Welcome. The American Society for Gastrointestinal Endoscopy appreciates your participation in this discussion on promoting the value of colonoscopy to referring networks and patients. My name is Eden Essex and I will be the announcer for this presentation. Before we get started, just a few housekeeping items. Currently, you're in the auditorium of our virtual environment. When you enter the lobby you may have noted seeing a meeting information banner. In there you will find the agenda for this session. Via the resource room you can access GI Leap, where a recording of this session will be posted in the coming weeks. If you have questions about the virtual environment, swipe your virtual badge and a representative will get in touch with you. The features of our virtual environment are available to you during and anytime following the event. At the close of the presentation, there will be a question and answer session with our panel. Questions can be submitted at any time via the Q&A function. Now it is my pleasure to introduce our moderator for this evening. Dr. Luke John Day is an associate professor of medicine at the University of California, San Francisco, and the chief medical officer at Zuckerberg San Francisco General Hospital. Dr. Day is the chair of the ASG Quality Assurance and Endoscopy Committee. I will now hand the presentation over to Dr. Day. Thank you, Eden. Welcome and good evening, everyone. Promoting the value of colonoscopy is something about which I know each of us feels passionately. We know it is both an effective diagnostic and therapeutic tool that is invaluable in the fight against colon cancer. During tonight's session, an exceptional and expert panel of your peers will update you on the latest United States Permanent Services Task Force guidance for screening colonoscopy, as well as the appropriate use of the newer stool screening test looking for abnormal DNA. We will also discuss quality indicators in colonoscopy, as well as strategies, and then assess tools to further empower you as you discuss the value of colonoscopy with referring networks and patients. Without further ado, let's welcome Dr. Jonathan Cohen. Dr. Cohen is an ASGE governing board counselor and co-chair of ASGE's Promoting the Value of Colonoscopy campaign. He remains active in private gastroenterology practice in Manhattan, teaches and performs therapeutic and discopic procedures at NYU Langone Medical Center and Lenox Hill Hospital. Jonathan, the audience is yours. Luke, thank you so much. I'm excited to start off this great evening to talk about what we've been doing with this Value of Colonoscopy campaign this year. The campaign began really out of a grassroots effort of people, members concerned about all the information about various modes of colon cancer prevention and, you know, and wanting to have more information to be able to give to internists and to promote what we see as a, you know, signature value of colonoscopy. So, what we did after we sort of were emerging from the restrictions of the pandemic was to reinvigorate the campaign to promote the Value of Colonoscopy, focusing on both the public and primary physicians, but providing tools for gastroenterologists to be able to interact with them. We also have a large number of industry partners which share the mission and hoping to reduce colorectal cancer and promote the value of colonoscopy to do so. So, what we did, first of all, was to reorganize the content into pillars of themes, if you will, to try and then gather content to fit these themes and then present it as such. So, the themes this year were that, you know, the value in that colonoscopy really is a preventative of cancer, and not just a screen. And really focusing, especially early on, of the safety of colonoscopy, and shouldn't be delayed even in the pandemic. Then we talked about high risk groups and early onset colon cancer as an issue. And then another major area was ensuring equity to access high quality colorectal cancer screening and prevention in underserved communities. And lastly, but not least, really talking about the cost efficiency of colonoscopy and colorectal cancer prevention. So these were our themes, and we went about collecting a series of interviews about articles with authors, as well as some patient testimonials and some tools for gastroenterologists to show the safety in their unit and to help the staff provide information about safety as things were opening up again. So we have a lot of stuff on our website with a lot of rich content now, and we're organizing it, we're going to be continuing to organize it along those lines of the pillars in a patient facing area and a physician patient area that hopefully members of the URP and other physicians on the call might be able to look through and see what can I use. And we're going to talk tonight about ways in which we can use this directly with patients that come to see us, sharing information with our internists, or perhaps actually giving some presentations we have to local communities and local referring providers. So it's an array of content. So the tools that we're going to have, well, we have customizable safety materials for the GI units. We have educational videos on patient safety and strategies, how to promote colonoscopy to PCPs and to patients, we'll see that in a second. And then we have a series of video interviews on a number of topics, and several of the panelists tonight have done some of those interviews, as well as some really engaging talks with patients in terms of patient testimonials. We have some slide decks that you could use yourself. And we're also going to be putting some of the journal scans that's relevant up there shortly. So that's really what we have amassed and now we're going to spend the second half of the campaign. The next six to 10 months, getting the word out further on social media directly to patients if we can, to PCPs if we can, and also trying to get physicians, gastroenterologists, to use the materials in their practices to promote the value of colonoscopy among their PCPs in their communities. So with that, I'm going to turn it back to Luke. Thank you, John, for that outstanding introduction and overview, and for really starting us off tonight talking about the value of colonoscopy campaign. Now it's my pleasure to introduce Dr. Mandeep Swani. Dr. Swani is an Assistant Professor of Medicine at Harvard Medical School, and is the Director of Therapeutic Endoscopy and Endoscopy Research at the Beth Israel Deaconess Medical Center in Boston. His research interests include colon cancer screening and surveillance and outcomes in gastrointestinal endoscopy. Mandeep, we look forward to your summary of updated United States Preventative Services Task Force guidance for screening colonoscopy. Thank you very much, Luke, and thank you for inviting me. So, colorectal cancer is the third most common cause of cancer death in the United States. The lifetime incidence for an average risk adult is about four to five percent. And so the first message that we want to send to our referring doctors is that colon cancer screening is highly effective. In fact, of all the screenings that we do, it's probably the most effective form of cancer screening. In this one study, models estimated that if there was 100 percent compliance with