All right, so now we're going to start drilling down to the QI and safety issues I outlined. We're going to begin with Dr. T.R. Levin, who's going to address the quality indicators for colonoscopy. And I sort of gave you a taste of that, but I intentionally held back because he's such an expert in this. Dr. Levin is the Interim Associate Director for Cancer Research at Kaiser Permanente Northern California Division of Research, and he's a practicing gastroenterologist at the Walnut Creek Medical Center. He's an Associate Professor of the Health Systems Science at Kaiser Permanente School of Medicine and the Clinical Lead for Co-Arterial Cancer Screening for the Permanente Medical Group. He currently serves as the member of the ASGE Quality Assurance and Endoscopy Committee, and he really is a, you know, world leader in this in terms of both research and practice, so we're really lucky to have him here. And T.R., the audience is yours. Thanks so much, Raj. I really appreciated your talk, and I think it provides a really nice lead-in to what I'm going to be covering today. First of all, let me see if I, yeah, so just a little disclosures. I have had some research funding from one biotech company, Freenom, Inc. We're going to be discussing the quality indicators for colonoscopy today, want to demonstrate the practical value of measurement of colonoscopy quality, summarize some updated colonoscopy surveillance recommendations, and also some newer data around ADR in particular. And then we'll discuss some challenges in colonoscopy quality measurement, and Raj kind of nicely alluded to those. So and this kind of dovetails nicely with the outline of the talk today. So we are all about diversity, equity, and inclusion here at ASGE, and just want to emphasize that high-quality colonoscopy is really an expectation for all patients, from our poorest patients to our most wealthy, and we should be doing the same quality of colonoscopy for everyone. And just point out that the benchmark for adenoma detection is a little different for men and women. So why does it matter that we're measuring quality in colonoscopy? Obviously colonoscopy is probably the most commonly performed endoscopic procedure in the United States. Meaning colonoscopy is arguably the most valuable procedure that we do, because it's definitely associated with reducing cancer incidence and mortality. We know that there's variable performance of endoscopists, and this variation has an impact on effectiveness. So what we want to do today is define the elements of high-quality endoscopy, and also develop evidence-based quality measures and indicators, which is definitely a high priority for ASGE and all the GI specialty societies. So one of the key targets for colonoscopy quality is this phenomenon of post-colonoscopy colorectal cancer. In years past, we referred to them as interval cancers. These are cancers that occur kind of within three years, six months to three years after a quote-unquote negative colonoscopy, or a colonoscopy where cancer was not found. And there's a big range. You can have up to eight or almost 9% of patients will have interval cancers among the cancers that are found. So these were thought to be missed on the initial colonoscopy. Why would they occur? I mean, there are probably some other explanations besides just missing them. There could be biological variation in how the tumors are growing. Some tumors grow faster, some grow slower. There could have been polyps that were removed, but not removed completely. They definitely exist. We know there are technical limitations in detection. There's mucosa that was maybe hidden by some puddle of fluid or stool. Flat adenomas may be difficult to detect. The bowel preparation is inadequate, and that can limit a complete exam. And also the examination technique of the colonoscopist. So Doug Robertson pulled together several, eight large colonoscopy studies and really discovered that the majority of these interval cancers were because they were probably missed. Another nearly 20% were likely from an incomplete removal of an existing polyp that was definitely seen but not completely removed. So here's a poll question as we enter into the area of the quality indicators for colonoscopy. So those of you who are familiar with the ASGE ACG quality indicators document know the answer to this, but which of the following are not priority quality indicators for colonoscopy? And you can choose, I'll give you a hint, you can choose up to two of these. The frequency of documentation of an appropriate indication, frequency of appropriate surveillance recommendations, frequency with which colonoscopy bowel preparation is deemed adequate, frequency of sickle intubation, and frequency with which adenomas are detected in asymptomatic average risk individuals. So I'm unable to vote, as Raj pointed out, but I look forward to seeing what everyone else, how everyone else votes. No penalties for wrong answers, folks. Just a poll. And there's no penalties for guessing. It's not like the SAT. Yeah, exactly. So the responses are coming in. Thank you. This is a good one, though. You gave him a good hint. You gave him some help there. I think the not ones are always tricky. You always have to pause. Okay, we'll keep this open for a few more seconds, folks. Let's get a couple more responses in. Make your final selections. And I will share the responses now. I think you guys are onto the right track. We'll give you the answer in just a minute. All right. So this is the ASGE, the existing ASGE quality indicators document for all GI endoscopic procedures. Joe is leading work for our organization, along with Nick Shaheen from the ACG, in