Quality indicators for colonoscopy

Follow-up endoscopy rates as an indicator of effectiveness in colon capsule endoscopy: a systematic review and meta-analysis

OBJECTIVE

Colon capsule endoscopy (CCE) has emerged as a promising alternative for investigating lower gastrointestinal symptoms. However, its adoption has been limited due to concerns about cost-effectiveness, significantly influenced by follow-up endoscopy rates (FERs). Understanding CCE's FERs is crucial for its integration into routine clinical practice. We synthesised the evidence to evaluate the overall rate of further investigation in CCE.

DESIGN

A systematic review and meta-analysis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Medline, Embase, and PubMed were searched through 15 August 2024.

ELIGIBILITY CRITERIA

Studies included reporting FERs after CCE, including subsequent endoscopic procedures and radiological imaging. There were no language restrictions or limitations in CCE referral indications, patient recruitment criteria, or pathologies investigated.

DATA EXTRACTION AND SYNTHESIS

All studies were independently screened and extracted two times by four reviewers. A random-effects model was used for meta-analysis and meta-regression to identify key contributing factors.

RESULTS

2850 participants from 19 studies were included in the analysis. Compared with the key performance indicators for FERs in colonoscopy (0.10-0.15) and CT colonography (0.25), the pooled FER for CCE was found to be 0.42 (95% CI 0.34 to 0.50). The meta-regression analysis identified complete transit rates and adequate bowel cleansing quality as factors inversely associated with FERs. Furthermore, the CCE2 capsule demonstrated a higher reinvestigation risk than CCE1, likely due to its improved diagnostic accuracy. Although CCE indications were associated with lower FERs, subgroup analysis did not reach statistical significance with high heterogeneity.

CONCLUSION

This study highlights significant FERs for CCE and identifies key contributing factors, emphasising the importance of appropriate patient selection to reduce reinvestigation needs. Future research should focus on improving completion rates, bowel preparation protocols, and refining CCE indications. This will minimise environmental impact and enhance cost-effectiveness and patient satisfaction.

PROSPERO REGISTRATION NUMBER

CRD42024567959.

Artificial intelligence and colorectal neoplasia detection performances in patients with positive fecal immunochemical test: Meta-analysis and systematic review

OBJECTIVES

The combination of fecal immunochemical test (FIT) followed by colonoscopy has established itself as one of the preferred population-based screening strategies. Despite extensive exploration of various techniques and technologies, their impact on adenoma detection rate has shown inconsistency across studies in this specific setting "FIT+ population." We aimed to assess the impact of the computer-aided detection (CADe) system in all randomized trials focused on this subpopulation.

METHODS

We searched MEDLINE, EMBASE, and Scopus databases until September 2023 for randomized controlled trials reporting diagnostic accuracy of CADe systems for detection of colorectal neoplasia. The primary outcome was pooled adenoma detection rate, and secondary outcomes were adenoma per colonoscopy, advanced adenoma per colonoscopy, serrated lesions, and nonneoplastic per colonoscopy.

RESULTS

Ten randomized trials on 5421 patients were included. Adenoma detection rate was higher in the CADe group than in the standard colonoscopy group (0.62 vs. 0.52; relative risk 1.19; 95% confidence interval 1.08-1.31). CADe also resulted in higher detection performances of both adenomas (incidence rate ratio 1.16; 95% confidence interval 1.09-1.24) and serrated lesions (incidence rate ratio, 1.20; 95% confidence interval 1.05-1.38) at per-polyp analysis. No differences were found for advanced adenomas between the groups. On the other hand, more nonneoplastic polyps were removed in the CADe than the standard group (0.45 vs. 0.34; mean difference 0.06; P = 0.026) in a comparable inspection time.

CONCLUSIONS

The use of CADe during colonoscopy results in an increased detection of adenomas, and serrated lesions, in a FIT+ setting. The impact on advanced adenomas was not significant. Higher rates of unnecessary removal of nonneoplastic polyps were also reported.

Exploring intraprocedural performance in colonoscopy: Insights from a tertiary care center in Saudi Arabia

BACKGROUND

Colonoscopy is essential for diagnosing and managing colorectal conditions, and is recognized as the gold standard for early cancer detection and removal of precancerous lesions. The American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology have established benchmark indicators to minimize the risk of interval colorectal cancer. Despite their importance, research on these metrics in Saudi Arabia is limited. This study analyzes key intraprocedural indicators of colonoscopies at a tertiary care center to evaluate adherence to care standards.

