Hello, everyone, and welcome to a presentation on Assembling an ADR Improvement Toolkit for Your Practice, sponsored by the American Society for Gastrointestinal Endoscopy. My name is Eve Nessix, and I will be your moderator for today's call. The presenter for today's call is Dr. Asma Shaukat. And for our Q&A session, we will have a special guest with Dr. Doug Rex. Dr. Shaukat is the GI Section Chief at the Minneapolis VA Medical Center and Professor of Medicine at the University of Minnesota. Her area of clinical research is colon cancer screening and long-term outcomes. She has published her results on the long-term follow-up of the participants of the Minnesota Fecal Occult Blood Trials in the New England Journal of Medicine, and is now evaluating the age and gender-specific benefits of colon cancer screening. She also studies molecular markers of rapid colon cancer growth, as well as studying quality indicators for colonoscopy, such as adenoma detection rates and withdrawal times. She is studying the role of fecal microbiota transplant in recurrent C. diff infection. Her other areas of research include chemo prevention for colon cancer, biomarkers of risk of colon cancer, and evidence synthesis through systematic reviews and meta-analyses. Before we get started, a few housekeeping items. There will be a question and answer session at the close of the presentation. Questions can be submitted at any time online by using the question section in the GoToWebinar dialog box on the right-hand side of your screen. If you do not see the GoToWebinar dialog box, please click the white arrow in the orange box located on the right side of your screen. The presentation slides are immediately available via the handout section of the GoToWebinar dialog box. Please note that this learning event is being recorded and will be posted on GILeap, ASG's new learning management platform, in approximately one week. You will have ongoing access to the recording in GILeap as part of your paid registration. At this time, I would like to turn the presentation over to Dr. Shaka. Thank you very much, Eden, and good afternoon, everyone. I hope to make this session extremely informative and something that perhaps a venue where all the questions you might have on this topic, we're able to address most of them or point you to resources that might help you. So please feel free to type your questions in the chat box as we go along, and we'll try to get to them at the end of this call. I will present for about 40 minutes, and then we'll have a lively discussion, and your discussion will really enrich the topic. So I hope everybody can be interactive and think of lots of questions. I have no disclosures. So why should we care about quality? And I think that's the reason all of us are here on this call today and what we do every day in our life. We want to be effective in detection and prevention of colon cancer and reducing these missed or interval colon cancers. We want to have a safe practice and reduce the complications that might occur with colonoscopy. We're interested in getting proper reimbursement through the MIPS and APM programs and having a high-value practice for ourselves and our patients. And then we want this to be tied to patient satisfaction. At the end of the day, that's an important quality indicator. So really, if you look at this little graph, we want to be in the top-right quadrant of high-value and high-quality, and colonoscopy is certainly at the crossroads of this. There are many quality indicators for colonoscopy, as all of you are well aware. Today's discussion, we're going to focus on adenoma detection rate, which perhaps is one of the most important and complex indicators. So I'm glad we're talking about this today. So let's start with some definitions. Adenoma detection rate during screening colonoscopy is defined as number of colonoscopies where at least one adenoma is found divided by the total number of colonoscopy performed in a given time period per endoscopist in a population with men and women over the age of 50. And the idea is that higher ADRs equals a higher quality exam, which should lead to fewer missed cancers. The goals that have been set as national benchmarks or quality benchmarks are about 30% for men over the age of 50 and 20% for women for a blended rate of 25%. So really, on today's call, we're going to focus on how we achieve that 25% or exceed it. Why is adenoma detection rate important? Well, it's been associated with long-term outcomes, such as interval colon cancers. And these are colon cancers that occur in the interval before the next screening, and they undermine the effectiveness of colonoscopy. And certainly, it's something that we and our patients care about. As demonstrated by this study that was done in Kaiser Permanente North California Health Plan members that underwent a colonoscopy for any indication between 1998 and 2010, after 10 years of follow-up or another colonoscopy or a colon cancer diagnosis, they evaluated to see how many individuals developed a cancer before the next interval. The study included 139 gastroenterologists that had to have done at least 300 colonoscopies and 75 screening exams. And what they found was that they included 316,000 colonoscopies. They found 716 individuals with interval cancers. And what they found was lower adenoma detection rate was associated with a higher risk of interval cancer in the patients being scoped by that endoscopist. And on the table, you can see that physician adenoma detection rate very nicely correlated with the risk of interval cancer. And compared to physicians with the adenoma detection rate of 32% or higher, those with lower adenoma detection rate had a higher risk of having an interval cancer occur in a patient that they had scoped. There was no difference by right or left location. So these were cancers that were occurring in both the right and the left side. And the authors estimated that every 