the U.S. Preventative Services Task Force guidelines, colon cancer screening would save almost eight times more lives than breast cancer screening would. So that's the first message that we would like to send. We all know that for older adults, those over the age of 50, the incidence of colon cancer has been steadily declining by about two percent per year. But very alarmingly slow for young adults, those under the age of 50, the incidence of colorectal cancer has been slowly increasing by about two percent a year. And this increase in colorectal cancer can be seen even in those as young as 20 to 40 years of age. Another important epidemiologic finding is that for older adults, there seems to be a shift towards right-sided cancers. However, for young adults, the increase that we're seeing in colon cancer is being driven mostly by rectal cancer and by left-sided cancers. One of the thoughts is that there's been an increase in the risk factors amongst all ages, like obesity, sedentary lifestyle and diabetes. But the effects of this are being disproportionately felt in young adults because older adults are probably being protected from colon cancer by screening. So for these reasons, in 2021, the U.S. Preventative Services Task Force decided to lower the age of screening to 45 years. And this gets not an A, but a B recommendation by the task force. And the reason why it gets a slightly lower recommendation is that we don't have any trials specifically done in young adults. We're extrapolating that if screening works for older adults, it probably works for young adults as well. Most of the data that supports lowering the age of colon cancer screening comes from modeling studies done by the CISNET group. And these models estimate that if you lower the age of screening to 45 years, three colorectal cancers would be averted in addition for 1,000 patients screened. By lowering the age to 45 years, one additional colorectal cancer death would be averted per 1,000 screened. And just to put it in a broader context, if you were to look at the screening strategy of colonoscopy every 10 years, if you start screening at the age of 50, you save about 300 life years. And if you reduce that age of screening to 45, 27 additional life years are saved. So the magnitude of gain by lowering the age to five years is about eight to nine percent. So colon cancer in young adults seems to be a distinct type of cancer. These cancers are typically poorly differentiated. They have mucin or signet ring type histology. They have a unique molecular profile in that they are more likely to demonstrate microsatellite stability. And up to 30 percent of cancers in young adults could be part of an inherited colorectal cancer syndrome like Lynch syndrome. Unfortunately, most of these cancers are already advanced at the time of diagnosis. And one reason why they may be advanced is delays in diagnosis. In this one study, young adults took almost six times longer to report their symptoms to physicians. And even when they reported their symptoms to physicians, it took almost 50 percent longer for primary care doctors to make referrals to specialists for a diagnosis. So the second message that we want to send to our referring doctors is that we want to promptly investigate symptoms of cancer, especially rectal bleeding and anemia, particularly in men. But we want to emphasize that a history and physical exam are often inaccurate in differentiating benign from malignant causes of rectal bleeding. Up to 30 percent of cancers in young adults are beyond the reach of a sigmoidoscope. And in one study, colonoscopy was the most cost effective strategy when assessing those over the age of 35 for bleeding. So how to screen? The U.S. Preventative Services Task Force endorses six strategies, and we're all familiar with those. And the rationale that the task force provides for not rank listing these tests is that the task force found that for each of these strategies, there was convincing evidence that screening was superior to no screening in reducing colorectal cancer mortality. The task force points out that there are no head-to-head comparative trials that look and compare between these strategies, and they recommend that we individualize what screening tests we offer based on local resources and patient factors. Colonoscopy is considered the gold standard because whatever outcome you look at, numerically, colonoscopy has better outcomes than others. In this particular case, we're looking at the number of colorectal cancers averted by screening, and you can see colonoscopy outperforms the other strategies numerically. It's also important to remember that colonoscopy every 10 years is also associated with the highest risk of harm. So if you were to look at the risk of bleeding and perforation, colonoscopy does cause more of those than some of the other strategies. So therefore, it's important to individualize what screening test you're going to choose. Another important thing to keep in mind when you're deciding what screening test to choose is what setting screening is being conducted in. In the U.S., most screening is opportunistic, and by that, I mean it results from an office-based interaction between the patient and physician. In some settings, like the VA, we have system-wide screening or organized screening. Now, opportunistic screening in the U.S. has been enormously successful. The U.S. has the world's highest rate of colorectal cancer screening compliance, and it also has the highest reduction in colorectal cancer incidence and mortality attributed to screening. And all this has been dominated by colonoscopy every 10 years. And the reason why colonoscopy every 10 years works so well in an opportunistic setting is if you look at the table on the left, the task force estimates that if you use the strategy of colonoscopy every 10 years, patients will need only 4.2 tests over their lifetime, as opposed to if you use a stool-based strategy like FIT testing, they'll need up to 21 tests per year. So, in an opportunistic setting like the U.S., colonoscopy every 10 years, just because it offers such a long interval between the need for a repeat test, seems to be a good option. When should we stop screening? The task force recommends we selectively screen those between the ages of 76 and 85. Modeling studies suggest that few additional life years are to be gained by screening those over the age of 75 who've been adequately screened before. The task force also found good evidence to suggest that harms from colonoscopy, like perforation and bleeding, will increase with age. So, the bottom line here is that screen those between the ages of 76 and 85 who've not been screened before, screen those who are healthy, and then, of course, take patient preferences into mind. Those over the age of 86 are unlikely to benefit from screening. The task force found that competed causes of mortality likely preclude any benefit from screening. One quick slide on screening for colorectal cancer in Black adults. Black adults in the U.S. have the highest colorectal cancer incidence and mortality, and this is not attributed to any genetic differences. Sadly, this is mostly a result of inequities in access and utilization of screening and treatment. And the U.S. task force does not make recommends similar screening for those