METHODS

This retrospective study examined 3763 colonoscopies conducted by adult gastroenterologists at Johns Hopkins Aramco Healthcare from January 2021 to December 2022. Procedures were categorized as screening and non-screening, with demographic data collected alongside withdrawal time (WT), cecal intubation rate (CIR), polyp detection rate (PDR), adenoma detection rate (ADR), Boston Bowel Preparation Scale (BBPS), polyp retrieval rate, rectal retroflexion, and adverse events.

RESULTS

The mean age of participants was 54.13 years, with 81.56% of them Saudis and 44.6% female. The average WT was 10 min. The overall CIR was 93.6% (94.78% for screening), with a PDR of 33.9% and a retrieval rate of 96.6%. ADR for screening participants was 25.63%, and 88.94% of participants achieved a BBPS score of 6 or more. The adverse event rate was at 0.2%, primarily due to bleeding.

CONCLUSIONS

The study indicates that colonoscopy procedures adhere to care standards, with ADR among male screening patients approaching 30%. Further research is necessary to evaluate pre- and post-procedural indicators.

Artificial Intelligence in Biliopancreatic Disorders: Applications in Cross-Imaging and Endoscopy

This review explores the transformative potential of artificial intelligence (AI) in the diagnosis and management of biliopancreatic disorders. By leveraging cutting-edge techniques, such as deep learning and convolutional neural networks, AI has significantly advanced gastroenterology, particularly in endoscopic procedures, such as colonoscopy; upper endoscopy; and capsule endoscopy. These applications enhance adenoma detection rates and improve lesion characterization and diagnostic accuracy. AI's integration in cross-sectional imaging modalities, such as computed tomography and magnetic resonance imaging, has remarkable potential. Models have demonstrated high accuracy in identifying pancreatic ductal adenocarcinoma; pancreatic cystic lesions; and pancreatic neuroendocrine tumors, aiding in early diagnosis; resectability assessment; and personalized treatment planning. In advanced endoscopic procedures, such as digital single-operator cholangioscopy and endoscopic ultrasound, AI enhances anatomic recognition and improves lesion classification, with a potential for reduction in procedural variability, enabling more consistent diagnostic and therapeutic outcomes. Promising applications in biliopancreatic endoscopy include the detection of biliary stenosis, classification of dysplastic precursor lesions, and assessment of pancreatic abnormalities. This review aims to capture the current state of AI application in biliopancreatic disorders, summarizing the results of early studies and paving the path for future directions.

A Randomized Controlled Trial to Improve the Accuracy of Follow-Up Surveillance Time Intervals in the Electronic Health Record After a Colonoscopy for Colorectal Cancer Screening

INTRODUCTION

Electronic health records (EHRs) provide cancer screening reminders to patients and clinicians, but they are not always accurate. Updating the EHR after a colonoscopy for colorectal cancer screening is typically performed manually by the endoscopist when pathology results are available but may be error prone. We evaluated an electronic tool embedded in patient result letters that automatically updated the EHR follow-up time interval after a colonoscopy.

METHODS

A randomized controlled trial of endoscopists from 1 institution who performed colonoscopies on patients undergoing a screening or surveillance colonoscopy. Intervention endoscopists were trained to use the electronic tool in their result letters to patients. Control endoscopists continued with their usual care. The primary outcome was the accuracy of the follow-up surveillance colonoscopy time interval in the EHR compared with the time interval specified in the patient result letter.

RESULTS

Overall, 43 endoscopists were randomly assigned to intervention (n = 22) or control (n = 21) groups. Characteristics of patients in the intervention (n = 2,365) and control (n = 1,422) were similar. A result letter was sent to 1,498 (63.3%) intervention and 814 (57.2%) control patients ( P < 0.001). Among all patients sent a result letter, the accuracy of the follow-up colonoscopy surveillance time interval between the result letter and the EHR was significantly higher for the intervention (92.4% vs 76.2%, P < 0.001). Intervention endoscopists were more satisfied with the process of reporting results after a colonoscopy (88.2% vs 60.0%, P = 0.11).

DISCUSSION

For patients undergoing a colonoscopy for colorectal cancer screening, an electronic tool embedded in the result letter that automatically updated the EHR significantly improved the accuracy of the follow-up time interval compared with usual care.