1% increase in ADR reduces the risk of interval cancer by about 3%. So that's really important to know and to keep in mind. So I hope I've made a good argument why we should be focused on improving and keeping our adenoma detection rate above the threshold. Now let's talk about what interventions we could do to improve ADRs. And if you aren't already thinking or integrating these things into your practice, what other tools can you think about? So in this regard, I've summarized everything that we're going to talk about next on this slide. So really, if you take away one important slide from this presentation, it's this one. And I'll repeat the slide at the end. So essentially, on this slide, I've summarized all the tools potentially to think about how to improve adenoma detection rates. And essentially, it all depends on how much cost and effort we're willing to put into it. I would personally start at the left lower quadrant and think of things that could easily be integrated into your practice. And if that doesn't work, try to go up or to the right. And then move to this top right quadrant, which essentially takes more effort and comes at a cost. But I would also remind you the role of persistence. So don't give up very easily because these things, again, take some time and planning. So step one is essentially measure your ADR. So I hope everybody on this call has some way or someone who can measure the ADR for them. And then the second step there is providing report cards to the endoscopist. And these report cards could go to individual physicians. It could also be individual physicians plus what the group's average is. And then the next steps could be individuals having access to their adenoma detection rates but de-identified. Perhaps even identifying all the endoscopists in the practice with their adenoma detection rates. Finally, posting some of these results on the ASC wall or even publishing them online in the full spirit of transparency. So these are some of the steps one should think about. The endoscopist report card by itself seems to improve adenoma detection rates. And this was shown very elegantly by this study that included six endoscopists that were given quarterly report cards on their quality metrics starting in about 2009. And the authors compared their adenoma detection rate and sequel intubation rate before and after the intervention. And lo and behold, what they found was that the adenoma detection rate before was 44% and improved by almost 10 percentage points afterwards to about 54%. And this was a significant difference. So having this information and providing it to physicians itself is associated with improving adenoma detection rate. That would be the first thing to think about. Step two, and this speaks more to processes in your endoscopy suite, is improve the PrEP. There was a webinar which occurred a few months ago and it's also recorded, which deals entirely with how to improve the PrEP. So I won't go into that here. But just know that improving PrEP by itself will improve adenoma detection rate. And some of the strategies are, of course, using split-dose PrEP or taking the PrEP the same day if it's a late-in-the-day procedure, beginning the second dose four to six hours prior to the colonoscopy schedule time and finishing it at least two hours prior, judging the PrEP after all the washing has been done. Adequate PrEP should be achieved in about 85% of cases at least. And if inadequate, please repeat the colonoscopy in a short interval such as just one year. Split-dose PrEP has been associated with increasing yield of colonoscopy. In the blue bars, you see split-dose PrEP versus non-split. And you can see the percentage of individuals with adenoma was numerically higher, and also percentage of individuals with small adenomas was much higher, suggesting that improved PrEP leads to increased detection of adenomas, not doing anything else. Step three, know what to look for. So now we have a good PrEP. We are getting some kind of reports on our adenoma detection. Do we actually know what we should be looking for in order to remove it? And essentially, polyp recognition is very important. We are all comfortable looking at pedunculated or kind of polyploid lesions, but it's very important to think about these non-polyploid or flat lesions, which might be either completely flat, might be superficially elevated, or even depressed. So essentially, having a good eye for recognizing these is very important. There are numerous publications about what some of these missed polyps look like. And here you can see how easily these could be missed despite good PrEP. They tend to be right-sided. They're flat or sessile or minimally elevated. They may have irregular borders, such as you can see in this picture, or they might be covered in mucus, as demonstrated by this picture. So these are all important things to keep in mind, because these are the things we should be looking for as we're performing the colonoscopy. And then the next step, think of interventions that could improve adenoma detection rate. And I've broken them down into these three categories. We should think about our technique. Is there technology we can integrate that improves adenoma detection rate? And the role of education and feedback in helping us improve our adenoma detection rate. So let's talk about some of these things. What should we be doing with technique? The most important aspect of technique is withdrawal time and withdrawal technique. So the withdrawal time should be at least six weeks. So the withdrawal time should be at least six minutes in colonoscopies where there's no biopsy or polypectomy performed. But it's not just the time by itself that matters. It's actually what we're doing in that time. So the technique should have four essential elements. Adequately distending the colon, washing and cleaning rigorously, looking behind folds for some of those lesions that we just saw pictures