Hello, and welcome to a presentation on assembling an ADR Improvement Toolkit for your practice, and especially appropriate presentation for our favorite month, this being Colorectal Cancer Awareness Month. We are so pleased to welcome as your presenter, a highly regarded clinician, distinguished epidemiologist, and prolific researcher, Dr. Asma Shakhat. Dr. Shakhat is the Director of GI Outcomes and Research at New York University Langone Health. He has dual appointments as the endowed Robert M. and Mary H. Glickman Professor of Medicine and Gastroenterology in the Department of Medicine, and the Professor in the Department of Population Health. Dr. Shakhat has published extensively on colorectal cancer screening and prevention, and quality indicators for colonoscopy. You will be able to submit questions throughout the presentation. You can do so through the Q&A box. I think you all are familiar with that box by now. And we will be recording this presentation, so feel free to look for the recording of this presentation on the GI Quick website. We're also going to have it in the ACGU-verse, and we'll also have it in ASGE's GI Leap. So those are two online learning platforms from our sponsoring societies. This is a joint presentation between GI Quick, ACG, and ASGE. And without further ado, I will hand the presentation over to Dr. Shakhat. Hello, and thank you so much, Eden, for that wonderful and kind introduction. Hello, everyone, and happy March and Colon Cancer Awareness Month. Hopefully, everybody's thinking about it and doing their part in bringing patients to high-quality colonoscopy. And we'll do a deeper dive into what that means today. So let's review why we care about quality in colonoscopy. We want to be effective in what we do. In case of colonoscopy, that means detecting and preventing colorectal cancer in our patients. And we definitely want to reduce the risk of having a missed cancer after a colonoscopy. We want to be safe, which means reducing complications, doing the procedure safely. And it's tied to reimbursement through the MIPS and the APM programs, and really considered part of high-value practice. And finally, but not at all least, patient satisfaction is tied to quality. And we obviously all care about having satisfied patients and happy with their experience. So we want to be in this upper right quadrant when it comes to value and quality. Now let's review the quality indicators for colonoscopy that we think about and should be trying to maximize every day. I've listed a whole list of indicators for you, and each of these is extremely important. And we've had separate webinars on some of these other ones, such as appropriate screening surveillance recommendations. But today, I'm going to focus the bulk on the one that we obviously focus on the most, which is adenoma detection rate. So let's take a little deeper dive into what that is. So adenoma detection rate is calculated for screening colonoscopies in average-risk men and women. It used to be over age 50, but now we've dropped the screening age, so age 45 and older. And we take the total number of colonoscopies performed by an endoscopist in a given time period as the denominator. And out of those, the number of colonoscopies, but at least one or more adenoma is found as the numerator. So this gives us an ADR per endoscopist per time period. Now remember that this is an endoscopist level indicator. And the idea is that higher ADR translates to a higher quality exam, and that should lead to fewer missed or interval colorectal cancers and render the colonoscopy more effective. So in our current guidance document, the goal is set at 25%. And not to say that this is an aspirational goal, think of it as a minimum threshold. So we definitely want to be well above this number. And an aspirational ADR, for instance, would be about double this number, which is about 50%. But we should all be achieving a minimum ADR of 25%, which is a blended rate of 30% or higher in men over 50, and 20% in women over 50. So keep that number in mind. Now is ADR actually evidence-based and associated with interval cancers? We have some wonderful large studies that do give us that answer. And the answer is yes. The largest study on this topic is from Kaiser Permanente in Northern California, where they took all colonoscopies for any indication over a 12-year period. And individuals were followed for 10 years, or until they had another colonoscopy, or if cancer was diagnosed, or until they were Kaiser members. 