Optimizing bowel preparation quality for colonoscopy: consensus recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

Optimizing Bowel Preparation Quality for Colonoscopy: Consensus Recommendations by the US Multi-Society Task Force on Colorectal Cancer

This document is an update to the 2014 recommendations for optimizing the adequacy of bowel cleansing for colonoscopy from the US Multi-Society Task Force on Colorectal Cancer, which represents the American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy. The US Multi-Society Task Force developed consensus statements and key clinical concepts addressing important aspects of bowel preparation for colonoscopy. The majority of consensus statements focus on individuals at average risk for inadequate bowel preparation. However, statements addressing individuals at risk for inadequate bowel preparation quality are also provided. The quality of a bowel preparation is defined as adequate when standard screening or surveillance intervals can be assigned based on the findings of the colonoscopy. We recommend the use of a split-dose bowel preparation regimen and suggest that a 2 L regimen may be sufficient. A same-day regimen is recommended as an acceptable alternative for individuals undergoing afternoon colonoscopy, but we suggest that a same-day regimen is an inferior alternative for individuals undergoing morning colonoscopy. We recommend limiting dietary restrictions to the day before a colonoscopy, relying on either clear liquids or low-fiber/low-residue diets for the early and midday meals. We suggest the adjunctive use of oral simethicone for bowel preparation before colonoscopy. Routine tracking of the rate of adequate bowel preparations at the level of individual endoscopists and at the level of the endoscopy unit is also recommended, with a target of >90% for both rates.

AGA Living Clinical Practice Guideline on Computer-Aided Detection-Assisted Colonoscopy

BACKGROUND & AIMS

This American Gastroenterological Association (AGA) guideline is intended to provide an overview of the evidence and support endoscopists and patients on the use of computer-aided detection (CADe) systems for the detection of colorectal polyps during colonoscopy.

METHODS

A multidisciplinary panel of content experts and guideline methodologists used the Grading of Recommendations Assessment, Development and Evaluation framework and relied on the following sources of evidence: (1) a systematic review examining the desirable and undesirable effects (ie, benefits and harms) of CADe-assisted colonoscopy, (2) a microsimulation study estimating the effects of CADe on longer-term patient-important outcomes, (3) a systematic search of evidence evaluating the values and preferences of patients undergoing colonoscopy, and (4) a systematic review of studies evaluating health care providers' trust in artificial intelligence technology in gastroenterology.

RESULTS

The panel reached the conclusion that no recommendation could be made for or against the use of CADe-assisted colonoscopy in light of very low certainty of evidence for the critical outcomes, desirable and undesirable (11 fewer colorectal cancers per 10,000 individuals and 2 fewer colorectal cancer deaths per 10,000 individuals), increased burden of more intensive surveillance colonoscopies (635 more per 10,000 individuals), and cost and resource implications. The panel acknowledged the 8% (95% CI, 6%-10%) increase in adenoma detection rate and 2% (95% CI, 0%-4%) increase in advanced adenoma and/or sessile serrated lesion detection rate.

CONCLUSIONS

This guideline highlights the close tradeoff between desirable and undesirable effects and the limitations in the current evidence to support a recommendation. The panel acknowledged the potential for CADe to continually improve as an iterative artificial intelligence application. Ongoing publications providing evidence for critical outcomes will help inform a future recommendation.

Endoscopist adenoma detection rate associated with neoplasia detection during subsequent-round colonoscopy in fecal immunochemical test-based colorectal cancer screening: cross-sectional analysis of the SCREESCO randomized controlled trial

BACKGROUND AND AIMS

In colorectal cancer screening with the fecal immunochemical test (FIT), the optimal follow-up after first-round colonoscopy for a positive FIT, particularly after negative colonoscopy, is unknown. Therefore, using Screening of Swedish Colons (SCREESCO) study data, we aimed to elucidate the risk factors for the detection of colorectal neoplasia in second-round colonoscopy, which can affect recommendations for the optimal follow-up.

METHODS

We performed a cross-sectional analysis using data from SCREESCO participants undergoing colonoscopy after a positive 2-stool FIT, with a positivity cutoff value of ≥10 μg/g feces, in both the first and second rounds separated by a 2-year interval. We assessed the associations between colorectal neoplasia detection in second-round colonoscopy and participant characteristics, FIT concentrations, first-round colonoscopy results, and endoscopists' adenoma detection rates (ADRs), which were categorized as very low, low, intermediate, and high.

RESULTS

This study included 343 individuals. Despite negative first-round colonoscopies (n = 230), colorectal cancer and advanced colorectal neoplasia (ACN) were detected in 0.9% and 8.3% of participants in the second-round colonoscopy, respectively. An association was demonstrated between the first-round endoscopists' ADRs and the risk of second-round ACN detection. The multivariable odds ratios of the first-round intermediate and high ADRs, compared with the very low ADR, for second-round ACN detection were 0.17 (95% confidence interval [CI], 0.02-0.79) and 0.19 (95% CI, 0.04-0.86), respectively.

