We have a lot of great questions in the chat, so I'm going to try to direct them to the speakers who gave those specific discussions, and then we'll maybe open a few up for a group discussion. So, T.R., a few for you to start off with. So with calculating the ADR from all colonoscopies, it theoretically makes it easier by including more colonoscopies. However, I'll try to summarize, you know, for the inpatient setting, we might not expect the same number of polyps and such, and potentially this is inequitable for endoscopies who do more inpatient colonoscopies where polyps are not removed. How should we manage this? I think it's totally reasonable to exclude those inpatient cases from your calculation. If you're doing it mostly on inpatient procedures, the preps tend to not be as good. Often there's a lot of blood or other material in the colon, so you don't get as good a look. So I think it's totally reasonable to exclude those, and most of these measures and the benchmarks have all been derived from outpatient procedures. Yeah, great. So I'll move on to, when you are measuring appropriate follow-up surveillance, how do you perform this if pathology is not back at the time? Do you base it on the response of pathology post-procedure? Yeah, this is one of the reasons why this is a challenging measure to really implement in your practice, because you can't really assign a surveillance interval until you get the pathology back. And so we often would caution people against trying to put a surveillance recommendation just at the end of their procedure note, at the time of the procedure, before you know what kind of polyps you've actually removed. So some sites have done this by looking at, they have like a standard letter that they send to patients with their surveillance intervals after they get the pathology back, or maybe it's a secure message. There are ways to measure that. Some sites probably have an endoscopy recall or colonoscopy recall list, and so those usually get assigned intervals. So there are probably, there are ways to do it. I think it is tricky, kind of outside of a really more sophisticated electronic medical record kind of setup. For sure. I have so many follow-up questions, but we'll get to the other ones. I'll say, you know, there is this newer philosophy of resecting and discard, which would be very different than what's being proposed here, and not having to wait for the pathology if it looks like an adenoma on an NBI. I think if you are comfortable with the resecting, I think there's been kind of slow uptake of resecting and discard for probably a lot of reasons. Different level of people assigning endoscopic diagnoses, pathology provides some reassurance. So it's not a, I don't think it's a hugely prevalent case. I actually gave the talk in favor of resecting and discard at the ASGE meeting last May, and I went up against Carol Burke, and she, I went from 0% in favor of resecting and discard to like 10% pre and post question. So it's still not widely popular, but it was a fun experience. So, but I think if you're going to do that, then you'd kind of say, okay, these are the surveillance intervals based on the resecting, based on the characteristics that you use for your resecting and discard. I'll just briefly say at our institution, we've really tried to align our letters with what patients have in their chart for the health means modifier, because that's what the PCPs more often see. But you can see like, there's such a difficult transition from what the endoscopist might think is the right answer to what ends up happening in real life because of the communication strategies in between. So that's something to pay attention to. I think, you know, from doing this work for a couple of years and working with Eden, we sort of like aim for progress, not perfection on some of these measures. And just like the ADR is really like the, that's kind of a cynical one, so you gotta get that right. But the other ones are kind of like trying to improve, continue to improve, I think. Is there conclusive evidence that the distal cap improves ADR and is there any benefit from increasing average ADR above 40 or 50? Two different questions. Yeah. I mean, the initial, so the cap can improve it a little bit and probably makes a bigger difference for low detectors than higher detectors. And in terms of, you know, continue like ever higher ADRs, they're kind of a peak level of ADR. You know, the initial data would suggest that there was no threshold effect, but more recent data as more and more people are kind of getting, you know, we see ADRs of 50, 60, you know, really high 60% and some screening colonoscopies and most of those are going to be small polyps. So I think they're, you know, the data from the Joanne Schottinger, Doug Corley study that was in JAMA a couple of years ago would suggest there is kind of a threshold, maybe above 40 or 50%. It's probably diminishing returns, but there's probably some benefit, you know, can you get the best ADR you possibly can get? This is more of a thought for a non-guideline based question or something that's outside of the guidelines. When do