Hello, everyone, and welcome to the September 2024 edition of the GI QUIC Quick Bytes webinar series. My name is Laurie Parker, and I am the Executive Director of the GI Quality Improvement Consortium, or in short, GI QUIC. GI QUIC holds monthly webinars, which historically have been geared towards those participating in the GI QUIC Registry. We focus on specific and pertinent topics associated with the Registry. We allow ample time for Q&A, and post the webinars for future viewing on our Participant Registry website. This month, however, we are conducting a broader webinar, inviting GI QUIC participants and also ACG and ASGE members to hear from leading experts with respect to the recently released Updated Quality Indicators. This webinar will be recorded and posted on the GI QUIC public-facing website, as well as available via ACG and ASGE virtual learning platforms. Thrilled to have two of the leading experts in this field on the webinar, both being authors of the Updated Colonoscopy Quality Indicators. Dr. Asma Chakot is Professor of Medicine at New York University, a professor in the Department of Population Health, Co-Director of Translational Research Education and Careers, and Director of Outcomes Research in the Division of Gastroenterology and Hepatology. Dr. Sunanda Cain is Professor of Medicine at the Mayo Clinic in Rochester, Minnesota. Dr. Cain is also the Chief Patient Experience Officer for the Mayo Clinic Enterprise. On this slide, you will see both of the presenters' conflicts of interest. Here is a review of what we will be going over today. First, a quality indicators overview and timeline, then a review of the specific Updated Quality Indicators, including the new IBD-specific indicators, identifying and correcting low-level performers, and then how to put these Updated Indicators into practice or into your Quality Improvement Program. And then, as I said, we will be ending the call with taking questions and answers. So, before we jump into the actual meat of the presentation, let's take a minute to review the history and the timeline of the Endoscopy Procedure Quality Indicators and the evolution of the GI Quick Registry. The initial publication of the Quality Indicators for GI Endoscopic Procedures was released in 2006, which happened to be the same year that CMS released the Physician Quality Reporting System established by the Tax Relief and Healthcare Act. Based on these Endoscopic Quality Indicators, quality measures were developed and defined. In 2009, a pilot project led by Sentara Healthcare was initiated with dozens of physicians participating to collect the necessary data to calculate these quality measures. Dozens of procedures demonstrated that participation in the project improved overall outcomes. The pilot was deemed a success, and jointly ACG and ASGE officially introduced the GI Quick Registry in July of 2010. Over the last 14 years, GI Quick has grown to include over 4,300 physicians, representing hundreds of various practice sizes and types, encompassing over 20 million colonoscopy procedures and over 4 million EGD procedures. GI Quick will soon be capturing data and related quality measures on ERCP procedures and for patients with inflammatory bowel disease. Going on with the timeline, in 2014, CMS expanded the reporting options to the Quality Payment Program to approved Qualified Clinical Data Registries, of which GI Quick has been one for the last 10 years. This enables GI Quick participants to submit specialty-specific measure data to CMS. The quality indicators have been through two updates since 2006, one published in 2015, and then the most recent updates published just last month, so in August 2024. We will now turn the presentation over to Dr. Chakhat and Dr. Cain to review these updates. Thank you, Lori, for that great introduction. Hello, everyone. So, so glad that you could make it. We're looking forward to presenting some of the new findings from our new guideline and also present some of the evidence that led to these updated quality indicators and also what where we are and what we can do to achieve them. Why should we care about quality of what we do? Well, we want to be effective in what we do every day. In the case of colonoscopy, it's about detecting and preventing colorectal cancers, for the indicators I'm going to talk about, and really reduce these interval or post-colonoscopy cancers that undermine our effectiveness. We want to be safe, so reducing complications and doing things in a safe manner is extremely important. Quality is tied to reimbursement. The audience might be familiar with MIPS and APM pathways, and these are rapidly transforming into other pathways, such as MDPs. So we really want to tie our practice to be a high-value, high-quality practice, and perhaps the most important reason is it's tied to patient satisfaction. And our patients, obviously, are key in this paradigm. So this is where we were in 2015, just to refresh everybody's memory about what indicators we were following. And the idea of this slide is to demonstrate that quality is a continuum. It's not just one thing, but it's really, it starts in the pre-procedure area, where we have indicators, and as well as targets. The intra-procedure indicators, and again, we tend to focus on these quite a bit, since these are things that we could directly