There's been a big update in the colonoscopy quality indicators document, and we'll review some of those changes today and hopefully improve, help you understand how to actually incorporate this into your practice. So these are my disclosures, and the main objectives and the outline for today is to review the update to the quality indicators paper and document, and particularly highlighting new priority indicators, review some rationale for these indicators and what the targets are. We'll do kind of a broad survey of the additional indicators that are not the priority ones, and then a little discussion about improving quality. In terms of diversity, equity, inclusion, high-quality colonoscopy is the expectation for every patient, regardless of their background, and the benchmark for adenoma detection does vary a little bit for men and women, but I'll be talking mostly about a kind of a universal measure. Why does quality in colonoscopy matter? Colonoscopy is the most common endoscopic procedure in the U.S. Screening colonoscopy is associated with reduced colorectal cancer incidence and mortality. We know that there's variable performance of endoscopists, and we know variation does impact effectiveness, and I'll talk a little bit about that more. So defining elements of high-quality endoscopy and developing evidence-based quality measures is definitely a priority for our field. This is a review of some of the evidence that colonoscopy is able to reduce the incidence of colorectal cancer and prevent CRC mortality. This is from the new ASGE ACG quality indicators document. So we know that the incidence of CRC is lower in patients who undergo screening fecal blood tests. That's from randomized controlled trials. We know the incidence of right-sided colon cancer is lower in patients undergoing screening flexible sigmoidoscopy with liberal rules for performing colonoscopy based on flexible sigmoidoscopy findings. We know CRC incidence and mortality are reduced in adenoma cohorts compared to reference populations. This is all randomized trial evidence. CRC incidence in screening cohorts is reduced compared to reference populations. Case control studies in screening and non-screening populations have now demonstrated reduction in incidence and mortality. Case control studies show reductions in right-sided colorectal cancer incidence and mortality in screening and non-screening populations. We know there's evidence from U.S. population trends with overall declining colorectal cancer incidence. We also know that studies have shown variable prevention between endoscopists with different adenoma detection skills. Post-colonoscopy colorectal cancer, this has been looked at multiple different ways. This is not an exhaustive list. There was even a paper last year from Charles Cahi in Indiana at the VA there. But interval cancers range between 3.4% to 8.6% of all colorectal cancers that we find. The question of why interval cancers occur, there's definitely a concern or issue with the biological variation in growth rates of tumors. There can be incomplete removal of polyps and residual polyp tissue could grow and turn into cancer over time. There's some technical limitations in detection based on hidden mucosa, hiding behind folds and flat adenomas. Inadequate bowel prep also limits adenoma detection or cancer detection. Probably the biggest one is suboptimal examination technique. Doug Robertson looked at this over 10 years ago now, looking at eight large colonoscopy studies with a median follow-up of four years. Interval cancers were defined as between six months and three years following a colonoscopy. Based on the location and whether a polyp was removed in that segment of the colon, they defined them as either missed lesions where nothing was seen, that was over half, a probable new lesion, 24%, and probably incomplete removal, 19%. Real missed lesions were kind of the largest driver. Here's a poll question. So which of the following priority quality indicators for colonoscopy can be measured intermittently? This is from the new ACG, ASGE document. So A, appropriate surveillance recommendations, B, bowel preparation adequacy, C, secal intubation with photodocumentation, adenoma detection rates, or sessile serrated lesion detection rate. Well, it's pretty evenly distributed. So the right answer, and we'll talk a little bit more about this, is secal intubation with photodocumentation of landmarks. Generally speaking, when people are training in colonoscopy, they kind of take a while to learn how to reach the cecum, but once they are reaching the cecum regularly, they rarely kind of drop off. So it's still a very important quality measure, and it's definitely important for cancer prevention, but it does not have to be measured all the time. So there's some new priority indicators in the new document, and I just want to kind of go over those with you, and so you have it in one spot, particularly the priority indicators and their targets. So the new adenoma detection rate measure is what we would call all indication, and there's some exceptions, and I'll go over that in more depth, but the new target is greater than or equal to 35%. The old adenoma detection rate target was just for screening colonoscopies only, and that was 25%. It was 20% for women and 30% for men, but you can do a summary