Colonoscopy quality assessment

Is There a Difference in Adenoma Detection Rates According to Indication? An Experience in a Panamanian Colorectal Cancer Screening Program

Background

The benefit of colorectal cancer screening in reducing cancer risk and related death is unclear. There are quality measure indicators and multiple factors that affect the performance of a successful colonoscopy. The main objective of our study was to identify if there is a difference in polyp detection rate (PDR) and adenoma detection rate (ADR) according to colonoscopy indication and which factors might be associated.

Methods

We conducted a retrospective review of all colonoscopies performed between January 2018 and January 2019, in a tertiary endoscopic center. All patients ≥ 50 years old scheduled for a nonurgent colonoscopy and screening colonoscopy were included. We stratified the total number of colonoscopies into two categories according to the indication: screening vs. non-screening, and then calculated PDR, ADR and serrated polyp detection rate (SDR). We also performed logistic regression model to identify factors associated with detecting polyps and adenomatous polyps.

Results

A total of 1,129 and 365 colonoscopies were performed in the non-screening and screening group, respectively. In comparison with the screening group, PDR and ADR were lower for the non-screening group (33% vs. 25%; P = 0.005 and 17% vs. 13%; P = 0.005). SDR was non-significantly lower in the non-screening group when compared with the screening group (11% vs. 9%; P = 0.53 and 22% vs. 13%; P = 0.007).

Conclusion

In conclusion, this observational study reported differences in PDR and ADR depending on screening and non-screening indication. These differences could be related to factors related to the endoscopist, time slot allotted for colonoscopy, population background, and external factors.

Diagnostic accuracy of a novel artificial intelligence system for adenoma detection in daily practice: a prospective nonrandomized comparative study

BACKGROUND

Adenoma detection rate (ADR) varies significantly between endoscopists, with adenoma miss rates (AMRs) up to 26 %. Artificial intelligence (AI) systems may improve endoscopy quality and reduce the rate of interval cancer. We evaluated the efficacy of an AI system in real-time colonoscopy and its influence on AMR and ADR.

METHODS

This prospective, nonrandomized, comparative study analyzed patients undergoing diagnostic colonoscopy at a single endoscopy center in Germany from June to October 2020. Every patient was examined concurrently by an endoscopist and AI using two opposing screens. The AI system, overseen by a second observer, was not visible to the endoscopist. AMR was the primary outcome. Both methods were compared using McNemar test.

RESULTS

150 patients were included (mean age 65 years [standard deviation 14]; 69 women). There was no significant or clinically relevant difference (P = 0.75) in AMR between the AI system (6/197, 3.0 %; 95 % confidence interval [CI] 1.1-6.5) and routine colonoscopy (4/197, 2.0 %; 95 %CI 0.6-5.1). The polyp miss rate of the AI system (14/311, 4.5 %; 95 %CI 2.5-7.4) was not significantly different (P = 0.72) from routine colonoscopy (17/311, 5.5 %; 95 %CI 3.2-8.6). There was no significant difference (P = 0.50) in ADR between routine colonoscopy (78/150, 52.0 %; 95 %CI 43.7-60.2) and the AI system (76/150, 50.7 %; 95 %CI 42.4-58.9). Routine colonoscopy detected adenomas in two patients that were missed by the AI system.

CONCLUSION

The AI system performance was comparable to that of experienced endoscopists during real-time colonoscopy with similar high ADR (> 50 %).

Simplifying Measurement of Adenoma Detection Rates for Colonoscopy

BACKGROUND

Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly.

AIMS

Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR.

METHODS

We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites.

RESULTS

Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05).

CONCLUSIONS

Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

Effect of water exchange method on adenoma miss rate of patients undergoing selective polypectomy: A randomized controlled trial

BACKGROUND

Adenomas may be missed in up to 40% of screening colonoscopies. Although the water exchange (WE) method can improve ADR, as shown in several RCTs, it remains uncertain whether it can increase the detection of missing adenomas compared with standard air-insufflated (AI) colonoscopy.

METHODS

Patients aged 18-80 years who underwent selective polypectomy were randomly allocated to the WE or AI group. The primary endpoint was the adenoma miss rate (AMR), defined as the number of patients with one or more additional adenomas during the polypectomy procedure divided by the total number of patients in each group.

RESULTS

A total of 450 patients were enrolled, with 225 in each group. The overall AMRs were 45.8% (103/225) in the WE group and 35.6% (80/225) in the AI group (p = 0.035). More patients in the WE group had at least one missed adenoma in the proximal colon (38.2% vs 24.4%, p = 0.002). The adenoma-level miss rate was also higher in the WE group than in the AI group (35.1% vs 29.0%, p = 0.036). Subgroup analysis showed that patients in the WE group had more missed adenomas located in the proximal colon or with flat shapes.

CONCLUSIONS

This study confirmed that substantial adenomas were missed in patients undergoing selective polypectomy. The WE method significantly improved the detection of missed adenomas, especially those located in the proximal colon or with flat shapes. (ClnicalTrials.gov number: NCT02880748).