control. And then also post-procedure, such as tracking complications and surveillance interval recommendations. So those are still important. And of course, I'll be spending, we tend to spend a lot of our time on ADR, as it's the most important one, but just a reminder that there are many other key quality indicators. So, I'll summarize or preface our presentation by saying that the times are changing, more evidence has accumulated, and our practices have evolved. The practice of colonoscopy, and what we are able to find, and what we can expect to find. And as a result, the goalposts are moving. So from 2015, the benchmarks that were set, now you'll see that it's not sufficient to just meet or exceed those, but we're going to show you newer benchmarks. And remember, these are the minimum thresholds of where we should be worried about a physician not being a high quality performer. But really, an aspirational goal should be to be much, much higher than the benchmarks I'll show you. So, again, I'm going to take us back to ADR and its association with interval cancer. And the audience must be quite familiar with this study almost 10 years ago, which followed a large number of individuals that underwent a colonoscopy at Kaiser Permanente that were followed for 10 years or another colonoscopy. It included 139 gastroenterologists performing these colonoscopies. And the study very elegantly showed that the patients with physicians whose ADRs were in the lowest quintiles, meaning 19% and lower, had a much higher risk of post-colonoscopy colorectal cancer compared to patients whose physicians had ADRs in the higher quintiles, particularly, say, 23.9% and higher, or even the higher quintiles, such that each 1% increase in ADR was associated with a 3% decreased risk of cancer. And there didn't seem to be a threshold effect where the ADR kind of maxed out. Now, again, there weren't very many people, physicians, in the highest quintile ADR, so the same database was updated and published much more recently. And this time, it includes that same Kaiser Permanente Northern California system, but also other Kaiser systems. The number of physicians is a lot larger, 383, so they have a bigger range of ADRs for these physicians. And then what this shows is the graph on the bottom left shows that the risk of post-colonoscopy colorectal cancer seems to be inversely proportional to physician ADR, such that you can see that for physicians with ADRs, as they start rising above 25 and then actually 35 to 39%, the risk seems to be much, much lower. Now, again, not many physicians had these higher ADRs, so the confidence intervals are wide. So in the study, they found that a median of 28% was associated with a lower risk of post-colonoscopy colon cancer. And these weren't just incident cancers. These actually translated to a lower risk of dying from a post-colonoscopy colon cancer, which is a very, very important outcome. Again, you can see that the higher the ADR, the lower the risk of dying from a post-colonoscopy colon cancer in the graph marked B, and there seems to be a nice inverse association. So this tells us that our current benchmarks may be too low to actually provide maximal benefit. And higher ADRs are also possible and are being reported. So just to remind everybody, ADR during colonoscopies is a measure for average risk men and women, now 45 and older. And in the new guideline, we've actually flattened all the indications. So now the ADR includes all indications. And this is based on data showing that the ADR between the different indications was similar enough that pooling them gave meaningful differences. This makes it also much easier to operationalize and measure. And that way, you also can increase the denominator, which helps make the confidence intervals narrow. So the new ADR is all indications, excluding abnormal stool tests or patients with IBD or other special indications. And the new benchmark is 35%. So the goalpost moved from 25% before to 35%. And this is a blended rate of 40% or higher for men and 30% or higher for women. Now, again, just a reminder that this is a minimum threshold and practices should be thriving for ADRs much, much higher than this. Also, for a lot of practices that might be seeing patients after an abnormal stool test follow-up, the ADR benchmark, should they want to do it separately, and if that population is large enough in their practice, is set at 50%. So separately calculate ADR for patients that may have had stool test as a screening test, it was abnormal, and for that colonoscopy, 50% was the ADR benchmark. Sessile serrated lesion detection rate. So we've long struggled with this because we know that the sessile serrated lesions are extremely challenging for us to find and distinguish. They tend to be very subtle. They have irregular borders, cloud-like or burst-like appearance, as you can see in these pictures. So we finally set a benchmark now, and this benchmark is 6%. So this is a new benchmark to measure sessile serrated lesions. So they should not be part of your ADR, but measured and reported separately, and the benchmark is 6%. Some of the data that this number is based on, and the sessile serrated lesion includes sessile serrated polyps, traditional serrated adenomas, large or proximal hyperplastic polyps over 5 millimeters. So the average sessile serrated