statistic of 25%. So the new one is 30% for women, 40% for men, but 35% kind of overall. We have a new measure, which is sesal serrated lesion detection rate with a goal of greater than or equal to 6%. We're still really focused on surveillance and screening intervals and trying to get people to accurately adhere to those intervals, and I'll talk a little bit about that, but the target is still 90%, greater than or equal to 90%. Bowel preparation adequacy had been a measure previously with a target, I think, of 85%, but the new target is 90%, and for the EURP members, it was always 90%. And secal intubation rate, also 95%. So here's another poll question. How should we measure adenoma detection rate in the current era? Should we measure only screening? Should we measure screening, diagnostic, and surveillance procedures? Should we include the follow-up of abnormal stool tests, or should we just do it whichever way that your unit can actually get it done? So this is correct, actually. It's the screening, diagnostic, and surveillance procedures. Because this is a new measure, I think Eden and I have spoken about this in terms of the endoscopic unit recognition program, we will still kind of accept the screening only temporarily while people are sort of trying to learn the new way of doing their adenoma detection rate. This question of follow-up of abnormal stool tests is kind of an interesting one. Typically speaking, after a ColoGuard or fecal DNA test or a fecal immunochemical test, the yield of adenomas is closer to 50% than the 35%, 40% you might see on a screening and surveillance patient. Some units, particularly our program at Kaiser in Northern California, will probably lump in the stool tests and probably just aim for a slightly higher benchmark than what the ASGE is recommending. But some places don't do very many stool tests. So we wanted to create a measure, if you didn't do a stool test, you'd have a slightly lower cutoff in terms of what an acceptable test was. So for now, the ASGE current recommendation is the screening, diagnostic, and surveillance procedures lumped together, which is higher than our old screening-only patients. So the new definition of adenoma detection rate is the percentage of patients aged 45 years and older undergoing colonoscopy for screening, surveillance, or diagnostic indications who have one or more conventional adenomas detected and verified by pathology. So this will exclude positive non-colonoscopy screening tests, genetic syndromes, IBD surveillance, and referral EMR or ESD colonoscopies. This remains the single most important quality measure in colonoscopy. It is the best predictor of interval cancers and interval cancer mortality. This has good evidence with a direct correlation with colorectal cancer outcomes. And the ADR target overall is greater than or equal to 35%. As I said, 40% in men, 30% in women. What's the basis for this? There was a study done by my colleague, led by my colleague Doug Corley at Kaiser Permanente. He looked at 314,782 colonoscopies, really for any indication that were done between 1998 and 2010. What he did was for each endoscopist, they looked the year prior to that colonoscopy and determined the screening adenoma detection rate from the year prior. So out of 139 gastroenterologists with a minimum of 300 colonoscopies and at least 75 screening colonoscopies, they were assigned a screening ADR percent from the year prior and the follow-up over 10 years to look for either another colonoscopy, a colorectal cancer diagnosis, the end point of January, 2011, or a termination of membership. And what you can see is that each 1% increase in the ADR was associated with a 3% decrease in colorectal cancer in between. And there was no real upper limit or no threshold effect, at least within the range of these quintiles that were in this analysis. This was very early in the whole focus on, a lot of these colonoscopies happened before there was any focus on adenoma detection rate as a quality benchmark. So there was quite a range. You know, there were some endoscopists with a 7.4% ADR, although we have other endoscopists with 52.5%. And there was no threshold effect. So there was an update to this study done in three Kaiser regions, Northern California, Southern California, and Washington, including 383 eligible physicians, 735,000 patients. This was in 50 to 75-year-olds with a negative colonoscopy between January of 2011 and June of 2017, and with follow-up through December of 2017. ADR above the median of 28% was associated with a lower risk of post-colonoscopy colorectal cancer. So again, 1.79 versus 3.1 cases per 10,000 person-years. And there was a lower risk of post-colonoscopy colorectal cancer death among the higher detectors. This one does seem to have a little bit of a threshold effect where it seemed like a screening ADR between 35 and 39.9 was associated with a lower risk of post-colonoscopy colorectal cancer and post-colonoscopy colorectal cancer death. As you got to the higher levels, I think it was kind of a small numbers effect. You can see those confidence intervals get wide, but I doubt that you're at higher risk for post-colonoscopy colorectal cancer death because your endoscopist had an ADR of 49.9%, but definitely seems like the peak was sort of at the 30 to 35 range. So this is a priority measure, and