of, and then performing a segmental inspection and subjective timing, which means that spending a certain amount of time in each segment so that each segment gets its due diligence in being evaluated for adenomas. This study nicely demonstrates that time alone isn't enough, but technique matters. And this is comparing lowest versus highest ADR endoscopists. And as you can see, the withdrawal times are not very different, six minutes versus seven minutes. However, the technique score was much higher for physicians with high adenoma detection rate. Again, the elements of the technique are those four elements that I mentioned on the previous slide. Another study that also demonstrated that doing a segmental withdrawal plus enhanced inspection leads to higher adenoma detection rate. This comes from a 12 GI community-based practice in Rockford, Illinois, where they adopted an eight-minute withdrawal time, but you also had to spend two minutes per segment of the colon using an audible timer. And they also reviewed inspection techniques with all the partners and integrated them into their practice. And the results were that their adenoma detection rate as a group improved from 23% before the study to 34% after the study. And that's a pretty big numerical increase of about 11 percentage points. Again, showing good technique really matters. Does good technique also help us reduce interval cancers? And the answer is yes. We performed the study in a community-based practice in the Twin Cities, Minneapolis-St. Paul with 51 endoscopists performing 76,000 screening colonoscopies over a six-year period. And we linked a record to the state cancer registry. Now, the annual adenoma detection rate was pretty high for this group, 26%, and withdrawal time of eight minutes. There were 56 interval cancers in the follow-up time period. And on this graph, you can see very nicely that as the physician's mean withdrawal time increased, the risk of interval cancers decreased exponentially, such that at right about seven to eight minutes was the sweet spot. And having a withdrawal time longer than eight minutes didn't seem to make such a big difference. But compared to physicians with shorter withdrawal times, having a longer withdrawal time was definitely associated with reduced risk of interval cancers. Other techniques other than adequate withdrawal is that we should be thinking about trying, and these are evidence-based as shown by multiple randomized control trials, is things like retroflexing in the cecum versus reexamining the right colon during withdrawal, which means coming all the way out to the stenic flexure and then going all the way back into the cecum, again, reexamining the right colon for any lesions that could have been overlooked. Changing the patient's position, if they started on the left side, perhaps putting them supine or right laterally cubitus during withdrawal, because changing the position itself exposes different aspects of the mucosa and changes the orientation of the folds and might expose lesions that otherwise would be hard to see. Having a second observer looking at the screen, such as a tech or a nurse in the room, we generally have two people in the room, a tech and a nurse. So essentially having a second set of eyes also help look at the screen and detect things that might otherwise be overlooked. And then integrating a technique of water immersion and water exchange into your practice. What that implies is essentially it means insufflating the colon with water, turning the air off completely, insufflating the colon with water, one to two liters, and then essentially suctioning the water as the procedure goes on, is what the water exchange technique is. And this technique has been very successful in improving ADR, as I'll show you. A lot of these studies have somewhat mixed results, but one thing that seems to be consistent is integrating some of these techniques seems to really benefit the low performers. So if you have anybody with ADRs that are either borderline or falling below thresholds, then these techniques are a very, very good first step to try. And here's a few studies that show water exchange and immersion, how that improves ADR. And this was a randomized trial where individuals either underwent air insufflation, water immersion, or water exchange. And you can see that the adenoma detection rate is numerically higher with the water immersion and much higher with the water exchange. And those differences were significant. Other factors that were important were the patient's age, the indication for the exam, having an adequate withdrawal time, were all predictors of high adenoma detection rate. So a lot of these things, as you can see, go hand in hand. So after these techniques, let's talk about some of the education or other interventions that could be done to help improve or boost adenoma detection rates. So educational interventions do seem to work and this was a study called Equip which included 15 endoscopists. Half of them received training and half of them did not. The training consisted of two educational sessions, about an hour, hour and a half each, where techniques to improve detection were discussed, techniques to distinguish adenomas from hyperplastic were discussed, and they also viewed videos of high adenoma detection rate physicians' withdrawal method. So the education session seems very similar to what we're talking about today. The physicians were also given monthly feedback on adenoma detection rate and withdrawal time, so again, integrating those report cards that we talked about, and then the results were posted on the ASC wall and they were de-identified, but the results were there for everybody to see. So what happened? So physicians that underwent these interventions compared to controls all started at the same point, baseline ADR of about 36%, but you can see that there was an immediate improvement in the group that underwent this educational session