detection rate from 5 million colonoscopies over 4,000 endoscopists in our analysis that we did was 6%. So that kind of gives us a good benchmark of 6% being the correct number. And is it associated with post-colonoscopy colon cancer risk? The answer is yes. The New Hampshire Colonoscopy Registry compared endoscopists with sessile serrated detection rates less than 3% to anything higher, and physicians with sessile serrated detection rates 3% to 9% had a lower risk of post-colonoscopy colon cancer, and physicians with 9% or higher sessile serrated detection rate had even a lower risk of post-colonoscopy colon cancer in their patients. So again, this and other compelling data suggesting that it should be measured, and 6% is the benchmark. And then withdrawal time. In the previous guidance, 6 minutes was suggested, and that time has been lengthened to 8 to 9 minutes during withdrawal. And this is time spent just inspecting the colonic mucosa, not including time to take biopsies or perform polypectomies or other maneuvers. But really, this time is to be taken to have a good withdrawal technique, and the four hallmarks are adequate distention, washing and cleanup, looking behind folds, segmental inspection, and subjective timing. Because we know it's not the time that's important, but what we do in that time. And is withdrawal time associated with these post-colonoscopy colon cancers? The answer is, again, yes. This was a study from a large community practice in Minnesota, and you can see that physicians' withdrawal time was inversely proportional to interval cancers over the next 5 years, such that anything shorter than 6 minutes had a very high rate of interval cancers. 8 to 9 minutes was truly the sweet spot, and this is with adequate ADR benchmarks. So it does provide some extra benefit in addition to ADR. And then again, a study demonstrating time alone isn't enough. This study looked at technique during that time, so they mandated a withdrawal time of 6 to 7 minutes. But really, the technique of the better endoscopists led to the higher ADR. The next updated quality indicators are resection measures. For the first time, we've now again acknowledged something that is very intuitive, but we hadn't put in the guidelines before. Detecting is only half the game. Complete resection is extremely important, because these incompletely resected polyps are obviously risk factors for interval cancers. So the resection measures that apply to most of us are the following. Percentage of polyp resections for which the report documents the lesion size, shape, location, and method of resection. So again, completeness of report is extremely important. It helps us plan surveillance, and it really tells us what needs to happen based on the polyps size, location, morphology, and how it was resected. And then polyps between four to nine millimeters should be preferentially resected using a cold snare. Again, a lot of accumulating data showing that cold forcep biopsy leads behind tissue and really cold snare is a better technique for complete resection. So the benchmark that's been set is 90% or higher polyps between four to nine millimeters should be resected using a cold snare. And these are the vast majority we see in our practices. So some data supporting that recommendation, a large study with almost 350 neoplastic polyps by 11 gastroenterologists, and the incomplete resection rate was 10%, which is very high. And it was significantly higher for larger lesions, as one would suspect, and also higher for sessile serrated lesions. Again, emphasizing the importance of detecting and completely removing sessile serrated lesions. And then the consequences of these incompletely resected polyps were that on follow-up colonoscopy, the risk of finding an advanced polyp or cancer was much greater in sub-segments where incomplete resection had occurred. There was also greater risk of advanced neoplasia. In fact, when they did the analysis of factors associated with risk of neoplasia at that next colonoscopy, what was the strongest factor was incomplete resection rate. So again, if we are going to give patients confidently the appropriate surveillance intervals, complete resection is of paramount importance. And then another one that we did propose is the APC, or adenomas per colonoscopy. And the reasons behind that, ADR is a very important and validated metric, but it has that limitation of one and done, meaning perhaps after the first adenoma removal, the endoscopist may not be compelled to look for any more as diligently. So the APC essentially gives you credit for number of adenomas per colonoscopy. So it's the number of adenomas over total number of colonoscopies. And studies have shown that once endoscopists achieve a good ADR, what really distinguishes them is the APC. And as you can see in this study that we did, physicians with adenoma detection rate of 25% or higher, there was still a separation between low and high APC rates. APC rates are associated with adenoma misrates, and they're also the APC is associated with post-colonoscopy colorectal cancer rates. Again, making it an important indicator, again, getting the ADR adequate and as high as possible is the first thing. And if practices are looking for then looking for a deeper dive into quality of adenoma resection, then APC might be something you could