139 gastroenterologists were included in this time period, and they had to have performed a minimum of 300 colonoscopies over this 12-year period, 75 or more screening, which is, you know, a pretty small number. And this is what they found. The adenoma detection rate of the physicians was inversely proportional to the risk of interval cancers. Physicians that had adenoma detection rates of 28.4% or higher, meaning in the highest quintile, compared to the lowest quintile, had a significantly lower number of interval cancers appear in the patients on follow-up. So this suggests that quality matters, it's operator-dependent, and physicians with higher ADRs are likely to have more effective colonoscopies, such that each 1% increase in ADR is associated with a 3% decrease in the risk of colorectal cancer. And because most of their endoscopies were up to in the fifth quintile, there didn't seem to be a threshold effect above which the benefit of ADR plateaued out. So these were pretty important data. What interventions improve ADR? And we'll spend a lot of our presentation on things that we can do in our everyday practice or with some more effort and time to improve ADR for our providers in our endoscopy units. So first I'll summarize the slide or the entire lay of the land for you. So if there was one summary slide, which would be a take-home, it would be this. And don't worry, I'll show this again at the end. So we have many tools to improve the adenoma detection rate, and it really depends on how much effort and cost we're willing to put and how many things we want to try. Again, I recommend starting at the lower left corner and starting things that we can do without too much effort or too much cost, and then increasing our interventions to things that take more effort or perhaps add cost or both. So things to think about right away are things we can do at the bedside, such as changing patient positions, second look in the right colon, or even eye exam for older physicians has been evidence-based. And I'll talk about a lot of these interventions. And then in terms of other things we can do at the bedside, timed withdrawal with good withdrawal technique, using water exchange, video recording of endoscopists and giving them feedback, and report cards are extremely essential. And then we can think about other interventions that I'll discuss. But the overlying theme to all of these is being persistent. So meaning trying one thing, but then sticking to it before giving up on it. Because again, persistence really pays when it comes to changing behavior and improving the overall quality of all providers. So I'll start with break down the interventions and how we think about them into several steps. And step one starts with measurement. We can't improve something that we have not been measuring or providing feedback on. So step one is measuring our adenoma detection rate and providing that as feedback. So we should measure these quality indicators, provide report cards to individual physicians, perhaps as a group average. Individuals could be de-identified. They could get their own report cards with their own information. Practices have gone as far as posting them on the ASC wall, de-identified, of course. But again, that really helps give us a visual of where the practice stands, or even publishing them online, which is a great marketing tool, plus it really shows practices that have put an effort into quality of colonoscopy and are showcasing it. This is what a sample report card looks like from our practice. And again, yours can be much more detailed or less detailed. We do it by quarter, but you can do it monthly, bimonthly. The idea is it needs to be somewhat of a continuous feedback. So I would discourage kind of six monthly or yearly because that's a lot of time not to get any feedback about our performance. So we do it by quarterly and you can see we give each endoscopist kind of a blinded ID and we report out to them number of colonoscopies they performed, how many were screening, how many were complete exams. Again, these are all quality indicators. Their ADR, their withdrawal time for procedures where no polypectomy or biopsy was done as a surrogate of time spent looking in the withdrawal phase. And then colonoscopies with inadequate bowel prep. And these are all quality indicators. So this is a fairly straightforward card. Again, you don't have to count all their colonoscopies for the ADR. I know it can be cumbersome, but we recommend as many as possible. 50 is a great number, but maybe a minimum of 30 is the way to go. Turns out endoscopist report cards not only provide us great feedback, but they're an intervention themselves. This was a very early study from Indiana University with six endoscopists. And they went from not doing any report cards or feedback to giving their providers quarterly report cards on how they were doing. And they only included ADR and sickle intubation rate. And they compared the ADR and sickle intubation rate of their providers before and after the report cards started to be given out. And just by giving report cards and doing nothing else, you can see there was almost a 10 percentage point improvement in the ADR and also in the sickle intubation rate. Now also notice their ADR even before the intervention was well above that threshold of 25% that we just discussed. So that shows that even high performers can have room to improve further just by fairly straightforward interventions, in this case, endoscopist report card. And there's other studies showing similar results. Now step two would be to improve the PrEP. We've all seen PrEPs on the left side of the screen, and this is the kind of PrEP we want to avoid, especially when we get in the cecum and it's coated with chyme. As you can probably guess, this kind of a PrEP, it would be really hard to look for sessile lesions, flat lesions, or those covered by the chyme and the stool. So we want our PrEPs to look like the picture on the right. And to do that, I hope everybody is now using either split dose PrEP