and endowed Robert Mary Glickman Professor of Medicine and Professor of Population Health at NYU Grossman School of Medicine. I was joking before the course that her accomplishments and her titles are longer than my CV. So Asma, no better person to give this talk on an update on quality indicators of colonoscopy surveillance guidelines and bowel prep. Take it away, Asma. Thank you so much for the kind introduction, Amit. Let's get started. So let's take it right from the top. What are the quality indicators for colonoscopy? And then we'll dig into them throughout the course. These are my financial disclosures. All right. So hopefully everybody that's attending today knows the importance of quality and colonoscopy. But why should you care about quality? Well, there's four parameters that I'm going to submit to you. One, we want to be effective in our practice. And in the context of colonoscopy, we want to be effective at detecting and preventing colon cancer. And we want to reduce these missed or interval cancers, which we'll talk about more. We want to be safe and reduce complications of what we do. Quality is now tied to reimbursement through the MIPS and the APM programs. And as you know, reimbursement is now based on high value practice models. And finally, but not the least to be ignored, is quality is tied to patient satisfaction. Our patients demand it, and hence we must ensure that we have quality and we're transparent about it. As many of you know, CMS has a website called Physician Compare, which essentially is the idea is to put our quality indicators and make them publicly available for anybody that is a Medicare provider. This website hasn't quite been fully developed yet, but it looks like that this is probably going to come in the next few years. So having said that, what quality metrics should we care about? And there's a practice guideline by the ASGE that I highly recommend everybody review. It outlines the quality metrics into three categories. We like to think of them as pre-procedural, intra-procedure, and post-procedure. And the ones that we care about are listed here along with the benchmarks. And just to understand that the quality scale is kind of a continuum and starts pretty much in the pre-procedure area and goes well beyond the post-procedure period. The ones I'm going to talk about briefly in the next few minutes are bowel prep quality and surveillance interval recommendations. And you can see the benchmarks. Bowel prep quality must be adequate and our targets are in 85% or higher of our exams. And then post-procedure in our recommendations, the surveillance interval recommendation should match our guidelines in 90% or higher of the cases. So let's do a deeper dive in these two. I think this audience understands why bowel prep quality is so important. As we're doing our colonoscopies, the last thing we want to see is this. And unfortunately, we do see this and literature suggests in up to 25% of colonoscopies, we see poor prep. And also understanding that bowel prep is a process. There's a lot of events that need to start. It starts with dietary changes, perhaps two to four days before. There might be some medication changes involved such as stopping iron. Then there's just the mental preparation. There's all the logistics of having the prep and then knowing how to take it and well, then the prep itself. And then if any of these break down, the bowel prep may or not be adequate. Bowel prep is important because as we said, it's found to be inadequate despite best effort in 10 to 20% of cases. And we perform over 20 million colonoscopies per year. So that amounts to almost two to 4 million colonoscopies with inadequate bowel prep. And as we know, this has huge impacts on our system, delays in diagnosis of care, wasted endoscopy slots, and repeat procedures which undermine our capacity for colonoscopy. Well, there's other consequences of bowel prep. Intra procedure, it increases our procedure time, results in repeat procedures, and increased cost to both the healthcare system and the patients. And it is associated with lower sequel intubation rate, poor patient and provider experience, and lower detection of adenomas. Also, it pays to get a good colonoscopy prep because as we know, payments are now bundled and the colonoscopy bundle includes the pre-procedure, the procedure, and the post-procedure events. And having inadequate bowel prep truly adds cost to this burden. Now let's review some of the FDA-approved PEG-based agents. These are probably the first line that most endoscopy centers use. I know ours uses go lightly for the vast majority of cases, but there's also smaller volume ones, such as MoviePrep, and then there's even smaller volumes, which is ClenVue. There are other FDA-approved agents also that can be used either as prep or particularly when there's been a failed prep in the past, and they're listed here. Again, there's a lot of options to choose, and there's some warnings to think about, but it's really important to understand who your patient population is for your endoscopy center. And if you practice at multiple locations like I do, for instance, at the VA or at the university or outpatient clinics, you might use different prep solutions depending on the population. Also, a note that there's some non-FDA-approved regimens that are used commonly in practice, such as the Mirelax Gatorade Prep, Magsitrate, or Biscodal. So just understand that these are not FDA-approved, even though they're very widely used, and understand how you might use them in practice. Now, one of the best strategies for prep is using split-dose prep. There's overwhelming data, and without belaboring you with each and every one of these studies, it's sufficient to say that there are multiple meta-analyses summarizing anywhere between 5 and 47 studies that show that using split prep compared to prep the night before results in higher adequate prep, and you can see the percentages there. So one thing, if you're not already doing this, is using split-dose prep for all your bowel preps, or same day, as in same morning prep, particularly for afternoon cases. And this practice is endorsed by all four guidelines. Again, more data that split-dose prep not only increases adequacy of prep, but it results in better detection or higher adenoma detection rate. So we'll be talking about