Strategies to Increase Adenoma Detection Rates

EVALUATION OF QUALITY INDICATORS OF SCREENING COLONOSCOPY PERFORMED IN A PRIVATE QUARTERNARY HOSPITAL IN BRAZIL

BACKGROUND

Colorectal cancer is the third most common type of cancer in Brazil, despite the availability of screening methods that reduce its risk. Colonoscopy is the only screening method that also allows therapeutic procedures. The proper screening through colonoscopy is linked to the quality of the exam, which can be evaluated according to quality criteria recommended by various institutions. Among the factors, the most used is the Adenoma Detection Rate, which should be at least 25% for general population.

AIMS

To evaluate the quality of the screening colonoscopies performed in a quarternary private Brazilian hospital.

METHODS

This is a retrospective study evaluating the quality indicators of colonoscopies performed at a private center since its inauguration. Only asymptomatic patients aged over 45 years who underwent screening colonoscopy were included. The primary outcome was the Adenoma Detection Rate, and secondary outcomes included polyps detection rate and safety profile. Subanalyses evaluated the correlation of endoscopic findings with gender and age and the evolution of detection rates over the years.

RESULTS

A total of 2,144 patients were include with a mean age of 60.54 years-old. Polyps were diagnosed in 68.6% of the procedures. Adenoma detection rate was 46.8%, with an increasing rate over the years, mainly in males. A low rate of adverse events was reported in 0.23% of the cases, with no need for surgical intervention and no deaths.

CONCLUSIONS

This study shows that high quality screening colonoscopy is possible when performed by experienced endoscopists and trained nurses, under an adequate infrastructure.

Linked color imaging improves colorectal lesion detection especially for low performance endoscopists: An international trial in Asia

BACKGROUND AND AIM

Linked color imaging (LCI) is an image-enhanced endoscopy technique that accentuates the color difference between red and white, potentially improving the adenoma detection rate (ADR). However, it remains unclear whether LCI performance in detecting colorectal lesions differs based on endoscopists' experience levels. We aimed to evaluate the differences in LCI efficacy based on the experience levels of endoscopists by conducting an exploratory analysis.

METHODS

In this post hoc analysis of an international randomized controlled trial comparing the detection of adenoma and other lesions using colonoscopy with LCI and high-definition white light imaging (WLI), we included patients from 11 institutions across four countries/regions: Japan, Thailand, Taiwan, and Singapore. We retrospectively reviewed differences in the lesion detection of LCI according to endoscopists' colonoscopy history or ADR.

RESULTS

We included 1692 and 1138 patients who underwent colonoscopies performed by 54 experts (experience of ≥ 5000 colonoscopies) and by 43 non-experts (experience of < 5000 colonoscopies), respectively. Both expert and non-expert groups showed a significant improvement in ADR with LCI compared to WLI (expert, 61.7% vs 46.4%; P < 0.001; non-expert, 56.6% vs 46.4%; P < 0.001). LCI had no effect on sessile serrated lesion detection rate in non-experts (3.1% vs 2.5%; P = 0.518). LCI significantly improved detection rates in endoscopists with relatively low detection performance, defined as an ADR < 50%.

CONCLUSIONS

This exploratory study analyzed data from a previous trial and revealed that LCI is useful for both experts and non-experts and is even more beneficial for endoscopists with relatively low detection performance using WLI.