or same day PrEP for procedures that are later in the day, such as noon or in the afternoon. But the idea is that we want to have a smaller runway time, which is the time between the last dose of the purgative that the patient takes and scoping. So that time needs to be four hours or six hours, whatever your anesthesia allows, but as small as possible. So really, if it's a procedure at noon, you know, I'll often tell my patients to finish their PrEP, the second part of the PrEP, between 6 and 8 a.m. So finish the PrEP two to four hours before the colonoscopy. And again, important that the PrEP is judged after all the washing and cleaning has been done and adequate PrEP should be achieved in at least 85% of all cases and 90 to 95% of screening colonoscopy cases. So it's an endoscopist level measure, but also a measure at the endoscopy unit level. And if the PrEP is inadequate in any segment of the colon, such as the picture on the left, the only evidence-based recommendation is to repeat the colonoscopy within a year as the next available up to a year. Any other intervals such as two, four, six years are not evidence-based. So really your decision branch point is after all the washing, is the colon entirely, are all the segments adequate or not? If they are and nothing was found, then it's a 10-year interval. And if any segment was inadequate, then it would be within a year. And that's the two branch points. Now split PrEP, so PrEP itself is a quality metric, but split PrEP and high quality and good PrEP actually improves ADR. As was shown in this study where they started to use split PrEP for their colonoscopies and compared it to the non-split PrEP, which was traditionally given the night before. And you can see the percentage of individuals with one or more adenoma went up. Also and not surprising, the individuals with adenoma smaller than nine millimeter was a very large increase. And that makes sense because now we're able to see smaller lesions and even sessile lesions. So again, split PrEP or same day PrEP to think about. Step three would be knowing what to look for. So now we know that polyps come in all shapes and morphologies. Our traditional teaching was mostly about pedunculated or semi-sessile polyps. Now we know polyps can be flat. In fact, they can be even depressed, which almost sounds like an oxymoron when you think about a polyp. But having a very, very low threshold for looking for some of these different morphologies. And obviously you can see that it requires a good inspection technique as well as adequate or good PrEP to be able to look for these lesions and confidently be assured that we didn't miss anything. So again, polyp recognition is extremely important. And we know there's challenges there. The areas where we have challenges with polyp recognition tends to be mostly on the right side. The polyps there are generally flat or sessile. They tend to have irregular borders, as you can see in the picture on the right. They're often covered by mucus. So unless we spend enough time cleaning and looking closely, we can easily miss them. And it's hard to tell on a fold where they start and where they end. So again, having a low threshold for looking for them, understanding what they should look like and using the right techniques to look for them. Because again, it turns out right-sided location is where we miss a lot of polyps or even early cancers. And that's also where PrEP tends to be sometimes suboptimal. So, a confluence of factors that definitely we need to know about and try to address. So, after doing all those things, if there's still room for improvement in ADR, think of interventions to try in these following categories. What techniques can we do, especially at the bedside? Can technology help us and which ones? And what is the role of educational or other programs to improve adenoma detection rates? So, let's talk about technique. And I did mention withdrawal time. It should be at least six minutes in colonoscopies without biopsies or polypectomy. And that six minutes is a minimum benchmark. We are updating the quality indicators document, and more and more evidence is accumulating that truly it's closer to eight minutes that's really required to get a good look. But the time itself is not important because time can be gamed as the audience can guess. So, the idea isn't to just kind of watch the clock until the time is up, but it's what we do in that time is what's really important. So, time is a surrogate of the technique. And the withdrawal technique is key. There's four hallmarks of a good withdrawal technique. And they are adequate distention, washing and cleaning up, looking astutely behind poles, and then kind of subjective timing and inspecting each segment very carefully. And if you fall out, you know, going back in the segment, so that we can reassure ourselves that we've thoroughly evaluated all segments of the colon that needed to be investigated. So, time alone isn't enough. And this was elegantly shown by this study. It's truly the technique that matters. So, they took videos of endoscopists and ranked them on their withdrawal technique. And they scored them on the same criteria that I just mentioned. And they also mandated that all endoscopists spend at least six minutes during