So, I'm going to bring back all of our esteemed speakers. Rahul, Jason, thank you so much. We wanted to move to our first interactive discussion. We'll take any questions from the audience. Julie, I think there are two really excellent questions in the Q&A that I read. Maybe we can start with that and then hopefully do one case if that's okay. Sounds great. Excellent. So, I think these questions, I'll start with Dr. Dominic. So, Jason, with the 45-year age cutoff change, how do we sort of now interpret and where do you see the ADR, but in general, the colonoscopy metrics heading to? That's a great question. Thanks for putting that in there. So, the new document that's being worked on right now is going to address that issue officially. So, all I'm going to say is unofficial. There are a couple of papers that have looked at the rate of adenomas in people 45 to 49, and it's pretty similar to the rate of adenomas in people 50 to 55 or so. It's a little bit lower, but it should not impact your adenoma detection rate in any significant way. So, given that the benchmark is only 25%, you know, there's no recommendation right now to lower the benchmark. So, short answer, yes, you should include 45 to 49-year-olds, and you don't need to lower the ADR benchmark to account for that. Can I jump in with a little question? This is Eden. How should people, should people document this in their QI programs when they've made this change, this change in their denominator, or is the change going to be so slight in what we'd expect for ADRs that you don't need to make that note? Yeah, that's a good question. I mean, I think you should document when you change it. You know, if you start reporting people, the physician's ADR over time, you might see a slight decrease, but I don't think it's going to be very substantial, to be honest with you. The literature, there's a paper by Peter Liang and colleagues, there's a paper by, I believe it's Trivedi is the other one. I think that's my shot, because it's got a paper on this topic, so. Excellent. And just to follow up on that, I think colonoscopy, and then I'll turn over to Uli. The withdrawal time of, you know, the question was, should we increase the withdrawal time to nine minutes? And so, I think the six minute has sort of, you know, been sort of ingrained into our minds. So, how do you see that withdrawal time changing, and where do you think that the societies are going? Yeah, my, again, I cannot speak officially, because I, you know, the documents need to undergo review by governing boards and whatnot, but I would not be surprised to see the recommended average withdrawal time increase, based on the graph I showed you from us, Michelle cut. There's two aspects to it. One is what's your average withdrawal time, and then is there a minimum withdrawal time? I am not the fastest endoscopist. I might be on the spectrum of being one of the slowest endoscopists. I don't know. I generally spend well more than six minutes. I don't know if I've ever done a six minute withdrawal in my life, to be honest with you, but there are great endoscopists who say that you can do, you know, a straight colon, very clean prep, you can do it, you know, in under six minutes, and do a high quality exam. For me, I always end up having to do a lot of washing, so I don't see that. But, you know, so, but if you end up with an interval cancer, and you've documented, you know, a five or six minute withdrawal time in the chart, I do worry about medical legal ramifications. So, you know, there is no established minimum. It's all about your average, but I do worry if you do have a quick withdrawal, you better be documenting, I think, you know, this was an incredibly clean colon with very straight colon, therefore we're able to do a high quality exam in X minutes. I think otherwise you might be at risk in a lawsuit. Yeah, great point. So Julie, do you want to take the bleeding question? Yes. So one of our audience members mentioned the recent meta-analysis that was in GIE that suggested second look endoscopy is non-inferior to no second look endoscopy in patients with acute peptic ulcer bleeding. And so our subsequent quality measure recommendations likely to take this into account for future consideration. I think that's a great point. That paper that came out in GIE did review nine, I think it was nine RCTs that looked at this particular question about second look. They did say that the level of great evidence was low to moderate. So it will be interesting as to what our next quality measurement recommendations are going to be after they sort of tease out the state a little bit more. I presume that it might be a little bit different when we look at the types of bleeding stigmata lesions that we're talking about. And so I think it's going to be very difficult to say broadly. But yes, that paper was important to talk about this exact issue. Do you guys have any thoughts about that too? Yeah, I'm not familiar with that specific paper, I'm afraid. But is it, you know, a second look just to see if it's healed is not recommended. But if they're having active symptoms, that's a different issue, right? Yes. It used to be the practice of, you know, you see you have a patient with a bleed, you go and you scope them, you treat it, then we would routinely do a second look to check on it a few days later. That has fallen out of favor. Yes, we don't have to do that. But I agree. If