Let's start drilling down into the quality and safety issues that I just outlined. We will begin with Dr. Jason Dominitz, addressing quality indicators for colonoscopy. Dr. Dominitz is the National Director of Gastroenterology for the Veterans Health Administration and Acting Chief of Gastroenterology for the VA Puget Sound, as well as a professor of gastroenterology and medicine at the University of Washington. Dr. Dominitz currently serves as a member of the ASGE Quality Assurance and Endoscopy Committee. Jason, the audience is yours. Why don't we start with a couple of polling questions. The question is, which of the following quality indicators are tracked in your practice? The adenoma detection rate only, CEQA intubation rate only, appropriate surveillance recommendations only, all of the above, ADR and CIR, which is the adenoma detection rate and the CEQA intubation rate only, ADR and surveillance recommendations only, or CIR and surveillance recommendations only? I guess I should have had none of the above as a choice. But I guess if you don't answer, there might be a none of the above and we can talk about that in the discussion. So, please go ahead and pick your responses. Again, CIR is the CEQA intubation rate. So, we're getting a lot of... So, 60% of people do all of the above. That's great. And 20% are doing ADR and CEQA intubation rate. And 10% are doing CEQA intubation rate only or CEQA intubation rate and surveillance recommendations only. So, that's really great. I'm pleasantly surprised that people are doing a lot of measurement of these measures. Let's go on to the second metric, which is the second point question. How are quality indicators reported in your practice? So, you don't track them or QI performance is reviewed by practice leadership only, or the QI performance is shared privately with individual physicians, or the performance metrics are shared with all physicians. In other words, everyone sees everyone's data. And are the QI data published publicly, online, a poster or something along those lines? And if you can pick, there may be multiple things that are true here, but pick the one that you think fits best. Okay. So, everybody's doing some measurement. So, 17%, it's only the practice leadership, but half is sharing the information privately with individual physicians and a quarter is sharing with all physicians. Everyone sees everyone's data. And 8% are sharing publicly. Well, that's really great. Thanks, everyone. We'll talk more about that perhaps during the panel discussion. So, let's move into my talk. And Rahul did a great job setting this up. So, I have no disclosures. Over the next 30 minutes or so, I'm going to outline in a little more detail the colonoscopy quality indicators. Rahul did an excellent job setting up this talk and introduced you to some of those quality indicators. And I'll spend a few minutes talking about how to improve colonoscopy quality and some of the challenges in quality measurement. I will, with regard to DEI, it's really important to keep in mind that, of course, DEI is important. We want all of our patients to have high-quality colonoscopy. And the question that Rahul asked earlier about what is the doctor with the highest ADR in the practice, that highlights a really important DEI issue because women patients tend to prefer women endoscopists and women have less adenomas than men. And so, a woman endoscopist might end up having a lower ADR than a male endoscopist simply because of the population they tend to serve. And so, if my ADR is 40% and my female colleague's ADR is 35%, she may actually be better at detecting adenomas than me, even though her ADR is lower. So, I think it's really important to keep that in mind. And it's one of the reasons why many advocates stratifying ADR reporting by gender. So, we'll touch on that a little bit more in a few minutes. Now, Rahul went over why quality matters. I won't belabor this point. You know, colonoscopy is the most common procedure we perform in the U.S. in gastroenterology. And he outlined the data from Doug Corley showing the impact of colonoscopy on reducing cancer incidence and mortality. And we do see that significant variability in performance, which leads to mortality among our patients, which is really unacceptable for us to have endoscopists with low ADR. We need to do better than that. Our patients deserve high quality endoscopy. And we have ways to improve ADR amongst our colleagues. Post-colonoscopy colorectal cancer or interval cancers are not rare. If you look at all of the cancers that are diagnosed between about three and 9% of those patients had a colonoscopy in the preceding three years that did not detect that cancer. So, between three and 9% of all colon cancers potentially could have been prevented by a higher quality colonoscopy in that three to six to 36 month interval. So, it's possible that the tumors are growing fast and that's why they were not seen on a prior colonoscopy or it's possible there was inconceivable removal of polyps. Psychobol has some excellent data on this. There's also technical limitations in detection. So, the polyp could have been hidden behind a fold or was a flat adenoma that's very hard to see. There may be inadequate bowel preparation. I'll talk more about that in my subsequent talk. But the most important one for us to focus on right now is suboptimal examination technique. And Doug Robertson did this study looking at old colonoscopy studies and found that about half of the interval cancers were thought to be due to misleasions and 19% due to incomplete removal of polyps. So, most of these interval cancers were felt to be potentially preventable by higher quality endoscopy. Now, Rahul mentioned the quality indicators that have been published by the