Hello, welcome to a discussion on quality interventions in the upper GI tract. My name is Eden Essex and I will be the announcer for this session. This session is being recorded and will be available to you in the near future via GI Leap, ASG's online learning platform. By registering for this event, the program will populate your GI Leap account automatically and you'll find handouts for the session there. You can also contact the ASG office if you need assistance accessing your account. You will be able to submit questions and comments throughout the event via the Q&A box. A Q&A session will be held at the conclusion of the presentations. Now it is my pleasure to introduce our presenters for the session, who are the lead authors of the papers under discussion. Drs. Fatah Bazarbachi and Raj Kishwani. Dr. Bazarbachi is the Director of Interventional Endoscopy for CentraCare St. Cloud Hospital in Minnesota. Dr. Bazarbachi currently serves on the ASGE Quality Assurance and Endoscopy Committee. He is the lead author of the paper, Interventions to Improve the Performance of Upper GI Endoscopy Quality Indicators. Dr. Raj Kishwani is a gastroenterologist and nationally recognized expert in interventional endoscopy who leads efforts to improve healthcare quality. He is the Medical Director of Quality for the Northwestern Medicine Digestive Health Center. Dr. Kishwani is the lead author of the paper, Interventions to Improve the Performance of ERCP and EUS Quality Indicators. I will now hand the proverbial floor over to Dr. Bazarbachi. Thank you very much, dear Ian, and I'm very grateful for all the colleagues who are attending this webinar and appreciate the efforts from the ASGE to further the education and knowledge of us in GI and in endoscopy. I'm delighted to have this opportunity to present to you as part of this exposition with Dr. Kishwani focused on quality and endoscopy. I'm actually presenting on behalf of our ASGE Quality Assurance and Endoscopy Committee, and the information provided today would not have been well gathered without their input and recent efforts with guidance from our ASGE Governing Board. The title of my presentation is Quality Intervention in Upper Gastrointestinal Endoscopy. I have no disclosures. Before proceeding into the details of this topic, I thought it would be informative to take a step back and talk about quality in healthcare in general. First asking the question, what is quality in healthcare? This can be defined as the degree to which healthcare services increase the likelihood of desired outcomes. These outcomes are providing consistency with professional knowledge, which equates with evidence-based practices, efficiency, which can equate with cost effectiveness, and finally, importantly, minimal risk equating with safety. Having now identified this definition, it follows that transforming this concept into a measurable effort is the next step since we can't improve what we don't measure. This results in the identification of quality indicators that strive to achieve these tenets. These quality indicators define the minimum standard and benchmark or measure performance against it. Why does it focus on quality matter? The importance of quality in healthcare in general, and endoscopy in particular, stems from what it achieves. It improves the care delivered, it decreases the burden of inadequate procedures, it curtails morbidity and mortality, achieve a cost-effective model, and perhaps assuage medical legal concerns and fiscal concerns to stakeholders. So who is looking at our performance in GI and in endoscopy? In the rising demand for healthcare, payers are looking for efficient, cost-effective interventions, but it's not really that simple. Value-based care puts what patients value at the center of all we do. So we're moving from high-quality care to high-value care, and for us, specifically in endoscopy, to delivering high-value diagnostics and high-value therapeutics or interventions. Our GI societies have been prescient, putting programs in place to ready us for these evolutions in healthcare delivery and payment reforms. In 2006, the ASGE, in collaboration with the American College of Gastroenterology, formed a task force on quality in endoscopy, which developed the first quality indicators for endoscopic procedures, which were later updated in 2015. So how can we evaluate quality in endoscopy? It is a difficult task to retrospectively judge the quality of an endoscopic procedure for many reasons. Direct observation outside the confines of a trained program is not possible. Depending on the type of procedure, adverse events are rare in endoscopy and may not relate to poor quality when they occur. This poses challenges when trying to judge a low-from-a-high-quality procedure and demonstrate the need for objective, clinically relevant, easily measurable, and representative parameters to assess quality. Those parameters are called quality indicators. These indicators should be clinically relevant, readily measurable, reflective of the highest quality of care, correlating with improved outcome, and are based on evidence. And when applied to the endoscopic procedure, we can really divide them into three domains, which represents the domain of the endoscopic procedure itself, pre-procedure, intra-procedural, and post-procedural. As outlined in the quality indicators documents produced by the ASGE, there are quality indicators common for all endoscopic procedures, be it EGD, colonoscopy, and as Dr. Keswani will tell us in his lecture, EUS or ARCP. In the pre-procedure arena, proceeding for an appropriate indication is germane to all endoscopic procedures. Similarly, informed consent, outlining clear risk stratification for the patient, providing prophylactic antibiotics when needed, addressing antithrombotic management prior to endoscopy, and performing a pre-flight, if you will, or a checklist procedural timeout. During the procedure, ensuring a complete exam with photo documentation of key findings and documenting the medications given and logging any events. And after the procedure, having a discharge from the endoscopy suite protocol with instructions, communication of the results, and providing a satisfaction survey afterwards. Specifically for upper endoscopy or EGD, in addition to what we have relayed as common quality indicators for all procedures, priority indicators are also identified, delineated in the slide with the green star. Other indicators also exist. Those emphasize the appropriate