as I said, and I think we've talked about all these at this point, the new benchmark is 35%. And when we look at ADR for patients who are over 45 with an abnormal stool test, our target is 50%. This is another way of looking at the post-colonoscopy colorectal cancer risk stratified by ADR. And you can see on this, this is from that same Schaudinger paper that was in JAMA, that updated model, updated analysis. And you can see that the group that's kind of clustering with the low post-colonoscopy colorectal cancer risk was all kind of under, I'm sorry, was above 30 to 35%. And as you get into the lower numbers, either 20, 20 to 25, or 25 to 29, those, their risk of post-colonoscopy colorectal cancer are much higher. So this is kind of the basis for a lot of the recommendation that we're currently using. There's a lot of, there's been a lot of interest for a number of years in kind of looking at ADR for all indications. Tanya Kaltenbach did a study in 2021 with VA data, and generally just showed that the screening ADR, the other ADR, and the overall ADR by endoscopists in a group of 21 endoscopists was, they were very tightly correlated. So people that were high on one tend to be high on another. And another way of looking at it is this one from Doug Corley, also looking at a similar thing. And you can see there's a very tight correlation between the screening ADR, the diagnostic ADR, and the surveillance ADR. The surveillance ADR does tend to be a little bit higher when you look at all three approaches, but I think it's still, but still tightly correlated. So we, it definitely makes it simpler to be able to include more colonoscopies. You'll get a larger N in your analysis, the confidence intervals will be tighter. So in general, we're in favor of trying to lump as many different procedures together into your ADR to get a best, best estimate. The other thing that's really being focused on this year is the CES ulcerated lesion detection rate. And this is defined as the percentage of patients age 45 years or older undergoing screening surveillance or diagnostic colonoscopy for symptoms with one CES ulcerated lesion removed and documented by pathology. Patients with positive non-colonoscopy screening tests, genetic syndromes, or a colonoscopy for therapy of known neoplasms are excluded from this calculation. And in case anyone doesn't know what a SSL looks like, these are some pictures. You can tell that they're much more subtle. There's not really like a huge color change. They often are raised, but not always. And usually you see some disruption in the vascular pattern and that kind of tips you off that they're present. Often you can see an adherent mucus cap as well. So the rationale for including the CES ulcerated polyp detection rate is that the average SSDR from GI-Quick and the number we chose out of 4,000 endoscopists was 6%. There was a strong association with PCCRC from the New Hampshire colonoscopy registry. If you had a higher SSDR versus being less than 3%, there was a lower risk of post-colonoscopy colorectal cancer with the SSDR above 3, between 3 and 9%, like half the risk, and even lower risk if your SSLDR was 9% or higher. So there's a clear benefit to being better at finding these CES ulcerated lesions. They are not necessarily more risky than tubular adenomas in terms of being missed, but it's really kind of a marker of careful exams. And we think the risk is probably comparable to the tubular adenoma. So we want to make sure they get removed before they turn into cancer for sure. Okay, now, one of our targets, one of our priority indicators is surveillance recommendations. So we want to try and review some of those surveillance recommendations and see how well you guys are at kind of knowing what the current guidelines are. So when should you recommend surveillance in an average risk individual found to have one 10-millimeter adenoma on a high-quality colonoscopy? One year, three years, three to five years, or five to 10 years? Yeah, three years is actually the right answer because it's sort of less than 10 would be up to, would be like a seven to 10-year interval, but this one is three years because it's the 10-millimeter adenoma. If you have one eight-millimeter adenoma and one nine-millimeter adenoma, when would your recommendation be? Yeah, actually, seven to 10 years is the right answer. And so this kind of highlights some of the challenges of trying to get surveillance intervals correct because these guidelines are, it's complicated for sure. So the measure for adherence with recommended intervals is the use of appropriate screening and surveillance intervals, the frequency with which colonoscopies follow recommended post-polypectomy and post-cancer resection surveillance intervals, and the frequency of a 10-year intervals between screening colonoscopies in average risk patients who have negative examination results and adequate bowel cleansing. This is really the key, is that you want to make sure you had a good exam and the bowels were well prepped in order to be able to reliably adhere to surveillance intervals. The target is to do it more than 90% of the time. Examination intervals assume complete examination to the CECM, good preparation, and high-quality examination. So why do we care about this? Certainly both overuse and underuse of surveillance