of all races. So, just to summarize, the message we want to send to our referring doctors is that we should start screening average risk adults at the age of 45 and continue screening until the age of 75. We can select from one of six screening strategies and the old adage that the best test is the one that gets done still holds. A colonoscopy every 10 years is probably the preferred strategy in an opportunistic screening setting like what we have in the United States. We should selectively screen adults between the ages of 76 and 85, and we should probably stop screening those over the age of 85. Thank you for your attention. Thank you very much, Mandeep, for that clear and comprehensive overview of the new guidelines and recommendations. Next, we will move to a review of appropriate and inappropriate uses of stool DNA testing for colon cancer screening. And for that, we welcome Dr. Ilche Novesky. Dr. Novesky joined Rockford Gastroenterology Associates in 2008 and has led several initiatives to deliver the highest quality of care to the patient's practice community. Ilche, the proverbial floor is yours. So we're going to spend some time talking about appropriate and inappropriate use of fecal DNA testing. To echo what Dr. Sawney had said, the perspective that I've been taking as a participant on this panel is to try to create materials that allow us as gastroenterologists to go to the community, whether it's our primary care community or to share best practices with our GI colleagues. So a lot of this is going to be focused on how to deliver messages to our patients and our primary care community so that information is appropriately then disseminated to the patients that they serve. So, needless to say, colon cancer is common and deadly. We know that. We've heard that. We're seeing it rise in younger patients. We stress, but I think as a community we don't stress nearly enough that colon cancer is nearly entirely preventable with a high quality colonoscopy and we are faced with the concerns that nearly 50% of our population that's eligible for screening is not getting screened. As Dr. Sawney echoed, any screening is better than no screening, but we do have opportunities to stress that colonoscopy remains the only test that prevents cancer of the entire colon and that's one of the posts that the ASGE recently put on their social media pages We have the opportunity to prevent colon cancer and using the Multi-Society Task Force recommendations, we then have the opportunity to offer FIT testing every year, followed by FIT fecal DNA testing, more commonly known as ColoGuard. And what we'll see here in subsequent slides is that there's been certainly an increased use of various types of noninvasive stool testing, including FIT fecal DNA. And as we'll see through some studies that have come out recently, there unfortunately has been some inappropriate use of FIT fecal DNA in the community. So to build on what we've seen already, these are some of the materials that we provide to our patients in various forms. We'll add our logo and do some co-branding, but when patients are asking about various types of screening and prevention methods, this is what we provide them. And this is, I think, a very good resource for all of us, an excellent resource for all of us to be able to offer to our patients when they have questions specifically. You can just print this out and give it to them. I think understanding appropriate and inappropriate use, you have to have a strong background when you're presenting to a community about what the various numbers are. And this is a slide that's pretty busy because I thought this would be a little bit more of an academic bent. This is a chart that served me well in terms of helping patients and primary care community understand the strengths and the limitations of the various methods we have for screening. And, of course, this compares FIT fecal DNA to FIT testing to colonoscopy. And what I tend to focus mostly on is understanding the limitations and finding in FIT fecal DNA's ability to find high-risk polyps. I stress the data that shows that 12% of all FIT fecal DNA testing turns out to be false positives. And of the positive tests, 70%, as we'll see, are false positives. This is from the Imperiali study in 2014, the seminal article there. And then when you start talking to patients about missed rates of colon cancer, they're often surprised to hear that FIT fecal DNA testing and FIT testing has high miss rates. The slide here includes zero to 6% of interval cancers being missed by colonoscopy. Those are old data that took into account some Korean studies in the past. I think, in some respects, looked at some studies that predated high-definition scopes. But a study that came out last year by a collaboration between Kaiser and Northwestern showed that the more up-to-date interval cancer rates, both in early or in an extended period of time between 2003 and 2015, were anywhere from 0.4 to 0.15%. And so when patients will say, well, no test is perfect, this is part of our informed consent, one of the things that I stress is that, yes, but the rate of a missed cancer, an interval cancer, developing in a high-quality colonoscopy and with a gastroenterologist with a high ADR is very, very small. So within that context, we have used this as an outreach to our primary care community, and I just gave a talk to one of our hospital systems last week at a town hall, presented this data and got quite a bit of positive feedback of them not realizing the strengths and limitations of the various screening and prevention methods that we have. Of course, this is the stool test that we use, that's commonly used for fecal DNA, namely Coligard. Won't spend too much time looking at this, but we all know that it's a combination of fit fecal DNA, and the fecal DNA has methylation markers, but yet the fit accounts for the majority of positive tests. The intention is for average risk patients age 45 to 85. It's not recommended for patients who have adenomas or on prior colonoscopies and who have family history of colon cancer or advanced polyps, and we have had patients that have come in with a positive fit fecal DNA testing that presented with certain symptoms, which prompted the fit fecal DNA test to be ordered. If the fit fecal DNA test is negative or normal, it needs to be repeated in three years, we all know that. Obviously, some significant advantages that it's done at home, there's no prep, there's no days off, there's no driver needed, but if it is positive, a colonoscopy is needed. This is a summary slide that Dr. Rex had provided in a very comprehensive summary article back in 2019, highlighting some of the strengths and advantages and limitations of fit fecal DNA testing. The high false positive rate, I think, is something that we all know about, that 12% is all tests being done have a false positive rate of 12%. As we'll see, their study, in fact, the Imperiality study showed that up to 76% of all positive tests turn out to be false positives. And because of increased methylation with age in all of us, the false positive rate tends to increase with age, and so some of the times patients will have this fit fecal DNA test ordered because they're older and they don't want to go through the hassle of the prep, but those are exactly the patients