antibiotic prophylaxes that we relayed in all endoscopic procedures. The delivery of important therapies before commencing upper endoscopy, such as giving proton pump inhibitors before a GI bleed, vasoactive medications in variceal GI bleed. And during the procedure, adhering to a sampling protocol, as well as a systematic approach to the description and sampling of unique pathologies such as Barrett's esophagus, in addition to the accurate characterization of high-risk stigmata lesion during GI bleed and therefore delivery of therapy. In the post-procedural phase, delivery of important therapies such as PPI and peptic strictures after dilation, as well as peptic ulcer disease management, as well as providing a follow-up plan such as repeat upper endoscopy for upper GI re-bleed or checking for peptic ulcer disease healing. Importantly, after we identified these quality indicators, how can we increase the adherence to their performance? And this was the topic of the effort that the Quality Assurance Endoscopy Committee has led, where the committee performed a scoping review of the literature to identify what has been suggested as means to improve this adherence. This effort was recently published in Gastrointestinal Endoscopy, and I will give a broad summary of the findings. To increase adherence to quality indicators, we should think of clinical scenarios. For example, to increase documentation of quality indicators, audits, order sets, as well as providing templates for documentation and training programs can take place. To increase adherence to the delivery of medications, as we mentioned prior to EGD, for bleed or variceal bleed or strictures, etc., or even placement of feeding tubes, order sets and standardized time-out sheets might help increase that adherence. And for specific pathology, such as Barrett's esophagus description or peptic ulcer disease recognition of high-risk stigmata, focused educational interventions may be warranted. In this table, it's a busy table, but what we're trying to really take a big picture from is we have identified quality indicators throughout time by the ASGE efforts. We're trying to find what kind of practices improve the adherence to these quality indicators and for what desired outcomes. For example, when we think about documentation of appropriate indication for upper endoscopy in the procedural report, why are we doing that? We're doing that because we've seen, as we'll see in some examples, that adherence to legit indications for upper endoscopy will increase the detection of relevant pathology on EGD, upper endoscopy. Similarly, when we say that the best practice quality indicator, endoscopy should occur no later than 12 hours after presentation with an upper GI bleed in cirrhosis, the purpose of this is to decrease the rate of re-bleeding and decrease the rate of mortality by doing this intervention. Similarly, in patients with cirrhosis giving prophylactic endotracheal intubation, other considerations during endoscopy, such as which position to place the patient on during that endoscopy for bleed, the reason this is important is because it will increase the procedural safety. Lastly, when we recommend specific therapies, such as endoscopic band ligation, when feasible as the treatment of choice, understanding that there are rescue measures, we are aiming to decrease mortality. So it's two prongs. It's what's the best practice and what's the desired outcome. When we are performing upper endoscopy for diagnostic intent, for example, in ulcers, taking a certain number of biopsies, three to five biopsies from the rim or the edge of the ulcer, the yield that we're trying to achieve here is to have high diagnostic accuracy in detecting cancer, if present in these ulcers. Similarly, when we specify a certain number of biopsies, we're also trying to increase the accuracy of detecting H. pylori when present. The same applies when intestinal metaplasia is suspected and in celiac disease evaluation, where we specify the location and the number of the biopsies that we are trying to take. Most of us, all of us are familiar with Barrett's esophagus standard practices. Similarly, adhering to adequate inspection time is the best practice. To what end? To increase the likelihood of discovering advanced lesions and not missing high-grade dysplasia or esophageal cancer. Adding a distal attachment at the end of the scope might help increase the likelihood of Barrett's esophagus diagnosis by allowing us for more targeted sampling. Adhering to established protocols, such as the Seattle Protocol for sampling in Barrett's esophagus will increase the likelihood of discovering advanced lesions. We can consider adding more newly described technologies, such as wide transepithelial sampling brushes, again to increase the representativeness of sampling in Barrett's esophagus. And when we implement white light endoscopy and virtual chromoendoscopy, for example, with MBI, for us who use certain types of scopes, this will increase the likelihood of discovering advanced lesions. And at times, if virtual chromoendoscopy is not feasible, dye-assisted chromoendoscopy should be pursued. Lastly, as we talked about efforts to increase education in recognizing lesions, whether it is in, mentioned GI bleed, identifying high-risk stigmata, or in Barrett's esophagus, training program aims to increase the detection and delineation of Barrett esophagus-associated neoplastic lesions. All these recommendations for best practices that relays our quality indicators and the interventions are our desire to have interventions to improve the adherence for these quality indicators stem from literature. Recent meta-analysis showed that approximately 20% of upper endoscopies are performed for inappropriate indications. That's why documentation of the indication as a reminder is important. As we mentioned, we know when upper endoscopy is performed for an appropriate indication, the rate of clinically meaningful findings is higher in adults and in children, in all age groups. An intervention would be the implementation of a virtual clinic and decision trees to decrease the burden of inappropriate EGD referrals. Other examples, several studies looked at implementing order sets or sometimes called action sets in the protocolized management of upper GI bleeds. Implementation will lead to streamlining of the hospital stay and avoiding unnecessary medications. Specifically, in upper GI bleed and cirrhosis, they improve overall adherence to quality