Now it is my pleasure to introduce our course director, Asma Sukhat, and one of the beauties of being a course director, you can choose your topic, right? We didn't have to assign it, and thank God she chose a very pertinent one. I'm looking forward to what is to come. Thank you. Thank you so much, Peter, and thank you all for being here. There is a Twitter poll, so if you haven't settled the debate on cold versus hot versus selection, make sure you go and vote on it. So I'll be talking about another really important aspect of colonoscopy, which is ensuring high quality. What are our indicators, what's coming down the line, and what can we do to be good endoscopists? These are my disclosures. Quality as you know is a continuum. It's not just one thing that we do, but it's the whole cascade of our patient going from the pre-procedure to intra-procedure and post-procedure, and I've highlighted some of the guidelines where some of the metrics for these quality indicators are outlined. And not to say one is less important than the other, but we'll today mostly be concentrating on ADR, since it's our predominant quality indicators, but I'll give you a preview of what else we should be looking at. ADR, as we know, is the number of colonoscopies where one or more adenomas found divided by total number of colonoscopies. Age 50, we're going to provide an update on lowering it to age 45. But the idea is higher ADR translates to a higher quality exam and should lead to fewer missed cancers, more effective colonoscopy. The minimum threshold that has been set is about 25%, and this definition does not include SSAs or SSLs. It's a validated quality indicator, multiple studies. This is perhaps the largest, coming from Kaiser Permanente, where individuals underwent colonoscopy and were followed for another 10 years or another colonoscopy, 139 gastroenterologists included. Everybody's seen these results, compared to endoscopists with ADRs in the lowest quintiles, which were 7 to 19%. Those in quintiles that were higher had a lower risk of a post-colonoscopy cancer in their patient in subsequent follow-up, and each 1% increase in ADR translated to about a 3% decrease in the risk of post-colonoscopy colon cancer. These data were recently updated with larger data from all the Kaiser Permanente systems, including Southern California and Washington, with 43 endoscopy centers and a very large number of endoscopists, 383. You can see large number of patients, again, more recent follow-up. And here, the magic number for them seemed to be about 28%. So endoscopists with, how do I go back, ADR above or below 28% seemed to have a very different risk of post-colonoscopy colon cancer, and then there was also a lower risk of post-colonoscopy cancer-related death for endoscopists with ADR 28% or higher. But in the graphs, you can see that once it starts getting above this 25% or 28%, there isn't a lot of difference, and that could also be, you know, the numbers get smaller, but by and large, it does appear that there seems to be some kind of a threshold right at above 28%. So important number to know about. What else is coming down the line? So ADR, as much as we use it, has limitations. Many know about the one-and-done phenomenon, where we might tend to not look anymore after finding one adenoma because we've kind of satisfied, checked the box. So another indicator, particularly in the context of with AI, is adenomas per colonoscopy. And this is the number of adenomas divided by the total number of colonoscopies. So the idea is it rewards us for finding that second or third polyp and looking more astutely for those additional lesions, which could be equally important. There are data to suggest endoscopists with similar ADR still have different APC numbers, and here you can see this is data we looked at with the endoscopist above that 25% ADR. There's still a difference in their APC. And APC is associated with adenoma misrate on tandem colonoscopy studies, and recent data suggests that it's associated with post-colonoscopy colon cancer. Again, it's a metric used particularly as we start using AI, so this is one that is an important one to look at. So again, now I'm gonna look at polyp detection rate and APC in association with post-colonoscopy colon cancer. So in a pinch, can we use polyp detection rate? The answer seems to be yes. As we know, adenoma detection rate is difficult to calculate, it requires histology, putting that back into the equation, so polyp detection rate is another surrogate, and at least according to this very large study, it tracks very well with post-colonoscopy cancer, such that an ADR of 25% or higher kind of translates to a polyp detection rate of 43% or higher, and an APC of 37% or .37 or higher. And you can see that all of them predict the risk of developing a post-colonoscopy colon cancer. The reason we don't recommend polyp detection rate is because it looks great in retrospective studies, but prospectively, it can be gamed, and there's little hyperplastic rectal polyps that perhaps don't amount to much, but would contribute to the polyp detection rate, but more to come on that. Now I'm gonna turn to sessile serrated polyp