Endocuff Vision-Assisted Resection for Difficult Colonic Lesions-Preliminary Results of a Multicenter, Prospective Randomized Pilot Study

Background-Screening programs for colorectal cancer are implemented due to their ability to reduce mortality. The Endocuff Vision is a new endoscopic device that significantly improves the adenoma detection rate. The primary outcome was to assess the efficacy of ECV in improving stability and reducing operation time during difficult colon polypectomies in a multicenter randomized prospective study. Methods-In a randomized multicenter pilot study, two groups of patients who underwent difficult polypectomies with and without the assistance of Endocuff Vision were compared. Demographics and clinical characteristics of patients were obtained, and polyps' size, morphology, site, and access (SMSA); polypectomy time; and endoscope stability were evaluated. Results-From October 2016 to April 2020, 32 patients were enrolled. In total, 12 patients underwent Endocuff Vision polypectomy, and 20 patients underwent standard polypectomy by using a computer-generated random number table. No statistical differences were found in clinical characteristics, SMSA, and polypectomy time. The most interesting findings were the positive correlations between shaking and SMSA (r = 0.55, p = 0.005) and shaking and polypectomy time (r = 0.745, p < 0.0001). Conclusion-Endocuff Vision seems to be adequately stable during difficult endoscopic resection procedures. The new parameter proposed that shaking is strongly correlated to the stability of the endoscope, the difficulty of the resection (SMSA), and the polypectomy time.

Comparison of missed adenomas in deep-sedated and unsedated colonoscopy: A multicenter retrospective study

BACKGROUND

Deep-sedated colonoscopy with propofol is widely used in China. However, its impact on quality metrics remains controversial. We aimed to investigate the effects of deep-sedated colonoscopy on missed adenomas, specifically in each colorectal segment.

METHODS

Data of 3710 individuals from seven hospitals in China who underwent an initial colonoscopy with or without propofol sedation and a second colonoscopy without sedation within six months for surveillance or polypectomy by endoscopist of the same level between October 2020 and September 2021 were retrospectively analyzed.

RESULTS

A total of 1113 missed adenomas in 3710 patients were evaluated. The adenoma miss rate (AMR) was significantly higher in deep-sedated colonoscopy than in unsedated colonoscop [19.14% (578/3020) vs. 16.15% (535/3313), P < 0.05]. The risk of missing adenomas in deep-sedated colonoscopy was 1.229 times higher than in unsedated colonoscopy (OR, 1.229; 95% CI: 1.080-1.399). AMRs of the splenic flexure (26.02% [96/369] vs. 16.04% [47/293], P < 0.05) and descending colon (20.86% [102/489] vs. 13.37% [54/404], P < 0.05) were significantly higher in deep-sedated colonoscopy than in unsedated colonoscopy when performed by middle-level endoscopists rather than high-level endoscopists (P < 0.05).

CONCLUSIONS

AMR was higher in deep-sedated colonoscopy than in unsedated colonoscopy. Furthermore, adenomas in the splenic flexure and descending colon were more frequently missed in deep-sedated colonoscopy than in unsedated colonoscopy, particularly when performed by less experienced endoscopists.

Efficacy of oral sulfate tablets for bowel preparation and adenoma detection rate

BACKGROUND AND AIM

The adenoma detection rate (ADR), which is closely related to bowel preparation, is the most important factor for colonoscopy quality assessment. New oral sulfate tablets (OSTs) have been developed to improve bowel preparation compliance. This study evaluated the efficacy of OSTs in terms of the ADR and bowel preparation status.

METHODS

Medical records of subjects under the age of 65 who underwent colonoscopy from March 2019 to February 2021 were retrospectively reviewed. Polyethylene glycol with ascorbic acid (PEG-A) was used as a bowel preparation for the first half of the study period, and OSTs were used for the second half. In total, 16 971 subjects were included in the study: 9199 (54.2%) used PEG-A, and 7772 (45.8%) used OSTs. Bowel cleansing quality was assessed by the Boston Bowel Preparation Scale (BBPS).

RESULTS

The average age was 50 years. The rate of adequate bowel preparation was higher in the OST group than in the PEG-A group (97.2% vs 95.0%, P < 0.001). The mean BBPS was also higher in the OST group (8.02 vs 7.75, P < 0.001). The adenomas per colonoscopy (APC), the ADR and the sessile serrated polyp detection rate (SSPDR) were higher in the OST group than in the PEG-A group (APC 0.56 ± 1.01 vs 0.48 ± 0.91, P < 0.001; ADR 34.5% vs 30.7%, P < 0.001; SSPDR 5.2% vs 3.3%, P < 0.001).