their withdrawal. So, as you can see by the end of the study, all endoscopists had achieved that minimum of six-minute withdrawal time. But what truly distinguished low versus high ADR endoscopists was their technique. So, it's truly what they did in that time that led to more adenoma detection and a higher ADR. So, again, underscoring the importance of a good withdrawal technique. There's other studies that have also shown good evidence for this strategy. So, this setting from a community-based practice in Rockford, Illinois, with 12 GIs, and their intervention was they adopted an eight-minute withdrawal time, but there was an audible timer that alerted the endoscopist to spend at least two minutes per colonic segment. They also reviewed inspection techniques so that what they were doing in that time was considered good withdrawal technique. And just by instituting this intervention, the ADR for the practice improved by almost 11 percentage points. So, great evidence that, again, enhancing our withdrawal technique and spending enough time doing it is truly an effective intervention. Now, one might ask, you know, does withdrawal time mean anything if the ADR is adequate in terms of further reducing the risk of interval cancer? And the answer is yes. Withdrawal time is an independently associated factor associated with reduced interval cancers, even when ADR is controlled for. So, we did a study with 51 community practice GIs. We included 76,000 colonoscopies over six years. And then we linked records of the colonoscopies to the state cancer registry for cancers that appeared in the next five years. Now, everybody achieved an ADR of 26% or higher and a good withdrawal time. There were still 56 interval cancers. And when we controlled for ADR, but looked at the relationship between withdrawal time and interval cancers, you can see that physicians with a low withdrawal time, anything less than six minutes, had a very high risk of having an interval cancer appear in their patient in the next five years. About eight minutes seemed to be the sweet spot. And actually, withdrawal time, much prolonged beyond eight minutes, actually didn't confer any additional benefit. So again, really important to think about that kind of eight minute as being the magic number or the sweet spot. So, other techniques that we mentioned we could do at the bedside. So, think about retroflexing in the cecum versus re-examining the right colon during withdrawal. Again, doesn't require any extra training or effort. So, essentially, we know things can hide behind folds and it's hard to see folds just on forward view. So, the idea is in the cecum, particularly with a pediatric or a flexible colonoscope, retroflexing to see on the backside of the folds that we just looked on forward view, or coming all the way back to the transverse colon and then doing a second look in the right colon is very effective for exposing other polyps that we may have missed on the first pass. Another technique is to change the patient's position, starting on the left lateral decubitus, but then maybe flipping them on the right during withdrawal, or continuously changing their position during withdrawal, such that they start on the left, but they might be supine on their right. This requires a little more effort, particularly with endoscopy units that use monitored anesthesia care. It's not easy to turn the patient very well. But for moderate sedation, it's another strategy that has been looked at because it opens up extra folds that we may not have looked at, and also shifts the pooling of fluid within the colon. And again, allows for areas to be examined that otherwise, you know, weren't exposed. Another great intervention that has been tried is having a second observer looking at the screen with the endoscopist. Now, not always feasible, but most endoscopy units now have at least two people in the room, at least ours does. So there might be a tech who's just waiting to pass you an instrument, or help out in other ways. So perhaps the tech could be a second pair of eyes, or the nurse, as the situation allows. But that itself makes the endoscopist look more closely. And, you know, a second set of eyes can also pick up things. And water immersion and then water exchange have great evidence. The idea behind that is first getting to the cecum, and then suctioning all the air, flooding the colon with water, somewhere between 500 to 750 ml of saline. And then without air, kind of suctioning, doing kind of a water exchange. Sucking out the water, putting in air, distending the area is a great technique. So the way it works is, again, enhancing our withdrawal technique and making us look at folds that we otherwise wouldn't pay attention to. So many of these and other interventions, you know, they have mixed results, but they definitely seem to benefit low performers. And because they can be done at the bedside without too much cost, or hopefully training or effort, these are great things to recommend or try. How much improvement can you expect with using withdrawal water exchange or water immersion? This systematic review very nicely summarized multiple randomized control trials. And you can see, even with starting with baseline and ADR of 37%, there was a substantial increase with