use. So the way to approach it, if the ADR is adequate, then you could consider APC as an additional measure because it is a little more burdensome to measure the number of adenomas per colonoscopy. But they go hand in hand and they are comprehensive and complementary is how I would think of them. Here's one study that I've highlighted that shows the relationship between adenoma detection rate, polyp detection, and APC. So this was a large Polish colonoscopy program. You can see 173,000 colonoscopies, and they found that ADR is associated with post-colonoscopy colon cancer and risk of colon cancer death, as well as polyp detection rate, as well as adenomas per colonoscopy. And the way they translated is an ADR of 25% translated to a polyp detection rate of 43% and an APC of 0.37 or 37%. So again, you know, they kind of correlate really well, but maybe some discriminatory value. So I'll put it all together for you. Here's the new list of quality metrics and where they are currently and what the updates are. And some I didn't get a chance to present, but I encourage you to look at the document that's attached with this webinar and several other ones that are complementary to the presentation. So adequate bowel prep, the current benchmark was 85% or higher in all cases. It's now been updated to 90% or higher for all colonoscopy cases. Withdrawal time, that was anchored at six minutes or higher. Now it's eight minutes or higher. SQL intubation rate was at 90% or higher. And in the updated guideline, we realized that it's kind of many practices have achieved this and it kind of tops out. So it may not be as meaningful. So you could consider measuring it intermittently, especially if the endoscopists are high performers. Adherence to surveillance guidelines is still at 90% or higher. Resection method and resection documentation are new and complete documentation in 98% or higher of resections and cold snare use for polyps four to nine millimeters in 90% or more of the cases. And just to summarize, it requires multifaceted interventions to address some of these indicators and some of the things you can think about. And we've attached several documents for you to review this topic comprehensively. But think of interventions in these broad categories is your practice using report cards and feedback, perhaps educational interventions. Certainly this webinar qualifies as one techniques and role of technology. And there's a AST document that we prepared where we summarized each of these techniques that you could try in a lot of detail and what benefit you could expect to drive from that. So again, it's attached to this webinar and something for you to use as a resource. So I'll summarize. Colonoscopy quality is key to effectiveness. ADR is a validated quality indicator. There's new minimum benchmarks for ADRs, that's isolated detection, withdrawal time and resection. Monitor quality of colonoscopy and there's many tools available to you to improve the quality. So with that, I'll turn it over to my colleague, Sophie King. Great. Well, thank you. That was quite an extensive discussion, Dr. Shaukat. And I'm thrilled to be here and to talk about IBD quality indicators, which was very insightful of the group to try to want to include. And so the first point of discussion is the what. And so the what here is the percentage of colonoscopies that are performed for the indication of ulcerative colitis in which a formal assessment of disease extent and activity is recorded. And we'll talk about what some of those score options are. And then the percentage of colonoscopies performed for the indication of Crohn's disease in which a formal disease activity score is reported. And we're going to talk about those as well. And then third, the frequency of appropriate recommendations for a follow-up surveillance colonoscopy interval for those patients who have ulcerative colitis or indeterminate colitis or even Crohn's colitis that involves more than a third of the colon who are undergoing dysplasia screening without dysplasia detected. And so a little bit of a difference here, obviously, from what Dr. Shaukat has talked about, where there's a lot of data and evidence about the specificity of some of these indicators. So here, the indicators are the use of a scoring system to reflect disease activity. Okay, so why? And again, we've seen all of the data about cancers, missed cancers, lesions, polyps. Here, we are trying to talk about the fact that we do have validated indices with specificity to help better communicate disease activity. And we all have seen in clinic those patients who have been referred or who are coming to see us who bring reports, and it just says severe colitis. And you're like, well, that's not helpful. And so trying to use these indices is a common language where then you get the sense of whether it's mild, moderate, or severe, and not just based a lot of subjectivity and expertise of the person who is performing that endoscopy. And also, you know, in certain parts of the country, we have colorectal surgeons who are performing endoscopies. And certainly, they're not as knowledgeable or educated about how to talk about ulcerative colitis or Crohn's disease. So the other thing too, is if you are doing that index endoscopy for disease diagnosis, or you are doing that baseline endoscopy before you're