Gastrointestinal endoscopy nurse assistance during colonoscopy and polyp detection: A PRISMA-compliant meta-analysis of randomized control trials

BACKGROUND

Previous studies showed difference results about the effect of nurse in improvement of the colonoscopy detection rate. This meta-analysis aims to investigate whether nurse participation during colonoscopy can help in improving the detection rate of polyps and adenomas.

METHODS

Original studies in English were searched from the MEDLINE database, PubMed, Web of Science, and the Cochrane Library database. Randomized control trials (RCT) comparing colonoscopy with and without nurse participation for the detection of colorectal polyps and adenomas were identified. A meta-analysis was performed using Revman 5.3 software.

RESULTS

A total of 2268 patients from 4 RCTs were included in this meta-analysis. Outcomes of colonoscopy with nurse participation were compared with those of colonoscopy without nurse participation. The results showed that nurses' participation during colonoscopy could significantly increase both, polyp detection rate and adenoma detection rate.

CONCLUSION

Nurse assistance during colonoscopy can help improve the rate of detection of polyps and adenomas.

Stool-Based Tests for Colorectal Cancer Screening: Performance Benchmarks Lead to High Expected Efficacy

PURPOSE OF REVIEW

Participation goals for colorectal cancer (CRC) screening in the USA have not been met. Non-invasive screening strategies may improve CRC screening participation. We highlight recent literature on stool-based screening performance and expectations for emerging non-invasive screening tests.

RECENT FINDINGS

Stool-based CRC screening detects screen-relevant colorectal neoplasia and outperforms a currently available plasma assay. Though modestly sensitive for CRC, adherence to annual fecal immunochemical testing (FIT) is sub-optimal. Multi-target stool DNA (MT-sDNA) has greater adherence, superior sensitivity for screen-relevant lesions (including those in the proximal colon and sessile serrated architecture), and equivalent specificity to FIT over a 3-year period. Stool-based CRC screening tests are anticipated to reduce the incidence and mortality of CRC through detection of early-stage cancers and high-risk polyps. These endpoints in performance will need to be met by emerging blood sample-based tests in order have meaningful impact in clinical practice.

The performance indicator of colonic intubation (PICI) in a FIT-based colorectal cancer screening program

Objective: Cecal intubation rate (CIR) is known to be inversely associated with interval colorectal cancer (CRC) risk. Cecal intubation may be achieved by the use of force and sedation jeopardizing patient safety. The Performance Indicator of Colonic Intubation (PICI) is defined as the proportion of colonoscopies achieving cecal intubation with use of ≤2 mg midazolam and no-mild patient-experienced discomfort. We aimed (i) to measure the variation of PICI between colonoscopists and colonoscopy units; (ii) to assess the correlation between the individual components of PICI; and (iii) to evaluate the association between PICI and commonly used performance indicators. Materials and methods: For the period 1 July 2015 through 30 June 2017 of the prevalent round of the Danish FIT-based CRC screening program, we included colonoscopies performed at four units in the Central Denmark Region within 60 days after a positive FIT-test. The PICI variation was evaluated using rates and ranges. Correlations between individual PICI components were assessed using Pearson correlation coefficients. Polyp detection rate (PDR), Adenoma detection rate (ADR), Polyp retrieval rate (PRR) and Withdrawal time (WT) were assessed within PICI quartiles. Results: The overall PICI was 78.7% with substantial variation between colonoscopists (40.0-91.9%) and units (72.6-82.0%). CIR was significantly correlated with patient-experienced comfort (r = 0.49, n = 73, p < .0001) and we observed that colonoscopists with a PICI between 79.9% and 84.3%) had the highest ADR. Conclusion: We found a substantial variation in PICI between colonoscopists and between colonoscopy units, which may reflect potential for quality improvements.

Efficacy of autofluorescence imaging for flat neoplasm detection: a multicenter randomized controlled trial (A-FLAT trial)

BACKGROUND AND AIMS

Colorectal flat (nonpolypoid) lesions can be overlooked during colonoscopy. This study evaluated the efficacy of updated autofluorescence imaging (AFI) for detecting colorectal flat neoplasms.

METHODS

This was a prospective, multicenter, randomized controlled trial in 9 Japanese tertiary institutions. Patients undergoing colonoscopy because of positive fecal immunochemical tests, surveillance after polypectomy, or investigation of minor symptoms were enrolled and randomly assigned to either the white-light imaging (WLI) or the AFI group. Primary outcome measurement was number of flat neoplasms per patient.

RESULTS

From November 2015 to June 2017, 817 patients were enrolled. After excluding 15 patients, 802 were finally analyzed (404, WLI; 398, AFI). Patients' backgrounds (sex, age, indication of colonoscopy, experience of endoscopists) and quality of colonoscopy (bowel preparation, sedative use, cecal insertion rate, insertion and withdrawal time) were not different between groups. Number of flat neoplasms in each patient was significantly higher in the AFI than in the WLI group (.87 [95% confidence interval [CI], .78-.97] vs .53 [95% CI, .46-.61]), whereas overall and polypoid neoplasm detection was not significantly different between the groups (1.33 [95% CI, 1.22-1.45] vs 1.14 [95% CI, 1.03-1.24], .46 [95% CI, .40-.53] vs .60 [95% CI, .53-.68]). Flat neoplasms were more frequently detected in the right-sided colon with AFI (.61 [95% CI, .54-.70] vs .30 [95% CI, .25-.36]) but not in the left-sided colon and rectum (.26 [95% CI, .21-.32] vs .23 [95% CI, .19-.28]).