updating all of these quality indicators. So if you come to this talk next year, the answers might be slightly different than what they are now, but this is our existing document. So for all GI procedures, we want to make sure we perform the procedure for an indication that is included in a published standard list of appropriate indications, and that we document the indication. If prophylactic antibiotics are needed, they should be administered appropriately, and the frequency with which management of antithrombotic therapy is formulated and documented before the procedure. These are ones that are definitely relevant for colonoscopy, and these are priority indicators also for all GI procedures. If we look at the priority quality indicators for colonoscopy, the number one is adenoma detection rate among screening colonoscopies. Number two is the frequency with which colonoscopies follow recommended surveillance intervals, and particularly a 10-year interval between screening colonoscopies. For average risk patients, that's very important. And then the frequency of visualizations of the CECM, with notation of landmarks and photo documentation of the landmarks, documented with every procedure. So those are our three priority indicators for colonoscopy, and just with a caveat that this may change in the next year or so. So just to remind you of the quality indicators, ADR, appropriate surveillance, and sequel intubation rate. If you look at, before you're doing the procedure, the quality indicators you want to look at, you definitely want to make sure that you have the proper indication. You definitely want to make sure that you have informed consent obtained, including specific discussions of risks associated with colonoscopy fully documented, frequency with which colonoscopies follow recommended post-polypectomy and post-cancer resection intervals, and also that 10-year interval between screening colonoscopies. And then the frequency with which ulcerative colitis and Crohn's colitis surveillance is recommended within proper intervals. So let's talk a little bit about surveillance intervals. And I think these have become pretty well accepted at this point, but see it's been out for a few years, but we'll review it. So when should you recommend surveillance in an average risk individual found to have one 8-millimeter adenoma and one 9-millimeter adenoma on high-quality colonoscopy? So is that 3 years, 5 years, 5 to 10, 7 to 10, or 10 to 15 years? We'll let everyone vote while I try and clear my throat for a minute. Well, everyone's very engaged. The votes are rolling in much faster now. We'll keep this open just for another couple seconds. We just hit 7 o'clock here on the West Coast, so I think people are starting to wake up a little bit. We do appreciate our West Coast attendees and faculty, and we'll share the results. Yeah, so 5 years actually would have been the old guideline, and 7 to 10, it actually would have been 5 to 10 on the old guideline, but nobody chose that one. 7 to 10 is the current guideline, and we'll go through that in a little more detail. So let me click on that. Now, what if you had one 10-millimeter adenoma on a high-quality colonoscopy? Let's hear about that one. Go ahead and vote. This one I think people might be a little more familiar with, because this one did not change on the last guideline. Update. You're always good at giving hints. Okay. Keep this open for a second more. We're not trying to trick people too hard. Yeah, yeah. Let's see where people are before I start yammering on here for a minute. So 3 years was the right answer, and if I had said 12 millimeters, maybe more people would have gotten that, but it's 10 millimeters or greater. It becomes a 3-year interval, so we'll go through some of the guideline stuff now. Yeah, so as demonstrated by just the variation in knowledge among the course attendees, if you look in, this is a little bit of an old data from the prostate, lung, colon, and ovarian cancer screening study where they looked at what kind of follow-up people were having. The first thing is that 26% of people with no adenomas have another colonoscopy within 5 years. So this is old data. Hopefully the numbers have improved a little bit, but definitely people were getting surveillance probably more often than they needed, at least back in 2010. But the other thing that's also worrisome potentially is that only 58% of those who had advanced adenomas had another colonoscopy within 5 years. And remember that the guidelines call for 3-year surveillance for advanced adenomas. This may reflect a lot of things. It may reflect people having symptoms and coming in early for a colonoscopy. It may reflect people declining to do a colonoscopy within the time interval that they're recommended surveillance. But probably most often it reflects just a lack of a systematized approach where you have a systematic way of identifying who's due for a colonoscopy and reaching them effectively and getting them in for their procedure kind of in a timely way. And this has all been kind of completely exacerbated by the COVID pandemic where many of us developed backlogs and are just really keeping up with symptomatic patients and people with follow-up to a non-invasive screening test like a FIT or a Cologuard and getting those patients in and maybe not getting in our low-risk surveillance patients as much. And we're all kind of feeling that, I think, almost everywhere. So remember that the appropriate recommendation for timing of the next colonoscopy with the ASGE recommendation of greater than 90%. Doing colonoscopy more often or less often than the appropriate surveillance intervals is not