practices and timeliness of initiating therapy. Another example is from the Enigma study, a European study, which is the European network for investigation of gastrointestinal mucosal alterations. Adherence to upper endoscopy sampling guidelines in patients with signs of gastric pathology was poor, even in academic center. And a comparative study in two cohorts, control and intervention, showed that a simple training program improved adherence to EGD quality indicators, including sampling. This is the cohort we mentioned about that training programs, whether to recognize a pathology, high-risk stigmata, or even be aware of adequate sampling criteria, is important. All this is great, but what are the challenges and barriers that each of us have in our endoscopy suite to dissemination and implementation? There's lack of motivation sometimes from adopting new ways of attempting to improve quality. These are efforts that are significant and require multiple stakeholders and sometimes champions. There's also resistance to change. There's a saying, culture eats strategy for breakfast. People will say, we've been doing this, the same thing for 10 years and no one complained, et cetera. We have to be mindful that, as I said, in upper endoscopy, especially upper endoscopy that's perceived to be a low-risk procedure performed at high volume, we have to raise the awareness of all colleagues who practice these procedures that there are data that show that certain practices will have downstream implications for patients. How can we combat that? Well, we can identify champions. We can use our resources, and for example, the ASGE EURP program is a great way for endoscopy centers to apply and to see if their current practices are adhering to what the ASGE EURP program will deem as certifiable. This is very good, in my opinion, it's a very good thing for all of us to think about because it's not only about the application, but it's also about doing the internal work to see if we are reaching these thresholds that are related within the program. Efforts are counted as qualifying efforts to incentive-based payment systems by payers, so it might contribute in the future even to reimbursement, so that's also a fiscal consideration that we should consider. Other real challenges and barriers specifically for upper endoscopy stems from the diversity of complexity or quality indicators for different pathology, for example, variation. Variation in this sense is variation in key quality metrics among international GI societies that may not necessarily agree on all the quality indicators that we have. There's also perhaps no consensus on what makes up a high-quality procedure according to the fidelity in capturing these metrics in daily practice. There is also benchmarking challenges such as lack of tangible thresholds and benchmarks given that they're diluted by the diversity of pathology we encounter during upper endoscopies. The need for longitudinal follow-up and local comparative data, unlike other metrics, for example, in colonoscopy, are straightforward metrics for colorectal cancer screening. This may not be necessarily the case for the different pathologies that an upper endoscopy aims to evaluate for. And clearly there's a need for GI-specific repositories to capture pre-procedural and post-procedural practices. A systematic approach in ensuring situational awareness is one potential solution. For example, pre- and post-endoscopy checklists, endoscopist participation in learning or self-assessment tools like we talked about in Barrett's esophagus, and perhaps the addition of report templates as daily tools for us when we're writing our endoscopy reports will show awareness to evaluate for specific pathology as a surrogate for the individual pathology detection rate. In other words, if we are mentioning that we are aware during our endoscopy report of certain pathology presence or absence, that might be a surrogate for actually tracking that metric, given that it's very diverse in upper endoscopy unlike, as I said, in colorectal cancer screening. So in summary, a focus on quality in endoscopy beyond colorectal cancer screening is relevant and is directing how endoscopic operations are conducted and reimbursed. Efforts from GI societies to delineate quality indicators that are reportable, measurable, and scalable are underway. Evidence-based support both to the validity as well as adherence to these indicators is paramount and should ideally emanate from endoscopist to endoscopist rather than having some committee somewhere dictating this to us. Future research should focus on key practices conducive to optimal diagnostic and or therapeutic yield and optimal patient safety. Thank you so much for your attention. So that is a tough act to follow, so I have two choices. I can just not follow it and we can all log off early or I can give my best shot. So I think we'll we'll give it my best shot to sort of go through my sort of work with our committee on the Quality Assurance and Endoscopy Committee to really work on interventions to improve the performance of ERCP and EUS quality indicators. And as you can see here, we had a number of authors that worked hard on this document, including our first speaker, Fatah, who really did a wonderful job presenting his document. So I'm going to try to sort of talk you through why I think this is such an important topic, but really give you concrete things that you can take back to your practice today in terms of improving ERCP and EUS quality in your practice. So just to sort of start with the ERCP concept, I think it's really important for us to understand what an important procedure this is and what can happen after an unsuccessful procedure. So this is just a highlighted statistic, which would be that a patient is nearly twice as likely to experience in-hospital mortality after an unsuccessful ERCP. So for an inpatient ERCP, when you're, when you have a failed procedure, that patient's nearly twice as likely to die during that hospital stay. So we really want to be pushing our field towards, you know, avoiding any failures whatsoever the best we safely can. And this gets to the idea of, you know, what should a minimum non-surgical anatomy native papillary cannulation success rate be? And you'll get lots of different opinions from people from 80% all the way up to greater than 98%. And this is one of those things where there's probably a good balance, right? You don't want to make your metric so high that people do unsafe