and feedback to almost, again, 11 percentage points, 47%. And remarkably, that difference was sustained after five months in the third phase of the study, whereas the control group remained about the same. So you can see these interventions seem to immediately improve adenoma detection rate, but also sustain that improvement through at least six months of follow-up. So again, very encouraging findings. Participating in GI Quick, which is a national benchmarking registry, so for sites that are participating in GI Quick or start to participate, at least one study suggested that their adenoma detection rate increases, and the increases were over four years from 28% to 40% in this one study presented a couple of years ago. So that seems to suggest that measuring these indicators, reporting them, seems by itself to have a benefit of improving ADR. Other interventions. Training the leader or the lead endoscopist was a technique that this study was aiming to evaluate, and these were 40 Polish endoscopy centers where the adenoma detection rate was below that 25% benchmark for the lead person in the endoscopy unit. So those individuals were randomized to feedback only, meaning they only got individual report cards, or training, which included assessment of their technique, hands-on training, some post-training feedback. So 24,000 colonoscopies performed by 38 endoscopy leaders were included in this study, and here you can see that feedback, so you can see pre-intervention, the ADRs were pretty low and similar in the two groups, but early post-intervention, within six months, providing that training resulted in a pretty significant increase in adenoma detection rate, and that effect was somewhat sustained at least a year later. So again, giving us very good evidence that providing feedback, but also training, which includes assessment of technique, some hands-on training, improves adenoma detection rate. And the whole concept of giving feedback and recording was also examined in this study by Doug Rex and colleagues. So essentially, they took nine endoscopists in the endoscopy suite and video recorded them without their knowledge, and they graded those colonoscopies for quality scores. And then they told the endoscopists, we're gonna record you, and then again rated those videos for overall quality. And essentially, what you can see is that for every aspect of quality, once endoscopists knew that they were being recorded, the quality of the exam improved. The full examination, luminal distension, cleaning up, adequate inspection, and the inspection time all improved significantly once they knew that they were being monitored. And the adenoma detection rate also improved from 33 to 38%, and this was a significant difference. Again, seeming to suggest that giving that feedback and monitoring endoscopists seems to have a benefit in improving adenoma detection rate. The effect of multiple interventions over time. So we looked at this closely in our community practice, in the Twin Cities again, and we looked at multiple interventions that the practice instituted in order to get its providers to improve their adenoma detection rate. And the interventions they tried were a combination of all the above, somewhat in a sequential fashion, but some were done at the same time. So they started by giving physicians or endoscopists their report card, and then showing them de-identified adenoma detection rates, and then adenoma detection rates, but they were identified so everybody in the practice could see everybody else's adenoma detection rates. There were some group discussions about how to improve adenoma detection rates, and then there were discussions with individuals who had low adenoma detection rates. The practice also implemented some PrEP quality improvements, such as enhancing split PrEP and same-day PrEP. They required withdrawal time to be at least six minutes, and that was mandated. They provided education and feedback to the providers about endoscopy technique. And finally, financial incentives were added of about 1% for physicians that are meeting or exceeding the adenoma detection rate benchmarks. And then financial penalties were instituted for physicians not meeting the benchmarks. So you can see this is pretty much throwing the kitchen sink at it. And the period of measurement here is about nine years, and 181,000 screening colonoscopies during this time period were examined. And essentially, it worked, but it took a little time because changing provider behavior isn't straightforward and certainly not instant. But it did work very successfully. The adenoma detection rate for the practice went from 22% to 31% overall. Again, you see that percentage point numerical increase. But the remarkable thing was the detection rates of sessile serrated adenomas and advanced adenomas also increased. And on the graph, you can see these squiggly lines. Each of these squiggly lines is an endoscopist. And you can see how physicians changed over calendar years between 2004 to 2012 during this period of measurement. So you can see there's some fluctuations year to year, but overall, the trend of this graph is on the upslope. And on the y-axis, you can see the adenoma detection rate. And they went up very nicely from being in the 20% range to more being in the 30% range for most physicians and some even exceeding that. So these might be what might be required to really change behavior over time. I wanna switch to role of technology since this is a very rapidly growing area and one that might interest a lot on this call about what technology should we be investing in that could enhance our colonoscopy practice and improve adenoma detection. So in this regard, there is, again, there's a lot of advances to talk about. So first, high definition colonoscopes versus standard video endoscopes seem to make a difference. And at least we have switched to high definition. I think most practices should now have high