CONCLUSIONS

Compared with PEG-A, OSTs yielded superior APC, ADRs, SSPDRs, and better bowel cleanliness. Therefore, OSTs are a good alternative for patients who have difficulty taking large-volume bowel preparation formulations.

Comparison of adenoma detection in different colorectal segments between deep-sedated and unsedated colonoscopy

To investigate if deep-sedated colonoscopy affects adenoma detection in certain colorectal segment. Review of colonoscopy reports, electronic images and medical records of individuals underwent screening colonoscopy with or without propofol sedation between October 2020 and March 2021 from seven hospitals in China. A total of 4500 individuals were analyzed. There was no significant difference in ADR between deep-sedated colonoscopy and unsedated colonoscopy [45.4% vs. 46.3%, P > 0.05]. The APP of deep-sedated colonoscopy was lower than unsedated colonoscopy (1.76 ± 0.81 vs. 2.00 ± 1.30, P < 0.05). Both average number of adenomas and luminal distention score of splenic flexure and descending colon were lower in deep-sedated colonoscopy (P < 0.05), and average number of adenomas was positively correlated with an improved distension score in splenic flexure and descending colon (splenic flexure r = 0.031, P < 0.05; descending colon r = 0.312, P < 0.05). Linear regression model showed deep-sedated colonoscopy significantly affected luminal distention of splenic flexure and descending colon as well as average number of adenomas detected in splenic flexure (P < 0.05). Deep-sedated colonoscopy decreased adenoma detection in splenic flexure and the luminal distention of splenic flexure and descending colon compared with unsedated colonoscopy.

Comparison of three sedation models for same-day painless bidirectional endoscopy: A multicenter randomized controlled trial

BACKGROUND AND AIM

We investigated the most beneficial propofol sedation model for same-day painless bidirectional endoscopy (BDE).

METHODS

Asymptomatic participants scheduled for same-day painless BDE examination from October 2020 to September 2021 were randomized to three groups: sedated esophagogastroduodenoscopy followed by unsedated colonoscopy (Group A); sedated esophagogastroduodenoscopy followed by sedated colonoscopy (Group B); and sedated esophagogastroduodenoscopy followed by sedated insertion colonoscopy (Group C). Patient discomfort, colonoscopy performance, doses of propofol, cardiovascular stress, anesthesia resuscitation, and sedation-related adverse events were evaluated.

RESULTS

A total of 3200 participants were analyzed. Baseline demographics, patient discomfort, cecal intubation rate, adenoma detection rate and sedation-related adverse events were similar in the three groups. Propofol dose was the lowest in Group A (137.65 ± 36.865 mg) compared with Group B (177.71 ± 40.112 mg, P < 0.05) and Group C (161.63 ± 31.789 mg, P < 0.05). Decline in vital signs was most obvious in Group B during the procedure (P < 0.05). Recovery time was the shortest in Group A (5.01 ± 1.404 min) compared with Group B (9.51 ± 2.870 min, P < 0.05) and Group C (5.83 ± 2.594 min, P < 0.05); discharge time was the shortest in Group A (3.53 ± 1.685 min) compared with Group B (11.29 ± 5.172 min, P < 0.05) and Group C (6.47 ± 2.338 min, P < 0.05). Adenomas per positive patient of Group A (2.29 ± 1.055) and Group C (2.28 ± 0.931) were more than that in Group B (2.11 ± 0.946, P < 0.05).

CONCLUSIONS

Sedated esophagogastroduodenoscopy followed by unsedated colonoscopy is the superior model for same-day painless BDE with the benefits of satisfactory patient comfort, reduced sedation dose, less cardiovascular stress, faster recovery, shorter discharge time and high colonoscopy quality.