things so that they can meet the metric, but it can't be low so that patients are suffering from low quality providers. And our societies have put some documents around this. On the top left is what the ASGE has put as a target on our initial ASGE quality document that looked at quality metrics in ERCP and said we should get at least 90% of cases that have a successful cannulation with native papilla. And the ESGE, which has developed analog metrics, similarly said 90%, but had set a target of 95%. So 90% is a minimum, 95% as a target. And so, you know, we have these types of documents out there and what I'm really happy about what the ASGE has done with this document today is to say, let's not just talk about how we should do, let's first of all talk about how we are doing, and then even more importantly, how we can do in the future. And what do I mean by that? So how are we doing in the US? We don't have a mandatory registry in the US. I don't actually know how we do in ERCP because we're not mandated to report. We have done studies in the past. This was an example study that we published four years ago in gastro, where we actually looked at how people did in their first year of independent practice after a fourth year training program. And we see that the cannulation success rate was greater than 90%. It was a 93.1%. The combotic stone extraction rate was 93.6%. Our target is 90%. So also those fellows are graduating as our graduated fellows did well. And they also did well in putting a stent below the bifurcation for obstruction target is 90%. They made it to 93.9%. But there's some concerns that that's a very isolated group. Like these are people who just finished their fourth year fellowship. How do people perform in general practice? This is a nice study that came out of the Netherlands, where they showed that the average success rate for ERCP was 86% among all providers. But you can see there's a lot of people that are sort of straggling around that mean. A lot of people are in that 70-80% range. More recently, that same group made a mandatory registry for ERCP procedures. And they again show a higher overall procedure success rate of 89%. But now you're seeing still that same number of stragglers, some people around the 80-85% range, not meeting the targets that we've set. So I think we know that ERCP quality and routine practice on average is pretty good. We see both at academic and non-academic centers. But there are people who are not meeting the metrics that we want, which is troubling. And we need to understand what we can do about it. This is not just limited to ERCP. That's the same thing in EUS, where you can see that our providers are not necessarily failing to meet targets, right? Our graduating fellows are doing well at EUS FNA sampling. They're doing well at diagnostic rates for malignancy. But when you look at all comers in practice, not just people who are very invested in a study and graduating advanced fellows, there are some people who have very low positive diagnostic rates and others who have very high positive diagnostic rates after EUS FNA of solid pancreatic lesions. So there is room to grow for all of us as providers. And that's why this document was developed. It's to talk about we published so many times the guidelines and what metrics we should achieve. What can you actually do to get better, right? It's enough to say, oh, here's where you should be. How can we help our providers get better? Unfortunately, one of our summary statements was this. This comprehensive review of the literature identified a paucity of evidence-based interventions to improve ERCP and EUS quality indicators. There is scant evidence on how to ensure that ERCP is performed for the appropriate indications and when performed, how to reliably improve technical and clinical success. It's a very negative statement, but there are some things from the paper that I hope you can take back to your individual practice. And how did we go about this? You know, similar to how you heard before, we really made a focus on what the priority indicators for ERCP and EUS are, right? One of the things that the people who wrote this document several years ago said we should really focus on. So once we had those priority indicators, we created these things called PICO questions. As you know, the population intervention comparison outcome questions to really say, okay, for those metrics that we care so much about, what things can you do to make things better? And I'm going to walk you through that. And this is going to be really just a step-by-step. These are the things that you can do in your individual practice to improve the quality of ERCP focused on these priority indicators. And so we'll go through each of these one by one. So what interventions have been shown to increase the frequency for which ERCP is performed for an appropriate indication and that indication is documented? Again, performing ERCP for an appropriate indication was a priority indicator, but do we have any idea how to actually make sure that providers are doing ERCPs for appropriate indications and documenting them as such? The only work out there that has tried to improve this priority indicator is a single study published over 20 years ago in abstract form, where endoscopists were given verbal feedback on their ERCP performance at six to 12-month intervals over a four-year period, and that ERCPs were performed for an inappropriate indication decreased from 21% down to 1% after that audit and feedback. So basically, giving providers feedback on whether or not the ERCPs are being performed for an appropriate indication appeared to decrease at least the documented inappropriate ERCP indication rate. So these data would suggest that auditing ERCP indications might reduce inappropriate ERCP usage. Again, this was never published in paper form and has not been replicated in the past, but it makes some sense. If you actually start to look at why people are doing procedures, they either are going to start fraudulently documenting why they're doing it or they're going to do it only procedures for appropriate indications. Obviously, we hope it's the latter. Well, what about interventions that are associated with rates of improving the rates of cannulation of the ductive interest in patients without surgically altered anatomy? I told you that our goal here is 90% minimum rate of cannulation for patients with native anatomy, right? So what are the things that you can do today that can