definition colonoscopes. This was a meta-analysis with five studies and included almost 4,400 colonoscopies. And what they found was that the incremental yield for adenoma detection with high definition increased by 3.5% without doing anything else. There was no difference in the detection of advanced adenomas, but this seems to suggest that technology does have a modest benefit in improving adenoma detection rate, which makes sense because when we can see better, we can detect better. There's also a lot of interest in different types of colonoscopes. Here, you can see a picture of three different types of colonoscopes, one that has a 210 degree tip deflection. This allows easy retroflexion in the cecum and the right colon. And the idea is that once we reach the cecum, we retroflex and withdraw in retroflexion, which allows us to see polyps or adenomas that might be hiding behind folds that we would not be able to see just on a straight forward-looking camera. So these kinds of colonoscopes, as you can imagine, might enhance our ability to detect polyps. Next, I'm gonna talk about accessory devices that are very popular, and there's a lot of literature on these. And different devices are now in use. These include things like endocap, endocuffs. So here's an endocap. It's a clear plastic cap that goes at the end of the colonoscope, an endocuff, an endo-ring. There is a GI colonoscope, and then also a colonoscope with a panoramic view. These first three accessory devices have been subject of multiple studies, and the bottom line is all of them seem to work. The benefit is modest, and again, seems to benefit low performers, but all the studies showed a numerical increase in adenoma detection rate for colonoscopies performed using one of these accessory devices, as compared to standard colonoscopy. And the idea behind these devices is that upon withdrawal, they allow the endoscopist to flatten out the folds and essentially distend the folds a lot more, exposing mucosa that would otherwise be seen and lesions that might be hiding in that mucosa. The GI endoscope is an interesting device. It is still in its early development phase, but the idea is, again, there's a integrated balloon at the end of the colonoscope. It is deflated on the way in, so the endoscopist advances the colonoscope to the cecum, and then once reaching the cecum, this balloon is inflated. And then upon withdrawal, what the inflated balloon does is essentially it distends or widens the lumen and also flattens the folds, exposing more colonic mucosa. Early studies seem to indicate a lot of promise. This was a multicenter randomized control trial of same-day back-to-back tandem colonoscopies using a standard colonoscope and then the GI colonoscope. And here you can see what their results were, but essentially you can see that more adenomas were detected with this GI scope, and the additional adenomas detected were numerically higher with the GI scope. There was no difference in ADR, at least in this study, but it might have been a small sample size. So the impact on clinical outcomes is still awaited, but you can see that the additional adenomas detected were much higher with the GI scope. So when a second colonoscopy was done with a standard colonoscope, an additional 8% adenomas were detected. However, with the GI scope, an additional 81% of patients had an additional adenoma detected. So not only does it might help with ADR, it might help with adenomas per colonoscopy, which is another important quality indicator which is being developed. Other emerging technologies, the extra wide angle view colonoscope. And the idea is that instead of the 140 degree angle that the standard colonoscope allows, this particular colonoscope has a wider view, 170 to 210 angle view. And what that does is here, as illustrated in this picture, with the standard colonoscope, one might miss this tiny bump or polyp on this fold because it's not in the field of view. However, with the extra wide angle colonoscope, it would be easier to see this lesion because it has a wider angle of view. So again, more emerging technology that holds promise and might help enhance our practice. Another promising technology is this third eye panoramic. It's a panoramic device that essentially clips on the outside of a standard colonoscope. And this device has cameras on both sides, which when supplemented with the camera of the standard colonoscope, almost give you the picture in three different dimensions. So you can see the left-sided image, the standard forward viewing image, and then the right-sided image. So this is analogous to driving in a car and you not only see what's in front of you, but you can see kind of out of the peripheral vision outside both the windows. And the idea again is improving the amount of mucosa that we see and not missing any lesions that might otherwise be missed because we're not seeing the left and the right side just with a standard front forward viewing colonoscope. So again, very promising technology. And then finally, how about a 360 degree view colonoscope? This is again being developed, but it has five cameras. So not just one for the left and right and a front facing one, but one on top and one at the bottom. And when recreated, it gives us a picture, a 360 degree picture of the colonoscopy lumen. And then essentially the lesions have no place to hide because every single angle of view is being visualized. So again, in development, but something exciting to come. How do all these things compare? So should we be focusing on technique, enhanced imaging, or should we be investing in new scopes? Well, the answer isn't clear because none of these have been compared head to head. A very fresh and recent study was a very, very important meta analysis where the authors took all the studies that looked at enhancing techniques, such as water exchange, second observer, position changes that we discussed. They looked at studies that looked at