cost-effective, increases the risk of the procedure if you're doing it sooner. It's considered an inappropriate indication. The one thing that has been noted is that non-gastroenterologists are more likely to use shorter intervals. And definitely measuring the intervals, it's an important quality measure for everyone who's practicing colonoscopy. So let's get to the new guidelines that Sameer Gupta put together just a couple of years ago. Just to walk you through this flow sheet, which I think is really useful to keep in a prominent location wherever you are reviewing your colonoscopy pathology. Even though I give the talk and I've participated in some of the research, sometimes I need to just take a moment and make sure I'm doing the right thing by checking this flow sheet when I get my pathology back, just to make sure I'm doing it right. So the first thing, it starts with high-quality colonoscopy. Make sure it's complete to the cecum. You got an adequate bowel prep to detect polyps that were greater than five millimeters. The colonoscopist has an adequate adenoma detection rate, which according to current quality indicators is 25% for all procedures. And then complete resection, complete polyp resection, that you're confident that that happened. So if you're confident of all those things, then the 10-year intervals for people with normal colonoscopies, or for people who have hyperplastic polyps, primarily in the rectum and sigmoid, if there were fewer than 20 of them, and they were smaller than 10 millimeters. Okay, so the seven to 10-year interval is primarily for that low-risk adenoma category, those with one to two adenomas that were less than 10 millimeters in size. We go to five to 10 years for the sessile serrated polyps, one to two, less than 10. In reality, the risk of those two lesions is probably not that much different. The slightly tighter follow-up for SSPs is primarily because those are a little harder to see, and also a little harder to be sure that you got a complete resection on those polyps. So that's why we're just hedging a little bit by going five to 10 instead of seven to 10 on those polyps. Three to five-year interval for people with three to four adenomas less than 10 millimeters. So this is a change because it used to be the three to four adenomas were considered kind of automatically three years, and then also the three to four SSPs less than 10 millimeters, and then hyperplastic polyps greater than or equal to 10 millimeters, either probably anywhere in the colon, but particularly concerning are the hyperplastic polyps that are found in the proximal colon, because that may reflect pathologist variation in recognizing SSPs. So we tend to treat proximal hyperplastic polyps as kind of similar or identical to CES ulcerated polyps. And then we get to the more high-risk findings. This is a three-year follow-up. Five to 10 adenomas, five to 10 SSPs of any size, an adenoma or SSP that is greater than or equal to 10 millimeters, an adenoma with villus or tubular villus histology and or high-grade dysplasia, any SSP that has dysplasia. Most SSPs do not have dysplasia. And then a rare finding that couldn't be small, but it's definitely worrisome when it's found, the quote unquote traditional serrated adenoma. And then if you have more than 10 adenomas, you should bring people back kind of within a year. And the other thing to point out is that if you're resecting something piecemeal, if it's an SSP or an adenoma 20 plus millimeters, and then you should bring those people back within six months or so, just to really be sure that you've gotten a complete resection. It can be very hard with a piecemeal resection to be sure that it's been completely resected. So why do we, why did we extend the interval to seven to 10 years instead of five to 10 years? There's lots of data that there's a similar colorectal cancer risk in people with one to two small tubular adenomas compared to those who have a normal colonoscopy. There's also a lower colorectal cancer risk compared to the general population. So these are really low risk lesions that look very similar in their natural history compared to people who don't have any adenomas at all. We definitely, in the most recent guideline, they've reinforced the importance of surveillance colonoscopy in three years among those with advanced adenomas because of the increased colorectal cancer risk among those patients compared to either those with a normal colonoscopy or to the general population. The three to five year interval for patients with three to four adenomas is because this is likely a very low risk group, but the evidence base could be a little stronger. So this was kind of a change in practice for sure. And then serrated polyps. There's growing body of evidence that patients with large serrated polyps are definitely at increased risk for metachronous large serrated polyps, as well as CRC on follow-up. So when they get larger, we definitely want to follow those a little more closely. Smaller ones, it's not entirely clear that those are at as much of an increased risk. So this is another way of looking at the same information where you can just, but also thinking about in terms of when you do a second surveillance after you've done a first, people come back for their second colonoscopy. So you really want to look back to the baseline finding, look at the recommended interval, which was for their first colonoscopy, and then think about the findings at the first surveillance. And does that change? So one thing is that the one to two tubular adenoma group, remember this is generally kind of a low risk group. If they have either a normal colonoscopy or one to two small