detection rate and post-colonoscopy colon cancer. This is one of the questions everybody asks is, are we going to have a metric, and is it associated with post-colonoscopy colon cancer? So we are in the process of revising and updating the quality indicators for colonoscopy, so stay tuned for that. In the meantime, these are some of the data we're looking at. Sessile serrated polyps, or traditional serrated adenomas, larger ones, proximal hyperplastic polyps, were included in this study from GI Quick with five million colonoscopies and 4,000 endoscopies, largely from community practices and all kinds of GI pathology. And where we are as a national average is about 6%, so that's averaged across everybody. And sessile serrated detection rate is associated with post-colonoscopy colon cancer, as was shown in the New Hampshire Colonoscopy Registry, compared to endoscopies with a sessile serrated detection rate less than 3%. There was a reduction in post-colonoscopy cancer when the SSDR was between 3 and 9%, and even a larger reduction when the sessile detection rate was over 9%. So another metric to think about, think about starting to track, see where you are, and trying to see if you meet and exceed these marks. Next I'm going to talk about incomplete resection rate. You heard about polypectomy, and truly the effectiveness of colonoscopy is not just detecting polyps but removing them and removing them completely. So incomplete resection rate is a very important quality metric. We just don't have great ways of measuring and quantifying it. But looking at these studies, so these were 346 polyps removed by 11 gastroenterologists with an incomplete resection rate anywhere between 6 to 22%. So averaged about 10% polyps could be incompletely resected. And as is very intuitive, the incomplete resection rate is higher when we're trying to take out larger polyps, and also for SSLs than tubular adenomas. And we all know the challenges there, difficulty looking at the borders, the margins, and being able to remove them, sometimes difficult position. Does it matter? Yes, it does. It turns out on follow-up surveillance colonoscopy, risk of metacrinous neoplasia, or finding an advanced lesion on the subsequent colonoscopy, was much higher when there was incompletely resected polyps, as much as 52% versus 23% when the resection rates were complete. And again, this was greater for advanced neoplasia. In fact, the incomplete resection rate was the strongest independent risk factor for metacrinous neoplasia. So that's another one, when we think about surveillance intervals, how good was our resection? Something to think about. Next, I'll turn to withdrawal time. And withdrawal time is associated with ADR, but as we saw in a large community practice with 76,000 colonoscopies, even for endoscopies that have that adequate ADR above 25%, the withdrawal time was still associated with risk of interval cancers. So here you can see the risk of interval cancers plotted against physician's withdrawal time. Withdrawal times of less than six minutes had a very high risk of interval cancers. And right about seven to eight minutes seemed to be the sweet spot. Increasing withdrawal time beyond that did not reduce the risk any further. So again, this is where the six to eight minutes comes. This is done retrospectively, prospectively, as we know, withdrawal time is another variable factor that can be gamed. But hopefully, if we do it correctly, it does translate into quality. So now, I've given you several indicators, what are some of the things we could be doing or are doing to improve our quality metrics? So step one starts with measuring them. We can only act on things that we know about. So measuring quality indicators, hopefully everybody in this room has some idea of where they stand. Think about, we use provider report cards in our practice. This is what a report card might look like. Everybody has a blinded ID. And we do this every quarter, but you could do it monthly or at a different frequency. But the idea is, this feedback is very important. And it could be at the individual physician level, group average, individuals de-identified, you may have to identify them. And people, practices have even posted this on their ASC wall for patients and public to see. And in fact, patients are encouraged to ask endoscopists their ADR, was one of the recommendations in our multi-study task force document. And there's practices already doing it. I pulled this from the internet for a practice. And they actually have it on their website. This is where we stand for our colonoscopy completion rate. This is where we stand for our adenoma detection rate. And they plot it against their benchmark and plot it yearly for everybody to see right on their website. They even document their adequate PrEP score. So it turns out, the report cards are not just helpful for helping us understand where we are. They're an intervention themselves. As Charles's group very elegantly showed with the six endoscopists that started to receive quarterly report cards. And you could see their ADR and SQL intubation rates went up by many percentage points just by receiving that feedback. Step