actually improve your cannulation success rates? So the use of prone position compared with supine or left lateral position, and this is like mentioned with the data I'm presenting to you today, got some heterogeneity to it, but the results are variable on whether patient position improves bowel duct cannulation in the literature. There was systematic review that was pretty useful which had comparing 309 patients in the supine position to 1400 patients in the prone position, and they found the technical success rate was 89.1% for supine cases and 95.6% for prone cases. So this didn't reach significance, but I think that's a powerful non-significant difference, right? A 6% improvement in technical success in the prone position. Now, there have been some other studies that are prospective studies and they focus on variable things including technical success and cannulation success, but all of them have had different endpoints that favor the prone position. For example, even though one group, one study showed this similar to technical success for prone and supine positions, the rate of inadvertent PD cannulation was more in the supine position than the prone position, suggesting that prone may be safer than supine. So I would say despite some conflicting conclusions and variable endpoints, the data appears to support the use of the prone position compared with the supine position to improve ERCP efficacy and safety, and I would say it should be considered to improve bari cannulation success rates. So if you're having a provider or you are a provider who's having lower success rates, switching to prone position may help you. What about deep sedation and moderate sedation? The data, again, are conflicting on the effect of deep versus moderate sedation. While the data is conflicting, some studies show no difference between cannulation success between moderate sedation and deep sedation, but others do show increased success rates and or procedural completion rates among the deep sedation cohorts. So I would say although there's some conflicting data, obviously none of the data favors moderate sedation, and so if you're having lower success rates and you perform moderate sedation ERCP, adopting deep sedation may be something that can help improve your cannulation success rates. What about sphincter tomes and cannulas? These are obviously very old studies, but the old studies have shown higher rates of bile duct cannulation with sphincter tomes compared to cannulas. And then this gets to be a confusing topic about physician-controlled wire-guided cannulation compared with standard technique. Multiple studies and meta-analyses shown that wire-guided cannulation results in greater cannulation rates and lower rates of posterior superior pancreatitis, or PEP, when compared with conventional contrast guided wire and bile duct cannulation. That said, there are other studies that would suggest that in expert hands the rates are similar in terms of success rates, and this has a lot to do with who's controlling the guided wire, which may depend on whether you have an experienced technician or nurse assisting you. All right, what about the things that we're not sure help us get into the ductive interest in patients without surgically altered anatomy? So I showed you the ones that I feel pretty strongly are useful. Well, there's limited data on really any educational tools, so things like mechanical simulators where you're actually practicing ERCP technique ex vivo. There's only data in trainees, and it's somewhat marginal data. So we really have done a bad job as a profession of really seeing how we can remediate people using simulation. And then what about advanced cannulation techniques? I think it's clear that advanced cannulation techniques in expert hands can help you achieve cannulation successfully and safely, but there's a concern about how generalizable this is to the average practitioner who's the one who might need the most help improving cannulation success rates. So I would say that getting familiar with an advanced cannulation technique is very important. So what interventions have been shown to increase the success rate of extraction of stones less than a centimeter? And so again, this is kind of old data now because we sort of use this and expect it to be part of our practice. But before, one of the big questions was, is baskets better or balloons better? The most robust studies comparing the use of balloons and baskets for the extraction of small or less than 10 millimeter stones found that balloon extraction was either superior to the basket or equivalent. For example, there was a study of about 172 patients where they randomized removing the stones with either a balloon or a basket. Balloon removed all the stones in 92% of cases, whereas a basket did in 80% of cases. So if you have a choice, a balloon is superior to basket. And what about sphincteroplasty? Selected use of sphincteroplasty with or without sphincterotomy compared to sphincterotomy alone appears to be helpful, especially when the sphincterotomy is incomplete. So overall, the existing data suggests that when complete or any barrier sphincterotomy cannot be performed, dilating the barrier orifice to the maximal diameter of the distal bile duct can improve the frequency of complete stone extraction. What about things I'm not sure that the data is not sure about can improve stone extraction rates? You know, as you know, the rates of residual cold ooclothiasis can range from about 10 to 35%, so we leave stones behind because fluoroscopy is an imperfect science. So there's been some interest in selective use of cholangioscopy or even introductal ultrasound to ensure that all stones are removed. However, there is no prospective study published to date that shows that either use of cholangioscopy or introductal ultrasound can significantly reduce the rate of residual stone disease. Now moving on to interventions that can increase the success rate of stent placement for biliary obstruction below the bifurcation in patients without surgically altered anatomy. So selective use of a guide wire with a hydrophilic tip but a stiff shaft has been shown in a prospective study to actually increase the likelihood of traversing a stricture. So the main reason you're not going to get a stent in the appropriate position are either you can't get the wire across or you can't place the stent over the wire because the stricture is so severe. So this study shows, and as we all know in our practice, having