tubular adenomas on their follow-up, they'll stick with the seven to ten or ten year surveillance interval because they really seem to be low risk. But then you start reacting to the findings on the first surveillance and do the surveillance interval based on those findings. The three to four tubular adenomas, remember this is a three to five year group, but we think it's generally like a low-risk group, but just not completely satisfied with the information. Then if it's normal, you can go 10 years in that group. If they have one to two smalls, you can treat them as if it was one to two small tubular adenomas, and then for the other findings, just react according to the way you would for those findings. Oops, let me go back. The last group is the ones who had a high-risk lesion on their initial colonoscopy. They tend to have a five-year interval that will follow them through even if their subsequent colonoscopies are normal. Raj did a nice job helping us think about who's getting different follow-up and also how to make sure that you're really doing the best practice for colonoscopy. The best practices for colonoscopy are definitely to avoid late surveillance among high-risk patients and also to avoid overuse of surveillance among low-risk patients. That's really what we're aiming for with this high-quality colonoscopy practice. Now we'll talk a little bit about some of the intra-procedure quality indicators. I'll talk about bowel prep a little later today, but we'll talk some more about cecal intubation and also adenoma detection. So cecal intubation, you didn't get to the cecum unless you documented that you got to the cecum. So you want to be able to see the ileocecal valve, and you want to be able to locate the appendiceal orifice and take a picture of those. Photo documentation is mandatory. We would expect people to get to the cecum in 90% of all examinations, 95% of screening exams. Exceptions for poor prep, severe colitis, you don't want to push through severe colitis, and then indication of the therapeutic intervention distal to the cecum. So if you're doing some kind of large polyp removal, for example, or dilation of a stricture or something like that, you may not necessarily need to get to the cecum on that exam, but that will affect your surveillance intervals, whether you actually got to the cecum. Definitely variation among endoscopists in terms of cecal intubation, and this is definitely associated with post-colonoscopy colorectal cancer as well. This has been documented. This was documented in Ontario, but it's been documented in other settings as well. A couple of things to say about adenoma detection rate. Eden always reminds me to tell everyone that this should be the frequency with which adenomas are detected in asymptomatic average risk individuals over age of 50 undergoing screening colonoscopy. So again, these are based on 2015 quality indicators. I think we'll need to look at in the next iteration of this quality indicators, what's the impact of being 45 and having a colonoscopy, and also whether we might consider all comers for colonoscopy, but currently diagnostic and surveillance colonoscopies are excluded from the denominator. This is the single most important quality measure we have in colonoscopy. We were talking before about process measures versus outcome measures. This is a process measure, but it's directly correlated with colorectal cancer incidents. So remember the targets, greater than or equal to 25% overall, greater than or equal to 20% in women, 30% in men. The rationale starts with some work that was done in Poland by Michael Kaminski. And there was a clear difference in post-colonoscopy or interval cancers between the colonoscopists who were greater than or equal to 20% compared to those who had lower ADRs. Doug Corley worked on this with Kaiser data over like a 10 year period, Kaiser Permanente in California. And he demonstrated that with each 1% increase in the ADR was associated with a 3% decrease in the risk of post-colonoscopy colorectal cancer. And if you look, there's like a 50% improvement in outcomes by moving from the lowest quintile to the highest quintile in terms of the hazard ratio for colonoscopy. That's almost the effectiveness of doing colonoscopy itself, that you can make that big a difference between the variation in endoscopists. The good news is that this can be improved. Again, there's also increased ADRs associated with decreasing of fatal cancer. Every 1% increase in ADR was associated with a 5% decrease in the risk of fatal cancer. So how can you improve your ADR? Well, one way is to work on your withdrawal time. And the QI target is to document your withdrawal time greater than 98% of the time. The target is an average of greater than or equal to six minutes. In many other studies, six minute withdrawal times seem to separate low and high level detectors. And there was a correlation between interval colorectal cancer and the withdrawal times that were shorter, that averaged shorter than six minutes. And the primary value as a quality metric is in correcting low performers. So if you have someone who's a low performer on ADR, the first place to look is their withdrawal time. And the first thing to do is tell them to slow down. There's a lot more you can do, but that's kind of the way in. Definitely the withdrawal time as demonstrated in this paper from the New England Journal a long time ago now, 2006, showed that withdrawal time predicts the number of adenomas that were found. And that was the basis really for the six minute cut point, because you can see there's a big drop off below six or seven minutes in this graph. Longer withdrawal time associated