is a long-standing issue. People have been reporting on this for actually several decades. Screening colonoscopies are performed more frequently than indicated or without a clear indication in between 17% and 25% of procedures. This was from a paper in JGM, the Journal of General Internal Medicine, in 2022. Overuse of surveillance colonoscopy occurs in low-risk subjects and underuse among subjects with advanced adenomas. There's multiple papers showing that. There's lots of reasons that for non-adherence to polyp surveillance guidelines, the perception, there's a strong perception that a patient has risk factors not addressed by guidelines, like a family history that might be kind of outside of the currently focused on guidelines, incomplete guideline knowledge, which can happen, fear of missed polyps or cancer, questions about the strength of the underlying research, or lack of belief in the strength of guidelines. So there's still a lot of uncertainty around this. A number of investigators have looked to clinical decision support, which may help with improved adherence with the guidelines. I think this is probably better, this kind of measure of surveillance, and actually for ADR, I think what we're talking about when we talk about ADR, I think I got a little note about this, is that we're really thinking about outpatient colonoscopies for the ADR. But in terms of the surveillance issues, there's a lot of reasons why people may or may not recommend, may not adhere to guidelines. But I think we could all agree we need to do a better job. From the recent multi-society task force guideline, there was a number of kind of a summary or overview of kind of new evidence supporting the current surveillance interval. So people who have no neoplasia, there's two large cohort studies that demonstrate a reduced risk for incident colorectal cancer and mortality after a normal colonoscopy. The risk is durable for at least 10 years. There have been several studies that have shown that the risk is probably durable for at least 15 years. Low-risk adenomas, there's stronger evidence that this is really a low-risk group. There's a cohort study, fatal colorectal cancer was decreased by 25% in patients with low-risk adenomas compared to the general population. And a U.S. stigmatoscopy study followed over time. Patients with low-risk adenomas had a relative risk of 1.2 for incident colorectal cancer compared with patients with no neoplasia. But this is really kind of looking like a low-risk group. The high-risk adenomas, there's much stronger evidence that this is really a high-risk group and these folks should be followed more closely. Individuals with high-risk adenoma had higher risk of fatal colorectal cancer compared with the general population. High-risk adenomas are higher risk of incident and fatal colorectal cancer from stigmatoscopy studies. In the UK, individuals with high-risk adenomas had reduced risk of CRC if they had more intensive surveillance compared to those who had no surveillance. The Cecl serrated polyps, the evidence is actually really weak for these. But there is growing evidence that having baseline Cecl serrated polyps is a predictor of detecting large Cecl serrated polyps during surveillance. And colonoscopy surveillance after the first surveillance examination, there's new evidence that the finding of a high-risk adenoma at baseline or at the first surveillance examination is associated with a higher risk of detecting high-risk adenomas on subsequent surveillance examinations. So in case anyone missed this, this came out about, it's now almost four years ago or over four years ago. This was a multi-society task force guideline for adenoma surveillance. And this algorithm is really important to kind of keep in mind. Many sites handle this by putting a poster in the exam room or wherever the physicians are reviewing their pathology to make a decision about when the next colonoscopy is due. But it does get a little tricky. I keep a picture of this on my phone. Sometimes I'm actually looking at it to make sure I am following it closely. So again, you start with a baseline high-quality exam, complete to the cecum, adequate bowel prep, and the endoscopist with an adequate adenoma detection rate, and your confidence that you have a complete polyp or section. Then you can do a risk stratified repeat colonoscopy interval. People with greater than 10 adenomas should come back in one year. People with 5 to 10 adenomas or 5 to 10 SSPs, or any adenoma or SSP that is greater than or equal to 10 millimeters, if the adenoma has villus or tubular villus histology and or high-grade dysplasia, or usually the SSPs do not have dysplasia, but if it's actually noted that there is dysplasia on an SSP of any grade, and or if there's a traditional serrated adenoma, these should all come back in three years. The 3 to 5 year group is the patients in the 3 to 4 adenomas. We used to put 3 to 4 adenomas, all of them in the 3 year category. But if there's 3 to 4 adenomas less than 10 millimeters, you could potentially go to a 5 year interval. 3 to 4 SSPs less than 10 millimeters could also go to 3 to 5 years. Or if there's a hyperplastic polyp greater than or equal to 10 millimeters, they should go to 3 to 5 years. 