CONCLUSIONS

The impact of endoscopists' ADRs on ACN detection in subsequent-round colonoscopies underscores the importance of considering ADR for optimal follow-up after first-round colonoscopy in an FIT-based screening program.

Adenoma Detection Rates by Physicians and Subsequent Colorectal Cancer Risk

Importance

Patients of physicians with higher adenoma detection rates (ADRs) during colonoscopy have lower colorectal cancer (CRC) risk after screening colonoscopy (ie, postcolonoscopy CRC). Among physicians with an ADR above the recommended threshold, it is unknown whether improving ADR is associated with a lower incidence of CRC in their patients.

Objective

To determine the association of improved ADR in physicians with a range of ADR values at baseline with CRC incidence among their patients.

Design, Setting, and Participants

A total of 789 physicians in the Polish Colonoscopy Screening Program were studied between 2000 and 2017, with final follow-up on December 31, 2022. Joinpoint regression analyses were used to identify trends between changes in ADR and postcolonoscopy CRC incidence. Rates of CRC after colonoscopy were compared between physicians whose ADR improved and those without improvement. ADR improvement was defined as either an improvement by at least 1 ADR sextile category or remaining in the highest category.

Exposure

Physician ADR.

Main Outcomes and Measures

Association of improved ADR with postcolonoscopy CRC incidence.

Results

Of 485 615 patients (mean [SD] age, 57 [5.41] years; 60% female), 1873 CRC diagnoses and 474 CRC-related deaths occurred during a median follow-up of 10.2 years. Among individual physicians at baseline, median (IQR) ADR was 21.8% (15.9%-28.2%) and maximum ADR was 63.0%. Joinpoint regression showed a change in CRC incidence trends at an ADR level of 26%, corresponding to a CRC incidence of 27.1 per 100 000 person-years. Patients of physicians whose ADR was less than 26% at baseline and improved during follow-up had a postcolonoscopy CRC incidence of 31.8 (95% CI, 29.5-34.3) per 100 000 person-years, compared with 40.7 (95% CI, 37.8-43.8) per 100 000 person-years for patients of physicians with an ADR of less than 26% at baseline who did not improve during follow-up (difference, 8.9/100 000 person-years [95% CI, 5.06-12.74]; P < .001). Patients of physicians whose ADR was above 26% at baseline and improved during follow-up had a postcolonoscopy CRC incidence of 23.4 (95% CI, 18.4-29.8) per 100 000 person-years, compared with 22.5 (95% CI, 18.3-27.6) for patients of physicians whose ADR was above 26% at baseline and did not improve during follow-up (difference, 0.9/100 000 person-years [95% CI, -6.46 to 8.26]; P = .80).

Conclusions and Relevance

In this observational study, improved ADR over time was statistically significantly associated with lower CRC risk in patients who underwent colonoscopy compared with absence of ADR improvement, but only among patients whose physician had a baseline ADR of less than 26%.

Use of Artificial Intelligence in Lower Gastrointestinal and Small Bowel Disorders: An Update Beyond Polyp Detection

Machine learning and its specialized forms, such as Artificial Neural Networks and Convolutional Neural Networks, are increasingly being used for detecting and managing gastrointestinal conditions. Recent advancements involve using Artificial Neural Network models to enhance predictive accuracy for severe lower gastrointestinal (LGI) bleeding outcomes, including the need for surgery. To this end, artificial intelligence (AI)-guided predictive models have shown promise in improving management outcomes. While much literature focuses on AI in early neoplasia detection, this review highlights AI's role in managing LGI and small bowel disorders, including risk stratification for LGI bleeding, quality control, evaluation of inflammatory bowel disease, and video capsule endoscopy reading. Overall, the integration of AI into routine clinical practice is still developing, with ongoing research aimed at addressing current limitations and gaps in patient care.

Strategies, Technologies, and Tips for Successful Cecal Intubation

Successful cecal intubation is crucial in ensuring a complete evaluation of the colonic mucosa. Although completion of colonoscopies should be successful in close to 100% of all examinations in the hands of experienced gastroenterologists, there are some patients with colons which can be difficult to navigate. Factors such as older age, presence of diverticular disease, as well as high or low body mass index can present challenges for endoscopists. Challenges can be divided into those that are left sided and are associated with severe angulations of the colon versus those that are right sided and present as redundant colons. Both require different strategies to achieve completion. This review will cover methods, technologies as well the evolution of colonoscope insertion tubes which can help in navigating colons, especially those that are challenging. There will also be a discussion about basic principles and techniques that should be employed in all colonoscopies.