Does i-scan improve adenoma detection rate compared to high-definition colonoscopy? A systematic review and meta-analysis

Background and study aims  Recent studies evaluated the impact of i-scan in improving the adenoma detection rate (ADR) compared to high-definition (HD) colonoscopy. We aimed to systematically review and analyze the impact of this technique. Methods  A thorough search of the following databases was undertaken: PubMed/Medline, EMBASE, Cochrane and Web of Science. Full-text RCTs and cohort studies directly comparing i-scan and HD colonoscopy were deemed eligible for inclusion. Dichotomous outcomes were pooled and compared using random effects model and DerSimonian-Laird approach. For each outcome, relative risk (RR), 95 % confidence interval (CI), and P value was generated. P  < 0.05 was considered statistically significant. Results  A total of five studies with six arms were included in this analysis. A total of 2620 patients (mean age 58.6 ± 7.2 years and female proportion 44.8 %) completed the study and were included in our analysis. ADR was significantly higher with any i-scan (RR: 1.20, [CI: 1.06-1.34], P  = 0.003) compared to HD colonoscopy. Subgroup analysis demonstrated that ADR was significantly higher using i-scan with surface and contrast enhancement only (RR: 1.25, [CI: 1.07-1.47], P  = 0.004). Conclusions  i-scan has the potential to increase ADR using the surface and contrast enhancement method. Future studies evaluating other outcomes of interest such as proximal adenomas and serrated lesions are warranted.

Segmental Withdrawal During Screening Colonoscopy Does Not Increase Adenoma Detection Rate

OBJECTIVES

The aim of this study was to compare a standard versus segmental withdrawal during screening colonoscopy and its effect on the adenoma detection rate (ADR).

METHODS

We performed a single-center clinical trial of average-risk patients 50 years of age and older undergoing screening colonoscopy. Patients were randomized into four groups: a standard withdrawal of at least 6 or 8 minutes and a segmental withdrawal, in which ≥3 or ≥4 minutes were dedicated to the right side of the colon, with a minimum withdrawal time of at least 6 or 8 minutes, respectively.

RESULTS

There were 311 patients in the study. There was no difference in ADR between the standard and segmental groups (relative ratio [RR] 0.91, P = 0.50), even after stratifying for right-sided adenomas. During standard withdrawal, an increased continuous withdrawal time was associated with a higher ADR (RR 1.08, P <0.001) and total adenomas per patient (RR 1.12, P < 0.001). A binary analysis of ≥8 minutes or <8 minutes withdrawal was associated with an increased adenomas per colonoscopy (RR 1.86, P = 0.04). These differences were not observed in the segmental group.

CONCLUSIONS

Overall, there was no benefit from a segmental withdrawal protocol on ADR, but this may have been the result of the inherent limitations in the study design. After sensitivity analysis, a segmental withdrawal protocol led to an improvement in the detection of adenomas per colonoscopy and polyps per colonoscopy. A larger sample size is needed to confirm these findings.

Impact of cuff-assisted colonoscopy for adenoma detection: A protocol of systematic review and meta-analysis

BACKGROUND

Previous studies have reported that cuff-assisted colonoscopy (CAC) can be used for detection of adenoma (DA). However, there are inconsistent results regarding the CAC for DA. Thus, this study will systematically explore the impact of CAC for DA.

METHODS

In order to retrieve potential eligible articles, this study will identify the following electronic databases from their inceptions to present: MEDLINE, EMBASE, Cochrane Library, PSYCINFO, Web of Science, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. All electronic databases will be searched without any language limitation. We will consider case-controlled studies that focused on exploring the impacts of CAC for DA. Two authors will perform study selection, information collection and risk of bias assessment, respectively. Any discrepancies between 2 authors will be resolved through discussion with a third author.

RESULTS

This study will summarize the most recent evidence to assess the impact of CAC for DA.

CONCLUSION

The findings of this study will provide evidence of CAC for DA in clinical practice.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202040042.