access to these hydrophilic tip guide wires can get access across a stricture, and in this study the success rate with the hydrophilic tip versus a standard guide wire was 94% versus 79%, so this must be in your armamentarium if you're an ERCPS to have one of these hydrophilic tip wires. Now once the wire is across, you may not still be able to get a stent in if there's a very refractory tough stricture, and there is low quality data suggesting that a stent retriever, which essentially can screw its way over a wire through a stricture, can help dilate very severe strictures that are refractory alternative methods. So we should consider having this in our armamentarium, but again I would say these are very fringe cases that are often performed in very high volume centers, and so it's probably not the thing that the average endoscopist that needs remediation or improvement will need to worry about. What about reducing post-serious pancreatitis? As everyone knows, we just spoke about before, physician-controlled wire guided cannulation can reduce post-serious pancreatitis rates, but again this may not be something that is significant for experts who are proficient in other techniques. What about rectal endomethysin? It should be utilized at minimum in high-risk patients. Lots of trials on this. I could go through all of them. I just want to sort of highlight that one meta-analysis showed that NSAIDs did significantly reduce the risk of PEP in the entire population of patients by about a half, high-risk patients by about two-thirds, and all risk patients by about a half. So this seems to be effective in all comers, right? So rectal endomethysin should be utilized, and in some guidelines it is recommended, such as ESGE guidelines, to be used in all patients. So what about aggressive periopercedial hydration? you know, we've seen a lot of single center studies as well as mud analysis, showing that aggressive hydration can reduce the risk of posterior ERCP pancreatitis, especially when it's with LR and with higher volumes. But this is still a little bit unclear because we all know that aggressive hydration isn't as effective for pancreatitis in general. So it's a little bit confusing why it's so effective for ERCP. And finally, pancreatic stents at minimum should be utilized in patients with repeated inadvertent pancreas duct cannulation. We'll be getting more and more data around this as time goes on, but pancreatic stenting, you need to be proficient in this if you're gonna be performing ERCP because if you are not proficient in this and you're repeatedly getting the pancreas duct and not putting in a pancreas stent, I think you're committing something that's gonna give your patient a higher likelihood of getting posterior ERCP pancreatitis. And so I'm not gonna get into all the data about supporting pancreas stents, but understand that it is a well-supported intervention with data. And finally, we're gonna shift to the priority indicators for EUS. Similar concept, there's a lot of priority indicators for EUS, lot of PICO questions we developed to try to understand what things can we do today to improve our EUS technique. This is a little bit easier because there is some more data for some of these things, but not for this one, right? So this is the same thing. What techniques or interventions can improve the frequency with which GI cancers are staged using the AJCC-IUC-TNM staging system, the classic TNM staging system? Two studies have evaluated the impact of EUS quality assessment, an audit and feedback on compliance and appropriate TNM staging, and they were sort of equivocal, right? They said, yes, it can help, but these weren't like the most robust studies. In general, it makes sense, right? You start to audit people how they're doing on this, they'll improve, but the generalizability of this has not been established, but it's something you could consider in your practice if one of the goals of your practice is to improve diagnostic staging and the documentation of it. What about improving the diagnostic rates and sensitivity for malignancy in solid pancreatic masses? This is the sort of the big one, right? Can we actually get a diagnosis for pancreas cancer or other pancreas masses? There's a lot of data behind this, and just covering it's gonna be overwhelming. Understand that implementation of negative pressure suction or slow-pull stylet, as you're slowly pulling the stylet back, as well as a fanning technique all have randomized control data to support them to improve the diagnostic sensitivity and diagnostic rates for pancreas masses. There's a lot of data, again, about core biopsy needles over aspiration needles. For pancreas masses specifically, not other non-pancreatic masses, for pancreas masses specifically, in general, a lot of trials will show that both EUSFNA and EUSFNB, or FNA needles and core needles, can get you a diagnosis at similar rates for a pancreas mass. However, there is some data showing the superiority of a core biopsy needle over an aspiration needle for pancreas masses, especially when rapid onsite evaluation is not available, but this is mainly in the reduction of the number of passes in procedure time. So the best way to put this is a core biopsy needle is likely superior to an FNA needle, but this is best shown by reducing the amount of passes you need to perform and reducing your procedure time. What about things that we're not sure make better, make us better, at diagnosing pancreas masses? There's limited data supporting the use of deep sedation versus moderate sedation. For example, a retrospective study showed diagnostic rates of 83% with anesthesia and 73% with moderate sedation. Rapid onsite cytology evaluation arose. That seems to lead to fewer US and FNA passes, but doesn't improve the overall diagnostic rates and sensitivity, and because it actually increases procedure time and cost, it's hard to recommend ROSE in the era of other alternative ways to improve diagnostic rates and sensitivity. So I would say that this is something to consider in practice in selective cases, but in general, ROSE does not have very strong evidence anymore in the era of higher quality core biopsy needles. What are things that do not help? Use of Stilette for US FNA. So once you have that Stilette out, you do not need to put it in during US FNA cases. Needle size, innumerable studies back in the day were published comparing 25, 22, 19, all these things. They essentially are all equivalent, and so they're