Real-World Assessment of the Efficacy of Computer-Assisted Diagnosis in Colonoscopy: A Single Institution Cohort Study in Singapore

Objective

To review the efficacy and accuracy of the GI Genius Intelligent Endoscopy Module Computer-Assisted Diagnosis (CADx) program in colonic adenoma detection and real-time polyp characterization.

Patients and Methods

Colonoscopy remains the gold standard in colonic screening and evaluation. The incorporation of artificial intelligence (AI) technology therefore allows for optimized endoscopic performance. However, validation of most CADx programs with real-world data remains scarce. This prospective cohort study was conducted within a single Singaporean institution between April 1, 2023 and December 31, 2023. Videos of all AI-enabled colonoscopies were reviewed with polyp-by-polyp analysis performed. Real-time polyp characterization predictions after sustained polyp detection were compared against final histology results to assess the accuracy of the CADx system at colonic adenoma identification.

Results

A total of 808 videos of CADx colonoscopies were reviewed. Out of the 781 polypectomies performed, 543 (69.5%) and 222 (28.4%) were adenomas and non-adenomas on final histology, respectively. Overall, GI Genius correctly characterized adenomas with 89.4% sensitivity, 61.7% specificity, a positive predictive value of 85.4%, a negative predictive value of 69.8%, and 81.5% accuracy. The negative predictive value for rectosigmoid lesions (80.3%) was notably higher than for colonic lesions (54.2%), attributed to the increased prevalence of hyperplastic rectosigmoid polyps (11.4%) vs other colonic regions (5.4%).

Conclusion

Computer-Assisted Diagnosis is therefore a promising adjunct in colonoscopy with substantial clinical implications. Accurate identification of low-risk non-adenomatous polyps encourages the adoption of "resect-and-discard" strategies. However, further calibration of AI systems is needed before the acceptance of such strategies as the new standard of care.

Climate Sustainability as a Catalyst for Quality and Excellence in Gastrointestinal Endoscopy: A Narrative Review

The significant contribution of greenhouse gas (GHG) emissions to global warming and the resultant negative impact on health is well established. Within the hospital setting, the endoscopy center has been ranked third-after the operating theater complex and intensive care unit-in terms of the volume of hazardous medical waste generated. Such regulated medical waste cannot be recycled, and the disposal process results in higher costs and a larger carbon footprint. There have been clarion calls to reduce the number of endoscopic procedures as a means of reducing GHG emissions. Previous studies have demonstrated the carbon footprint of inappropriate endoscopic procedures. However, endoscopy is an important diagnostic and therapeutic tool that has been shown to be cost-effective. A focus simply on reduction in procedural case volume alone raises the unintended consequences of inequitable access to endoscopy for those in need. A more nuanced approach that is aligned with the innate sense of healthcare professional aspirations and pride, in terms of seeking quality and clinical excellence, should be considered. An evidence-based approach, with a focus on quality and efficiency, as well as appropriate and timely use of new technology, will serve as a catalyst for positive behavioral change toward quality procedures and excellence. This will improve patient satisfaction, increase professional expertise and pride, and reduce carbon footprint through minimization of inappropriate and avoidable repeat procedures.

Which is the better polyp detection metric: adenomas per colonoscopy or adenoma detection rate? A simulation modeling study

Background and study aims We compared the ability of adenoma detection rate (ADR) and adenoma per colonoscopy (APC) to assess endoscopist detection, using statistical principles and simulations. Patients and methods We simulated a population of endoscopists and patients to compare the ability of ADR versus APC for capturing true endoscopist ability (TEA). We compared these rates with and without adjustment for patient and exam factors using multivariable models, and adjustment for imprecision due to low volume using empirical Bayes (shrinkage). Power calculations were used to compare the ability of ADR and APC to distinguish higher from lower rates over two time periods for an endoscopist. Results APC and ADR had similar discriminatory ability for assessing TEA. This increased with higher volumes and after adjusting for risk factors and low volume using shrinkage. Higher APC and ADRs had higher power for comparing endoscopist detection over two time periods, but APC was superior to ADR. For example, there was 29% power to distinguish APCs (n = 200 colonoscopies) 0.10 from 0.15, similar to the power (28%) to distinguish corresponding ADRs: 10% and 14%. However, at same volume (n = 200), the power to distinguish higher APC rates (0.50 vs.0.75) was greater (89%) than the power (78%) for corresponding ADRs (39% vs.53%). Conclusions Adjusting for patient and exam factors and/or using shrinkage techniques for lower-volume endoscopists can increase the correlation between TEA for both ADR and APC. For higher detection rates, APC offers more power than ADR in distinguishing differences in detection ability.