5 to 10 years is the 1 to 2 SSPs less than 10 millimeters. We treat these differently from the adenomas of similar size. Those could go 7 to 10 years, mainly because of uncertainty around the evidence for their risk and uncertainty that whether those polyps are being completely removed. But remember to stick to a 10 year interval if there's a normal colonoscopy, or if there's less than or equal to 20 hyperplastic polyps less than 10 millimeters in size. This is what happens if the baseline colonoscopy has one finding, and then the recommendation from the first surveillance, and then what's found at the first surveillance, and what do you recommend? So this gets a little tricky. This is like people who've had two colonoscopies. The baseline one had 1 to 2 tubular adenomas. We recommend it 7 to 10 years. If you find a normal colonoscopy on that one, go 10 years. If there's only 1 to 2 tubular adenomas less than 10 millimeters, you can go 7 to 10 years. If you start to see the 3 to 4, then you can go 3 to 5 years. And if there's an advanced adenoma based on size or histology, or if there's 5 to 10 of those adenomas less than 10 millimeters, those would all come back in 3 years. So this looks very similar to the baseline exam. But people have 3 to 4 tubular adenomas less than 10 millimeters on their initial exam. Those people are in a 3 to 5 year category. If it's normal, then you can go to 10 years, 1 to 2 adenomas on their first surveillance less than 10 millimeters, 7 to 10 years, 3 to 4, also 3 to 5 years, similar to the baseline and high-grade lesions. The difference is really this last group, which is the ones who have a large adenoma or an advanced adenoma based on size or histology or based on number of like 5 to 10 adenomas. Those people will tend to stick to at a minimum 5 years of surveillance, either if it's normal, if there's low-risk adenomas, 1 to 2, or 3 to 4. When there's an advanced adenoma, just like if you found an advanced adenoma baseline, you go to 3 years for those folks. There is a bowel preparation measure, which is a priority indicator. Based on just keeping things simple, I'm not going to a lot of depth on this. Remember that the recommended approach is a split dose, half the dose the day before the procedure and the other half the morning of. Lists of potential interventions for people who fail a PrEP and when you want to bring them back the next time. This was reviewed by the Multi-Society Task Force about 10 years ago. The lead author was David Johnson, but an update has been promised. I think they're working on it, but I have not seen a draft or heard about any progress being made. There's lots of new bowel preparation agents, including tablets, including discussions around whether people can eat a low-residue diet or not. All those things are worth considering, but we're just going to skip over that for today. We'd be happy to address it during the case discussion. CEQL intubation rate definitely should be documented with a photograph. There's one on the right of the ileocecal valve and on the left the appendiceal orifice. The target is 95%. There's lots of evidence that high CEQL intubation is associated with prevention of colorectal cancer and failure to intubate the CEQM can lead to cost and inconvenience associated with supplementary imaging, such as CT colonography or barium enema. Some people are doing colon capsules, I think still on a more experimental basis, and then also repeat attempts at colonoscopy. There's a lot of cost associated with having a low CEQL intubation rate. The target is 95%. I believe in the older version, the target might have been a little lower, but 95% is the current target. Photo documentation is important. This is actually a picture of the terminal ileum. You can photograph the appendiceal orifice and the IC valve, or if uncertain, then intubate the terminal ileum. The change for 2024 is that you can measure this intermittently or until success is achieved. Once they become successful at reaching the CEQM, continue to do so. But for new docs in your practice, for sure, it's important to make sure that they are hitting those high numbers. In terms of other quality measures, I put the priority measures in red. The ones in black are the other quality measures that are not priority. We always want to make sure we're following the appropriate indication for colonoscopy more than 95% of the time. The FET, the Fecal Immunochemical Test, or Multi-Target Stool DNA Test, adenoma detection rate, again, as I alluded to, the target was more than 50% for those folks. There is a measure called adenomas per colonoscopy, which is meant to address the issue of what's called one and done, where people, I found my one adenoma, I can just whip through the rest of this colonoscopy and not really pay attention. There's some evidence that that is associated with improved outcomes. Evidence is not as strong as it is for the adenoma detection rate measure that we talked about. The withdrawal time used to be six minutes that we recommended based on new data. There's some evidence to believe that eight minutes is probably a better measure, but withdrawal time tends to be kind of a process measure. It's a nice target if you have people with low adenoma detection or low SSL detection to kind of make sure that they are taking enough time to look, but it's not really a proxy for good technique. You still have to have the good