ADRs in the next few talks, and you can understand that just improving the prep at the endoscopy level can improve the ADR itself. The things to consider about the split-dose prep is this concept of runway time, which is that the second dose of the cathartic is taken three to five hours, whatever anesthesia will allow, before the colonoscopy begins. And that's truly what makes the prep so effective. At the patient level, it's well accepted. There's higher compliance, and most patients do report willingness to repeat the split prep. Same day prep, as I mentioned, is a very good option for afternoon cases in particular. And in this scenario, the prep is taken at 6 a.m. So patients don't have to wake up the night before to take even half the cathartic, but at 6 a.m. they can take the full bowel prep, and this is superior to the day prior prep. Again, as long as they finish the last dose of the purgative four to six hours before their colonoscopy. So that runway time is important to understand. And in particular, low-volume AM preps compared to low-volume split dosing is found to be equally efficacious and better tolerated. Now, a few words on diet. Common question our patients always ask is this. So clear liquid versus low fiber. And there's evidence for both. So in certain populations where you know that they have more difficulty with prep, perhaps clear liquids is a better choice. But studies show that low-residue diet works just as well. Where the issue comes is the patient's ability to understand what constitutes low-residue diet, and then if you give them an inch, they take a foot. So, you know, it can kind of snowball from there. But if they can actually understand the low-residue diet, it's perhaps better tolerated and is comparable to giving them just liquid diet instructions. And meta-analysis do support that excessive dietary restrictions are unnecessary, and a low-residue diet for breakfast or lunch compared to a clear liquid, no difference in prep quality, again, if it's followed well. It improves tolerability, greater willingness to repeat the prep, and a mix of split dose same-day PM prior preps, they all work well with a low-residue diet. But the U.S. Multi-Study Task Force says that if we're going to split the dose, we can use low-residue diet or for liquids until the evening day prior to the procedure. So what's included in the low-residue diet menu? Well, so pretty much most things that don't have high fiber. So they can actually have white bread, white rice, again, in moderation, pretzels, yogurt, cottage cheese, and then a lot of things like eggs, bananas, applesauce. So those are all things to consider. Use of water jets also helps. So if we are now in the intra-procedure period, and we are thinking about the need to augment the ability to clean, we have a lot of great tools now. We have, hopefully, everybody in the endoscopy suites has pumps that we routinely use, and they come in different shapes and sizes, but the purpose is all the same. And the latest kid on the block is this new system, which can actually, which is actually a sleeve that can be threaded over the colonoscope and really has a jet action that can even convert inadequate preps into adequate preps and might be desirable, particularly for inpatients or difficult-to-prep patients. So these are all tools available for us during the procedure. So standard recommendations would be use a split-dose four-liter PEG solution prep with the instructions to take the second half of the prep four to six hours prior to start of the procedure. And studies show that the low-volume PEG is non-inferior to the full-volume one-gallon PEG solutions. Consider same-day prep for afternoon cases. Low-residue diet for breakfast and lunch the day before seems to be okay. And there's no need for routine use of adjuncts such as biscodil or dulcolax. And always consider patient factors when you're prescribing preps. And again, the volume and also their side effect profiles. Personalized regimens can improve satisfaction and adherence. And some of the common situations that we hear from patients, nausea, they don't like the taste, the volume's too much, the mental barrier, no day off to prep. There are things that can be done to mitigate all these circumstances. So perhaps have a standard prep for your endoscopy, and then also have a second or a third option for patients that do have certain challenges. So in summary, using both written and oral instructions helps with prep instruction adherence. Split the dose. Consider low-residue diet to improve patient satisfaction. Same-day salvage options are available for inadequate preps. More intense prep for prior inadequate prep or special populations. And if inadequate prep, consider repeating it less than a year. There should be no other interval other than to repeat it next available but within a year. All right. So with that, I'll talk about how to holistically measure quality indicators. And I hope everybody has thought about using report cards or is already using them. This would be interesting to discuss in our discussion. But this is what a sample report card might look like. This is what we use in our center. So I have a blinded endoscopist ID. We do it by quarter. And essentially, we give each endoscopist a report card of how many procedures they did, how many were screening, how many were completed, the ADR, withdrawal time. And very important, we do report number of colonoscopies with inadequate bowel prep. And if that number starts looking large or there's a lot of differences within physicians, then this is something that we discuss at the group level. So report cards like this might be very important. And again, giving it to the individual physician, comparing group averages, looking at it, be identified, then identify the individuals, even going to the step of publishing them on your ASC wall or online might be things to consider. Next, I'm going to pivot to the other very important aspect of quality, which is following adequate follow-up intervals for repeat colonoscopy. In 2020, there was a new guideline from the U.S. Multistudy Task Force. I hope everybody is aware of this change that occurred and what the intervals are. So in terms of definitions, low-risk adenomas is the vast variety of what we find after colonoscopy, which is individuals with one to two small tubular