that will end up with higher rates of false positives. As far as fit fecal DNA testing, inappropriate use, a recent study that came out of the University of Maryland found that out of 902 patients, one in six patients, or 17%, ordered by PCP were off-label or incorrect indications, and of those tests, 19% were positive. And going back to what we talked about, the methylation patterns, there was a bias towards older patients, and in this particular study, older women were the ones that were getting the test ordered inappropriately. What's more disheartening and frightening is we, almost a fourth of patients that did have positive fit fecal DNA tests did not complete a colonoscopy, even though the PCPs recommended it almost 100% of the time. So one of the things that I stress with our primary care providers is if you're prepared to offer this test, of course, going through the appropriate amount of informed consent and describing the limitations, but you have to make sure there are infrastructure in place to be vigilant about making sure patients follow up and get the follow-up colonoscopy. Similar study that we recently presented at DDW, Dr. Matthew Steer, one of our newest partners, presented his medical student presented a normal presentation at this year's DDW, found that out of 440 ColoGuard tests, 68 or 15% were ordered inappropriately. You can see that 32 were ordered in patients who had prior history of adenoma, 23 with a respectable or correct family history, and then secondary indications or symptoms occurred in 13 of those patients. We found that our false positive rate was about 68%. 34% had no adenomas, 34% had non-advanced adenomas only, so that is based, that's considered a false positive. Our true positives were 32%, 30% with advanced adenomas, and 2% of the patients that we had seen who had a positive fit fecal DNA test ultimately ended up having colon cancer. We did find that when patients had a positive ColoGuard, they were more likely to have an advanced enoma considerably, as well as cancer compared to our screening cohorts. And the ADR, we tend to pride ourselves on having pretty high ADR, but it went up in those patients who had a positive fit fecal DNA test. Not surprising when we have those types of tests, perhaps the amount of scrutiny that we're undertaking is a little higher than what we would do in a, it's just kind of the nature of the process. So we know that fit fecal DNA is easier than a colonoscopy, but when I talk to patients in PCPs, I stress the importance that it misses 1 in 13 cancers, it misses greater than 30% of polyps that will become cancer, misses almost 60% of polyps that could turn into cancer, and it's inappropriately ordered in approximately 1 in 6 patients. There's high false positive rates, and of course it only prevents colon cancer if it results in colonoscopy and polyp removal, that's the key. All of this information will be available in a slide deck that is as part of the value of colonoscopy resource for our community. I just found out recently that there was a physician in Colorado that found that the slide deck that we had created provided her with quite a bit of material and success when she went to present to the community. So we hope that the same thing can translate to a greater population of our colleagues. Thank you. Thank you so much, Elche. I really appreciate your approach and love the data that you presented and how we can share that with our patients, community, and our referring providers, so thank you. Now let's welcome our last presenter, Dr. Asma Shatkat. Dr. Shatkat is the GI Section Chief at the Minneapolis VA Medical Center and is a professor of medicine at the University of Minnesota. Dr. Shatkat is a national expert on colon cancer screening, and her area of clinical research is colon cancer screening and long-term outcomes. She also studies quality indicators for colonoscopy such as adenoma detection rates and withdrawal times. Asma, thank you for reviewing the quality indicators for colonoscopy with our audience tonight. Thank you so much, Luke, and I'm very excited and thrilled to be presenting on this. Hopefully we'll leave you with some practical tips if you are looking for ways to measure quality and ways to improve it. So let's get started. So why should we care about quality? If we do colonoscopy, shouldn't that be enough? Well, the answer is no. Quality has several domains. I've listed a few here. We want to be effective in what we do. In the realm of colonoscopy, that means detecting and preventing colon cancer and certainly reducing these missed interval or post-colonoscopy cancers. We want to be safe by reducing complications. Quality is tied to reimbursement if you participate in the MIPS or the APM programs and also through high value practice reimbursement models. And definitely not least, it's tied to patient satisfaction. Our patients demand it and hence we must be transparent about it. And if that's not enough reasons, many of you might be aware that CMS had started this information about performance metrics on physicians on their website called Physician Compare. And among other things, one of the proposals was to put quality indicators for endoscopists on here. Now it's been stalled for a little while, but expect this to be up and running again. So you want to be ahead of this and not behind. So what quality metrics are we concerned about and what are some of the benchmarks? So there's several, and I've given you some references that nicely lay out the quality metrics we should care about. They fall in the pre-procedure, intra-procedure or post-procedure categories. And intra-procedure are the ones that we care about the most where the endoscopist has a very large role. And adenoma detection rate is perhaps the most well-studied and thought to be the most important one. The current benchmark is a minimum of 25% overall, 30% in men and 20% in women, but you can see the other benchmarks also. So how do we achieve this? Well, step one is measuring it. If we don't measure something, we'll never know how well we're doing. And for many of us, it's also a reporting requirement. For instance, for us, it's a requirement for our FPPE or OPPE for ongoing professional evaluation. So this is what our sample report card looks like. Each endoscopist has a blind ID that they know what the ID is, and then we give them quarterly report cards. And there can be different iterations of this, but very simplistically for one quarter, this is a physician in my group, number of colonoscopies performed, number of screening exams, how many were complete, the ADR for the screening exams only, the withdrawal time, and number of colonoscopies with inadequate bowel prep. So this would be step one. Then these data can be presented in aggregate to the group, and then individual physicians can be given feedback that's identifiable. And then these results can also be posted on the ASC wall, and practices are going as far as publishing these online in aggregate de-identified. And here's an example of that. This is a practice that has its quality metrics published right on their website, and they pretty much give their colonoscopy completion rate, their adenoma detection rate, and this is an example of a public report card. So they say what the benchmark is and how they've been doing