enhanced imaging technique or new scopes, such as the ones we talked about. And essentially did a network meta analysis, which is an indirect way of comparing these different strategies. And they found that the adenoma detection rate improved with just about each of these interventions other than the new scopes. So definitely changing technique compared to not doing anything additional seemed to have a benefit for improving adenoma detection rate, as well as enhanced imaging also seemed to have a benefit. But what they found was no specific technology was superior to others. So meaning at this point, it's unclear if one of these is better than the other, but they all seem to work. There's no difference in detection of advanced adenomas or polyp detection rate or mean number of adenomas per patient. So more studies are awaited, but essentially it looks promising to use either technique or enhanced inspection. And then some emerging technologies. Artificial intelligence is everywhere. I'm sure everybody's seen it in not just medicine, but in every aspect of our lives. But for GI, it's particularly very, very exciting and appealing because this can enhance our ability to improve our colonoscopy quality. And the software that, and there are multiple companies working on this, but essentially the software allows for polyp detection. Here you can see on this image when this artificial intelligence software sees a polyp and whether we see it or not yet, the corners of the screen turn red and it gives a 98% probability that there's a polyp on the screen. When you see these red triangles or corners in your screen, you might wanna look more closely and figure out if what it's looking at is indeed a polyp or not. So this itself will enhance polyp detection. Or even more sophisticated, it outlines the polyp, not only sees it, outlines it and gives a certainty of that this is a polyp. And this is based on artificial intelligence, which essentially learns and gets better with time. Not only can it detect polyps, it can also predict the histology. So in the future, it might tell us if this is a hyperplastic versus an adenoma, which might help us plan removal technique or if it's a small hyperplastic in the rectum, whether we should just leave it alone. It can also give a very objective PrEP quality score. So instead of us having to give a subjective rating, this evaluates the PrEP quality in different segments and gives an overall score. It tells us about mucosa exposed or seen. And essentially, if a physician is falling below that 80% mark of not having seen enough mucosa, the corners might turn red, suggesting, hey, we didn't quite get a good look at this left lower quadrant. And perhaps going in with the colonoscope and focusing at looking at that area as an enhanced inspection technique and also detecting more lesions that might be hiding there. And finally, it probably will tell us about whether our retroflexion in the rectum was adequate. There are many lesions missed due to either failure or inadequate retroflexion. So the AI software will tell us that, yes, we did get a good look and it was satisfactory for finding lesions of interest, again, giving us confidence that we're not missing anything. So these are the prototypes are out and these are getting more and more data behind them. So very soon, we will see some of this software integrated with our everyday technology. It could be with our endoscopy tracking or reporting software, or it could come standard with our endoscopes. So that remains to be seen. But I predict we'll see this in the next five years as part of our practice. And finally, a very interesting study and something that looks very promising. This is, again, hot off the press. It's still in an online form only from this month gastroenterology. And this is looking at an oral methylene blue formulation for screening colonoscopy. And this is a phase three study from Italy with twelve hundred colonoscopies. And they randomized individuals to take either 200 or 100 milligrams of oral methylene blue MMX capsule versus placebo as part of their prep. So they would take it as part of their prep before they underwent the colonoscopy and then they would undergo the colonoscopy. As you all know, methylene blue stains the mucosa and highlights lesions and adenomas. So what they wanted to see was the MMX allows it to essentially release the methylene blue in the colon and they wanted to see how many adenomas could be identified. And lo and behold, they found an increased number of patients with at least one adenomas. That were detected if this formulation was used and what it did look like was something like this. So these are pictures again from the publication. This would be a lesion without the methylene blue, but for patients that did take the methylene blue, it stained the polyps. It was much easier to see. And you can see these lesions are much easier to see and you can and they're also much better delineated and hence easier to remove. So again, very promising technology and we'll see how quickly we see that in our practice. So I'll end by summarizing that our landscape for colonoscopy has changed. It used to be that we could look for polyps that were predunculated and large, but now our goal is to look for these extremely subtle lesions that are difficult to see and difficult to recept. And what we need to do to be prepared is essentially have these tools in our practice. We should be committed to quality colonoscopy. We should measure and track our quality metrics. We should ensure that excellent prep is done for every case. We should perform careful segmental inspection and use proper resection technique and really start thinking not just for detecting one adenoma, but are we able to detect every lesion that we can possibly detect for that patient. So in summary, ADR is a valid quality metric that should be tracked and can be improved. Good technique is essential and the elements