you stop surveillance in patients 75 years old or older when they continue to have polyps? Yeah. So, I mean, there's been some recent evidence that people older than 75, you know, have a lot of competing causes of mortality beside colon cancer. I think particularly if people had low risk adenomas on their most recent colonoscopy, when you get to sort of the 75, 80 range, it's probably reasonable to not try so hard to get people back in. I think these are tricky conversations to have. I've done some work with Algae Calder where we spend a lot of time talking to patients about their need to continue surveillance. And some people are greatly relieved if you don't, that they don't have to continue surveillance and other people feel like, oh, you're just kind of putting them out to pasture and, you know, kind of letting them, you know, quote unquote die, you know, because of this. And I think it's, you know, we really need to be realistic about the risk of those low risk adenoma patients. I think people with advanced adenomas on their most recent colonoscopy should be kind of continue to follow probably into the 80, 85 range if they are healthy enough to have a colonoscopy and, you know, with a five or 10 year life expectancy and still benefit from it. But the low risk adenoma patients can probably, you know, safely stop. And yeah, Audrey and I are doing a randomized trial for older patients with a sort of fit versus colonoscopy for surveillance for people above 65. We initially started with 70. We sort of went down to 65. So we're just getting started with that trial. And so stay tuned in five or 10 years, we might have an answer for you about whether people can do fit or are technically non-invasive surveillance as they get older. It's another option. Yeah. Great. This one I'll open up in a moment to Neil and see for who has any thoughts as well. We actually tried to design some shared decision-making tools for our PCPs to discuss with their patients above 75. But, you know, it's a different conversation with every patient. I try to talk about with patients before their procedure to be like, well, you know, if you don't have anything right now or you only have one polyp, I think you've graduated and people seem to like that. So it's a fun conversation sometimes to be able to have. I think it is really about setting those expectations, you know, when you find the polyps and thinking clearly about how old people are when you're making recommendations, because that does carry a lot of weight. It's much harder when they're 82 and they were told to come back in five years for their colonoscopy and say, well, you might not need to, but, you know, if you're 77 and you're finding low-risk polyps, you know, be realistic about how people are going to actually benefit from it. Setting expectations. Great. I think this is in our domain of patient-centeredness in terms of helping people make some of these decisions. Neil, you have your hand up. Oh, I wanted to, Tiara, I wanted to bug you about, so specifically, once you start exiting 75 to 75 to 85, what are you doing with your patients who have like SPS or colonic polyposis of unknown etiology? Like is there a time point where you start thinking about stopping surveillance or are you, at least in my practice, because I have a decent population of those with like advanced endoscopic resections and all that sort of stuff, that it's normally their comorbid disease until around 85 that makes me starting to stop their surveillance. But yeah, I was just so curious about your thoughts. Yeah, no, I think that's very realistic and very appropriate to kind of do it that way. I think, you know, there's been a number of papers, Samir Gupta has one that he, I think he's presented at DDW, but it's sort of the competing mortality for people in this age group is so much higher than their risk of developing colorectal cancer and kind of being realistic about it. But, you know, to one person, a risk of colorectal cancer of way less than 1% is low risk. And for other people, it's like if there's any risk, you know, they're very worried about it. So it's, there's some personal preference, but you don't, you definitely, you're doing, these procedures have risk and the risk goes up as people get older. Dehydration during colonoscopy, perhaps arrhythmias, you know, ability to withstand the stress of a post polypectomy, bleeding, you know, all those things kind of go off as people get older. Thank you for that. Rahul, your thoughts? Yeah, no, it's a great conversation about, you know, we see this in the pancreatic cyst aspect also about the cessation of surveillance is a very complex topic. I think it comes, one of the things is, is objectifying really that risk assessment in terms of going away from age as a number and what you were talking about competing comorbidities and there are measures of that, but I was curious, I mean, you look at it from a patient perspective and then a societal perspective and really it's, it's a tough nut to crack. So as you're designing your study and I'm sure you've thought a lot about it, how do people go about calculating a global risk score