yearly. And again, report cards by themselves, and this is also their adequate bowel prep rates. Report cards by themselves serve two purposes. One is for information, and also the feedback has been associated with improving quality of the colonoscopy, as demonstrated by this study where six endoscopists started receiving quarterly report cards on quality metrics and no other feedback. And just by getting this feedback, their ADR and sacral intubation improved ADR by almost 10 percentage points. The second step is improving the prep at the endoscopy unit level. You can see the difference between these two preps, and you can also very clearly see intuitively what might be missed on the picture on the left versus the right. So the standard pretty much has moved to using split dose or same day prep, particularly for afternoon exams, such that the second dose is begun four to six hours prior to colonoscopy and finished at least two to four hours prior to the colonoscopy. And prep should be judged after all the washing has been done, and adequate prep should be achieved in at least 85% of colonoscopies. And if inadequate, the only interval is to repeat it within a year, but next available if possible. The third step is knowing what to look for and resecting it completely. So, i.e. having a good polyp recognition. We all know that polyps have very subtle features, particularly the sessile serrated lesions that tend to be right-sided, flat or sessile, have irregular borders, often covered by mucus. So hard to see, hard to completely resect, and challenging, and we think a large source of post-colonoscopy cancers. And then complete resection is imperative. Our resection standards have moved along, and such that we now should be using SNARE with a rim of normal tissue for pretty much even the smallest and diminutive polyps, and you can see some of the more advanced techniques, but really the emphasis is on complete resection. And then finally, think of interventions to improve quality indicators if there are deficiencies in the following categories, technique, technology, and education. And the most important aspect of technique is withdrawal time, which should be at least six minutes in colonoscopies without biopsies or colopectomy, but it's truly not the time that matters, but the technique or what we spend that time doing. And there's four hallmarks of good withdrawal technique, adequate distention, washing and cleanup, looking behind folds, segmental inspection, and subjective timing. Because time alone isn't enough, it's really the technique that matters. This study nicely demonstrates it. These are comparisons of lowest and highest ADR endoscopists in a practice, and you can see the withdrawal times are very similar and above six minutes. However, the technique score is truly what distinguishes higher performing endoscopists. Other interventions, such as train the leader, which means taking a few select endoscopy directors or leaders and giving them training and feedback so that they can go back and disseminate this information at their endoscopy centers or networks. So this was a study with 40 Polish endoscopy centers with low ADRs, and they were randomized to feedback only, such as report cards or feedback plus training, which was assessing the hands-on training and post-training feedback. And with 24,000 colonoscopies by 38 leaders, the train the leader program resulted in an improvement of ADRs, which was sustained at least a year after this intervention. It's a very effective way, and ASGE certainly has many course offerings to pick from. And then finally, accessory devices are available. These are digital attachment devices, come in different forms, the endocap, endo-ring, endo-cuff, and then some more fancier things. I've given a reference that reviews these really well, but again, all of these numerically improve ADR. And then finally, we've ushered an era of emerging technologies. AI for GI software has already been approved and many more coming down the line. And you can see that this will aid our colonoscopy quality by helping us with polyp detection, histology prediction, giving us an objective PrEP quality score, telling us how much mucosa we've seen or exposed, and whether our retroflection was adequate. So, and they come in different forms, but this technology is very exciting. So, in summary, multifaceted interventions are needed to improve quality of colonoscopy, and one can pick which interventions they want to try, and they go from low effort, low cost to high effort and high cost. But think of them in these categories, and sometimes multiple steps need to be done. And on my last slide, I wanted to predict what the future of colonoscopy practice might look like. So, from our endoscopy suites, what might happen is we might be able to dictate the note or the findings and what we're doing, and that might transcribe our report so that there's accurate reporting. AI enabled automated reporting as well as polyp detection and populating our report with pictures, and then automatically that data would result in aggregate summary quality tools, and based on that, we can give physicians individualized feedback on where they stand and what areas need to improve in real time. And then this data could go seamlessly into a registry for benchmarking for pairs and patients to see. So, more to come on this field, certainly very exciting. Thank you very much. Thank you for that fantastic overview, Asma. I especially like the demonstration of the report cards, both at the individual and aggregate level, really using that to drive performance improvement in our endoscopy units, and then also really the multi-faceted interventions you talked about. Before we move into our question and answer session, I would like to take a moment to review how ASGE's endoscopy unit recognition program and the value of colonoscopy campaign work hand in glove together. Through the endoscopy unit recognition program, healthcare teams turn a critical eye on the infrastructure of their unit to ensure essential right pieces are there to support the delivery of high quality, safe, patient-centered, and efficient care. Translating quality concepts into practice is hard but needed work, especially at this time as we're emerging from the COVID-19 pandemic, with patients slowly returning to preventative care services. They want to know their healthcare team is committed to quality care. Earning the ASGE Quality Star is a way to demonstrate to your patients and to your community your team's commitment to quality and safety. There is one component of the endoscopy unit recognition program, which is the application process where you can capitalize on the materials available through the value of colonoscopy campaign, and this is really for the quality improvement project requirement. Your endoscopy unit or healthcare system can start an improvement project aimed at increasing the public's knowledge of the importance of screening colonoscopy, and you heard about some of those tools here today in the application of that. As an example, we recently had an EURP honoree submit a project where they sought to increase their screening colonoscopy referral rate by 10% over a three-month period. Here, this group developed targeted education materials for their surgery patients 50 years and older who