with fewer interval cancers. This is just independent of the adenoma detection rate. This is some work that Asma Shaukat presented or published in Gastro in 2015. Post-procedure, we look at complications for sure, and then both perforation and bleeding. And also the recommendation of the appropriate surveillance interval after the colonoscopy. And so the ways to improve the colonoscopy quality. Number one, you should measure it, and you should feed it back to the endoscopist in your practice. This is the first thing. And it could be a simple report card, adenoma detection rate. If possible, separating out proximal adenoma detection, because that does seem to be a differentiator, as well as CEQA intubation rate. That's also important if you can find that variation. The good news is you can train people and they can improve their ADR through training. The first step is feedback and education. And definitely you can see a change from before the feedback and education to after in terms of their ADRs over time. Even higher detectors, at least those above the benchmarks, could detect even more. And there's lots of devices you can stick on the end of your scope that are part of the scope that may help by flattening out the folds, making it easier to see behind the folds. As you can see in the lower right there, there's a little polyp kind of hiding on the back side of a fold. As you pull that device through, it'll flatten the fold out, make it a little easier to see. These have their biggest value primarily for load detectors. And it may not have to be affixed to the scope all the time for those folks, just enough to kind of improve their identification or awareness that there are polyps kind of hiding behind those folds. A lot of times we don't know what we can't see until someone shows it to us. So using these different devices can help us identify that there are things behind the folds. And also you could also retroflex, particularly in the right colon, another important step. Raj kind of laid out a nice framework for us last year in gastro and some of the keys to high quality colonoscopy. And we'll definitely be talking more about preps, but split dosing, high definition scopes, second look in the right colon with a retroflex scope, cold sneering for polyps under 10 millimeters, not sending patients to surgery for complex polyps if they're benign, but working with people who can do endoscopic mucosal resection, providing good documentation, and he nicely summarized the surveillance intervals based on the newest recommendations from the multi-society task force. So this is really a multi-component process, reporting back to your endoscopists, educational interventions. I could have some more to say about that in a little while, definitely improving your technique and using the best technology. And these are kind of tiers of improved colonoscopy. You know, you start off with poor colonoscopy quality, and then you can move up to variable or adequate. And I bet that most people in the audience are kind of in the adequate to optimal colonoscopy quality. But the ways to really optimize your quality, make sure people are monitoring and optimizing their polyp detection, optimizing care for patients with large polyps, making sure your procedure documentation is good and monitored for adverse events, and then improving the bowel preparation, improve the polyp detection for all providers, and the interventions to improve polypectomy practices. So make sure you're really practicing the peak of the best practices for polypectomy. And if you want to get to tier one, and this is really the ASGE quality goals, adequate bowel preparation greater than 90% of the time, using split dose, measuring withdrawal time, measuring ADR, meeting ADR benchmarks, interventions to improve polyp detection for load detectors that could be slowing down, could be some targeted training, or potentially with use of devices, making sure that you're meeting the goals for procedure documentation, and then adhering to surveillance recommendations. There are tools coming to help us. Number one, this is the GI Genius, the device sold by one of the vendors, Medtronic. This will help us find primarily small polyps by using artificial intelligence to kind of flag these lesions. And you can definitely find more of them. And it can reduce endoscopist fatigue because you're not constantly scanning. The machine's kind of helping you a little bit. So these are something to look out for. At this stage, it's not clear that it's making a big difference in terms of outcomes in terms of cancer, interval colorectal cancer, but I think it could definitely improve the accuracy. And many endoscopy units are using this as kind of a quality advertisement, saying we're practicing state-of-the-art care. I don't know that we've really seen this completely change outcomes, but definitely something worth keeping an eye on. And I think more things are coming. This is just for detecting adenomas. Kind of the next stage is when the AI will actually help us make a diagnosis and help us understand which polyps we might be able to safely leave in place versus those that we need to remove. We definitely know that there's variation in how often quality metrics are measured. They're definitely not measured universally. And I did want to highlight this one new study that just came out this year from some folks I work with, looking at, okay, is there a threshold above which improving ADR is not really improving post-colonoscopy colorectal cancer? And it's still kind of early days in this, but I think we generally recognize that the 25% benchmark, which we demonstrated by this kind of dark blue or dark