versus just going by, I stop always at 75 or 85 and things like that. So I just thought I would put that out. There are some predictors of mortality. There's a, there's one that at UCSF that on the, that UCSF has that you can access on the web. Mostly that's kind of geared around screening, whether you should continue screening, not so much the surveillance, but I think those are pretty, they can be pretty useful. But it, there is a lot of, there's a whole realm of kind of personal preferences and patient wishes that we have to also keep in mind and kind of how we'd sell it. I usually find like Sonali was saying, like right before you do the colonoscopy, they've just gone through the challenge of completing that prep and you say, well, you know, if I don't find anything, if I only find one or two small polyps, you know, I, instead of graduating, I say, well, you've paid your debt to society and people tend to kind of go like that. And then, cause they feel like they sort of owe, many people feel like they owe it to society to kind of do the right thing and do their screening. And people, most people at that point are, that's when they're most willing to kind of think about not doing another colonoscopy. That's a great point, T.R. All right. So another question, is there any way we can get CMS to mirror the timeframes colonoscopy follow-up as suggested? They state we cannot use timeframes, yet the guidelines do use timeframes. I'll say we actually don't allow our physicians to give timeframes in the letters because we don't know how to track that, you know, in the computer. But I'm curious how you guys manage timeframes. Yeah. You know, I don't really deal with CMS billing, so you might have to kind of explain this to me a little more. Fair enough. More so, just like, instead of saying, you know, your follow-up colonoscopy is due in three to five years, is it, do you say three years? Do you say five years? Because if you say three to five, it gets confusing in terms of how it's being interpreted. No, I do think we should probably put our nickel down. I think if you had a good exam and, you know, some people, some people break it, like if your follow-up was less than five, then they'll go 10 years. If it was five to nine millimeters, they might, some people choose seven at that point. But we tend to lean towards longer intervals in our group. We have, you know, we're trying to deal with accumulated backlogs that we're still working off from the COVID pandemic, and some sites, you know, if you're maintaining a surveillance list, it's, you know, you're going to have a lot of people that you need to get back in. And some sites are kind of like deferring all that to primary care. It's like, we'll see the patients if they get referred to us, but we're not tracking them. That feels like, you know, as gastroenterologists, we're in the best position to know when somebody's due for their next one, so we feel like we should own that. But I think, you know, definitely choose a specific time interval rather than a range. Clearer for all parties, yeah, that makes sense. So whether CMS dictates it or not, just generally better to give a number. Hopefully a straightforward question for TR here, what's the recommended surveillance following piecemeal EMR, and what's the interval recommended for inadequate prep? The second one we might open up a little bit, but piecemeal EMR first. Piecemeal EMR is sort of like in the six-month range to kind of make sure, particularly for flat polyps, particularly if they're larger, you know, small ones, maybe not as important, but yeah, six months. And then if it's an inadequate prep, if it was a screening exam or an exam with just low-risk findings, you know, sometime within a year, I think is probably reasonable for the inadequate prep. But if you start people with, who might have a positive fecal test, you might want to do it sooner, or people with symptoms, iron deficiency, anemia or something, you know, definitely choose a sooner interval, maybe potentially three months, but, you know, just for low-risk screening, you know, kind of within a year, it seems reasonable. I'd be curious for Rahul as well. So I guess I go by how inadequate it is, you know, like if you're like, well, I'm pretty sure I saw most of the colon, but there was one pool of dependent fluid and whatever. I'm like, I think I can go longer than one year. And oftentimes I'll do that. Or if it's like the, what would be a flexible sigmoidoscopy was totally clear, but it was just a cecum that I couldn't get a very good look on. That's a tough one, right? Because per guideline, the flexible sigmoid says five years, I don't know if I feel comfortable enough with that. So I'll kind of, you know, base it on what I see for the rest of it. Because as you said, our backlogs are so long to bring that many people back at a year when I'm not that concerned about therapy. The other option that we actually just talked to our staff about is if it's for an average risk procedure and they would have qualified for a stool-based test anyway, then you can save them from trying to do the prep because clearly it was difficult