had never had a colonoscopy. The unit's end result was an outstanding 20% increase over that three-month period for referrals for first-time colonoscopies. On screen is a direction for learning more about ASGE's endoscopy unit recognition program. We hope you will join this wonderful community of practices if you are not already currently an honoree. Now we will take the balance of our time addressing your questions. We're going to ask all of our presenters to join us on screen. Also, we'll be joined by Dr. Mazen Jamal of Oceana Gastroenterology and Dr. Barbara Kosher, Director of Operations with the Oregon Clinic. While the audience questions come in, I'd like to kick us off by starting with a few questions. The first question I'm going to pose to everyone is, how are each of you planning to leverage the resources available via the ASGE value of colonoscopy campaign? Well, this is Barbara. I'll start off. We are just starting to reach out to our primary care providers to see if they are willing and able to see us now that some of the COVID restrictions are becoming lifted. And of course, the one we would love to use is the choosing amongst the colorectal cancer screenings, as well as the posters of selecting the test that's right for you. And of course, I can't wait for this slide presentation to be available on the website as well. This was really good. Thank you very much for this. Thank you, Barbara. Any of the other presenters have ideas of how they want to implement this or some tips for our audience? Luke, we've embraced it pretty early and pretty robustly. Every patient that leaves our ASC will get a summary sheet that will have some facts about various colon cancer screening and prevention, providing them with information about strength limitations of various studies. We have active social media and a marketing team that spends a lot of time on Facebook promoting the value of colonoscopy. And in fact, our Facebook post today from our Rockford Gastroenterology website posts the VOC ASGE post talks about preventing colon cancer and how colonoscopy can prevent that and gives a link to the value of colonoscopy. I really can't stress how important simply having the EURP star on our marketing materials, what that's done for us, when we send these patients home with the marketing, with our materials, the ASGE recognition program is on there. We're the only ERP in a 50 mile radius, and that's quite a differentiation strategy for us. We send our, we have email blasts that go out to our market about 25,000 emails a month. And then every month we look at the metrics and see what, did the GERD topic get some attention? Did the colon cancer topic get the attention? At the very bottom, we always have the recognition star and invariably 10 to 15% of all the clicks are on that star. And that then allows those patients or those prospective patients to realize what a potent and powerful tool it is to distinguish what we can do compared to perhaps other places that don't. And just to let them have the peace of mind that the work we're trying to do to provide the highest quality colonoscopies are being recognized on a national level. So we've embraced that. We use the slide decks, of course, that are on there to reach out to our primary care community and they've been quite successful. Thank you, LJ. I was just gonna give you a little, a view from the standpoint of the VOC campaign. See, we were truly, you saw some great materials tonight. We're constantly updating and organizing that. Now, part of what we're gonna do the rest of the year is we're gonna package little bits of this into small little packets of information that we can message out to internists in general. That's something we can do. And we have a social media effort from the ASGE. Our industry partners also have social media efforts and they're interested in using some of our really good content and getting the word out in that regard. What's really exciting about tonight and the prospect of working with the URP, this is such a wonderful grassroots from the community all over the country, to hearing about how different practices already have used it and can see meaningful, tangible results is very promising. So hopefully some of these materials that we put together can actually be used by some of the URPs in their communities to reach out. Because I think we think that a lot of this, the benefit is just gonna be local. And I'm very excited to get feedback from the URP members on the call and as you hear about it, as to how it's working, how these materials work and what new things you might need so we can be responsive and come up with new updated materials. Thank you, John. We have a question that came in and just as a reminder to the audience, please submit any questions you have to the Q&A box down below. We're happy to answer all of them. The first question is, is how do you deal with the issues of having to do a diagnostic colonoscopy and the cost to patients after a positive fit or Poligard? Usually patients are not informed by their PCP that would now have to be diagnostic as opposed to screening. Do people run into this in their practice? And if so, how do you handle that discussion with your patients? This is Barbara again. It's a very difficult discussion with patients. And we actually, that's been one of the primary motivators for us to go out and talk to our primary care physicians, especially those primary care physicians who deal with a large Medicare population. Cause this rule primarily affects them and Medicare doesn't allow for colonoscopy after the positive Poligard test. And it's amazing how many primary care physicians don't know that little aspect and how important it is. So yes, that's gonna be one of our core messages going forward this year, along with the screening age of dropping to 45. Thank you, Barbara. Any other thoughts on that topic or any other advice that people would have? All right. Well, one question I have in light of the new guidelines, especially now that they're recommending screening starting at age 45, I'm curious how all of you sort of handle one, those discussions with providers now, but also secondarily patients, especially since it seemed, at least outside of the field of GI to be a dramatic change. I'm curious how you all sort of navigate that in having those discussions with your patients and providers. John, I can start with that. Someone who practices an academic institution, I think one of the really important things we can do is educate our residents because you have access to a large number of residents at a morning report or a grand rounds. And these are gonna be our future primary care doctors. So it's much easier to educate them and have them practice correct guidelines from the get-go as opposed to letting them pick up other practices. So we've really engaged our residents and that's really the core of how we're getting this message out is through education directed at our residents, which then very quickly moves up to the attendings they work with. As far as screening for those starting at age 45, we're really trying to push this message that colonoscopy is one of those one and done and you do this test once every 10 years and that's what you need to do. And perhaps a message that four colonoscopies over someone's lifetime is what's