are careful segmental inspection, looking behind folds, segmental and time withdrawal, looking for flat lesions and using techniques such as water exchange. Technology can help, but is not a substitute by itself. And educational programs can really help, but there is effort and cost involved. And I'll lead you with this slide again, which again summarizes many of the tools we talked about and their range in the amount of effort and cost involved, but they all seem to have a benefit in improving adenoma detection rate. And with that, I'll stop and open the line for questions. Thank you, Dr. Shaka. Again, we thank you for joining us today for assembling an ADR improvement toolkit for your practice. At this time, Dr. Shaka will address questions received from the audience. As a reminder, you can submit a question through the GoToWebinar dialog box. So we have that on screen. So you can see where you can type in your own questions there. And our first question, Dr. Shaka is, should I include sessile serrated adenomas in my calculation for ADR? Yeah, that's a very good question and an important one to ask. The answer is no. That's because we really want to compare apples to apples. With sessile serrated adenomas, the trouble is there's a lot of variation in how pathologists read it. So while it's a very important endpoint to detect, and these lesions are very important. So from the quality standpoint, it's important to detect sessile serrated lesions. However, more than the endoscopist, it might be the pathologist that might determine whether it's an SSA or not. So for that reason, to compare apples to apples, we should only include conventional adenomas, which include tubular adenomas, tubular villus, villus by itself, or a tubular adenoma with high-grade dysplasia in the calculation of ADR. Hey, Asma, this is Doug. I'm on the phone. Can you hear me? We sure can, Dr. Rex. Thank you for joining us. And this is our special guest, Dr. Rex, joining Dr. Shaka for our Q&A section. Did you have more comments on that, Dr. Rex? No, that was a good answer by her. She was absolutely right. It's just for what we call conventional adenomas for the ADR. But as she said, we definitely want to find those lesions. If you want to, in your own practice, set up a separate detection target for patients who have one or more sessile serrated polyps or sessile serrated adenomas, whatever the term is that you use, then there's some evidence that suggests that if you're in the vicinity of 8% to 9%, you're pretty good at it. Recent studies suggest that experts are getting even higher in screening populations. And of course, you've got to have a pathologist who's tuned into it. But for right now, it shouldn't be part of the ADR. Thank you, both of you. So our next question is, I noticed for public reporting that it's taking all screening colonoscopy and it's not limited to first-time screening colonoscopies. Has this been a change? Yeah, because it's so hard to determine whether it's a first screening or a subsequent one. So I think the ADR for screening colonoscopy is what we should use. And I think it's really hard to quantify whether it's the first one or subsequent one. So I would use ADR for any screening colonoscopy. I think that's reasonable. The original definition was that it should be done for first-time screening colonoscopies. And we've seen some data now from second-time screening colonoscopies in people who were negative the first time. And it's interesting that ADR is a bit lower, even though they're 10 years older. It's like the first situation in which people who are older have been found to have lower ADRs, but not such that it's going to be a problem for the calculations. You have to remember that, you know, reaching the minimum, as was probably talked about, we want to try to get as high as we can, at least we think right now. But certainly for reaching the minimum thresholds, there's no problem in doing that with second-time colonoscopies. Wonderful. Thank you. And I'll direct this question first to Dr. Rex and then Dr. Shawkat, if you could add in, which accessory devices do you recommend? So my personal take on it right now is that the endocuff vision is really good. First of all, it doesn't impede intubation to the cecum. It actually makes it faster, probably because the fingers sort of catch the mucosa and allow you to straighten the loops faster. If you use unselected patients, there are going to be a couple of percent of patients where you have to take it off because the sigmoid is narrowed diverticular disease. But it also allows faster withdrawal. This has been shown now in both an observational study and in our anamoxic controlled trial. So the work of withdrawal, looking behind folds, and you can do it faster with a device that helps you with that. Endo rings does the same thing, but it's harder to push it through the sigmoid because it's bulkier. And so if you're going to get a mucosal exposure device, I think, first of all, you don't want any scope that impedes image resolution. We learned from this recent randomized trial that image resolution trumps angle of view for good examiners. Good examiners can compensate for limited angle of view by using good technique, but you can't compensate for impairments in resolution. So you want to have a really high definition, high quality image. And then I think EndoCuff helps with that. If I was going to do something else now, I'm sure Adam's already talked about this, but brighter forms of chromoendoscopy, they seem like they're working. The 190 series MBI blue light imaging from Fuji, this is basically shining blue light on the colon. They work, but they're uncomfortable to use if the colon's not really clean. And so it takes some getting used to. People that are in ASCs and office practices don't like the idea of anything that cuts into their bottom line and they get that. So if you're in that situation, then I think you have to weigh the cost of