We don't have any other questions just yet, so would we like to move to a case study? Maybe the first one for this segment? While they're pulling up case 11, we did just get a question. Why is ADR a good colonoscopy quality metric for now? What is your experiencing with measuring SSADR, so the sessile serrated lesions, and how can you automate these reports? In addition to this, what other QI indicators do you recommend for EGD, EUS, or ERCP? That's a lot of questions in one question, right? So the reason why ADR has been used as a quality metric, because it's been shown to be associated with the reduction in colon cancer itself when people have high ADRs, the percentage of people in those particular endoscopies populations have lower chances of developing colon cancer in the future. And so sessile serrated adenomas in particular have been looked at. I think the problem is, is that if you look nationally, there's a wide variability in pathologist interpretations. Sessile serrated polyps are often used in reporting from pathologists, and it doesn't necessarily mean it's a, quote, has dysplasia in it, because it's technically an adenoma, but the issue is with semantics and nomenclature. And so I don't think that we've become robust enough or accurate enough to develop a widespread system for this, though it is coming down the pike. In regards to how these can be automated, it really depends on your electronic health record and the integration of endoscopy pathology reporting systems. In my own institution, we have issues in Epic in using our pathology, third-party pathology reporting system. Obviously, Beaker, which is a software within Epic, can be used to try to calculate these scores automatically, but we found some errors when we are doing a manual evaluation. And then there are a number of US ERCP EGD quality metrics that have been published by the ASGE. Those have been updated recently. And then, as you probably realize, GI Quick has also provided a lot of these metrics. And in addition, CMS has published the quality metrics that focus on various different metrics in regards to GI in particular. So those are resources that we can provide in the chat if necessary. Sure. The GI Quick has been working great. I mean, it's a great platform. So with the GI Quick, we do keep track of a lot of measures for colonoscopy and EGD. And we also did build another platform, which is the QlikSense, where all the GI Quick data goes to the QlikSense. What we do with the QlikSense is we give all the providers, all 100 providers, with the QlikSense data. And in the QlikSense, we have set up the way that providers get to see their data and all the other providers' data, but the other provider data is being anonymous, which is great. And I feel like the provider loves to look at other providers, and they always are reaching out that how can they do better. So myself and also the GI Quality Directors, we do work closely, and we love GI Quick. I mean, we are looking forward for ERCP now, because we already started keeping track on ERCP post-pancreatitis data. So we're looking forward for GI Quick to go live with ERCP now. And we've gotten another question in, interesting one. Six-minute withdrawal time was more than enough to have excellent ADRs. Now there's a push for eight minutes. Is that really a reasonable move that will significantly affect productivity? So Dr. Eisenberg, would you want to respond to that first? Yeah, so, I mean, I don't know that, you know, if you look in the grand scheme of things that a two-minute difference is actually going to result in significantly reduced efficiency and productivity within the endoscopy unit. I can think of so many other low-hanging fruits, basically, in the endoscopy unit that would probably improve your productivity and efficiency. I don't know how you feel about that, Neil. Yes, I agree. I think it depends how you look at it. If you say, well, two minutes per procedure, say I'm a busy gastroenterologist in private practice, say I do 15 a day, let's just say that's 30 minutes. Well, that's one extra procedure that I could do. So you can kind of piece together the numbers to make a case for impacting productivity. But I think to your point, we also kind of have to sort of maintain the perspective that quality is almost more important, or at least as important, as time. And time does not always mean improved quality. For example, right-sided lesions have been investigated a lot in colonoscopy quality literature and with a time component. So one could argue that even if we stick with a six-minute withdrawal time, but advocate for a second pass in the right colon or retroflection in the right colon, that may also cause increased time during withdrawal and impact productivity as well. So I think maintaining a big-picture perspective in that, yes, there are some endoscopists where more time means better quality, but there are also many endoscopists where that may not necessarily be true. I think it's just important to maintain that perspective and see what works best for you in your practice. This is a physician-nurse leadership team that's at a practice ASC and notices that expenditures for hemoclips in particular has risen five-fold over the past year. They find that in their investigation that two physicians in particular are using hemoclips to close most of their post-polypectomy sites. What suggestions do you have to initiate a GI cost-effectiveness project? What aspects of hemoclip use should be considered? How do clinical care decisions get formulated for each clinical scenario in your unit? And if there's disagreement about a particular accessory use, how do you get these handled and what strategies are available to reach an equitable decision? This kind of goes on some of the things that we talked about a little bit earlier on with supply chain. So I think there are many endoscopy units around the country that have noticed that when there's a particular change in practice, sometimes the pendulum goes to the other side. So what's the reason for why some physicians use hemoclips more than others? And it's often this fear that if they don't close the defect that they're going to have a higher bleeding risk, as one example, or if it's a particularly large polyp that they're trying