water exchange of almost 12 percentage points, such that water exchange compared to using air alone was statistically and clinically meaningful. And this is ensuring that the withdrawal time is eight minutes, which is, or longer, which is also a significant predictor of the adenoma detection rate. So, again, another intervention to try and see how well it works for you. And it's a good technique to learn in a different context. It also helps with polypectomy. So, something to think about and bring back to your endoscopy unit. Next, I'm going to address the role of systematic interventions and what we can do at systematic or the endo unit level that can improve our ADR. One of the most wonderful things about participating in a quality benchmarking registry like GI-Quick is that just by participating in GI-Quick, the ADR can show improvement because it encompasses all the elements we talked about and emphasis on quality, report cards, feedback, tracking, discussing interventions to help low performers. So, altogether, those constitute a quality improvement program. So, as was shown in an early abstract by NDW and then later published, practices over the subsequent five years improved their ADR simply by participating in GI-Quick. And again, they may have done interventions locally, but we didn't see this trend otherwise. So, you'd expect to stay static, but participating in GI-Quick alone is associated with an increasing ADR well above the minimum threshold that we discussed. So, another reason to participate and continue participating over time. And I hope every practice is curved and it looks like that or perhaps even more impressive. Now, other things. And now we're getting into the realm of slightly more effortful things, but these are highly effective. Another intervention is to take somebody who's a champion or say it's called train the leader, a leader of the endoscopy practice or a champion. It could be the director of the endoscopy or somebody that just wants to champion the cause and giving them the training and letting them kind of diffuse it to all their peers. This works very effectively at the group level. This was a Polish study where they identified endoscopy centers with ADRs pretty low, lower than that 25%. And then they invited them and randomized them to feedback only, which was individual report cards or kind of a training session, such as the ones we do through ASGE and other online courses, where they had an opportunity to have their technique assessed. They got some hands-on training and they got some post-training feedback. They included 24,000 colonoscopies by 38 leaders from individual endoscopy units across the country. And you can see the group that got feedback only did not improve or change their ADR at six months or at 12 months. But the practices where there was at least one or more champions that actually were exposed to training and post-training feedback had a pretty marked improvement in their post-intervention ADR. And it met that kind of that minimum threshold. Now at 12 months, it dropped a little bit, but still much higher than the pre-intervention level. So again, done at a very large level, these show us that you don't need to send every endoscopist to training. There's diffusion of excellence by training few individuals and letting them disseminate that information to their peers. All right, technology. We're in the realm of AI. It's a very exciting time. And we have several other technologies that have been developed and are available to us for improving our quality, especially our ADR. So let's see which quality, which technology is helpful. So this systematic review kind of summarizes what benefit we can get from high-definition endoscopes. And I hope everybody on the call today is using high-definition endoscopes in their practice. But compared to standard video endoscopes, just using a high-def endoscope itself has an incremental improvement in adenoma detection rate of about 3.5%. So again, not very large and tells us we can't really just rely on technology, but it definitely does help. There's also a whole host of accessory devices. Many of you might be using this in your practice. They are an additional cost, but it all depends if, you know, the value they provide is justified. And there's several. There's EndoCav, there's EndoCuff, which is most widely used. There used to be an EndoRing, but largely discontinued. There's a GI scope with an integrated balloon at the end. And then even a panoramic camera. So the most commonly used of these is, again, the EndoCav. And I encourage everybody to at least try using it to see how it might benefit you and whether it's something that you want to use for your particular practice. Again, not necessary, but something to try. What these accessory devices do is they essentially flatten the folds. And by doing that, they expose areas that would otherwise be hidden from us during forward view or during withdrawal. So certainly something to try and see if it benefits your providers and has a role in your practice. Now, how do these things stack up? Comparing technique, devices and endoscopes. So this is how they stack up. And this was, you know, a very informative network meta-analysis where they indirectly compare each of these technologies