ASGE back in 2015. There is one paper on quality indicators common to all GI procedures. There are 23 quality indicators. I don't have time to discuss those in any kind of detail, but I will focus on the four priority quality indicators common to all endoscopic procedures. The first of which is making sure that the endoscopy is performed for an appropriate indication. Second has to do with the proper use of prophylactic antibiotics. And the third is the frequency with which you're managing the anti-thrombotic therapy is formulated properly and documented before the procedure. Now, let's focus on quality indicators for colonoscopy. We have 15 of these and I will touch on each of these briefly with a little bit more detail on the priority indicators. So, we have four pre-procedure quality indicators, eight intra-procedure and three post-procedure. And three of those are priority indicators, which I think merit the most attention. So, the pre-procedure quality indicators include, of course, the frequency of performing colonoscopy for an appropriate indication. We should not be doing colonoscopy unless we have a good indication for it, makes common sense. The second has to do with appropriate informed consent. And the third is the frequency with which the colonoscopies are done following appropriate surveillance recommendations. I'll come back to this in more detail in a subsequent slide. And the fourth is the frequency with which UC and pro-surveillance is recommended at proper intervals. So, pre-procedure, a lot of these process measures and the priority one, the priority quality indicator is following appropriate surveillance intervals. Unfortunately, we see a lot of underuse and overuse of endoscopy. Overuse is problematic because it exposes patients to risk, inconvenience, and cost without proven benefit. Here we see data from Rocky Shone's PLCO trial. And what's highlighted here in the lower curve are people who had no adenomas. And you see within five years, people who had no adenomas are getting colonoscopies at a rate of 26%. So, 26% of people have another stroke in five years when they had no adenomas. So, some of these people may have had symptoms that merit another look, but that number seems awfully high. And you can see when you get to 10 years, it's 60%. So, that's overuse. But also of concern is underuse. In the black line, the dark black line, we're seeing individuals who have advanced adenomas. And surveillance recommendations call for repeating endoscopy with three years for these individuals. And here we see that by five years, less than 60% have been stoked. And we want that number to be much closer to 100%. So, underuse of surveillance in this group also poses risk because these patients are at high risk for colon cancer. So, just to reemphasize this point, if you don't have appropriate surveillance intervals, we are increasing the risk of the procedures. It's not cost effective. If you're stoking people too early, that's considered an inappropriate indication. That's one of the priority metrics. So, it's also been shown that non-gastroenterologists are more likely to use shorter intervals. And there may be many reasons for this, could be lack of knowledge, lack of confidence in their technique. So, I strongly recommend that all practices track appropriate surveillance recommendations for the endoscopist, although it's tricky to do, as we'll touch on later. Now, the U.S. Multi-Society Task Force published last March new recommendations for follow-up after colonoscopy. The surveillance recommendations have been changed in substantial ways in a couple of cases, and I'll highlight those. If you haven't seen this already, this is the table from Gastroenterology published last year from the spotlight document. There's a poster that you can put up in your endoscopy unit that discusses the appropriate surveillance recommendations. I don't have time to go through this in detail. There's separate tables for follow-up of adenomas and another for serrated lesions. In terms of major changes, when patients have one or two small adenomas that is less than 10 millimeters, the recommendation now is to repeat colonoscopy in seven to 10 years. It used to be five to 10. The reason for this change is that it's been shown in several studies that the risk of colon cancer is similar in individuals with two small tubular adenomas, similar to that of people with normal colonoscopy, and the overall risk of colon cancer is lower than the general population. We also emphasize the importance of doing colonoscopy in three years among people with advanced adenomas because we have increasing evidence that this cohort is at very high risk of colon cancer compared to those with normal colonoscopy. Another change is that for those with three to five small adenomas, we now recommend three to five year follow-up instead of three years for people with three to four small adenomas. So before these guidelines, anyone with three or more adenomas got a three-year follow-up. Now, if there's only three or four adenomas, the recommendation is three to five years. We also have specific recommendations for serrated pulse, as I mentioned before, and those are shown here. We don't have detailed recommendations on what to do if you have both serrated lesions and adenomas, so you have to use a bit of the art of medicine more than the science of medicine because the literature just isn't there yet. We summarize all the data with this table here, this figure. So you can see, based on your normal colonoscopy findings, we'll get a 10-year follow-up or less than 20 hydroplastic polyps, we'll get a 10-year follow-up, and on down to one-year follow-up for people with 10 or more adenomas. That document from last March also outlines what to do on your second