adenomas, meaning smaller than 10 millimeters. And the guidelines definitely have evolved in these two areas. And the change that has been is individuals with one to two small tubular adenomas, we now should be giving them a seven to 10 year surveillance follow recommendation. So, and this has changed from before it used to be three or five years. So, and there's sufficient evidence to make this change. Individuals with three to four adenomas that are smaller than 10 millimeters should be, can be given a three to five year interval. So this has also changed from being three and no more than that. And again, we reviewed a lot of evidence on this because our colonoscopies are higher quality now, we're able to confidently give patients a longer recommendation. How this affects our practice is majority of our patients will fall in these first two categories. So that's where truly the change will take place. Low risk adenomas, again, seven to 10 years instead of five to 10. This is because of accumulating evidence that their risk of colon cancer is similar compared to individuals with a normal colonoscopy. In fact, their risk of colon cancer is even lower than the general population. And that's because the general population tends to be a mixed bag of high risk and low risk. Whereas individuals who've had a high quality colonoscopy and the highest finding is one to two small tubular adenomas, we've kind of earmarked them for individuals that are at low risk for future neoplasia. Again, multiple studies, this is a meta-analysis with eight studies and over 10,000 patients. Again, you can see individuals with low risk adenomas over the next five years had very similar findings to the group that had no adenomas. And again, looking at this in terms of incidence of colon cancer over a 15 year follow-up, you can see in my top graph, the individuals that had no adenoma versus non-advanced small adenomas were very similar in terms of their incidence of colon cancer, whereas individuals with advanced adenomas tended to have a higher incidence. Not only that, their risk of fatal cancer for individuals with low risk adenoma was even lower than the general population compared to individuals with a high risk adenoma. So these kinds of data give us enough confidence that this is truly a low risk group. Now, why did the three-year interval change to five-year for individuals with three to four small adenomas? It's because there's almost this paradox that for individuals that we were finding three to four small adenomas, we were aggressively bringing them at three years. Well, their risk of colon cancer was even further lowered because they were perhaps being brought too often. And multiple studies suggest that individuals with three to four small tubular adenomas do not have the high risk that we worried about in the past. So because of these studies, we actually moved the recommendations to five years for three to four adenomas. Not only that, the guideline also has recommendations on what to do for the next colonoscopy for surveillance. So individuals where we find one to two small tubular adenomas and say we bring them back in seven years, now, if that colonoscopy is normal without any adenomas, they don't come back in another seven years, they can actually come back in 10 years. Similarly, individuals with three to four tubular adenomas that we bring back, say, in three to five years, if their next colonoscopy is normal, then they would actually come back in 10 years after that. So there's very few scenarios in which somebody just stays on that three-year plan or that five-year plan. And that's mainly reserved for individuals with either advanced adenomas or large adenomas, where we would first bring them back in three years and then five years after that. So again, it starts with a high-quality colonoscopy, which hopefully we're covering, and then you can see that the intervals depend on what's found. 10-year for a normal colonoscopy, seven to 10 for one to two adenomas, and then shorter intervals. Now, again, why use seven to 10 instead of a firm recommendation? Because the range is kind of confusing, and a lot of EHRs, it's difficult to program a range in. Well, we wanted to kind of give endoscopists and patients some wiggle room, because some patients and providers might feel more comfortable bringing the patient back at seven years, and some might be in 10 years. Plus, it allows us to kind of make these determinations. Somebody with excellent prep, only two small adenomas, we might give a 10-year pass. However, somebody who had small adenomas in the past and now comes back, and there's only one to two, might be more comfortable going to a seven-year interval instead of a 10. So it kind of gives us some wiggle room. A quick word on serrated polyps. Again, we have little data to understand what their natural history is. Therefore, we took a more cautious approach, and what the data seems to suggest is serrated polyps first aren't as bad of a player as we first thought them to be, and they tend to predispose an individual to have more serrated adenomas, but not so much colon cancer, unless the serrated polyps are large, or they're in the setting of advanced adenomas. So for serrated polyps, our recommendations are that for individuals that have one to two SSPs or a combination of tubular adenomas with at least one SSP, the repeat interval would be five to 10 years and not seven to 10. Again, that's because the data are fairly weak, and we wanted to err on the side of caution. So I'll summarize my take-home points. Surveillance colonoscopy in appropriate individuals is high-value care. There's new evidence that shows one to two small adenomas or SSPs have very similar outcomes to individuals with normal colonoscopies. New follow-up colonoscopy intervals have been lengthened, and particularly for individuals with these low-risk adenomas, surveillance has been extended to seven to 10 years for one to two small adenomas, and three to five years for those with three to four adenomas, and in the future, the surveillance intervals can be lengthened based on the findings of the first surveillance colonoscopy for what the next interval should be. With that, I'll stop. Thank you so much.

quality indicators

colonoscopy

colonoscopy surveillance guidelines

bowel prep

CMS Physician Compare

ASGE practice guideline