the first time around and offer the idea of a stool-based test or other screening modalities and then bring them back if it's positive. And that's something that we're- I think that's, I think that's a really good point is like using an alternative approach or alternative screening approach for people, if it's just screening and you didn't find any worrisome lesions. Yeah. Rahul, what do you guys do, what do you do? I have to acknowledge I'm not in the colonoscopy practice, so I will do sporadically, but I'll be honest and say, you know. You don't have to deal with the inadequate preps as much. No, we do. I mean, I can give you a general sort of sense of what we do, but I didn't want to say, you know, it's, I think all the points made are true. I think we are trying our best sort of from a pre-procedure perspective to optimize it, you know, so, but I think there's so much variability. I think we've, in the practice, between the ASC practice and the hospital practice, there's that other level of complexity to it, so, you know, we tried for a bit to use sort of this in-procedure cleansing sort of tool, like a jet suction tool that had come out, but it really, there was not enough uptake of that, so that sort of, you know, has not become very common, so I guess it's what you guys are doing, trying everything. Makes sense. All right, I think our last question for colonoscopy is before we move on to the other ones, so T.R., what is the current feeling on improved ADR with MAC-assisted exams versus conscious sedation or unsedated exams? Could or should this be considered a quality measure? Yeah, I don't think there's great evidence that people do better with MAC exams versus none. I think the important thing is that the prep is good and the patient is comfortable. For people that can get adequately sedated with, you know, usual procedural sedation, I don't think it matters. You know, some people feel like they get better insufflation of the colon without MAC when they're, because they get preserved kind of sphincter tone in the anal sphincter, and so the colon holds the air a little better, so when you're trying to distend the walls and actually look closely, you can actually see better potentially without MAC, but I think the important thing is the patient's comfortable and you don't feel like you're rushing through the procedure because they're so uncomfortable and you're like, okay, I got to pull back from this spot because the patient's, you know, really uncomfortable. That's a really great point, T.R. I'll bring back our equation of value equals quality over cost. We do know that MAC may double the cost depending on where you are, so just another thing to be kind of thinking about if you're moving, you know, trying to figure out who benefits from MAC and what that means for the rest of your... Interesting though, we have a ASC practice that's all moderate sedation and then we have a hospital practice. I can clearly see declining, you know, set of requests for moderate sedation such a way that it's extremely hard to have people order moderate sedation anymore. Everybody wants MAC, so there's that patient preference and physician, ordering physician preference that I think is changing the dynamic in general towards MAC, so. Yeah, yeah. I actually, we don't, I don't think we give that option because we're like, oh, MAC is a six month wait, you know, our in sedation, you know, there are so many other factors involved, right? For pros and cons, but it's definitely a good point to be making when someone comes in for our in sedation and they say, all my friends were put out, like, like they were completely asleep. What do you mean? I might be awake, you know, their expectations as well to be working on. Yeah. All right. We have the same thing where it's like we have some designated MAC days, but we have, you know, more days where it's just our in sedation. It's a lot better, a lot easier access for those days. Yeah. All right. So we're going to move on. Thank you, Tiara, for fielding all those questions and everyone else for participating. We're going to move on to a couple of questions about the upper endoscopy. So Sean asks, do you use Selvizio and how effective do you think it is for diagnosing baritissophagus? I was going to respond by saying, you asked the wrong person because I'm from Canada. We don't have CLE. I don't know, Tiara, or Sonali, or Rahul, if any of you guys have CLE at your centers. I can tell you that, at least from my perspective, I think that when talking about quality and upper endoscopy specifically for barits, I think, especially with the lens of this being for general endoscopy, it's focusing on the basics. Like, so for instance, like what's the linear anatomy, do prod classification, you know, you clean the esophagus, you know, distend it and spend the time actually looking at it under standardized high-definition white light and NBI. And I think that will probably make the world of difference. My perception, at least with a lot of the novel technologies, it is really in that niche space. But I don't know, again, Rahul or Tiara or Sonali, if you guys have experience