to reduce the risk that somebody develops a perforation post-procedure. But it's interesting that the data has been changing, that it doesn't necessarily mean one or the other happens. Neil, I think you had experienced this somewhat in your endoscopy unit or having issues like this, right? Yeah. Yeah. It sort of touches on what we were talking about in the last segment with trying to standardize our supply chain with what Dr. Apollini was talking about, and also keeping in mind and respecting endoscopists' individual preferences. I think here, I totally agree with you that it is important to have a data-driven approach, especially from the quality perspective. So in terms of initiating a QI cost-effectiveness project, I think, Gerard, to your point, that would be the first place I would start is what does the data and the literature currently show about hemoclip usage and indications and bleeding risk and delayed perforation risk? And then how can we incorporate that from a cost perspective into our individual unit's practice? And then from there, stratify it further to individual endoscopists, and even compare outcomes data per endoscopist to see if we can reconcile all three of these things. Praveena, how would you go about doing a QI project with this kind of in mind? I'm curious to hear your expertise. For this particular QI project, any QI project has to get approval first. First of all, we do collect the data. Like you said, the data speaks. But once we collect the data, then we present it to the council meeting to see if we should go for it. So for any equipment that needs approval, what we do is there is a product request. It's put in an internal tracker, and the physician will complete the form, and the product request will get presented in the GI Endoscopy Council for approval. And once it gets approved, the request will go to the CBT, which is the Clinical Value Team Council. And if they approve it, then it goes to the local leadership in the regional. And based on their budget, they will see if they can approve that or not. So there's so many processes for us, since we have nine hospitals and four regions. And usually, it's not a problem getting approval once it gets presented in the GI Council, because there is a discussion within all the providers, all the leaders, saying why it needs to be, why they need that. Sounds like a really good approach. Dr. Williams, how would you get these endoscopists to sort of be on the same page in their clinical practice. Say they were very adamant about using their methodology and reporting to their experience and anecdotal outcomes. How would you kind of approach the situation where it looks like you have a couple of outliers here, but you also want to tread lightly in how you approach that? As I said, I use data. I think if someone's using CLIPS, there's data for large defects on the right side. CLIPS maybe are good in terms of preventing post-polypectomy bleeds. And if someone's using CLIPS to close every time they do a post-polypectomy, I just use data to say, this is evidence-based medicine. And again, to your point, I think people can get very defensive about their practice, but showing this is the evidence behind why we're saying what we're saying. I think that's how I would do it, honestly speaking. I love CLIPS myself. And sometimes if you're on the left side and you have a big defect, you feel a bit uncomfortable, but that's not what the data supports. And then what sorts of team members would you sort of incorporate into that conversation? Would you maybe have a one-on-one approach or medical directors and nursing managers? Or how would you kind of go about that? I'm very proponent of one-on-one approaches, specifically if you're... I think we're very protective of our practice and our space. And if I need to give someone some constructive feedback around how they're practicing, I think having a third or fourth party may not be the best way to go. I think the initial meeting should be between you and that individual to have a conversation. And you'll also gauge that person's reaction. And it goes back to what we were saying earlier about active listening. And then based on that interaction, you may then bring in maybe the director of endoscopy or someone else to say, hey, you're using this many CLIPS, and this is how much it's costing the suite. It's not financially, it's not cost effective. But I'm a big proponent of just having one-on-one conversations with people in the beginning, only because I feel like it just makes the environment less tense. And constructive feedback is always hard. And they may think you're attacking them personally when that's not what's happening. And that's why I'm very big about sticking to data. Here's what the data supports. Here's the evidence. This is how many CLIPS you're using on a monthly basis. Here's the cost. It's not cost effective. And I think then have a second conversation, meaning it's not a one-time conversation. It's a follow-up conversation with the stakeholders within the endoscopy unit. But if that first time is going to be with a group of people, they're not going to respond well to it at all. Just my opinion. It's really helpful to have that perspective of having a candid one-on-one conversation and gauging the reaction. I like that. And then perhaps formulating a group-based approach based on that. That's really helpful. Any other thoughts from the panel? Yeah. So the other thing is that somebody had mentioned using a committee to evaluate these things and come up with evidence-based data to support its use or not versus one product versus another. Looking at things from a perspective from supply chain, cost, reimbursement, the financial side, the business side, the reimbursement side. Looking at all of these factors and not just whether or not it reduces complications because that obviously plays a role in the equation overall. And so thinking about if you don't already have one of these committees evaluating these types of products, this is the perfect opportunity for you to initiate a process with your leadership to get one. I'm just going to reiterate, hopefully having GI representation on your value committees and in your supply chain, in your institution can be really helpful. Just wanted