Efficacy of withdrawal time monitoring in adenoma detection with or without the aid of a full-spectrum scope

Background and study aims  Withdrawal time (WT) monitoring and full-spectrum endoscopy (FUSE) have been suggested to increase adenoma detection rate (ADR) due to more accurate evaluation of the hidden areas of the colon. We aimed to evaluate the efficacy of WT monitoring and FUSE on ADR. Patients and methods  This was a prospective observational study involving consecutive outpatients, aged 18 to 85 years, undergoing colonoscopy with unselected indications. In phase 1, endoscopists performed 660 colonoscopies either with standard forward-viewing endoscope (SFVE) (n = 330) or with FUSE (n = 330). In this phase, WTs were measured without endoscopist awareness of being monitored. In phase 2, endoscopists were informed of being monitored and performed additional 660 colonoscopies either with SFVE (n = 330) or with FUSE (n = 330). Results  WT was lower in phase 1 compared to phase 2 (SFVE: 269 ± 83 vs. 386 ± 60 sec, P  < 0.001; FUSE: 289 ± 97 vs. 403 ± 65 sec, P  < 0.001). Use of FUSE increased ADR both in phase 1 (33.0 % vs. 27.3 %, P  = 0.127) and in phase 2 (41.8 % vs. 33.6 %, P  = 0.037). When endoscopists were aware of being monitored, ADR was higher in SFVE (33.6 % vs. 27.3 %; P  = 0.090) and FUSE arms (41.8 % vs. 33.0 %; P  = 0.024). Improvement in detection of proximal adenomas was associated with WT monitoring [OR 1.577 (95 % C. I. 1.158 - 2.148); P  = 0.004], whereas detection of distal adenomas was associated with use of FUSE [OR 1.320 (95 % C. I. 1.022 - 1.705); P  = 0.037]. Conclusions  Unmonitored endoscopists have suboptimal WT, which increases when they are monitored. WT monitoring and use of FUSE are two reliable and alternative strategies to increase ADR.

Effect of video monitor size on polyp detection: a prospective, randomized, controlled trial

BACKGROUND AND AIMS

The adenoma detection rate (ADR) is the most important quality metric for colonoscopy. Numerous factors are known to influence ADR. However, no data on the effect of monitor size on ADR exist. The aim of this study was to compare the ADR and polyp detection rate (PDR) achieved using 2 different-size video monitors (19-inch diagonal and 32-inch diagonal).

METHODS

In a single-center, prospective, randomized clinical trial, endoscopists were randomized on a daily basis to perform routine ambulatory colonoscopies with either a 32-inch diagonal or a 19-inch diagonal video monitor.

RESULTS

The study was conducted between October 2013 and April 2014 in an outpatient center of a tertiary referral hospital. Fifteen endoscopists performed 1795 outpatient colonoscopies (mean age, 55 years; 56% women; screening, 56%). There was no substantial difference in baseline patient characteristics between the 2 arms. The overall ADR (27.4% vs 27.9%; P = .80) and PDR (32.8% vs 34.4%; P = .50) were not significantly different between the 32-inch and 19-inch monitor group, respectively. The findings were not significantly altered when stratified by indication, cecal intubation, bowel preparation, operator experience, and time of endoscopy as well as in a multivariable model that included these variables as potential confounders (all P > .05). Overall, the ADR and PDR for each individual endoscopist did not appear to be influenced by monitor size.

CONCLUSIONS

The results of this trial do not support the notion that larger video monitors improve ADR. Future efforts to increase ADR should focus on other aspects of colonoscopy. (Clinical trial registration number: NCT01952418.).