surveillance. So if your first colonoscopy had one or two adenomas under a centimeter, the recommendation is a seven to 10-year follow-up. If the subsequent colonoscopy is normal, then you go to 10-year follow-up. Likewise, three or four small adenomas will get three to five-year follow-up, as I said, but if that follow-up exam is normal, then you can go out to 10 years. The days of repeating colonoscopy every three years or every five years in people who have a prior history of colonoscopy should be over. There's a nice paper published this year in Gastroenterology by Raj Goswami and colleagues that talks about best practice in colonoscopy, and he just emphasizes some of these points about avoiding late surveillance for high-risk patients and avoiding overuse in low-risk patients, and I urge you to take a look at that paper if you're interested in reading more about this topic. Now let's move on to the intra-procedure quality indicators. There's quite a few of these, and I'll just touch on them briefly. The first is the quality of the bowel preparation needs to be documented. The target is at least 98% of procedures, and we'll touch on that a bit in my later talk. The second is that the bowel preparation should be adequate at least 85% of the time, hopefully far more than that, and my talk on bowel prep will discuss that in detail. Next, CFLIN debation should be achieved and photo-documented, and I'll touch on that in more detail in a subsequent slide. Rob will talk about adenoma detection, and we'll talk about that in detail. Withdrawal time should be measured and should average at least six minutes in those with a negative screening colonoscopy. You should obtain biopsies in people who are scoped for an indication of chronic diarrhea. Tissue sampling should be done when you're scoping somebody for surveillance in UC and Crohn's colitis, and you should be removing polyps under two centimeters in size prior to referring to surgery. There are a lot of patients who get referred to surgery for lesions under two centimeters in size. In fact, the rate of patients being referred for surgery is increasing, and that is of significant concern because our techniques and our tools are getting better. We should be taking these out endoscopically. It's better for patients. There's lower morbidity and mortality with endoscopic removal of these lesions than from surgical approaches. So let's come back to cecal intubation. I think we all are familiar with cecal intubation, the passage of the scope to the point proximal to the IC valve, so you're seeing the entire cecal output, including the media wall of the cecum between the IC valve and the penicillar orifice. Lower rates of getting to the cecum are associated with increased risk of interval cancers, and you really should be photodocumenting cecal intubation. If you don't have a convincing picture of the penicillar orifice in the IC valve, then you should try to get in the terminal ileum and take a picture of their election in the upper right-hand corner. The target is to have cecal intubation with photography at least 90% of exams and at least 95% of screening colonoscopies. You can exclude from the denominator patients who have a core prep, severe colitis, or if the indication for the procedure is only to get to some point distal, like if you're going to follow up on a piecemeal resection of a lesion, for example. Now, here's the data showing why cecal intubation rates are important. This is a study from Canada, and what you see is the risk of proximal interval cancers. Those endoscopists who had a colonoscopy completion rate below 80% are the reference group in the second column on the left. And what you see is that as the cecal intubation rate increases, the risk of interval cancers decrease. Looking at the far right column, those with a 95% or above cecal intubation rate have a 0.72 odds ratio of interval cancers. So that's a 28% reduction in interval cancers with a higher cecal intubation rate. Rahul talked about adenoma detection rate, and I'm going to build upon what he said before. So this is the frequency with which adenomas are detected in asymptomatic average-risk individuals over age 50 undergoing colonoscopy. This is the single most important metric we have for colonoscopy quality. It directly correlates with colon cancer, as Rahul showed. The target is an average, it's an ADR over 25%. It should be at least 20% in women and 30% in men. This target is higher than it was in previous recommendations, and I would not be surprised if we move that target even higher. The first major study we have on the importance of this measure comes from the Pinsky Group in Poland, showing in the gold line right around zero is the hazard of somebody getting interval cancer when the endoscopist had an ADR over 20%. And as you can see, the risk of interval cancers was higher for patients who were scoped by somebody whose ADR was below 20%, but those numbers are really low. I mean, ADR to 20% is below that target I mentioned before. Rahul showed this slide. This is coming from Kaiser of Northern California. And what you see at the top are the adenoma detection rates of the five quintiles of endoscopists. The top quintile had an adenoma detection rate between 33.5% and 53%. The lowest quintile had an adenoma detection rate of seven and a half to 19%. That's a very low adenoma detection rate. And the middle quintile was at 24 to 28%. That's right where our target is right now. 25% is our target. But you can see that just moving that target up a little bit to 28 to 34% led to a decreased risk of interval cancer. So we really should be aiming toward that 33 to 53% quintile for all of our colleagues doing colonoscopy. And you saw this slide as well. This is the risk of fatal cancer. As