going to start a new therapy, it's important to be able to appropriately discuss and communicate that disease activity so that you can appropriately gauge response to therapy. And so for ulcerative colitis, the Mayo scoring system is what's commonly used, and probably because it's just the simplest, and it is very translatable across practices. For Crohn's, the indicators place more importance on disease activity scores, and that validated indices categorize inflammation per section of the colon and the small bowel. And the reason there, obviously, is because we can have skip lesions when it's actually Crohn's. And separate than the native bowel is importance of describing disease recurrence in a neoterminal ileum for post-op patients, and that's the Ruttgerd score. So there is a subtle nuance and difference here when a patient has actually undergone surgery for their Crohn's. Here's the how. So I mentioned that there are multiple indices, and if we just look at this snippet now. So here at Mayo Clinic, we use provation, and so that's all I can talk to. Now, I will tell you that in two years, we are transitioning to lumens, and unfortunately, nobody from the care team was knowledgeable enough yet to be able to share with me what that's going to look like for IBD, because they haven't built that set of report writing indices yet, but I suspect that it will look similar to what probation offers. So here is an example in probation that in the findings section, there is a separate category for inflammatory bowel disease, and you click over, and it gives you the four different indices. When there is previous history of surgery, and you want to use the Ruttgerd score instead for recurrence, that actually is under the lumen tab. So for the Mayo score, the definitions are supplied. If you were to click on each one of these for the CDEIS, which is the Crohn's simple endoscopy score, the program is very nice in that it walks you through each section and auto-calculates a score for you. So if you click on the Crohn's, it starts with ilium, then does cecum, and then transverse, descending, and sigmoid, and rectum, and it's a score between three and zero, and you can score the segment as a zero, and as you are going through, each of one of those scores has the definition, and it will auto-calculate a disease total score at the end automatically for you. There is agreement amongst us here at Mayo that we use the Mayo-Endo score for ulcerative colitis, and the SCD, so CDEIS for our Crohn's patients, and the Ruttgerd score for any post-op patients. But I think it's important that there is just agreement amongst the practice members of your group which scoring system to use for consistency and standardization. Whichever one you use, just stick with it, and it's still going to be the same language if that patient goes to another practice or institution, because we understand what goes into each one of those indices. And I think that it's important that if you have APPs in your IBD practice, or who see IBD patients, that the APPs understand the significance of these scores. And so being able to just say, well, that they have a Mayo score of three, means, yeah, this patient is really sick, versus a Mayo score of one, well, you're going to have the luxury of being able to think about what you really want to do for that patient based on other parameters. An APP may not understand the CDEIS score of 20 versus 40, and I would say that a lot of gastroenterologists wouldn't necessarily know. And that it really depends on where is the severity of the disease, that it might give you a high score in just one section. If you have a stricture, that that gives you a higher score automatically for that section. It's really important to have everybody on the same page to understand which index you're going to use, and the definitions for each one of those things. And I think for the Rootgard score, that again, it is for the post-op patient who you are assessing the neoterminal ileum, so this is a patient who has ileal Crohn's, and not any significant colonic disease, and that you are assessing the neoterminal ileum after surgery, and that the score is zero to four, where zero is no aptis ulcer seen, and that a score of four is where there is gross inflammation, ulcers, maybe even a stenosis there. And it is important to understand that the Rootgard score is for the neoterminal ileum, not the anastomosis. So you can have ulcers on the anastomosis, and that is not recurrent Crohn's disease. You know that my section was way smaller, but again, that we've, we realized the importance of trying to use the same language across patients, and across practices with the institution of these quality metrics for IBD. Thank you so much, Dr. Cain and Dr. Chakot. Before we switch to questions, I'm just going to review a couple upcoming events, both by ASGE and ACG. First one is improving quality and safety in your endoscopy unit. The end of October, it's October 26th, and this course is appropriate for all members of an endoscopy unit team. The next event is taking place at the ACG annual meeting in Philadelphia, also at the end of October. And then also at ACG, CI Quick will have an exhibit booth where we can display the registry and answer any questions. So I'm going to turn the presentation over to my colleague. Thank you so