Adenoma Detection Rate (ADR) Irrespective of Indication Is Comparable to Screening ADR: Implications for Quality Monitoring

Effect of Real-Time Computer-Aided Polyp Detection System (ENDO-AID) on Adenoma Detection in Endoscopists-in-Training: A Randomized Trial

BACKGROUND

The effect of computer-aided polyp detection (CADe) on adenoma detection rate (ADR) among endoscopists-in-training remains unknown.

METHODS

We performed a single-blind, parallel-group, randomized controlled trial in Hong Kong between April 2021 and July 2022 (NCT04838951). Eligible subjects undergoing screening/surveillance/diagnostic colonoscopies were randomized 1:1 to receive colonoscopies with CADe (ENDO-AID[OIP-1]) or not (control) during withdrawal. Procedures were performed by endoscopists-in-training with <500 procedures and <3 years' experience. Randomization was stratified by patient age, sex, and endoscopist experience (beginner vs intermediate level, <200 vs 200-500 procedures). Image enhancement and distal attachment devices were disallowed. Subjects with incomplete colonoscopies or inadequate bowel preparation were excluded. Treatment allocation was blinded to outcome assessors. The primary outcome was ADR. Secondary outcomes were ADR for different adenoma sizes and locations, mean number of adenomas, and non-neoplastic resection rate.

RESULTS

A total of 386 and 380 subjects were randomized to CADe and control groups, respectively. The overall ADR was significantly higher in the CADe group than in the control group (57.5% vs 44.5%; adjusted relative risk, 1.41; 95% CI, 1.17-1.72; P < .001). The ADRs for <5 mm (40.4% vs 25.0%) and 5- to 10-mm adenomas (36.8% vs 29.2%) were higher in the CADe group. The ADRs were higher in the CADe group in both the right colon (42.0% vs 30.8%) and left colon (34.5% vs 27.6%), but there was no significant difference in advanced ADR. The ADRs were higher in the CADe group among beginner (60.0% vs 41.9%) and intermediate-level (56.5% vs 45.5%) endoscopists. Mean number of adenomas (1.48 vs 0.86) and non-neoplastic resection rate (52.1% vs 35.0%) were higher in the CADe group.

CONCLUSIONS

Among endoscopists-in-training, the use of CADe during colonoscopies was associated with increased overall ADR. (ClinicalTrials.gov, Number: NCT04838951).

Comparison of Artificial Intelligence With Other Interventions to Improve Adenoma Detection Rate for Colonoscopy: A Network Meta-analysis

INTRODUCTION

Recent randomized controlled trials (RCTs) and meta-analysis have demonstrated improved adenoma detection rate (ADR) for colonoscopy with artificial intelligence (AI) compared with high-definition (HD) colonoscopy without AI. We aimed to perform a systematic review and network meta-analysis of all RCTs to assess the impact of AI compared with other endoscopic interventions aimed at increasing ADR such as distal attachment devices, dye-based/virtual chromoendoscopy, water-based techniques, and balloon-assisted devices.

METHODS

A comprehensive literature search of PubMed/Medline, Embase, and Cochrane was performed through May 6, 2022, to include RCTs comparing ADR for any endoscopic intervention mentioned above. Network meta-analysis was conducted using a frequentist approach and random effects model. Relative risk (RR) and 95% CI were calculated for proportional outcome.

RESULTS

A total of 94 RCTs with 61,172 patients (mean age 59.1±5.2 y, females 45.8%) and 20 discrete study interventions were included. Network meta-analysis demonstrated significantly improved ADR for AI compared with autofluorescence imaging (RR: 1.33, CI: 1.06 to 1.66), dye-based chromoendoscopy (RR: 1.22, CI: 1.06 to 1.40), endocap (RR: 1.32, CI: 1.17 to 1.50), endocuff (RR: 1.19, CI: 1.04 to 1.35), endocuff vision (RR: 1.26, CI: 1.13 to 1.41), endoring (RR: 1.30, CI: 1.10 to 1.52), flexible spectral imaging color enhancement (RR: 1.26, CI: 1.09 to 1.46), full-spectrum endoscopy (RR: 1.40, CI: 1.19 to 1.65), HD (RR: 1.41, CI: 1.28 to 1.54), linked color imaging (RR: 1.21, CI: 1.08 to 1.36), narrow band imaging (RR: 1.33, CI: 1.18 to 1.48), water exchange (RR: 1.22, CI: 1.06 to 1.42), and water immersion (RR: 1.47, CI: 1.19 to 1.82).