needed to prevent the third most common cause of cancer death in the United States. And I think that can be a very, very powerful message. And I think John Cohen's gonna really, really work on that. Thank you, Bandeep. Next question I believe is probably best suited for Asma to answer. Asma, the question is, has there been any movement on establishing an enforcement of colonoscopy screening metrics for Medicaid that are similar to Medicare that you discussed? Not sure if we had problems with Dr. Shaka's connection. So let me just jump in here to say this has been pretty slow moving. It is being discussed at the National Quality Forum. So there's a lot of ways that quality measures are vetted out there. And so CMS established the National Quality Forum and they're a primary funder of it, but ASG is a member of it as well as the other GI societies. And right now the National Quality Forum does have the core quality measures implementation work group. And they are talking about implementing this through both programs kind of at the state level. But again, it's a very slow moving process. So that's nothing I would see in the near term. But the dialogue is out there is the best I can give you at this point. Thank you. And definitely a lot of moving pieces on that. The next question I have is actually for each of the panel members. You know, as I said, I was very struck by Asma's presentation around having the reporting report cards. I'm curious from each of the presenters, do you have report cards or do you share data on your endoscopist at each of your units? And if so, I'm curious about sort of how the implementation of it went and then kind of sort of what results you've seen from it. And maybe we'll start with you, John. Well, you know, the data is king and data is real interesting. I've seen data from that. We had data from the C5 coalition in New York that showed by giving data and not just having, but actually reviewing data in different units, a number of disparities in colorectal cancer screening and actually compliance with correct guidelines were improved dramatically using the data from GI quick repository back in some of those units. So it's really exciting. In our unit, you know, we use the idea of you can identify yourself and then you see how you compare. You're using a little healthy competition just like Asma suggested. And I think that that's great. I think that we're not as advanced in terms of providing that report card to patients. You know, Doug Rex presented an article in the New York Times at one point and now what's your colonoscopist ADR? You know, and I think that, you know, we'll see how that emerges into the public domain. We'll see about that. But, you know, I do think that, you know, at least giving people feedback internally is something that definitely makes a difference. We've been collecting- If you tie the two challenges together, you know, this opportunity to screen this newly added group, which is 45 to 49, and there's 20 million of them in the US and improving quality, well, you could see a marketing strategy right there, right, by being visible. So first we need to reach out to these individuals because many of them don't even have primary care physicians and particularly men. So first we need to reach out to them. And how do we do that? Well, we go wherever they go. And there's some really creative things that have been tried like barber shops and media campaigns and advertising on sports channels. And then how do we entice them to come to our practice versus, you know, a practice next door or not undergo colonoscopy altogether? And that's where the quality metrics truly make a difference, showing that it's a very safe procedure and these are the metrics for our practice would really get us some buy-in and maybe we could get, you know, larger groups coming in. And then it's word of mouth also. So once one person starts asking about physician quality indicators, then I think the word quickly spreads. I know a lot of my colleagues, so they say, who should I go for a colonoscopy? Who do you know has a good ADR? So it's already out there. We've been collecting data for quite some time and we have that presented at our annual meeting and that measures not only ADR, but also SQL intubation rates and all the quality metrics Dr. Schalkot had outlined. And same thing, it does motivate us to try to be the one that has the highest ADR. We have a few partners that have a 70% ADR. So that's our sort of really high goal, but all of us are above, well above the threshold. And when I go and do outreach to primary care providers, as well as to patients, I'll show them our collective ADR is 200% better than what's considered acceptable. And because we collect data, we talk about SQL intubation rates, but we also talk about complication rates. Our complication rates for perforation, which is of course one of the most concerning for patients is one in 7,000. So when you show the one in 1,000 and one in 2,000, we can say that for the last 10 years, our collective rate of perforation is one in 7,000. It provides quite a bit of comfort to the patients to know that they're at the risk for having some of these more concerning complications go way down. So we've embraced the data. We have not yet put it on our website or Facebook. We're trying to figure out how to still, there's some little bit of hesitancy to do that, although I think it does make a lot of sense. But we have collected data and we've used it to really promote what a high quality colonoscopy is. So we don't compute report cards for individual physicians, but we do so for the unit as a whole. And then every month we look at that at our QA meeting. And if any of those quality metrics fall below our designated benchmark, then we'll do a deep dive and then look at individual physicians. So that's the strategy we've taken. So our group also looks at the aggregate data and then each physician also gets their key so they know where they fall on that. And a few years ago, we took a look at the top 10 physicians and we sent them a survey and asked them what they do, what did they do to have the top ADR rates? And they had things such as viewing the ASGE videos from Dr. Doug Rex, making sure that they had the split preps, that they washed, did all the washing. And then we turned that into basically a teaching point for those who had lower ADR scores. So now everybody's ADR score is moving up. And we will continue to do that with our newer physicians coming in and sharing those tips from our top 10 physicians. Markable, thank you. John, did you have a question you wanted to ask? Yes, I just, I wanted to get the sense from the panel. We were trying to get our hands around how to do the best outreach to internists and primary care providers in our communities. And of course we're faced with massive campaigns about other screening methods in one thing or another. So I'm wondering what will be the most compelling message or the best way to start. And I'm wondering whether the early onset colon cancer and the following up of symptoms that Dr. Sawney was talking about, whether that might be a most compelling start to really go to change attitudes among the primary care community who I don't really think fully are getting that message. I wonder what Ilche's thought from his in contact with