much, Lori. This is Eden Essex. I am the Assistant Director of Quality and Health Policy at ASGE. So you guys know me both wearing a GI Quick hat and my hat with the endoscopy unit recognition program. This document's out, and it's this amazing update. And so thank you, Dr. Chakot and Dr. Cain. You and the whole writing committee did an absolutely phenomenal job in terms of upping the game for all of us. So, but that also brings the question of timing and kind of what considerations. And the writing committee was very thoughtful and recognized that people are going to have different circumstances relative to how feasible it's going to be for them to change. I mean, some of the people on GI Quick were going to have those measures available in the registry in the near term, so you're aware of that. But if people don't have a resource like that, I'll just start with you, Dr. Shaka, what considerations should people have in terms of kind of starting to move from ADR screens only to ADR with all indications? Yeah, that's a great question. Actually, we try to simplify the ADR measurement because indications are problematic. We all know that they can be fuzzy and interpreted differently, so they're not always accurate. The second thing is a lot of programs and practices have trouble extracting only screening exams or may not have enough screening exams to really make a meaningful ADR calculation. So flattening the indications to all indications actually simplifies the work quite a bit. So now you don't have to parse out which indication it was and put them all together, with the exception being, you know, again, inflammatory bowel disease or those that were done as follow-up of abnormal stool tests. So we're hoping this will simplify and help practices and not make it more complicated. So if I didn't have a resource like GI Quick, and let's just say I'm doing manual chart review, I don't have to find 25 to 50 screening colonoscopies anymore. I can just find 25 to 50 colonoscopies on, say, a quarterly basis and make sure none of them had a positive stool-based test. And if not, then that's what I include in my calculation. Is that what we're hearing? Yes, absolutely. So you'd have, you know, larger numbers to pick from. Hopefully things will go quicker and, you know, more recent data, too. You don't have to go as far back. So one consideration that I will point out for those people who do use the GI Quick registry and may report through our Qualified Clinical Data Registry, we do have to turn measures into CMS ahead of time, and they approve those measures for what is used for public reporting. So if you are using the Qualified Clinical Data Registry benefit, the expectation would be that for the purposes of that reporting, and again, the measure report is already built in GI Quick, so it's really one click there, that that would be the screening, it would be ADR with screens only. And we have self-nominated to be a QCDR in 2025, and it's screens only for that as well. So that's a consideration, but it doesn't mean necessarily, would you agree, Dr. Shaka, that they couldn't, you know, use the one for public reporting but start moving to really using the all-indication ADR as part of their quality improvement program? Yeah, absolutely. And then you'd be kind of poised to pivot to an all-indication ADR when it does eventually make it into the quality measures that you submit. So and again, it should be more straightforward to do. So perhaps starting to work on that metric and what it looks like, getting the kinks worked out would be a great place to be. When people make that move in their quality improvement programs, they should just really note, we moved from this way of measuring it to this way of measuring it, is that just kind of to make sure everyone's on the same page, they want to make sure that this is communicated because they would expect to see a difference in the quarterly reports from 2024 versus whenever, say they started January 1 with all-indication ADR, they would expect to see a big difference there, and they're going to want to make sure everybody understands that. So communication is a big part of this as well. Yes, absolutely. And then obviously getting your providers on board and there isn't a hard deadline when you should get started. It really should be tailored to your practice and your needs and really be done at a time when everybody is, you have buy-in from everyone and it can be done seamlessly so that it can be sustained. That makes a great point. And it goes back to what you said earlier in your presentation about really downloading the handouts, and we have four handouts, everyone, just to remind you, and really reviewing those all as a team, like, you know, quality as a team sport, we like to say, so get your quality committee together, make sure everybody's read these documents and discuss them. In the documents, we do have priority indicators. Is it best that they start the discussion there and then start kind of folding in maybe sessile serrated lesion detection rate and those considerations? Yeah, absolutely. So focus on the priority indicators first and make sure you are either measuring them or have a good plan of measuring them and updating that measurement based on changes, what you might be doing versus what the guidance is suggesting, and then moving on to some