the end of the day. Our results imply that rather than mental or physical fatigue, lower ADR at the end of the day might be driven by endoscopists rushing.

ADENOMA DETECTION RATE EVALUATION AND QUALITY OF COLONOSCOPY IN THE CENTER-WEST REGION OF BRAZIL

BACKGROUND

Colorectal cancer is the third commonest cancer in men and the second in women worldwide. Peculiarities of its evolution allow secondary prevention measures through colonoscopy, with high diagnostic and therapeutic capacity. In this context, the quality indicators of the procedure become important, among them the adenoma detection rate (ADR).

OBJECTIVE

To relate the ADR in a medium risk population subjected to colonoscopy with sociodemographic, technical and histopathological indicators.

METHODS

This was a descriptive, observational and retrospective study whose data were collected from medical records of colonoscopy exams with the indication of colorectal cancer screening or prevention in the period from August to October 2016.

RESULTS

A total of 436 exams were included for analysis. Female sex represented 66.3% with 289 patients versus 33.7% for men. Patients aged between 50 and 59 years were 223 (51.1%) and those between 60 and 75 years were 213 (48.9%). In 99 exams (22.7%) chromoscopy was used, and 420 patients (96.3%) were adequately prepared. There were 118 patients with adenomas, resulting in an overall ADR of 27.1%. The ADR for men was 30.6% and 25.3% for women. Patients between 60 and 75 years old had a significantly higher ADR (31.9%, compared to 22.4% of the younger ones). Examinations in which chromoscopy was used also presented higher ADR.

CONCLUSION

The ADR values found for the population of the studied region were compatible with internationally established goals. Continuous evaluation of the ADR may yield interventions aimed at improving quality standards for colonoscopy and promote better prevention of colorectal cancer.

Impact of feedback and monitoring on colonoscopy withdrawal times and polyp detection rates

Background

Previous studies have shown colonoscopy withdrawal time (WT) to be a reliable surrogate indicator for polyp detection rate (PDR) and adenoma detection rate (ADR) in colonoscopy. Our aim was to assess the impact of feedback and monitoring of WT on PDR in routine colonoscopies with long-term follow-up.

Materials and methods

A total of 307 colonoscopies were performed in three separate clinical scenarios. First, PDR and WT were recorded without the staff being aware of the specific objective of the study. Before the second scenario, the staff was given interventional information and feedback on WTs and PDRs from the first scenario and was encouraged to aim for a minimum WT of 8 min. Retention of knowledge gained was reassessed in the third scenario 1 year later.

Results

The PDR in the first two scenarios differed significantly (p<0.01), with a more than 90% increase in PDR after intervention from 22% to 42% (95% CI 1.44 to 4.95), although the mean WT did not change (6.8 vs 7.2 min; p>0.05). The increase in PDR between the first and second scenarios was retained in the third follow-up scenario 1 year later where the WT of both polyp-positive and polyp-negative colonoscopies was found to be longer.

Conclusions

PDR almost doubled from the first to the second scenario of a real-life colonoscopy setting, indicating that awareness of WT is crucial. The knowledge gained from this intervention in routine practice was even retained after a year.

Blood-based microRNAs as biomarkers for the diagnosis of colorectal cancer: a systematic review and meta-analysis

Background:

Colorectal cancer (CRC) is common and associated with significant mortality. Current screening methods for CRC lack patient compliance. microRNAs (miRNAs), identified in body fluids, are negative regulators of gene expression and are dysregulated in many cancers, including CRC. This paper summarises studies identifying blood-based miRNAs dysregulated in CRC compared with healthy controls in an attempt to evaluate their use as a screening tool for the diagnosis of CRC.