two, again, this is something at the endoscopy level, improving our PrEP. So again, understanding what our inadequate PrEP rates are and meeting and exceeding the benchmarks. And some of the key points there are using split dose or same dose PrEP with the idea that the second dose is started four to six hours before the colonoscopy and finished two to four hours, whatever anesthesia allows before the colonoscopy to reduce that runway time between dose of flask cathartic and the procedure. Judge all the PrEP after washing and suctioning and adequate PrEP should be achieved in 85% of all cases and 90% or more of screening colonoscopies. And if the PrEP is inadequate in any segment or any area, including just the cecum, the only recommendation is to bring them back within a year. There's no other tailor made recommendations of two, three, four years that are evidence based. Split dose PrEP itself is an intervention. It increases ADR, not just for all polyps, but even polyps or adenomas smaller than nine millimeters. So that alone can boost an endoscopy unit's ADRs. Step three is knowing what to look for and resect completely. And the two previous speakers framed this very nicely. Polyp recognition is important. When we were training, we only looked for pedunculated or sessile polyps. We now know that they can be flat or even excavated. And again, challenges with recognition, particularly of sessile serrated lesions, which tend to be on the right side where PrEP could be poor. They tend to have a mucus cover, flat, sessile, irregular borders, cloud-like. So you can see the challenges in recognizing and removing. And again, as was discussed, complete resection is imperative. And I point you to the two multi-study task force documents that go over a lot of these techniques. And then finally, if there's still areas of improvement, you can think about these three areas to try to do something about ensuring good withdrawal time. But it's truly that time taken to have good technique. And the hallmarks of a good technique are adequate distention, washing and cleanup, looking behind folds very astutely, and segmental inspection and subjective timing. Because as we can all guess, time alone isn't sufficient in this particular study. They had all the endoscopists have withdrawal times over six minutes, but then they also critiqued endoscopists for their technique. And endoscopists with higher ADR had better technique, having elements that I just mentioned. Other techniques to try at the bedside, retroflexion in the cecum versus routinely reexamining the right colon during withdrawal, changing the patient position. This is harder if you use mostly MAC, but in moderate sedation. The idea is it exposes different areas of the mucosa, allowing you to see things you hadn't before. Having a second observer, a second set of eyes looking at the monitor, a fellow, a tech, or a second observer. And water immersion, water exchange is an excellent technique. These particularly benefit low performers. There's a wide array of accessory devices that can be used. And at least you should try them and see if they work for your practice and how well. Again, I point you to this very thorough review on each of these techniques or devices, but they all work. And they all improve ADRs by anywhere between five to 10 percentage points. How do these all stack up? So compared to just high deaf, white light colonoscopy technique, improving your technique improves ADR. Having enhanced imaging has somewhat of an impact. New scopes do not. So no specific technologies really are superior to another, and it comes down to technique, technique, and technique. And now we're in the era where we now have AI enabled programs, which are now FDA approved. So this is one of the first ones, and now there's two more actually that have been approved. And they all have impressive improvements in ADR and also APC. Again, something to think about and try for your practice if that's the direction you want to go. So in summary, high quality colonoscopy is imperative. There's different things that go into that. Report cards and feedback, educational interventions, such as courses like this, thinking about and improving your technique. And then finally, thinking about what technology you can integrate, including video recording or just feedback for endoscopists. And I point you to this recent review ASGE guideline that we published. And these are interventions to improve ADR. So everything I told you, we've summarized in these next two tables, where we've listed techniques, technology, interventions, and summarized for you how much of an improvement you can expect using these. So I encourage you to look at this publication for additional things that you could be adding to your practice. So in summary, ADR, APC, polyp detection rate, sessile serrated detection rate, and incomplete resection rate are important quality indicators. Most important, measure and track your ADR. And there's many available tools to improve these quality indicators. Thank you so much.

high-quality colonoscopy

adenoma detection rate

polyp detection rate

sessile serrated polyp detection rate

incomplete resection rate