Rahul said, every 1% increase in ADR leads to a 3% decrease in interval cancer risk and a 5% decrease in cancer mortality. Now withdrawal time is really a process measure. It's how much time we spend looking while pulling the scope back from the cecum to the anus in a patient who does not have polypectomies performed or biopsies performed. And you should be documenting withdrawal time in every procedure. And the target is an average withdrawal time of at least six minutes. Studies have shown that this six minutes can separate low and high level detectors. We had this nice study in the New England Journal back in 2006 from Rockford, Illinois group showing that the more time you spend pulling the scope back, the more adenomas you detect for a patient. Makes sense. Well, this study that came out a few years ago from Alice Michalka, looking at the Minnesota gastroenterology group, I think is really quite convincing about the importance of withdrawal time when you look back at data retrospectively. So there's 51 gastroenterologists represented here. And what you can see is that once you get to about eight or nine minute withdrawal time, you have a flattening of the curve of the interval cancer risk. This is on the y-axis, the risk of interval cancers per 1000 person years. But you see as the withdrawal time gets shorter, that risk goes up significantly. I would not wanna have patients scoped by people whose withdrawal times are on that lower end of the spectrum. And this is why the six minute average withdrawal time has been called into question. Many people are advocating that that average withdrawal time should be more like nine minutes. Now let's move on to the post procedure quality indicators. The first one deals with complications. The incidence of perforation should be less than one in 500 for all exams and one in 1000 for screening. The incidence of post polypectomy should be less than 1%. The frequency with which we are managing post polypectomy bleeding without surgery should be at least 90%. And then finally, appropriate recommendations for timing of repeat colonoscopy being documented at least 90% of the time. So let's move on to how do we improve colonoscopy quality. We talked about how to measure it and I don't have time to discuss this in detail. When you think about adenoma detection rate, a lot of people think it depends mostly on the patient, how old they are, whether they're male or female, as I discussed, whether they smoke, what are the risk factors they have, but actually one of the strongest predictors of whether or not a patient has an adenoma is who is the doctor. We have nine doctors represented here and doctor number nine outperforms all the others in terms of detecting one adenoma, two adenomas, large adenomas, et cetera. Bob Lee from Long Beach had this excellent study where he videotaped endoscopists and then had people score the quality of the colonoscopy using a standardized process. And then just from scoring a few colonoscopies, they were able to predict who had a good adenoma detection rate and who had a bad adenoma detection rate. So the technique of withdrawal of the scope is a significant predictor of adenoma detection as you would expect. And there are simple interventions to improve it. Charles Coggy from Indianapolis simply provided a report card. You know, Rahul talked about this and I'm gonna reemphasize it. By measuring quality and providing the information to people, performance improves. You see that the adenoma detection rate before the intervention was 45% and it went up to 54%. Proximal adenoma detection went up by 10%. Safe motivation rates, which were excellent at 96%, got even better at 98%. So just really significant improvements among high quality endoscopists just by providing this report card. The Polish study I mentioned earlier from Kaminski, that New England Journal study with the gold line, the ADR of 20%, they followed up on that study by taking the lowest performing endoscopy units, those with the lowest ADR, and they brought the director's endoscopy in for a randomized trial. Half the group got feedback alone, the other half got feedback plus a two-day training course. And they found that they were able to improve adenoma detection with that training program. Mayo Clinic, high adenoma detectors, 36% adenoma detection rate. Mike Wallace and colleagues did training to help them learn how to detect subtle lesions, how to distend folds and wash better. And they were able with the intervention on the right-hand side to increase ADR from 36% to 47% with a relatively simple training program. We also have other devices that have been put out there to help improve adenoma detection, distal attachment devices. There's an ASG tech review on this and many other papers on techniques to improve adenoma detection. And again, that Casuani paper I mentioned talks about ways to improve the overall quality of colonoscopy. When you look at it, we have a number of endoscopists who are unfortunately are at the left-hand side of this graph. We have poor quality colonoscopy with high risk of inadequate bowel preparation, insufficient withdrawal quality, suboptimal polyp detection, poor documentation and inappropriate surveillance recommendations. And we wanna move everybody off this stairstep process to optimal colonoscopy quality where everybody has adequate bowel preparation. We have appropriate withdrawal technique. The withdrawal times are exceeding the minimum standards. Polyp detection exceeds the benchmarks. High quality polypectomy, appropriate referral for EMR for large polyps to avoid surgery for benign lesions, detailed documentation, photo documentation and appropriate surveillance recommendations for all of our patients. Now, I make it sound easy, but it's not so