Methods:

A search of electronic databases (PubMed and EMBASE) and grey literature was performed between January 2002 and April 2016. Studies reporting plasma or serum miRNAs in the diagnosis of CRC compared with healthy controls were selected. Patient demographics, type of patient sample (serum or plasma), method of miRNA detection, type of normalisation, and the number of significantly dysregulated miRNAs identified were recorded. Statistical evaluation of dysregulated miRNAs using sensitivity, specificity, and area under the curve (AUC) was performed.

Results:

Thirty-four studies investigating plasma or serum miRNAs in the diagnosis of CRC were included. A total of 31 miRNAs were found to be either upregulated (n=17) or downregulated (n=14) in CRC cases as compared with controls. Fourteen studies identified panels of ⩾2 dysregulated miRNAs. The highest AUC, 0.943, was identified using a panel of 4 miRNAs with 83.3% sensitivity and 93.1% specificity. Meta-analysis of studies identifying a single dysregulated miRNA in CRC cases compared with controls was performed. Overall sensitivity and specificity of 28 individual miRNAs in the diagnosis of CRC were 76% (95% CI 72%–80%) and 76% (95% CI 72%–80%), respectively, indicating good discriminative ability of miRNAs as biomarkers for CRC. These data did not change with sensitivity analyses.

Conclusions:

Blood-based miRNAs distinguish patients with CRC from healthy controls with high sensitivity and specificity comparable to other common and invasive currently used screening methods for CRC. In future, miRNAs may be used as a relatively non-invasive blood-based marker for detection of CRC.

A Review on the Quality of Colonoscopy Reporting

Colonoscopy reports are important communication tools for providers and patients with potential to serve as information sources for research, quality, performance, and resource management. Despite decades of work, studies continue to indicate that colonoscopy reports are often incomplete. Although electronic medical records (EMRs) and databases can address this problem, costs, workflow, and interoperability (difficulty exchanging information between systems) continue to limit adoption and implementation of endoscopy EMRs in Canada and elsewhere. Quality and reporting guidelines alone have proven to be insufficient. In this review we have derived and applied five key themes to challenges in the current state of colonoscopy reporting and propose strategies to address them.

Natural language processing as an alternative to manual reporting of colonoscopy quality metrics

BACKGROUND AND AIMS

The adenoma detection rate (ADR) is a quality metric tied to interval colon cancer occurrence. However, manual extraction of data to calculate and track the ADR in clinical practice is labor-intensive. To overcome this difficulty, we developed a natural language processing (NLP) method to identify adenomas and sessile serrated adenomas (SSAs) in patients undergoing their first screening colonoscopy. We compared the NLP-generated results with that of manual data extraction to test the accuracy of NLP and report on colonoscopy quality metrics using NLP.

METHODS

Identification of screening colonoscopies using NLP was compared with that using the manual method for 12,748 patients who underwent colonoscopies from July 2010 to February 2013. Also, identification of adenomas and SSAs using NLP was compared with that using the manual method with 2259 matched patient records. Colonoscopy ADRs using these methods were generated for each physician.

RESULTS

NLP correctly identified 91.3% of the screening examinations, whereas the manual method identified 87.8% of them. Both the manual method and NLP correctly identified examinations of patients with adenomas and SSAs in the matched records almost perfectly. Both NLP and the manual method produced comparable values for ADRs for each endoscopist and for the group as a whole.

CONCLUSIONS

NLP can correctly identify screening colonoscopies, accurately identify adenomas and SSAs in a pathology database, and provide real-time quality metrics for colonoscopy.

Physician report cards and implementing standards of practice are both significantly associated with improved screening colonoscopy quality

OBJECTIVES

Adenoma-detection rates (ADRs) are associated with decreased interval colorectal cancer (CRC) rates and CRC mortality; quality improvement strategies focus on improving physician ADRs. The objective of this study was to examine the sequential effect of physician report cards and implementing institutional standards of practice (SOP) on ADRs.