blue lineup at the second from the top, or the 25% to 29% group, they still have a relatively higher interval colorectal cancer rate compared to people who are kind of below this line, which is these are 30%, 35%, and 40%, and even up to, there are some people with ADRs above 50%. And so it's likely that 25% will not stay as the benchmark, but stay tuned, more to come on this. There's definitely challenges. Raj kind of alluded to this. One is that we focus primarily on screening colonoscopy. It can be hard to tease those out exactly. And depending on the size of your practice, you may have more screening colonoscopy, you might have less. There may not be quite enough exams in the screening category to get a really precise estimate of what your outcomes are. So Tanya Kaltenbach and others have proposed using all comers for measuring ADR. And there's definitely a correlation between the screening ADR, other ADRs and the overall ADR by endoscopists. But what we don't have right now is a clear, good benchmark for kind of the all comer colonoscopy and what should the ADR target be for those. And by way of example, this was a recent paper just came out this month in the Annals of Internal Medicine from the Netherlands. And these are people who had a fit and then went ahead and had colonoscopy. And you can see there are some folks with, excuse me, some folks with ADRs after a fit as high as 70%, 60 to 70%. And you can see that the higher your ADR is on these fit positive colonoscopies, the lower the incidence or number of interval post colonoscopy colorectal cancers. So the sky's the limit really on some of these measures. So if you have a lot of fit positives in your practice, you know, 25% ADR benchmark is not going to fly. I think you probably would be in the 60 to 65% range for as a benchmark in this category. I think Raj is going to talk a little bit more about automation for quality measures. And I think that would definitely help. It's a very manual process right now for most groups. We currently intentionally don't include serrated polyps in the quality measure for ADR primarily because there's variation among pathologists and how well those are recognized. And that can make a big difference. It definitely emphasizes the detection of small lesions rather than the large adenomas, which are the ones that are really predict the risk of colorectal cancer. It also might encourage a one and done approach, which some people are worried about where you find the one polyp and then you just kind of zip along. And she's like, well, I found my one adenoma, so I guess I'm good. There's people that promoted a adenomas per colonoscopy or APC measure. That is intriguing, not as well correlated with interval colorectal cancer, at least based on current data. The manual review process for indication, family history, bowel prep quality, depth of insertion, to measure SQL intubation. If you have an automated report generator, hopefully there's a field for SQL intubation, you can just extract that data. But understanding what the findings were and whether the recommendation is appropriate for surveillance requires linkage to the pathology results. And you can't do it just from a procedure note. You've got to have linkage with pathology data. To say that automated systems are feasible primarily for SQL intubation with photo documentation, you might be able to use computer imaging, for example. And one approach to addressing this issue, if you're looking for photo documentation, would be to do a random sample with some auditing. Still, measuring this, despite all these challenges, measuring colonoscopy quality is definitely a standard of care. Some groups have required, some payers have required their endoscopists to publicly report their ADR. I think Raj was kind of alluding to that earlier. Definitely, people have an expectation as more awareness has arisen about how important ADR is in distinguishing, quote unquote, good and bad endoscopists. People are starting to become aware and they're starting to ask questions about it for sure. You definitely should have a workflow and develop workflows to facilitate quality measure, whether it's your GI endoscopy software, auditing of exams for photo documentation, and auditing surveillance recommendations. Just to kind of hit the high points on this one, colonoscopy quality is definitely associated with cancer incidence and mortality. Reporting colonoscopy quality can lead to improved quality, just feeding back to people, letting people know what is important about the exam, what you value, what you measure is what you value, and it's what you can improve. A focus on the priority quality indicators, particularly indication, adenoma detection, sequel intubation, and surveillance recommendations, low-level adenoma detection. I think I've made that point pretty strongly. There are lots of proven interventions to improve ADR. I encourage you to adopt those in your practice. Obviously, you can't improve what you don't measure or you can only improve something if you do measure it. With that, I'll hand it back to the leaders and look forward to the Q&A later in the roundtable. Okay, great. Thank you so much, T.R., for that outstanding overview. To be clear before we move on, from a public health impact point of view, improving quality and colonoscopy is the most important thing we can do as gastroenterologists. That certainly should be a priority in all of our units as the first place to start, for sure. Of course, we do much more than just colonoscopy.

colonoscopy

quality measurement

adenoma detection rate

cecal intubation

surveillance recommendations

interval colorectal cancer

withdrawal time