easy. There are some challenges. In the VA where I work, we surveyed chiefs of GI and asked them if they're measuring these quality indicators and we saw pretty high compliance with measuring bowel prep quality, sequentivation rate, complications. Not as much, but more than half measuring appropriate surveillance intervals, withdrawal time, adenoma detection, et cetera. But this is not where we wanted to be. We need to improve that. Measuring adenoma detection rate can be challenging. You need to look at both the indication for the procedure and the pathology results. Separating by indication makes it a bit challenging and is it really important to do that? The classic definition is that ADR is in screening colonoscopies only. And depending on your practice, you may not do large numbers of screening colonoscopy and that has sample size implications. If you look at this paper by Doe, I know this is a bit complicated, but let's just focus, for example, on the column of 20%. If you look at 50 charts, so 20% is below the target, but if you just look at 50 charts, the confidence interval around that is from nine to 31%. Well, 31% would be appropriate adenoma detection rate. So maybe you need to go to 100 charts. Well, 100 charts is 12 to 28. So they still may be adequate at detecting adenomas. So you need to go to 200 charts, even then 14 to 26%. So you need large sample sizes to get reliable estimates of the adenoma detection rate. Now, Tanya Kaltenbach and colleagues looked at what the impact is of combining all indications rather than just screening. And here you see 21 endoscopists represented. The blue dot and lines is the point estimate for screening colonoscopies in the lines of the 95% confidence interval. And what you see in the red dot and lines is if you combine all indications together, and you'll note that it really doesn't make a big difference in how you classify endoscopists or whether or not they are doing a good job with adenoma detection. What you do see is that combining indications gets you tighter confidence intervals, arguing that it is appropriate to combine these. Still not standard of practice, but I think we may be moving in that direction. It does give you a good sense, in my opinion, of what somebody's colonoscopy performance is. Now, the adenoma detection rate does not include serrated polyps. Ravel touched on serrated polyp detection rates, and many advocate for measuring SSL serrated lesions separately and reporting the serrated detection rate. This is challenging due to pathology issues when you go across institutions because some pathologists use different criteria for identifying an SSL than others. But within an institution, I think it could be more valid. So the data that Ravel showed was quite intriguing because those presumably are the same pathologists reading for all the various endoscopists. But we can discuss that more in the round table. It is labor intensive to calculate ADR, although automated systems have been developed. It does emphasize the detection of small lesions. And so people may find one diminutive adenoma and feel like they can let their guard down, and then they may not pay as close attention to future, you know, during the withdrawal in the subsequent minutes of their exam. So that's the encouragement of a one-and-done approach. And there is some evidence that that does occur from papers like the one-by-one et al. from the Los Angeles field. Now, determining appropriate surveillance recommendations is not something that is automated at this time. So you have to manually review the indication for the procedure, the bowel prep quality, the depth of insertion of the scope, the findings, and the recommendation. So you need to have linkage to the pathology results, and you cannot determine this at the time of the procedure unless you're dealing with negative exams, i.e. no pathology. Sequel intubation rate, you really should have photo documentation because self-report of sequel intubation can be misleading. So photo documentation requires manual review by someone who knows what the sequence looks like. Though automated systems are feasible, there's a paper that's been published on this topic, and I think a lot of the endowriter companies are looking at trying to incorporate this into their software. In my practice, we do a manual review of photo documentation on a random sample of charts. Every six months, we review charts on every endoscopist, and we look for photographs of the sequel. Despite all these challenges, I think measurement of colonoscopy quality is the standard of care today. You should develop workflows to facilitate quality measurement. Your GI endoscopy software has quality reporting tools. There's some variation between the different companies on how could they do this, but it certainly does help, I believe, in auditing a photo documentation of sequel intubation and auditing surveillance recommendations. So to close, colonoscopy quality is associated with cancer incidence and mortality. Reporting of colonoscopy quality with these report cards can lead to improved quality, and I think you should focus on the priority quality indicators, the appropriate indication of adenoma detection rates, sequel intubation with photo documentation, and appropriate surveillance recommendations. Low-level adenoma detection really endangers patients, and I don't think it's acceptable for us to move forward without measuring ADR and implementing interventions to improve ADR for endoscopists who fall below the benchmarks. If you don't measure quality, you don't know if you've achieved it. Thank you very much for your attention.

colonoscopy quality

quality indicators

improving colonoscopy

adenoma detection rate

cecal intubation rate

interval cancers

withdrawal time