METHODS

Colonoscopy metrics were prospectively evaluated at a single academic medical center over a 23-month period (November 2012 to October 2014). ADRs were evaluated over three time periods-Period 1: Before initial report card distribution or SOP (November 2012 to March 2013); Period 2: After individualized report card distribution detailing physician and institutional ADRs (April 2013 to March 2014); Period 3: After second report card and SOP implementation (April 2014 to October 2014). The SOP required physicians to have a minimum 5-min withdrawal time in normal colonoscopies (WT) and an ADR minimum of 20%; those who did not meet benchmarks would require further training or endoscopy block time alterations. Only endoscopists averaging >15 colonoscopies/month were included in this analysis.

RESULTS

Twenty endoscopists met the inclusion criteria, performing 12,894 screening colonoscopies over the 23-month period. Following report card distribution, physician ADRs increased by 3% (P<0.001). SOP implementation resulted in a further significant increase in mean physician ADR of 8% (P<0.0001). Overall, mean ADR increased by 11% from Period 1 to Period 3 (P<0.0001). All physicians met the minimum 20% ADR benchmark during Period 3. Although ADRs significantly correlated with WT overall (r=0.45; 95% CI 0.01, 0.75; P=0.04), mean WT did not significantly increase from Period 1 to Period 3.

CONCLUSIONS

Our data suggest that distributing colonoscopy quality report cards resulted in a significant ADR improvement. Further, we report evidence that implementing SOP significantly improved ADRs beyond report card distribution and resulted in all endoscopists meeting minimum benchmarks. This suggests that report cards and SOPs may have an additive effect in improving colonoscopy quality, and their implementation in endoscopy labs should be encouraged.

Trends in Adenoma Detection Rates During the First 10 Years of the German Screening Colonoscopy Program

BACKGROUND & AIMS

The adenoma detection rate (ADR) is an important quality indicator of screening colonoscopy; it is inversely associated with risk of interval cancers and colorectal cancer mortality. We assessed trends in the ADR in the first 10 years of the German screening colonoscopy program.

METHODS

We calculated age-adjusted and age-specific detection rates of nonadvanced adenomas and advanced adenomas for each calendar year based on 4.4 million screening colonoscopies conducted from 2003 through 2012 and reported to the German screening colonoscopy registry.

RESULTS

We observed a steady and strong increase in rate of detection of nonadvanced adenomas in both sexes and all age groups. Age-adjusted rates of detection of nonadvanced adenomas increased from 13.3% to 22.3% among men and from 8.4% to 14.9% among women. This increase was mostly due to an increase in detection rates of adenomas <0.5 cm, and it is partly explained by an innovation effect (higher ADRs among incoming colonoscopists than among leaving colonoscopists, and relatively stable ADRs among continuing colonoscopists). Only modest increases were observed in detection rates of advanced adenomas (from 7.4% to 9.0% among men, and from 4.4% to 5.2% among women) and colorectal cancer. In 2012, overall ADR reached 31.3% and 20.1% in men and women, respectively.

CONCLUSIONS

We observed a strong increase in ADRs from 2003 through 2012 in Germany. Although we cannot exclude the effects of secular trends in colorectal neoplasm prevalence, the observed increase was mainly the result of a steady increase in detection of nonadvanced adenomas (especially adenomas <0.5 cm). Further research should address potential implications for defining screening and surveillance intervals.

Colonoscopy quality assessment

Colonoscopy is the cornerstone of colorectal cancer screening programs. There is significant variability in the quality of colonoscopy between endoscopists. Colonoscopy quality assessment tracks various metrics to improve the effectiveness of colonoscopy, aiming at reducing the incidence and mortality from colorectal cancer. Adenoma detection rate is the prime metric, because it is associated with the risk of interval cancer. Implementing processes to measure and improve the adenoma detection rate is essential to improve the quality of colonoscopy.

Identification of physicians with unusual performance in screening colonoscopy databases: a Bayesian approach

BACKGROUND

The adenoma detection rate (ADR) is an important surrogate measure of performance quality for screening colonoscopies.