Determination of withdrawal times in individualized opportunistic screening colonoscopies

To investigate effects of bowel preparation, experience level of colonoscopists, and colonoscopy withdrawal time (CWT) on the quality of an individual opportunistic screening colonoscopy, according to adenoma detection rate (ADR).Data were retrospectively analyzed from opportunistic screening colonoscopies (n = 16,951) at 4 hospitals of various care levels in China.The ADR positively correlated with the experience level of the colonoscopist. The individualized CWT varied, depending on the quality of bowel preparation and the number of colonoscopies performed previously by the colonoscopist. In a setting of adequate bowel preparation, the mean CWT decreased with the increased experience of the colonoscopist. With poor and inadequate bowel preparation, no colonoscopist at any level of experience could obtain a satisfactory ADR.For adequately prepared colonoscopies, minimum CWTs have been determined. Repeat colonoscopy is strongly recommended for patients with poor bowel preparation, regardless of the colonoscopist's experience.

Is water exchange superior to water immersion in detecting adenomas during colonoscopies? Results from a Bayesian network meta-analysis

AIM

Water-assisted colonoscopy (water exchange [WE] and water immersion [WI]) has been shown to improve the adenoma detection rate. However, few studies have compared these two methods head-to-head. Thus, we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures.

METHOD

We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018. Randomized controlled trials (RCTs) reporting data in accordance with the eligibility criteria were included in this study. We performed a Bayesian random effects network meta-analysis with mixed comparisons.

RESULTS

Twenty-nine studies (n = 11464 patients) including 6 direct and 23 indirect comparisons were included in this network meta-analysis. There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI (risk ratio [RR]: 1.2, 95% credible interval [CrI]: 1.1-1.3), air insufflation (AI; RR: 1.3, 95% CrI: 1.1-1.4), and carbon dioxide (CO2) insufflation (RR: 1.2, 95% CrI: 1.1-1.5). The different methods were ranked in order from the most to least effective in adenoma detection as follows: WE, WI, AI, and CO2. Moreover, although there were no significant differences in pain scores, willingness to repeat, caecal intubation rate, or total procedure time between WI and WE colonoscopy, WE required a longer caecal intubation time than WI.

CONCLUSION

This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.

Full-spectrum versus standard colonoscopy for improving polyp detection rate: A systematic review and meta-analysis

BACKGROUND AND AIM

Full-spectrum endoscopy represents a new endoscopic platform allowing a panoramic 330 degree view of the colon, but evidence of its superiority over standard colonoscopy is still lacking. Our study is the first meta-analysis comparing the efficacy of full-spectrum endoscopy with standard colonoscopy.

METHODS

Through a systematic literature review until May 2017, we identified eight randomized-controlled trials. Primary outcomes were polyp detection rate and adenoma detection rate, while cecal intubation time and total colonoscopy time were secondary outcomes. Direct meta-analysis was performed using a random effects model.

RESULTS

No difference in terms of polyp detection rate and adenoma detection rate was found (risk ratio: 1.00, 95% confidence interval 0.89-1.12, P = 0.96, and 1.05, 0.94-1.17, P = 0.40, respectively). Adenoma miss rate resulted significantly in favor of full-spectrum endoscopy (risk ratio: 0.35, 0.25-0.48, P < 0.01), although the difference was not significant for greater (>5 mm) and pedunculated lesions (risk ratio: 0.38, 0.09-1.60, P = 0.19, and risk ratio: 0.15, 0.01-3.00, P = 0.21, respectively). Cecal intubation time was not different between the two techniques (mean standardized difference: 0.22 min, -1.18 to 1.62, P = 0.76), while total colonoscopy time was significantly shorter when adopting full-spectrum endoscopy (mean difference: -2.60, -4.60 to -0.61, P = 0.01). Sensitivity analysis confirmed all the findings.

CONCLUSIONS

Full-spectrum endoscopy appears as a promising and reliable technology able to significantly decrease the number of adenomas missed and procedural times, while its superiority over standard colonoscopy in terms of adenoma detection rate results is still unclear.

A short telephone-call reminder improves bowel preparation, quality indicators and patient satisfaction with first colonoscopy

BACKGROUND AND STUDY AIMS

 Addition of a reminder program to conventional indications improves colonoscopy. The aim of this study was to evaluate the effectiveness of a short telephone call reminder (STCR) on a patient's first colonoscopy.