to one another. And you can see technique has probably the highest value in terms of improving ADR. And technique includes all the things we just discussed. Water exchange, second observer, position changes and enhanced withdrawal techniques. Now, imaging can help. And there's a whole host of imaging tools. Many are in our scopes already, and they can also boost our ADR. And then there's some newer scopes that really didn't pick up in practice because they really don't offer any incremental benefit in improving ADR. So the idea is you can't rely on a specific technology to improve or increase ADR. And truly, it comes down to technique first and foremost. And as I mentioned, now we're in the era of AI enabled computer aided detection of polyps. And there are three systems, I believe, that are FDA approved now in the US. This was the first one that was approved. And this was based on a study done in three centers in Italy, where 685 patients, all indications mostly fit positive, were randomized to either standard colonoscopy or colonoscopy with computer aided detection. And you can see the adenoma detection rate is pretty high to begin with 40%, but in the standard, in the standard colonoscopy arm, but it improved by almost 15 percentage points with AI. And even adenomas per colonoscopy were higher with computer aided detection. And this was achieved without increasing withdrawal time or increasing the yield of kind of non-monoplastic polyp removal. And when they pooled the trials to try and see who benefited the most, they actually reported that the improvement with CAID was not just for experienced endoscopists, but even for novice or mid-level endoscopists. So it seems everybody benefited and at least a 10 percentage point improvement in the ADR. So again, these technologies are now available. They are the most expensive at the moment, more to come on these. So we also did a trial with computer-aided detection called a second system that was approved subsequently by the FDA and is commercially available. And the idea is very similar, randomized individuals, but in the U.S. there were 22 experienced endoscopists to either standard colonoscopy or CAID. We used APC as our endpoint. And you can see that compared to standard colonoscopy with computer assistance, we were able to show a 27 percent improvement in adenomas per colonoscopy. And APC might be a more refined indicator compared to ADR because ADR kind of has this limitation of one and done. So it doesn't give you credit for the second or third adenoma per colonoscopy, but APC does. So that's why it might be a more finer, more detailed indicator beyond ADR. But all these systems work similarly. They put bounding boxes and kind of watch the screen with us. And the idea isn't that we completely rely on this technology. We still have to do our job and be looking closely and, you know, doing a good withdrawal, but it's good to have some extra tools or eyes to assist us. And this improvement can be seen not just in tiny diminutive polyps, but also polyps five to nine millimeters, which arguably are important endpoints. So I'll summarize by saying that the landscape has completely changed. We are looking for polyps that have all morphologies and we now understand portent increased risk and are often missed. So compared to polyps on the left, which used to be the goal of colonoscopy detection about 20 or 30 years ago, has now changed. Our challenge is to find and completely resect the lesions you see on the picture on the right. And to achieve this, we need to make a commitment to quality. We need to measure and track our quality metrics and report on them. Participating in programs like GI Quick is perhaps the highest yield way to do that. We need to ensure that we have excellent prep quality at the endoscopy level unit and careful segmental inspection is extremely important. And then proper resection technique, which we didn't get into today. We mostly focused on detection, but of course the effectiveness of colonoscopy also depends on resection technique. So it goes beyond detection. So really think beyond ADR. There are some promising and upcoming indicators that we will be discussing in our forthcoming quality indicators document. If practices are already tracking their ADR and feel like they want to do kind of the next level indicators, there are some that you can think about and start tracking in your practice. So again, multifaceted interventions are needed to get to high quality colonoscopy, which should be our goal every day for every patient that we see. And it's a combination of report cards and feedback, educational interventions, techniques have a role and technology might be able to assist us. And then video recording feedback and other AI tools are there to help us. And if you're looking for more interventions, everything that I talked about, we've summarized in a guidance document for ASGE. And you can see that we discussed all these interventions in the same categories I discussed today, technique, technology, and systematic interventions and educational programs. So we summarize what benefit you can expect to achieve from each of these techniques and how they stack up. So definitely a good reference and a resource for you. Again, I mentioned, this is my