CONCLUSIONS

AI demonstrated significantly improved ADR when compared with most endoscopic interventions. Future RCTs directly assessing these associations are encouraged.

How to implement adverse events as a quality indicator in gastrointestinal endoscopy

Quality improvement through the registration of endoscopy-related adverse events (AEs) has been recognized by major international endoscopy societies as an important quality indicator. The theory behind this is easier to approve than its implementation in daily practice. The results of many valuable attempts have been published in the literature, mainly highlighting the diverse hurdles trying to capture events related to endoscopy and the sedation used for endoscopic procedures. The current review discusses the difficulties encountered attempting to register AEs and incidents related to endoscopic procedures. Government-driven and financed health-care databases with automated coupling of specific data seem the only efficient way to implement endoscopy-related AEs and outcomes on a prospective and complete basis. This will not only allow continuous confidential feedback to endoscopists in relation to the pooled national benchmark data, but also follow-up in time through data-driven credentialing aiming to progressively optimize these benchmark data.

Development, quality, and influencing factors of colonoscopy in China: results from the national census in 2013 and 2020

Background and Aim

With the increasing burden of colorectal cancer (CRC), the practice of colonoscopy is gaining attention worldwide. However, it exhibits distinct trends between developing and developed countries. This study aims to explore its development and identify influencing factors in China.

Methods

The Chinese Digestive Endoscopy Censuses were conducted twice in mainland China under the supervision of health authorities. Information regarding the practice of colonoscopy was collected through a structured online questionnaire. The authenticity of the data was evaluated through logical tests, and a random selection of endoscopic reports underwent manual validation by Quality Control Centers. Potential factors associated with colonoscopy were analyzed using real-world information.

Results

From 2012 to 2019, the number of hospitals that performed colonoscopy increased from 3,210 to 6,325 (1.97-fold), and the volume increased from 5.83 to 12.92 million (2.21-fold). The utilization rate rose from 436.0 to 914.8 per 100,000 inhabitants (2.10-fold). However, there was an exacerbation of regional inequality in the adequacy of colonoscopy. Regions with higher incidence of CRC, higher gross domestic product per capita, more average numbers of endoscopists and tertiary hospitals tended to provide more accessible colonoscopy (P<0.001). Nationwide, the cecal intubation rate improved from 83.9% to 94.4% and the unadjusted adenoma detection rate (ADR) improved from 16.3% to 18.1%. Overall, hospital grading, educational background of endoscopists, economic income, and colonoscopy volume were observed as the significantly positive factors affecting ADR (P<0.05), but not the incidence of CRC or the number of endoscopists.

Conclusions

Tremendous progress in colonoscopy has been made in China, but some issues needed timely reflection. Our findings provide timely evidence for better colonoscopy strategies and measures, such as quality control and medical education of endoscopists.

Long-Term Follow-Up of Colonoscopy Quality Monitoring

INTRODUCTION

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear.

METHODS

We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly.

RESULTS

Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%.

DISCUSSION

Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Second-generation distal attachment cuff for adenoma detection in screening colonoscopy: a randomized multicenter study

BACKGROUND AND AIMS

Randomized studies have demonstrated that a distal attachment cap with rubber side arms, the Endocuff Vision (ECV; Olympus America, Center Valley, Pa, USA), increased colonoscopic adenoma detection rate (ADR) in various mixed patient collectives. This is the first study to evaluate its use in a primary colonoscopic screening program.

METHODS

Patients over age 55 years undergoing screening colonoscopy in 9 German private offices in Berlin and Hamburg were randomized to either the study group using ECV or the control group using high-definition colonoscopies (standard of care). The main outcome parameter was ADR, whereas secondary outcomes were detection rates of all adenomas per colonoscopy (APCs), of adenoma subgroups, and of hyperplastic polyps.

RESULTS

Of 1416 patients (mean age, 61.1 years; 51.8% women), with a median of 41 examinations per examiner (n = 23; interquartile range, 12-81), 700 were examined with ECV and 716 without. Adjusting for the effects of the colonoscopies, ADR was 39.5% (95% confidence interval [CI], 32.6%-46.3%) in the ECV group versus 32.2% (95% CI, 25.9%-38.6%) in the control group, which resulted in an increase of 7.2% (95% CI, 2.3%-12.2%; P = .004). The increase in ADR was mainly because of small polyps, with adjusted ADRs for adenomas <10 mm of 33.3% (95% CI, 26.5%-40.2%) for study patients versus 24.0% (95% CI, 18.2%-29.8%) for control patients (P < .001). APC was also significantly increased (.57 ECV vs .51 control subjects, P = .045).