technique. Other indicators, we want to make sure people are documenting the size, shape, and location and method of resection of their polyps more than 98% of the time. And we also are really strongly recommending the use of cold snaring for four to nine millimeter polyps more than 90% of the time. There's lots of evidence that this is associated with lower risks of delayed bleeding for sure and perforation. And it also can speed the reuse of anticoagulants that people might need to be on this. And then post-procedure, you should make sure that you have some tracking and documentation of complications. And if they are occurring, you have some method to review those complications. And in terms of withdrawal time, eight to nine minutes with adequate distention, washing, cleaning up, looking behind folds, there's some association with withdrawal time and interval cancer, but technique is really much more important than withdrawal time. Incomplete resection rate remains a concern and then just really the approach to improving colonoscopy quality, I just want to review that for a minute. This is from a nice review that Raj Kuswani led in 2021. Really avoid late resection of high-risk patients, but have shorter surveillance for people with piecemeal resection or greater than 10 adenomas or polyposis syndromes. And really the key is to avoid overuse of surveillance in low-risk patients. And we definitely know that endoscopies quality and adenoma detection rate is definitely associated with post-colonoscopy colorectal cancer. We know that having a report card that you can share with your physicians can also help improve quality measures because it lets people know that people are paying attention, that there's a way to pay attention to all these things. We know that training can lead to improved adenoma detection rate. This was through a study where they trained the trainers, but it's definitely improvable through feedback and training. And we definitely have seen this with other studies as well. There's lots of devices you can put on the end of your scope. Those improve the adenoma detection rate a bit, but an endoscopist with good technique doesn't necessarily need these extra devices, but they could be helpful at raising awareness among endoscopists who are potentially low detectors and can be part of a training process. They don't necessarily need to continue to use these devices, but early on, that can be helpful. And definitely make sure there's a good prep, high-definition scopes, second look in the right colon can be useful, particularly with a retroflex view on the scope, cold snaring for all polyps, and patients with complex polyps should be referred for endoscopic resection and not surgery. That's another quality measure for sure. And making sure there's clear and detailed post-procedure documentation and follows surveillance guidelines. And I think report cards, educational interventions, improving technique and technology can kind of all lead to improved high-quality colonoscopy. So this is just kind of a way to, some advice about how to march your way through improving colonoscopy quality and what you should do. And then, you know, tier one for all providers, make sure there's adequate bowel preparation, use of split preps, measurement of withdrawal time, measurement of ADR, make sure they're meeting ADR benchmarks, and make sure they're adhering to surveillance guidelines and procedure documentation. When there's tier two quality improvement would be interventions to improve bowel preparation for all patients, interventions to improve polyp detection for all providers, and interventions to improve post-polypectomy practices. And then tier three, optimizing the quality, really make sure that all providers are continuously monitoring and optimizing polyp detection, optimized care for patients with large polyps, and detailed procedure documentation and monitoring of adverse events and interval cancer rates. So this is, and just a word about AI, it's definitely here, it's available. It can improve ADR somewhat, particularly for low detectors. It may have a minimal impact or a small impact on the key outcomes that we're interested in like mortality and PCCRC incidents, mainly because it improves detection of small polyps, much more so than larger polyps. So again, we just want to emphasize one last time with everyone, colonoscopy quality is associated with cancer incidents and mortality. Reporting colonoscopy quality can lead to improvements in quality. Just letting people know that you're paying attention is very important. Focus on the priority quality indicators, adenoma detection rate, cell-cell serrated lesions, recommended surveillance intervals, bowel preparation adequacy, and cecal intubation rate. Low-level adenoma detection does endanger patients, but it also can be improved. And I would encourage you to measure what you're doing because you can only improve what you can measure. And just thanks, just by being here at this course, you've already demonstrated that you're better than the average endoscopy programs because you're so focused on quality. So thank you for all that you do. Oh, I'm going to stop there and just end right at that point.

colonoscopy

quality indicators

adenoma detection

colorectal cancer

bowel preparation

surveillance intervals

patient outcomes