things that you can use per your preference or based on what amount of tissue you need. What about techniques and interventions to reduce the risks of adverse events after US-FNA? These are things that are helpful again. Selective use of antibiotics, and this is especially for mediastinal cysts and possibly periorectal lesions, but definitely for these mediastinal cystic lesions. Putting a needle in them without antibiotics or putting a needle in them in general, honestly, can increase your risk of infection. So when you're going to, and if you need to, antibiotics for the procedure and in a delayed fashion would be helpful. As you all know, there's no published benefit for antibiotics for US-FNA for pancreatic cystic lesions. And then of course, if you can discontinue non-aspirin antithrombotic therapy and antithrombotic therapy in general, if it's safe, right? If you can do that, that's wonderful because the risk of bleeding is higher when sampling cystic lesions especially, although it may be also higher with sampling solid lesions. So this is another way you can reduce an adverse event rate, which is bleeding. But again, you need to obviously do it only when it's appropriate, right? I want to thank you for your attention and obviously thank the ASGE for giving me this opportunity to present our group's work and supporting us through this. And I want to echo Fata's sort of emphasis on things like the EURP and other programs to help us move this field forward. Thank you. Thank you so much for those wonderful presentations. And to our audience, we do have a little bit of time for a question and answer session. So if you'd like to type in a question or if you'd like to raise your hand and ask a question, Drs. Keshwani and Vazir Bhatti would welcome any questions that you may have. As we're waiting, I have just a question to pick Dr. Keshwani's brain. He is a renowned intervention endoscopist. It's amazing that over 20 years, I mean, in the EUSERCP document and even in the EGD document, not the colonoscopy document, there's that dearth of data which doesn't exist in colonoscopy. So why is that the case? Is it, where does it stem from? In colonoscopy, there's a tangible colon cancer that we're trying to prevent. But similarly, we have serious pathologies we try to detect with EGDs. There are safety practices in EUSERCPs that we need to adhere to, which is really not shared in the surgical literature, which I looked at. The surgeons do better. Why is that the case, in your opinion, that there has not been an emphasis or a need vis-a-vis the push in colorectal cancer screening? Yeah, it's such a good question. It's actually very disheartening because I think you and I both agree that it is arguably a much more high-risk procedure. It is inarguably a much higher risk procedure. It has very immediate tangible outcomes in terms of success issues. So let's just talk about cannulation success in general. We've had essentially no work in the United States to really take lower-quality ERCP providers and figure out how to make them better. That's done at any society level, almost no research level. I would hazard that this is because, first of all, most ERCPs practice in small numbers at individual institutions. I can do a quality improvement effort of 30 colonoscopies at Northwestern, but if I'm doing ERCP, it's just four of us who have all do high-volume procedures, have all been fourth-year trained. So it's a little easier to study colonoscopy QI because of the number of practitioners than it is ERCP QI. But I don't think that's a good excuse. I think that's just what it is, right? I think to move the field forward, it's going to take investment either from federal funding or societal push to say, it's a kind of a big deal that we're not doing a good job at ERCP as much as we should, and we need to build a national registry and at least focus on audit and feedback like we do for colonoscopy. How are you doing? How are you doing relative to your peers? There is not a good opportunity for that. GI-Quick is a step forward in that process, but it's a voluntary thing. And the data is a little heterogeneous, right? It's still not easy to pick through. But I think it's just a question is who's pushing the agenda, right? And if you don't have anyone pushing it strongly, you don't get anywhere. I think we see this for a lot of things that aren't going. I mean, even in your discussion about Barrett's esophagus and all this, like who's really paying attention to make us better? I mean, it's not clear that anyone is. So we're talking to people who are relying on their own desire to improve today, but you kind of need a little bit of a push, a little bit of a carrot, not just a carrot, but a little bit of a stick approach too. And I agree, but even in colorectal cancer screening, if you're not looking at the adenoma detection rate, adenoma density rate, you're not looking at it. Germane to this is that the efforts, as you eloquently said, maybe it's more dissemination of colonoscopy by a wider array of people who are doing it that allowed interest in researching it, but a procedure, and you know, and I know that someone can kill someone easily. It doesn't take much talent to kill someone with an ERCP, yet there are no efforts on that. Do you think regulation is the answer? Whenever we hear regulation, people are fearful and rightly so. But given the trajectory of the past, how can we improve that for the future? Do you have any solutions that are applicable to us in the United States vis-a-vis Europe where ERCP is centralized to some extent? Yeah, I don't think that, I think that there has been some self-regulation over the last decade. I will say that, that things have changed over the last decade where ERCP has been more and more concentrated in people finishing a fourth year of fellowship, and then they've sort of swallowed up their partner's practices that were doing scant ERCP volumes. So I think that there has been some improvement in that, and I think that anything more than that is gonna be tough. I think what we need to do as a society is advocate to those systems and institutions that they should be regulating their providers. If they have six providers, they should condense it down to two if that the volume dictates that, right? And so that's where the advocacy part is. I don't, I would love a national registry. I don't see it. I think there's a lot, I mean, this one, when I think about your document and I sort of look at the stuff you were talking