PATIENTS AND METHODS

 One day before colonoscopy, we made a STCR of < 10 minutes to 141 randomly selected patients of 258 recruited. The STCRs informed patients about the procedure date, indications for taking laxatives, and dietetic requirements. Questions were clarified only when patients asked directly. We evaluated bowel preparation, quality indicators, and patient satisfaction. Data were expressed as mean ± SD and percentages. Statistical differences were evaluated by Student's t and Chi squared tests; alpha = 0.05. All authors had access to the study data and reviewed and approved the final manuscript.

RESULTS

 The STCR group had better bowel preparation which was demonstrated by higher completion frequency (97.16 % vs. 82.05 %), in less time (4.52 ± 3.06 vs. 5.38 ± 3.03 hours) intake of laxative, and higher Boston's scale (7.66 ± 2.42 vs. 5.2 ± 1.65). Quality indicators of colonoscopy were better in patients that received a STCR [cecal intubation rate: 100.00 % vs. 87.18 %; polyp detection: 42.55 % vs. 9.4 %; and cecal arrival time (min): 12.09 ± 3.62 vs. 15.09 ± 5.02]. STCR patients were more satisfied (97.87 % vs. 55.56 %) and would repeat colonoscopy (21.99 % vs. 11.11 %).

CONCLUSIONS

 A simple additional step such as a STCR improves quality of bowel preparation, quality indicators, and satisfaction of patients undergoing their first colonoscopy. Clinical trial registry in Mexico City General Hospital: DI/16/107/3/108.

Development and validation of a prediction model for adenoma detection during screening and surveillance colonoscopy with comparison to actual adenoma detection rates

OBJECTIVE

The adenoma detection rate (ADR) varies widely between physicians, possibly due to patient population differences, hampering direct ADR comparison. We developed and validated a prediction model for adenoma detection in an effort to determine if physicians' ADRs should be adjusted for patient-related factors.

MATERIALS AND METHODS

Screening and surveillance colonoscopy data from the cross-sectional multicenter cluster-randomized Endoscopic Quality Improvement Program-3 (EQUIP-3) study (NCT02325635) was used. The dataset was split into two cohorts based on center. A prediction model for detection of ≥1 adenoma was developed using multivariable logistic regression and subsequently internally (bootstrap resampling) and geographically validated. We compared predicted to observed ADRs.

RESULTS

The derivation (5 centers, 35 physicians, overall-ADR: 36%) and validation (4 centers, 31 physicians, overall-ADR: 40%) cohort included respectively 9934 and 10034 patients (both cohorts: 48% male, median age 60 years). Independent predictors for detection of ≥1 adenoma were: age (optimism-corrected odds ratio (OR): 1.02; 95%-confidence interval (CI): 1.02-1.03), male sex (OR: 1.73; 95%-CI: 1.60-1.88), body mass index (OR: 1.02; 95%-CI: 1.01-1.03), American Society of Anesthesiology physical status class (OR class II vs. I: 1.29; 95%-CI: 1.17-1.43, OR class ≥III vs. I: 1.57; 95%-CI: 1.32-1.86), surveillance versus screening (OR: 1.39; 95%-CI: 1.27-1.53), and Hispanic or Latino ethnicity (OR: 1.13; 95%-CI: 1.00-1.27). The model's discriminative ability was modest (C-statistic in the derivation: 0.63 and validation cohort: 0.60). The observed ADR was considerably lower than predicted for 12/66 (18.2%) physicians and 2/9 (22.2%) centers, and considerably higher than predicted for 18/66 (27.3%) physicians and 4/9 (44.4%) centers.

CONCLUSION

The substantial variation in ADRs could only partially be explained by patient-related factors. These data suggest that ADR variation could likely also be due to other factors, e.g. physician or technical issues.