CONCLUSIONS

A distal attachment cap with side arms significantly increased the ADR in patients undergoing primary colonoscopic screening. Because of the correlation of ADR and interval cancer, its use should be encouraged, especially in this setting. (Clinical trial registration number: NCT03442738.).

Impact of an Abdominal Compression Bandage on the Completion of Colonoscopy for Obese Adults: A Prospective Randomized Controlled Trial

METHODS

Eligible patients were randomly allocated into the abdominal bandage and conventional groups during a routine colonoscopy. The primary outcome was CCR.

RESULTS

A total of 250 eligible patients were randomly assigned to the abdominal bandage and conventional groups from January 2021 to April 2021. Eleven patients (five in the abdominal bandage group and six in the conventional group) were excluded due to schedule cancellation after randomization, and 239 patients were eventually included in the final analysis. There were no significant differences between the two groups regarding baseline characteristics (P > 0.05). Furthermore, no significant differences were observed in terms of advanced adenoma detection rate (AADR), polyp detection rate (PDR), bowel preparation scale (BBPS), bubble scale (BS), and withdrawal time between the two groups (P > 0.05). However, compared with the conventional group, the cecal insertion time (CIT) of the abdominal bandage group was significantly shortened (279.00 (234.50-305.75) vs. 421.00 (327.00-485.00), P < 0.001), and the CCR (96.7% vs. 88.2%, P = 0.01) and adenoma detection rate (ADR) (47.5% vs. 32.8%, P < 0.001) were improved. Besides, logistic regression analysis showed that body mass index (BMI) and abdominal compression bandage were associated with CCR.

CONCLUSIONS

Abdominal compression bandages could effectively shorten CIT and improve CCR and ADR for obese patients during a routine colonoscopy. This trial is registered with the Chinese Clinical Trial Registry (No. ChiCTR2100043556).

Leveraging electronic medical record functionality to capture adenoma detection rate

Measuring the adenoma detection rate (ADR) is critical to providing quality care, however it is also challenging. We aimed to develop a tool using pre-existing electronic health record (EHR) functions to accurately and easily measure total ADR and to provide real-time feedback for endoscopists. We utilized the Epic EHR. With the help of an Epic analyst, using existing tools, we developed a method by which endoscopy staff could mark whether an adenoma was detected for a given colonoscopy. Using these responses and all colonoscopies performed by the endoscopist recorded in the EHR, ADR was calculated in a report and displayed to endoscopists within the EHR. One endoscopist piloted the tool, and results of the tool were validated against a manual chart review. Over the pilot period the endoscopist performed 145 colonoscopies, of which 78 had adenomas. The tool correctly identified 76/78 colonoscopies with an adenoma and 67/67 of colonoscopies with no adenomas (97.4% sensitivity, 100% specificity, 98% accuracy). There was no difference in ADR as determined by the tool compared to manual review (53.1% vs. 53.8%, p = 0.912). We successfully developed and pilot tested a tool to measure ADR using existing EHR functionality.

Implications of stable or increasing adenoma detection rate on the need for continuous measurement

BACKGROUND AND AIMS

Measurement of the adenoma detection rate (ADR) is resource intensive, and the benefit of continuous measurement for colonoscopists with high ADR is unclear. We examined the ADR trends at our center to determine whether continuous measurement for consistently high ADR is warranted.

METHODS

Among colonoscopies performed between January 1999 and November 2019 at a tertiary center, we analyzed data from colonoscopists performing at least 50 screening colonoscopies annually for 5 consecutive years. ADR trends for individual colonoscopists were examined using Joinpoint regression models.

RESULTS

Eleven colonoscopists performed screening colonoscopies on 14,047 patients, and 5912 among them had at least 1 conventional adenoma removed (42.0%). Of 25,829 polyps, 13,585 (52.6%) were conventional adenomas or adenocarcinomas and contributed to ADR calculation. All but 1 colonoscopist included met the recommended minimum threshold ADR of 25% continuously over the study period. Of the 11 colonoscopists, 5 had an increase in their ADR and the remaining 6 had stable ADRs over the study period.

CONCLUSIONS

For colonoscopists consistently performing above the minimum threshold, diversion of resources toward improvement of quality measures other than ADR is justified.

Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

Impact of Community Referral on Colonoscopy Quality Metrics in a Veterans Affairs Medical Center

INTRODUCTION

The Veterans Access, Choice, and Accountability Act of 2014 expands the number of options veterans have to ensure timely access to high-quality care. There are minimal data currently available analyzing the impact and quality of colonoscopy metrics in veterans receiving procedures within the Department of Veterans' Affairs (VA) vs community settings.