to emphasize that point again. I'm going to add one thing. As I mentioned speaking one-on-one, I'm always a good proponent of getting someone else's perspective. If someone's using CLIPS all the time, potentially they may have had bad outcomes in the past or high level of post-polypectomy bleeds. So I don't think it's also important to ask, we noticed you're using an increased amount of CLIPS. Could you give us, let's just suggest this is the indication. Why do you do what you do? Because I think also pointing to the act and not to make it don't make it personal is important, but finding out why. Because if someone's had a complication or has had many complications, that may be feeding that particular behavior. Case 12, using quality metrics to drive improvement. When reviewing your colonoscopy quality metrics, you're pleased to see that the group average ADR is 42%. However, you discover that your most productive physician has an ADR that is 26%. Upon further examination, you note that this same physician has an average withdrawal time of six minutes, while the other physicians average eight to 10 minutes. This physician's metrics meet the current benchmarks. What, if anything, should you do? So this goes back to the question, I think somebody asked earlier on, are we changing the metrics in a way that it was kind of reverse? The most productive physician, instead of doing eight to 10 minutes, has six minutes. Do you penalize him and say, listen, you really need to do eight to 10 minutes because maybe your adenoma detection rate will even be higher and your long-term development of colon cancer in your population will decrease. And so it's a difficult thing, I think, to tread, but as your withdrawal time increases, certainly people's ADR has the potential for increasing. And so, if this physician is very concerned about productivity in terms of RVUs, one of the things that you could potentially point out to this person is that they may be able to detect more polyps, which in turn might increase the RVUs for their particular endoscopy. So for example, if they've got a diminutive polyp that they're removing with a cold biopsy forceps in one area of the colon and a cold snare in another part of the colon, generally that leads to a slightly higher RVU rate associated with that procedure. And so you might be able to convince that person to spend a little bit more time, even though they've met the benchmark for ADR. We have a great question. If you could put the questions in the Q&A, that's always best, but it did come through in the chat. And this person was just asking about, is it the index colonoscopy? If you're doing ADR based on screens, the index, using just the index went away a few years ago. So it was really all screens. And I believe you spoke to this earlier, Dr. Eisenberg, that the newest recommendations are to align with all comer ADR really. Yeah. I think somebody else entered that in the chat to the hosts and panelists asking about some of these questions regarding ADR, as well as how moving to a younger age might affect ADR. Certainly studies have shown that if you move from age 50 to age 45, your ADR is probably going to start to decrease in the populations. If you have a large population between 45 to 50 that you're doing screening on, but that doesn't necessarily mean that that's bad. As Eden alluded to, there is a move to look at ADR for all comers. So whether the patient's getting a colonoscopy for screening, surveillance, or for symptoms such as hematochezia, ADRs will be calculated based on all comers and those numbers are going to change. So somebody just entered into our Q&A. All comer ADR presents a significant time burden on the data collector, especially in private practice slash employed setting. Any comments on that? I think going back to our discussion about having a process that is hopefully hardwired into the EHR, I think that can really be helpful to mitigate some of that. If you already have the interface that can detect ADR between your pathology, even if it's a third-party lab in your home EHR, then hopefully extrapolating that to include all comer ADR would hopefully be not as much of an additional burden to collect, but it could be very useful in providing more data going forward. One of the references Dr. Eisenberg put in the chat was to the updated recommendations from ASG and ACG on quality indicators for colonoscopy. If you have logged into your GI LEAP account, we actually have this in the course module. We have a number of references there for you or papers, guidance documents from ASGE. Dr. Cashal talked about informed consent earlier. We have that in there. We have the updated recommendations for both colonoscopy quality indicators common to all GI endoscopic procedures, and the newest paper in the series is the upper endoscopy paper. Those are all available to you in the GI LEAP module. They're actually all available online at asge.org in the guidelines section, but we have the multi-society reprocessing guideline in there. Anything quality and safety, trust me, I chucked it at you. You have all of that in there. There's also an implementation tips guideline. I worked with the members of the writing team who kindly offered some thoughts on implementation or updating your program to align with the new recommendations. One of the things that the whole writing team wanted to emphasize from Doug Rex to Asma Shaka to Jason Dominance to TR Lemon, everyone on the team was don't stop what you're doing. If you're doing screening ADR, don't stop. Keep doing it and see how you can evolve your program because we are going to be able to leverage technology more and more in our favor. As Praveena can speak to, when you participate in a program like GI QUIC, it's already pulling in all the data elements and it's just reconfiguring the measure logic for you. That's very, very helpful. We have about a minute left. Any final comments on this particular section, Dr. Cashel, before we move into our next segment? Nothing further. I just have to thank the audience and our panel again for such great discussion and looking forward to rounding out the day here next.

quality metrics

adenoma detection rate

sessile serrated lesions

cost-effectiveness

GI QUIC

standardized supply chain