summary slide. So everything I hope makes more sense now that is on this slide. So again, it depends on cost and effort, but starting at the bottom left and going up as needed in terms of rolling out interventions, but staying persistent is truly the key. And that's a very important message. On my last slide, what does the future of colonoscopy practice look like? So as I think about kind of the bigger picture, I think our endoscopy units are going to become much, much more standardized and automated. Perhaps it's a dictation tool or AI that detects what we're seeing and actually populates a report for us. We think that this AI-enabled reporting will automatically be able to put in details of the polyp location, the morphology, and the technique for polypectomy. We'll have dashboards with automated reporting, much more sophisticated than the ones I showed you today. And that data would automatically go into benchmarking registries such as GI-QUIC to be submitted to peers for high value practice monitoring. So I think many of these pieces we have already, and many are developments that are ongoing, and hopefully we'll see in the next few years. So in summary, ADR is a valid quality metric that can be improved. Good technique is essential, and here are the hallmarks of a good technique. Technology can help, but is not a substitute for good technique. Educational programs can help, but there's effort and cost involved. And with that, I'd like to thank you for your attention. I'm open to taking any questions in the time that we have. Thanks so much. Thank you, Dr. Shaka. That was an excellent presentation. As you and I were talking about earlier, this is a presentation you gave five years ago, and as much as the landscape has changed and things have been updated, there are some fundamentals that remain true. And you covered that all beautifully. So, you know, we don't like to change measures much. ADR gets a slight tweak. We know that, you know, people, we used to start at 50, and now we start at 45. Do you ever envision that sessile serrated lesions would become part of ADR? Yeah, that's a good question. Often comes up because, you know, the other confusing part is sessile serrated lesions are also called sessile serrated adenomas, so it's easy to mix them with the other adenomas. And, you know, why not? They're important polyps for us to remove and find. So why not include them in the definition? Well, the reason is that there's still a lot of variation across the country in reporting out sessile serrated lesions. And it's not so much the endoscopist, but still pathology practices. So some favor calling them hyperplastic. So just to kind of have an apples-to-apples comparison, they're kept out of the definition for ADR. ADR does not include sessile serrated lesions. But in the quality document that I mentioned that is forthcoming this year, we have actually put sessile serrated lesion detection rate as its own quality metric. So when I was talking about kind of metrics beyond ADR, independently tracking sessile serrated detection rate is something that we are going to recommend. And we put some benchmarks based on some of the evidence, much of it from GI-QUIC, of where that number should fall. But approximately 6% seems to be kind of the minimum threshold that we hope practices can achieve and exceed. So yeah, important question, but its own indicator and separate from ADR. Thank you. So we have a couple of questions about AI. Do you have any sense of how expensive it is to integrate AI into adenoma, into detection of adenomas or otherwise? Yeah, so AI is probably, because it's the newest tool we have, it's probably the most expensive intervention at this time, amongst all the other things we discussed. So maybe done in conjunction with other things, or if practices are thinking about it, absolutely go ahead and give it a trial. But it does tend to be pretty expensive. Now, depending on which company, you know, there's multiple players in the field. And I think with competition, we'll see prices come down. So that's always good. Second, with more enhancements to AI, they'll be able to offer more, such as, you know, polyp size, morphology, completeness of resection, and even the histology of the polyp. So those would be all great enhancements, which would make it more valuable. And you should reach out to some of these three companies that I mentioned, and get a, perhaps a quote, and maybe not put it in every room. Think about starting with maybe one endoscopy room, and seeing how things go. And they all have different packages, depending on, you know, how many providers, or how many rooms. And they also have trial periods. So quite expensive, maybe to the tune of a few thousand per year per room. But, you know, something to think about, and evaluate for your practice, and see if it makes sense. And this person had a follow-up question, would it integrate with their endo writer? Great question. Some of them do, but others don't at the moment. So the enhancements that we're hoping to see is, if they could integrate with endoscopy report writers, and actually the AI could be smart enough to check the polyp, and then the report writer could actually populate the report, which would be great, and save us tons of time and angst