METHODS

All patients at our academic VA medical center who were referred to a community care colonoscopy (CCC) for positive fecal immunochemical testing, colorectal cancer screening, and adenoma surveillance from 2015 to 2018 were identified and matched for sex, age, and year of procedure to patients referred for a VA-based colonoscopy (VAC). Metrics measured included time to procedure measured in days, adenoma detection rate (ADR), advanced ADR (AADR), adenomas per colonoscopy, sessile serrated polyp detection rate, cecal intubation rate, bowel preparation quality, and compliance with guideline recommendations for surveillance. Patient comorbidities were also recorded. Variable associations with adenoma detection and compliance with surveillance guidelines were analyzed with univariate and multivariate logistic regression.

RESULTS

In total, 235 veterans (mean age, 64.6 years, and 95.7% male) underwent a CCC and had an appropriately matched VAC. ADR in the community was 36.9% compared with 62.6% for the VAC group (P < 0.0001). The mean number of adenomas per procedure in the community was 0.77 compared with 1.83 per VAC (P < 0.0001). CCC AADR was 8.9% compared with 18.3% for VAC (P = 0.003). The cecal intubation rate for community colonoscopies was 90.6% compared with 95.3% for VA colonoscopies (P = 0.047). Community care compliance with surveillance guidelines was 74.9% compared with 93.3% for VA (P < 0.0001). This nonconformity was primarily due to recommending a shorter interval follow-up in the CCC group (15.3%) compared with the VAC group (5.5%) (P = 0.0012). The mean time to procedure was 58.4 days (±33.7) for CCC compared with 83.8 days (±38.6) for VAC (P < 0.0001). In multivariate regression, CCC was associated with lower ADR (odds ratio 0.39; 95% confidence interval, 0.20-0.63) and lower compliance with surveillance guidelines (odds ratio 0.21; 95% confidence interval, 0.09-0.45) (P < 0.0001 for both).

DISCUSSION

Time to colonoscopy was significantly shorter for CCC compared with VAC. However, compared with VA colonoscopies, there was significantly lower ADR, AADR, and surveillance guideline compliance for services rendered by community providers. This impact on quality of care should be further studied to ensure that colonoscopy quality standards for veterans are not compromised by the process of care and site of care.

Adenoma and Serrated Lesion Detection by Colonoscopy Indication: The ADR-ESS (ADR Extended to all Screening/Surveillance) Score

BACKGROUND

The adenoma detection rate at screening (ADR) predicts interval colorectal cancer. Monitoring other lesion detection rates and colonoscopy indications has been proposed. We developed a comprehensive, automated colonoscopy audit program based on standardized clinical documentation, explored detection rates across indications, and developed the Adenoma Detection Rate - Extended to all Screening / Surveillance (ADR-ESS) score.

METHODS

In a prospective cohort study, we calculated overall and advanced adenoma and sessile serrated lesion (SSL) detection rates among 15,253 colonoscopies by 35 endoscopists from 4 endoscopy units across all colonoscopy indications. We explored correlations between detection rates, and the precision and stability of ADR-ESS versus ADR.

RESULTS

The overall "screening, first" ADR was 36.3% (95% confidence interval [CI], 34.5%-38.1%). The adenoma detection rate was lower for "screening, not first" (relative rate [RR], 0.80; 95% CI, 0.74-0.87) and "family history" (RR, 0.84; 95% CI, 0.74-0.96), and higher for "surveillance" (RR, 1.22; 95% CI, 1.15-1.31) and "follow-up, FIT" (RR, 1.21; 95% CI, 1.07-1.37). For "screening, first," the detection rates for advanced adenoma, SSL, and advanced SSL were 6.7% (95% CI, 5.7%-7.7%), 7.2% (95% CI, 6.2%-8.2%), and 2.6% (95% CI, 2.0%-3.2%), respectively. Adenoma and SSL detection were correlated (r = 0.44; P = .008). ADR-ESS had substantially narrower confidence intervals and less period-to-period variability than ADR, and was not improved by weighting for indication volume and correction for detection by indication.

CONCLUSIONS

Comprehensive, automated colonoscopy audit based on standardized clinical documentation is feasible. Adenoma detection is a fair but imperfect proxy for SSL detection. ADR-ESS increases the precision of adenoma detection assessments and emphasizes quality across colonoscopy indications.