of the other ones. As the document goes, we've kind of tried to demark some of those differences. So the idea isn't to be overwhelmed by kind of throwing a whole kitchen sink of different indicators at you, but going about it very systematically. So we have a question that had come in. So one person says, my centers are seeking clarification on the eight-minute withdrawal time recommendations. If an endoscopist has an ADR of greater than or equal to 35 and has an average withdrawal time of 6.5 minutes, does the endoscopist need to increase his or her withdrawal time to eight minutes? Right. So this often comes up and some of the compelling data is for also detection of CESA and SIR rated lesions. There, the optimal withdrawal time is considered to be eight to nine minutes. And then you're already at an adequate ADR, perhaps there's some incremental benefit to be gained by perhaps increasing the withdrawal time by a minute or so and seeing if that also improves the ADR. Because remember, the benchmarks are minimum thresholds and higher ADR leads, we think confers higher protection, at least up to a certain point. So that might actually confer additional benefit to what you're getting right now. So our next question is, what is the minimum number of colonoscopies to get an accurate ADR? 200, they suggested? Well, you know, the bigger number, the better, which is why an all indication ADR is, you know, I'm very excited about it because depending on which setting, sometimes, you know, the indication can really limit you. So the bigger the number, the better. So the more you can include, the better anything, you know, triple digit or higher. So 100 or higher, you start to get some stable estimates. Anything less than 30 tends to be very unstable in the literature. So there isn't a hard and fast number, start wherever possible. You also need to assess the burden. If an endoscopist is only performing 30 colonoscopies a year, you know, it's not a big chunk of the entire practice's endoscopy. So really focusing on the high volume providers first is really extremely important because they're obviously, you know, seeing more patients and it has bigger consequences. Perhaps 100 to 200 in the denominator would be, you know, would be kind of an optimal minimum. Our next question is, how will bowel prep impact the new ADR measure? And they write specifically as the new ADR will include cases beyond screening colonoscopy. Yeah, so bowel prep is obviously, you know, extremely important. We have a separate document coming out pretty soon from the U.S. Multi-Society Task Force on bowel prep also. So as we improve the bowel prep, there is an association of better bowel prep leading to higher adenoma detection rate. So we hope that those are some of the things that go hand in hand and will help us improve our ADR to these new benchmarks. Same argument for withdrawal time because these measures are, you know, independently important, but they also improve the adenoma detection rate. So you are correct. Some of the improvements in bowel prep and the new benchmarks were taken into consideration when proposing the higher ADRs, and we think these existing changes make the ADR more achievable. Our next question is, what is the goal for the new APC metric? And I believe we had APC in the last version of the document as well, but where it seemed to be emphasizing it maybe a little bit more this time around in terms of putting it in combination. But is the APC measured for all colonoscopies? So the APC is also measured for the same colonoscopies that you would do the ADR for, you know, just for simplification and keeping it simple. And we actually didn't give hard and fast metrics because the numbers vary from 37% to up to an APC of 0.37, all the way up to 0.7. But the study that I showed you, you know, suggested a minimum of 0.37. So somewhere at 0.4 or higher is what's desirable. Again, it's not one of those that you need to jump to. Getting the ADR improved is the number one step. And you may never need to use the APC, really. It's for practices because we often have this question that now that I've achieved a high enough ADR, what else can I do to demonstrate that I'm a high-quality colonoscopy performer? So that's where APC might come in. Collecting it is much more burdensome because it requires count of individual adenomas. So that can be a little tedious. And sometimes we can't even do it in every procedure, where sometimes we put multiple polyps in the same jar. So with those caveats, it still has value, which is why it's not a key priority indicator. So something to come to a little later. An interesting question just came in, and maybe we'll start with Dr. Cain, give Dr. Schalkat a break here, but Dr. Schalkat might want to chime in on this, too. What kinds of considerations are taken into account for physicians specializing in IBD who typically have lower ADRs, this person writes, when evaluating their benchmarks? You know, thank you for... I was almost falling asleep for Dr. Schalkat was having to get through everything. But yeah, this is a phenomenon that is real. So if you are an, quote unquote, IBD-er, and you scope IBD patients, and you don't do a lot of screening or surveillance colonoscopies, our ADRs are lower. And so our leadership has always said, well, it's because they're used to seeing different