OBJECTIVE

To demonstrate how physicians with unusual performance concerning the adenoma detection rate may be identified in screening colonoscopy databases.

DESIGN

Bayesian random-effects modeling and Winsorization of potential outliers were applied to develop a robust model for the majority of providers. Divergence was assessed with adjustment for multiple testing. The steps in the analysis were visualized by using funnel plots. Additionally, minimum requirements for the number of colonoscopies with 1 or more detected adenomas were derived.

SETTING

Data from 422 physicians offering screening colonoscopy and participating in a quality assurance program in Bavaria, Germany, were used.

PATIENTS

A total of 69,738 asymptomatic individuals 55 to 79 years of age.

INTERVENTION

Screening colonoscopy.

MAIN OUTCOME MEASUREMENTS

Physician-specific ADRs.

RESULTS

The overall ADR in the sample was 26%. From an initial model, 62 physicians (15%) were identified as potential outliers. A model with normally distributed random effects was then chosen as the robust null model. Of the potential outliers, 10 (16%) were confirmed as physicians with unusual performance at a false discovery rate of 5%. For all of them, the observed ADR was lower than expected, and together they accounted for 1.4% of all included colonoscopies.

LIMITATIONS

Analysis of routine data.

CONCLUSION

The applied statistical approach appears suitable to identify unusual performance in screening colonoscopy databases. Its application may help to evaluate and improve the quality of colonoscopy in population-based colorectal cancer screening programs.

Good is better than excellent: bowel preparation quality and adenoma detection rates

BACKGROUND

Inadequate bowel cleansing is associated with missed lesions, yet whether polyp and adenoma detection rates (PDR, ADR) increase at the highest levels of bowel cleanliness is unknown.

OBJECTIVE

To evaluate the association between bowel preparation quality by using the Boston Bowel Preparation Scale (BBPS) and PDR and ADR among colonoscopies with adequate preparation.

DESIGN

Cross-sectional analysis.

SETTING

Boston Medical Center (BMC) and the Clinical Outcomes Research Initiative (CORI).

PATIENTS

Average-risk ambulatory patients attending screening colonoscopy with adequate bowel preparation defined as BBPS score ≥6.

INTERVENTIONS

Colonoscopy.

MAIN OUTCOME MEASUREMENTS

PDR and ADR stratified by BBPS score.

RESULTS

Among the 3713 colonoscopies at BMC performed by 19 endoscopists, the PDR, ADR, and advanced ADR were 49.8%, 37.7%, and 6.0%, respectively. Among the 5532 colonoscopies in CORI performed by 85 endoscopists at 41 different sites, the PDR was 44.5%, and the PDR for polyps >9 mm (surrogate for advanced ADR) was 6.2%. The PDR associated with total BBPS scores of 6, 7, and 8 were higher than those associated with a BBPS score of 9 at BMC (BBPS 6, 51%; BBPS 7, 53%; BBPS 8, 52% vs BBPS 9, 46%; P = .002) and CORI (BBPS 6, 51%; BBPS 7, 48%; BBPS 8, 45% vs BBPS 9, 40%; P < .0001). This trend persisted after we adjusted for age, sex, and race and/or ethnicity and was observed for ADR and advanced ADR. PDR was higher among good compared with excellent preparations at BMC (odds ratio [OR] 1.3; 95% confidence interval [CI], 1.0-1.5) and CORI (OR 4.7; 95% CI, 3.1-7.1).

LIMITATIONS

Retrospective study.

CONCLUSION

The PDR and ADR decreased at the highest levels of bowel cleanliness. Endoscopists finding a pristine bowel preparation should avoid a sense of overconfidence for polyp detection during the inspection phase of screening colonoscopy and still perform a careful evaluation for polyps. Furthermore, endoscopists expending additional effort to maximize cleansing of the bowel should never sacrifice on their inspection technique or inspection time.