PCPs and what Mandeep feels and Asma. Yeah, so we, of course, all of us have had the stage four rectal cancer in the 42 year old that is quite devastating. And so a phone call to the PCP to say, hey, this is what we find, I think starts the, creates an experience where the PCP then is aware that symptoms shouldn't be ignored. When we go to these out, when we do these, when I do these outreaches, I spend a lot of time talking about colon cancer can be prevented. Colon cancer can occur at any age. If you have any symptoms, of course refer. But I think the motivation should be trying to get to the patients themselves so that as they're scrolling through their social media feed, one of the things that we noticed when we were looking at various campaigns is when you have more ominous type of messages, that message tends to be looked at. As human beings, we tend to be more concerned about some of that, some of the dreaded consequences of not doing something as opposed to maybe some good news. It's kind of how we consume information. So we look at, and we found that when patients say, when we say to patients, don't ignore your symptoms, we get more clicks. And it's one of those things where it would be great if there's a way that you could measure whether that click resulted in that patient being seen. There's certain infrastructure that allows to do that. But in most cases, you're never gonna be able to know whether that particular message impacted that person enough at that time, but repeated messaging to the community in various means, whether there's nothing like meeting patients, sorry, meeting PCPs the old fashioned way and sitting down and having lunch with them at their facility, providing them literature and going over that. I think those things still have a lot of value and then trying to then parallel that with giving patients information to understand, look, don't ignore your symptoms, get seen. It's never too early to get seen. So it sounds like Rockford has a very strong social media strategy. Is that what, are you on Facebook? We have Facebook and that's what we've decided is our target marketing. And so we've devoted our research, sorry, our resources to having a dedicated marketing team that provides every two or three days worth of posts and that will feature stuff, information on national news, when Chadwick Boseman passed away or when there was another type of incident that would gather attention. 45 is a new 50 was really what we promoted and we boosted in our region to stress that colonoscopies are now recommended to start at 45. We don't advertise on television. We have a local market. We have local TV. We haven't found that that necessarily works super well. We have done Sunday morning shows where we've had a physician and a nurse practitioner go in. Most of our efforts have been social media and providing patients who are here with the opportunity to have literature to go home with in color to say, hey, this is what we need to do. And these are some of the strengths and opportunities to prevent colon cancer. And Barbara out in Oregon, what are you all doing? Are you leveraging social media out there? Yeah, so when we have like a colon cancer awareness month, we'll post things on our Facebook and because we are a multi-specialty group, GI can't dominate it, but we do have a lot of posts on there. And right now we are doing a patient experience with somebody who was younger than age 50 and luckily paid attention to the signs and came in for the colonoscopy. So hopefully we'll have her story up, not only in what we call our P2P newsletter, which is to our referring providers, but also on the, probably a link to Facebook. Barbara, now you can also go on the website and look at, we have a couple of testimonials. I did one of my patients who was really young and who had a tubulovirus adenoma picked up because his PCP was a little bit proactive for a drop in ferritin. So I think that there are some stories like that where more stories where we're welcome on the campaign to get, but it's not just for to have it out there, but we're gonna try and message it out to patients directly. But that would be very useful for practices to be able to use those human stories to be able to get the message out to both the patients, but also to a lot of PCPs, if someone in their 30s is just having rectal bleeding, they may just run it off to hemorrhoids without necessarily thinking to push an evaluation. And I think that may be an area of really emphasizing our messaging. I agree, especially for smaller practices that may not have the resources to do their own patient experience video, it's a great way to just relink the ASGE one. Absolutely. And then, a lot of education. So what we did for our primary care physicians, I get on their quarterly clinic level meetings and then also team level meetings, including the general general medicine sections meeting and take five minutes, present like the high yield things, screening age, symptoms, family history and surveillance. And then also made little laminated cards that first we put all over GI for our nurses and rotating fellows and residents, but then we extended it to resident clinics and PCP clinics. So then it's a quick cheat sheet that is readily available. They know where to look. They don't even have to click on up-to-date or go looking for what they should be doing. And it kind of helps put things on their radar. So, and we also encourage a lot of messaging in-house from our primary care physicians and answer them pretty promptly. So I think that helps send the message that we really wanna support them. And these are the things that we're looking for for them to look for patients for. Well, Dr. Day, this has been such a wonderful dialogue. I didn't notice we went past the hour. Did you want to start wrapping us up? Thank you, Eden. I was gonna say we are quickly approaching our ending time, unfortunately. Before I hand the presentation back to Eden to close out tonight, again, I'd really like to thank our presenters for a truly comprehensive and engaging discussion, especially for all of you who joined this evening. Again, I know promoting the value of colonoscopy is a topic for which we all have tremendous passion and a deep commitment. We hope the information offered tonight, along with the strategies and tools that are available through the Value of Colonoscopy campaign webpage will further empower you in the ongoing dialogues you have with your networks, your patients, and your community, really relaying the importance of screening early for colon cancer, while also emphasizing that screening is safe and should not be delayed. Eden, I'm gonna hand it back over to you. Thank you, Dr. Day, and thank you to the panel. In closing, thank you for your participation in this discussion on promoting the value of colonoscopy to your referring networks and patients. Before you log off, we would appreciate your feedback on tonight's event by going to the networking lounge and completing our evaluation. This concludes our presentation. We hope this information is useful to you and your practice.

American Society for Gastrointestinal Endoscopy

ASGE

colonoscopy

referring networks

patients

virtual environments

resources

United States Preventive Services Task Force

screening colonoscopy

quality indicators