things on endoscopy. And as the person who's in charge of credentialing and quality metrics here, I don't buy that. You're a gastroenterologist first, and then you're an IBD second. And so it's a real phenomenon, but I think it's because, just as Dr. Schalkat just said, you have to... You know, more is better for calculation of your ADR and your other metrics. And if you only do the random surveillance or screening colonoscopy, but predominantly you're doing IBD cases, you're going to have a low end. And so the only way to fix that is to do more non-IBD cases. But it's definitely a thing, and it likely has to do with just the end, as Dr. Schalkat has pointed out. Well, I think we'll stick with you, Dr. Cain, here for a second. We'll let Dr. Schalkat take a little nap this time. Do you put scope on narrowband imaging lights on withdrawal for all colons or just with IBD? I do it for all. Here at Mayo, we have open access, and I scope all patients, not just my own IBD patients. And so if it's an IBD patient with colonic disease, I'll use NBI, and then I use a cap and NBI for my screening and surveillance for polyps cases. And then this person writes back in, the graph was showing increased adenoma as withdrawal time was prolonged more than 12 minutes. I don't know if that's the same person, but I'm not sure if that relates to the same question. Yeah. So essentially, of course, the numbers get really small, so I wouldn't read much into it. But increasing withdrawal time beyond eight to nine minutes didn't seem to confer added benefit. And there could be several reasons for that, right? Because people could be taking longer time to withdraw because they're having difficulty holding in a segment or other maneuvered difficulties. So essentially, we don't see any incremental benefit beyond eight to nine minutes, which is why we think that's the sweet spot. And the data with CESA and serrated lesion detection also shows similar results. And a clarifying question on withdrawal time here, is withdrawal time average time per physician or for every patient? Yeah. So it's average per physician. And it's, again, calculated in essentially patients where nothing's found, essentially negative colonoscopies, where the physician or the endoscopist is essentially taking the time on withdrawal for inspection. So you could take it on a subset of exams where nothing was found, otherwise, it gets a little complicated. You have to then start and stop a clock or take out time for any maneuvers, which again can be really difficult and does not give you accurate data. So I would just use procedures that, you know, where nothing was found and average that withdrawal time per provider or quarter or however length of reporting that you're using. Excellent. And we're going to sneak in one more question. It's kind of interesting. Is the calculation for ADR for patients for 45 and above only, and, you know, the lowering of the age from 50 to 45 was fairly recent, but I'm wondering if this person is getting at, if we're going to think about lowering it any further. So what are your thoughts on that, Dr. Shakhnaz? Yeah, good point. So this is because we lowered the screening age to down to 45, and we are all starting to see patients in our practice for screening, you know, at age between 45 and 49. So the idea is to include those patients. And then, you know, separately we've presented before that ADR sometimes tends to be a few percentage points lower in that population. So they're not a large chunk of the overall colonoscopy population. So you know, the effect dilutes out, but that again tells us that we should be really working at trying to improve our ADR. And whether it will be lowered, well, it all depends if in the future there's any changes to the guidelines to dropping the screening age, then we will review the quality indicators also and see if those should be dropped to 40. And then again, whether this current benchmark would be sufficient or would we need to make changes to it. And really the importance here is doing it consistently right now, whatever your parameters are. So thank you, Dr. Shalkot, Dr. Cain. This was a wonderful presentation. I will hand it back to Lori Parker. Great. Thank you. And one of the most important things we want to do before we close is recognize definitely Dr. Cain, Dr. Shalkot for the wonderful presentation and the contribution to medicine, specifically to gastroenterology. For those of you who don't know, September is when the medical community celebrates Women in Medicine Month. And it's a time to acknowledge and honor the significant contributions to all the women in the field of healthcare. This annual observance truly does underscore the invaluable role that female physicians, researchers, and healthcare professionals play in advancing the practice of medicine. So we felt like this was a prime opportune time to say thank you to Dr. Cain, Dr. Shalkot, to all those women in medicine listening either live or to the recording. And just one final appreciation to all. This was some very useful content. We have a feeling this will instill even more questions in the future. Thank you, everyone, and have a great rest of your day.

colonoscopy

quality indicators

adenoma detection rate

sessile serrated lesion

resection quality

IBD-specific indicators

gastroenterology

Laurie Parker