with CLE. I have experience and I use it, but not for barits. I use it for pancreatic cysts. I know that in our barits practice, they're not using it. Routinely for barits. So it goes back to what you were saying, high quality exam, NBI or something similar. So. Great. And then also for you, Neil, are any surveillance recommendations for squamous papillomas? Oh, I don't think so. You know, it's just there's like, I don't think there's like a squamous papilloma expert, if that makes sense. You know, you probably want to differentiate them from diffuse esophageal squamous papillomatosis, which I think behaves a lot more like traditional squamous cell neoplasia with, you know, with incidental papillomas. A lot of times I bring them back normally in a year after endoscopic resection and then I slowly just expand their interval. But again, there's not a lot of evidence to do anything in that population. And admittedly, in that cohort, I don't think I have anyone with concerns for like recurrent, you know, papillomas or alternatively progression to actually true squamous cell neoplasia. Very helpful. Thank you. And now for a question regarding our advanced procedure or interventional procedures, what systems can be used to measure quality for ERCP and EUS? These systems exist for colonoscopy and perhaps EGG? Yeah, no, I looked at that question. I think it's really important. I think I don't personally know whether GI-Quick has a ERCP-EUS module, but at least I can talk about what we do in our practice really is we look at the, you know, all the quality metrics that are documented as extracted from either probation or EPIC, post-ERCP pancreatitis, cannulation rates and things like that. We look at the EUS FNA sort of positivity rate. That has a little bit fallen by the wayside. It used to be a big deal a few years ago, but now with coronary biopsies and things like that, it has become pretty uncommon, at least in our practice in terms of establishing a diagnosis. But I think for ERCP specifically, having those, you know, having sort of a quality champion and if there's an ability to pull that data from the EMR or probation, that'd be helpful. Neil or T.R., do you know if your centers have ways that you monitor or have a measure set up? Go ahead, T.R. Yeah, no, go ahead, Neil. I was going to let you do it. Yeah, so for colonoscopy, because again, we have a programmatic colorectal cancer screening, so we get report cards and all of that essentially is recorded if you participate in the colon cancer screening and you have to do like all these courses to participate and maintain your competency in that program. But most people want to be part of it because it adds to your colonoscopy volume in your practice. As for quality measures in upper GI, EUS and ERCP, no, I don't think we have any recording measures yet for those three modalities. We have a dashboard for colonoscopy measures that gets released. I think we do it kind of twice a year just to allow people to have sufficient volume for all these quality measures. Mostly it's ADR. We've started including CEQA intubation and I think withdrawal time as well. But we haven't crossed that line to the surveillance intervals just yet. We have seen just by providing feedback, we've seen improvements. Doug Corley, early on after his initial paper, created a 30-minute video. Many of us, it was with Doug Rex's help, many of us who trained in the 90s had not really attuned to CES ulcerated lesions or flat polyps as well early on. So just even having some video education around like these are what these things look like. We saw a really strong improvement in ADRs just from a 30-minute training program. That's amazing. We just started to try to put together a list of indices for ERCP, recognizing that, I mean, it's a data stream that we didn't have before, so we're trying to work that out. So hopefully we'll have something in a few months, but even finding cannulation rates, complications as listed through readmissions to at least your own hospital, we're trying to work those things. I think you're right, that there's definitely not the same programmatic support or kind of system in place that there is for colonoscopies in most places. Definitely something to work towards. Rahul? Yeah, I just wanted to circle back. I'm just, Eden just informed me, you know, GI-Quick doesn't have a US and ERCP that work on getting the ERCP module out, and eventually EUS. So I just wanted to do that. Also just to round out the discussion, what has really helped in our practice is really we have a nurse dedicated to quality and she really goes over and about and collects the entire sort of colonoscopy metrics. We haven't done EGD, but colonoscopy, every physician who does colonoscopy gets extremely detailed quarterly reporting of all the indices that are measured. And we all get very detailed ERCP metrics in terms of cannulation rates, post-ERCP pancreatitis rates, post-hospitalization rates. So there's a lot of manual work. We don't have automated processes for that, but that has helped us really track and be at the sort of the forefront of knowledge, at least, of how well