over trying to remember which polyp was where. We're not quite there yet, but that's definitely the direction we're headed. Wonderful. And what, I'm going to do one last AI question before we switch to another topic. If I use AI, how much should I expect a change in my ADR? Would I expect, is there any study that gives us a certain sense of? Yes, absolutely. So the earliest studies from the clinical trials that I showed you, showed really impressive increases of about 11 to 15 percentage points in ADR. Now, the studies that have come out from the real world, where people have actually adopted it and put it in their endoscopy units, the numbers aren't so large. And in fact, in some studies, there has been no change in the ADR with the use of AI. So that's a little bit of a head-scratcher. When we look at systematic reviews that kind of pool all these different studies, we still see an improvement with AI, maybe not as large, but certainly between 7% and 12 percentage point increase in the ADR. But again, there's more to come on this and trying to understand who it benefits in terms of, you know, patients, indications, which providers and which settings. So I think we'll get a lot more refined in our technique of where AI might benefit us the most. Excellent. Well, I'm going to switch to quarterly report cards. Got a question here about this. And as we know, our outputs are only as good as our input. So we have a data manager here asking, is there, are there any best practices to encourage physicians to review their pathology? So to ensure that that data is getting, that's getting put in is reflecting a correct ADR. Yes, absolutely. I think this needs to be impressed at every staff meeting, you know, morning huddles is we're only as good as the data we put in. And it's very important to be accurate. In fact, by being accurate and reviewing the adenomas that really are adenomas, we actually will get a more realistic and probably a higher ADR compared to, you know, losing out on that benefit by not having adenomas counted because we didn't document them properly or didn't review them. So I think that's one of the initiatives. Again, when we talk about commitment to quality that we should take and kind of part and parcel of having the privilege to do colonoscopies should be this. So how do you promote that culture, working with the champions, working with your group, and then slowly kind of inching towards that mindset is extremely important. Excellent. And I think you touched on this in the program, but I'll ask it again here. Should I be measuring, this person said, should I be measuring adenomas per colonoscopy? So what's kind of the trigger points where people need to move from ADR to APC? Yes, it's coming. So if you're a high achiever, I think you're already thinking about it. So, you know, again, we emphasize that and realize that this is time consuming and again, not to do too much extra work. So at least get the basic indicators and we'll, we're going to list them out in our forthcoming document as kind of the essential few that you should focus on and report. Now, beyond that, if you are so inclined and looking to actually boost your quality, track it, and then maybe even, you know, advertise it, then APC truly makes sense. Particularly as we start thinking of a use of AI and these other things, once ADRs meet or exceed that minimum number, APC can truly distinguish high quality performers from others. So if you're looking for kind of that smaller discrimination, then APC would be of value. It is burdensome because now we're talking about measuring every adenoma. And as you can imagine, that can kind of get burdensome and there's some logistic challenges to it. But I hope with our improved reporting system, hopefully, you know, AI, our endoriders being able to help and track these, it's still doable. I mean, we did it for the clinical trial and it wasn't as bad of a lift as we were, you know, worrying. So definitely something to think about. And we do lay out the benchmarks in our forthcoming document. So you'll get a lot more information. Many kudos to you though, coming through Dr. Shakhat. Somebody said, I'm going to call one out in particular from Sharon, great presentation, concise, interesting, and very relevant topic. So thank you. And I'd love to come back and engage with everybody once we have this document that I keep referring to. It's undergoing final reviews by the society leaderships. So I'd love to come, you know, talk about the document and where people can expect some additional information and enhancements. If you're offering, you know, we are going to say yes. We love it every time you visit with us, Dr. Shakhat. So thank you so much for your time and your expertise. And I know with that, we're going to thank our audience as well. It was a really great hour. Thanks to Dr. Shakhat and your participation as well. We welcome your questions offline as well. So we want to keep this dialogue going because these are the kind of conversations we want to have. Thanks again, Dr. Shakhat. Thank you.

ADR Improvement Toolkit

colorectal cancer awareness

adenoma detection rate

quality colonoscopy

preventing colorectal cancer

AI technology

systematic approaches

adenomas per colonoscopy

continuous improvement