about, I think the thing we don't talk about is things like overuse, you know, for parents, esophagus. I mean, who's tracking out all the overuse upper endoscopies, the number of messages of patients who say, my doctor used to do an EGD on me every year with my colonoscopy every year, right? Who's monitoring that? And so I don't think there's a lot around regulation. That's just very antithetical to what we do in the United States. But I don't know, from an EGD perspective, did you come across anything in your document that you would say is really getting to really hold people accountable? From everything I have looked, and as you eloquently said, there was not much. It was so interesting to do this big systematic review and go through 2,000, 3,000 abstracts and not really see any work on this. I think it ultimately will end up with a payer. That's my own belief. And that's what we're really seeing now, now that the tune that we've been hearing. And if we don't ourselves seek the EURP, seek the ASGE, then someone from some committee somewhere behind some desks in other places that are not necessarily gastroenterologists are gonna tell us how to practice if we don't take initiative to that. And that is the ultimate fear that I have, that if it doesn't come from us, someone will be dictating this to us. Yeah, I think it's a reasonable fear, but I think it would be an appropriate response to us not doing a good job of self-regulation. Fair enough. I mean, we've had a long time to try to get better, but I think that's why you say the EURP and eating can sort of share information on the EURP as well. But these are ways that practices can start to figure out, are they really meeting the metrics and are they meeting the goals of what we should be doing? It's not as easy for EOS and ERCP, which is why it's actually much nicer we started with EGD as a topic. This is something that everyone can do in their own practice. There's enough people doing EGDs. There's such a high volume of EGDs. We can make a dent there and then maybe use that as a model towards moving towards these more high-risk procedures. And I must say also that the EURP interest, which you're mentioning also, is not necessarily only in the US. There has been international interest from endoscopy suites internationally in adopting this model and trying to improve whether it's in the US or outside of the US internationally. And as you said, Eden will be the best person to tell us more about that. And I always welcome questions, as you all know. We did expand recently, for those who do not know, the EURP program is now open to international beyond the US border applicants. So please feel free to email EURP at asge.org if you ever have any questions. So we haven't received any questions yet, but I'm sure you certainly are keeping people on the line with your own questions and interactions with each other. Any other thoughts for each other or questions for each other? I don't know if I have any more questions. I think it's helpful for, I would just maybe make a plug for people to read the documents, which is asking a lot of people in this day and age. There is a lot of information in there and both of them that are, I would argue very highly useful for daily practice. Just really, again, I've become very dismayed by how much we say what you should do in terms of reaching metrics and not enough about how you can get better. So I really like the fact that all these documents from the COLA and the EGD, the EUSP, EUS, give people some tangible things that they can take to their own practices. So instead of wasting people's time even more, rather they use that extra minutes to spend some time reading through the documents and hopefully getting better at practice. Because I think it's clear to all of us, we all have room to improve in our practices. And I would echo that. And I would say that sometimes there is paralysis by analysis. Think of the next certain X number of moves ahead, not a million move ahead. You can't think of a million move ahead. Think big, start small, execute small, but move fast. So those who have in their own endoscopy suite, the daily quotidian practices, as you eloquently said, they can review the documents. There are tables that summarize everything nicely prepared. And these documents, correct me if I'm wrong, the GIE shares them open access and anyone can access them. They can just start in our own endoscopy suite. And again, I'm not plugging the EURP, but that's an easy way that you can, with your group, with your practice, with the folks you're working with, have a systematic way of looking of what can we improve? And are we looking at these numbers? Because as I mentioned, you can't improve what you don't measure. So it all starts with measurements and doesn't have to be fascinating, big IDs, but 100% cannulation rate coffee mugs. We're not talking about that. We're talking about starting small in the basics. As you said, making a dent in the high volume procedure that we do, such as EGD for different pathologies and colonoscopy. So think big, start small and move fast. That's the title of a book by the CEO of the Mayo Clinic. I don't want to plagiarize it. Yeah. It's good. And I think you should plug the EURP. You don't feel like you should not plug your EURP. You're allowed to plug things that the ASG has put a lot of effort into. You plug in the EURP. I'm a believer. Yes. Excellent, excellent. And those articles are open access. They will be in your GILeap accounts as well. And I will just go ahead and email them out to everyone as well. Everyone who's registered for this. We want to make sure you have those articles and you do spend the time. Thank you, Dr. Baserbaci and Dr. Keshwani. Your presentations were wonderful and I'm sure everyone appreciated this discussion as they did hold the line. So we've come to the close of this presentation. Thank you to our presenters and to you, our audience. As a reminder, a recording of this session will populate your GILeap account when it's available. A PDF of the slide deck and other handouts will be available in your account in the near term. And again, I will email those papers out to you. This concludes the presentation on quality and interventions in the upper GI tract. We hope this information is useful to you and your practice.

quality interventions

upper GI tract

healthcare

patient care

quality indicators

endoscopic procedures

adherence

challenges

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