we are doing in both of these practices. How does she use, and you say manual, like is she able to pull it from probation? Because we're trying to get file cannulation rates just from pulling a probation report. But the challenging part is like one of our industries doesn't do it, so we're trying to encourage everyone to document it the same way. You mean for cannulation, biliary cannulation? Correct, yeah. Yeah, I mean, probation should be able to do that because it's a dropdown menu. We're able to pull from that and to do that. The cannulation, well, now we are moving to a different reporting software in Epic, so we'll see where that goes. But in probation, yes, we're able to pull up. But there's a lot of manual work involved. There's no doubt about it. I just want to recognize. Yeah. T.R., you're going to take the last question that's in the chat box? Yeah, there was a question about hyperplastic polyps on blood thinners. I assume that's in the colon, not in the stomach. But yeah, I mean, I think greater than a centimeter, I mean, hopefully you're doing colonoscopy when holding blood thinners for the requisite amount of time, whether it's a DOAC or antiplatelet agent. But yeah, I mean, you should probably hold the blood thinners and bring, if they haven't held, then bring them back after the blood thinners have been held. That's kind of the approach I would take. This is a great topic you bring up, actually. So we don't have our patients routinely hold blood thinners or antiplatelet agent before. Yeah, because a study that was done internally maybe 10, 15 years ago or so showed that the risk of cardiovascular events, strokes and heart attacks and I think even other blood clots for the people who held was higher than the risk of bleeding events for the people who had polyps taken out just numerically. And so since then, we have let everyone continue. And if it just so happens that you find something large or you're doing a dilation that you were expecting to, we bring them back. But I'll even admit, there've been a couple of people who were like 74 years old and really struggled through their prep and we have them and I see a big polyp and I just take it out and I let them know that there's an increased bleeding risk. But instead of having them prep again and all that, it's a risk that I decided to take. Neil? I wonder what Neil does. Oh, you go. Yeah, so I'm more along your lines, TR. We definitely hold antiplatelet and anticoagulants where possible other than aspirin. Like I think aspirin's in the water, I don't care. I'll do anything on aspirin. But I think the challenger situation with us is that if someone inadvertently doesn't hold their anticoagulation, what do I do? And normally if we're talking about colonic resection, sub 10 millimeter, I will normally take off. Above 10 millimeter, I probably will rebook them. Admittedly, I would be a little bit cautious about doing endoscopic resection on full anticoagulation. Like that's sort of the focus of my practice. And sometimes, like especially if I haven't had a good look at the lesion, I'll even talk to the patient and say, listen, we'll do your colonoscopy for pre-resection optical evaluation, but we won't be removing the lesion today. And then subsequently bring them back. But that's only if I'm concerned about the lesion. I won't make them do a double colonoscopy if they don't have to. But that's at least my pattern of practice. I mean, I think if you can take the lesion off cold, then you're probably in reasonably good standing. If it's something where you think you're gonna apply cautery, then I think it's a little trickier. Same, yeah, I think I would avoid electrocautery in the setting of anticoagulation. But I think- I think we all have gone to a cold scenario so much more often, especially for subcentimeter that thankfully that hasn't come up, that hasn't been a scenario too often. And I think that we're seeing papers increasingly, going to 15, 20 millimeter, it's particularly flat lesions. They do well with cold resection, but the pedunculated ones are a little trickier, I think. That's what I was gonna ask you, T.R. What do you do for your sub 10 millimeter? It's not very common, at least not in my practice, but sub 10 millimeter pedunculated lesions. I'm taking these off now cold snare. No, I would too. I would do the same thing. And they do pretty well. Sometimes if the stock is really thick, you can't quite get through it. So then I'm like, okay, plug in the cautery at that point. But if we can get it off, then just, I'd much rather deal with like immediate bleeding, whether it's like injecting epi or putting a clip on, then worry about delayed bleeding from the cautery. Especially if you're in the right colon and then the risk of perforation as well from that electrocautery. Thankfully there, Eden reminds there are the multi-society guidelines on colic removal as well as an anticoagulant and anti-platelets. And so maybe those can, they're probably on GI leaf as well for reference.

colonoscopy

endoscopy

adenoma detection rates

surveillance intervals

patient communication

resect and discard

advanced techniques