an add-on device against the inefficiency and the increase in revenue associated with more patients undergoing polypectomy and the peace of mind associated with better examinations. But that's the trade-off right now. They're not cost-free. Yes, I would echo those thoughts. EndoCuff seems to have more superior performance compared to EndoRings. And essentially there was a study published in August 2018 by Dr. Rex's group that compared EndoCuff, EndoRing, standard colonoscope, and the FUSE, the full spectrum endoscopy, and again found EndoCuff did better for adenoma detection rate compared to the other techniques. Wonderful. Thank you both. And we have a thank you to you and a kudos, Dr. Shaka, for your presentation today. This person asks, if there is one thing I can do today this afternoon based on your presentation to improve ADR, what is that first step I should take? So I'm assuming that this person knows their adenoma detection rate or has been given that quality report card. So getting or if not, then soliciting that feedback is perhaps the most important thing to do and understanding where the areas of improvement are. And I would say focus on technique as the first step. So enhanced inspection and water exchange would be the easy places to start. Any additional thoughts, Dr. Rex? So you got to assume that you're using split-dose biopreparations, a high-definition colonoscope, just no excuse for not having high-definition instruments in 2019. And I agree that if you look at the highest ADRs that are out there, they're being achieved by people using those scopes with good preps and standard white light careful examinations. So the biggest thing is, do you really know what everything that's precancerous in the colon looks like? Do you have a real appreciation for the full spectrum of adenomas and serrated lesions and you're looking for those? That's number one. If you do all that and you want to pick one add-on, I myself right now, I would go with endoconstitutions. Thank you both. So this next question comes, she says, I am a nurse manager at an ambulatory surgery center and we've just started with the GI Quick Registry. So we're excited to begin sharing back adenoma detection rate with our physicians. What are the advantages of de-identifying the data when we report out? Can we just go straight to sharing it as identified? Oh, very interesting question. So you have to present the data to the providers identified, so the providers know who they are, and that would be the first step. But providing perhaps the whole practice's average so the provider can compare it to the group's average would be important. And also providing de-identified adenoma detection rate of other providers in the practice might be very important because then they could benchmark where they stand compared to everybody else. Because we want individuals to improve not just their performance, but also where they fit in with the rest of the group because it's the same population that everybody is hopefully seeing. I mean, I think the most common thing that is done is to give a listing. I say there's 15 doctors in the group. You list them one through 15 with their ADRs, but you de-identify everybody except the doctor who's getting that individual report. That's the most common thing I see done. So the doctor sees where they stand compared to the other 14 doctors in the group, but they don't know exactly what the other 14 are. The only people that know those are the endoscopy unit director and whoever's making decisions about what to do with people that may be too low. But there's no reason why you can't decide to de-identify everything. And we've seen groups that publish the results of everybody. That I think is a very small percentage of it, but I think you have to discuss it at the group level and decide where people are comfortable with starting, maybe where they want to end up as the process proceeds. Thank you. And we have switched to the last slide of our presentation and it really kind of fits our final question as well. What kind of resources can I get to help with my low-level providers? Yeah, so these are some of the resources that are already listed on here. We are going to have this webinar recorded, so you'll have that resource to you. And very soon we'll be assembling a tool kit that summarizes and compiles all the different tools out there in one place. So please check back on GI LEAP and you will see enhanced resources. Any additional thoughts, Dr. Rex? No, I think that's a great answer. I mean, we've seen a program that the Mayo Clinic Jacksonville, Mike Wallace, developed that involves training in lesion recognition and actually differentiation. It may be that people that learn, you know, how to differentiate adenomas from SSPs also sort of pick up more of a sense of what subtle lesions look like. And then secondly, technique. Fortunately, it's not available to us yet, but that'll be another resource and maybe that'll get incorporated into, you know, these things that we have on GI LEAP when it becomes available. Well, thank you both, Dr. Shawkat, Dr. Rex, Dr. Shawkat for the presentation and both of you for this wonderful Q&A session. And we want to thank all of you for joining us today. We hope this information is useful to you in your practice. ASG has designated this learning event for a maximum of one AMA PRA Category 1 credit. Please take a moment to complete the evaluation after the webinar concludes. Your input will help us in improving on future webinars. The recording of this event will be available in approximately one week on ASG's GI LEAP and you will have ongoing access to the recording as part of your paid registration. This concludes our webinar. Please stay tuned for future educational opportunities from ASGE. Have a great day.

webinar

ADR Improvement Toolkit

ASGE

Dr. Asma Shaukat

adenoma detection rates

colonoscopy quality

withdrawal time

endocuffs

artificial intelligence