there is an indication or clinical suspicion that the patient is re-bleeding, particularly, I find it useful when you talk to your colleagues, you know, just give them a call. Hey, I saw that EGD you did yesterday, you know, that gnarly vessel, you know, did you really think you felt you got it well? Or, you know, that conversation I say goes a mile versus actually just reading the report. It's very helpful to talk and communicate. And that's, again, goes to what we were all talking about, which is, you know, this is an active team sport. Wonderful. I think we have five minutes. Julie, do you want to tackle a case scenario just to kind of get people engaged? Sure. So, I think we can do one. May, Eden, would you mind bringing up? Yeah, we should have the slide on screen. And the case reads, when reviewing your colonoscopy quality metrics, you are pleased to see that the group average ADR is 42%. However, you discover that your most productive physician has an ADR that is 26%. Upon further examination, you note that the same physician has an average withdrawal time of six minutes, while the other physicians are averaging eight to 10 minutes. This physician's metrics meet the current benchmarks. What, if anything, should you do? Yeah, this is a great case to discuss because it's not, you know, it's not just imaginary. This is real, right? I mean, I don't know if this specific case is real, but I've definitely seen this. I've heard this. I've consulted with a practice that had something along these lines. You know, I'm curious to hear what Rahul and Julie think about this. What would you do? Julie, I'll let you go first. Yeah, you know, I agree with you. I think it's actually a pretty common scenario that, you know, may be casually discovered when you talk with your colleagues or your endoscopy manager. But it's actually a tough conversation. I'm not sure how I would approach it. You have a lot of experience, Jason. Tell us how you consult. Well, I mean, so, yeah, and so as the executive director for GI for the VA, we've got 150 endoscopy units around the country, and we look at their adenoma detection rates. And, you know, my role has been shifting over time from policy to operations. And so, you know, looking at this data, I've had some uncomfortable conversations with some places. You know, people say, well, my adenoma detection rate is, I just had one a couple of weeks ago, my adenoma detection rate's above the benchmark. What are you talking to me about for? Like, what's wrong? It's like, well, the average adenoma detection rate in the VA is 50%, and yours is 36%. You know, what do you think's going on? Right? You know, 36% sounds great when you look at the benchmark. When you look at who you're comparing it to, it's not so great. And it's a difficult conversation. You know, they're going to say, well, I haven't had any interval cancers. Well, those are relatively rare. Or maybe they don't know about them. So, you know, I think this takes, this is the art of administration. I don't know how good of an artist I am in this regard. But if you're the quality manager for your practice or the senior partner or what have you, you know, you, I think you have to have that conversation in a non, you know, as non-confrontational as way as possible. You know, people will say, well, they're more productive, right? They're doing it. This is a highly productive position. Their withdrawal time is shorter. You know, maybe they're doing an okay job. Maybe they've got patient population. They're going to say, the usual thing is people get defensive. They say, well, my patients are different. I'm doing, you know, I've got a lot of IBD patients in my population. I've got more young patients. I've got more women patients. And so the more data you have to compare that, to adjust for that, the better. Like for the case I was talking about earlier, they said, well, I'm doing a lot of IBD. And we use all indications. So I looked at their FIT positive adenoma detection rate and I showed them that their FIT positive adenoma detection rate was 15% lower than the FIT positive adenoma detection rate for everyone else in the VA. You know, so the more data you have, the better the conversation can go. But it's hard. Yeah, I agree. I think data is probably, you know, something that is, you just have to tear off that bandaid and show them. But I agree. I agree. I think in this kind of situation, a simple report card may not do it. Yeah. I think the human element, and I'd be interested, we're going to run out of time in this, but I'm sure there are many in the audience who have a lot of experience in real life and how they handle this. But I think the human element goes a long way. I think doing this in a very sort of transparent, non-punitive manner and how we present that goes a long way. So, Julie, I'll give it to Jason. Were you going to say something? I was going to say, you know, no one wants to be below average. No one wants to do a bad job. Right. And so you just have to work with them to help them see where they might be falling short and help them achieve the outcomes you all want. Julie, I'll turn it over to you. I think we're spot on time to close. Yep. We are now going to transition to a break and we will see everyone back in about 15 minutes at 11 a.m. Central Time. Thank you.

colonoscopy metrics

quality measures

adenoma detection rates

withdrawal time

second-look endoscopy