CONCLUSIONS

Updated AFI improves the detection of flat colorectal neoplasms in the right-sided colon compared with WLI. (Clinical trial registration number: UMIN000019355.).

NEW BOWEL PREPARATION TECHNIQUE FOR COLONOSCOPY: CLINICAL TRIAL COMPARING AQUANET AND MANNITOL

Background:

Fifty-five percent of Americans aged 50-65 are submitted to colonoscopy. For over 65-year, this number increases to 64%. In Brazil, it is forecast that the population submitted to colonoscopy will grow, even though inadequate preparation is still a major problem.

Aim:

To analyze the quality of a new intestinal preparation technique, Aquanet EC-2000^®, compared to oral Mannitol solution.

Methods:

This prospective longitudinal study enrolled 200 patients with indication for colonoscopy. The sample was randomly allocated to two groups of 100; one group received Aquanet EC-2000^® to prepare for colonoscopy and the other Mannitol solution. The Boston scale was used to analyze the results.

Results:

As expected both preparations produced similar results with the bowel cleansing of the different regions of the colon being classified as Boston scale 3 (excellent) in most patients (p>0.05).

Conclusion:

The results of bowel preparation using Aquanet EC-2000^® were similar to using Mannitol solution.

Aquanet Bowel Cleansing Device Versus Oral Sodium Picosulfate for Pre-Endoscopy Bowel Preparation: Propensity Score Analysis for Interventional Effectiveness Evaluation

Background

Colonoscopy procedures are commonly performed and have high success rates. However, poor or inadequate bowel preparation is one of the most common reasons for a repeated or failed colonoscopy. We therefore performed an observational study followed by propensity score modeling to evaluate and compare the quality of bowel preparation with the use of Aquanet bowel cleansing devices (BCDs) versus the use of oral sodium picosulfate solution.

Methods

We performed a prospective cross-sectional study to compare the quality of pre-endoscopic bowel preparation using a BCD with oral solution. Our major outcome of interest was the quality of bowel preparation as measured through the Boston bowel preparation (BBP) scale. Our main predictor was the method of bowel preparation. The bowel was prepared using either sodium picosulfate or the BCD.

Results

A total of 314 participants were part of this study. The average age of the participants was 54 years and most of the participants were females (81%). Sodium picosulfate was associated with better scores at each segment. After propensity scoring with a 1:1 match and further adjusting for the unbalanced variable (age), we found that despite the apparent superior cleansing performance of sodium picosulfate over the BCD, the difference was not statistically significant.

Conclusion

This study reinforces previous reports regarding the quality, safety and comfort of BCDs, indicating that this technique should be considered for colonoscopy preparation. In the future, randomized controlled trials should be performed to validate these preliminary findings.

Quality measures in gastrointestinal endoscopy: the current state

PURPOSE OF REVIEW

The purpose of this review is to summarize the current state of endoscopic quality measurement and use of measures in enhancing the value of endoscopic services.

RECENT FINDINGS

Initially, quality measurement of endoscopic procedures was claims based or included small unit or practice-specific efforts. Now we have a mature national registry and large electronic medical or procedural records that are designed to yield valuable data relevant to quality measurement.

SUMMARY

With the advent of better measures, we are beginning to understand that initial process and surrogate outcome measures (adenoma detection rate) can be improved to provide a better reflection of endoscopic quality. Importantly, however, even measures currently in use relate to important patient outcomes such as missed colon cancers. At a federal level, older cumbersome pay-for-performance initiatives have been combined into a new overarching program named the quality payment program within the centers for medicare and medicaid services. This program is an additional step toward furthering the progress from volume-to-value-based reimbursement. The legislation mandating the movement toward outcomes-linked (value) reimbursement is the medicare access and children's health insurance program reauthorization act, which was passed with overwhelming bipartisan support and will not be walked back by alterations of the affordable care act. Increasing portions of medicare reimbursement (and likely commercial to follow) will be linked to quality metrics, so familiarity with the underlying process and rationale will be important for all proceduralists.

Colorectal Cancer: Genetics is Changing Everything

Cancer is fundamentally a genetic disease caused by mutational or epigenetic alterations in DNA. There has been a remarkable expansion of the molecular understanding of colonic carcinogenesis in the last 30 years and that understanding is changing many aspects of colorectal cancer care. It is becoming increasingly clear that there are genetic subsets of colorectal cancer that have different risk factors, prognosis, and response to treatment. This article provides a general update on colorectal cancer and highlights the ways that genetics is changing clinical care.

The Secondary Quality Indicator to Improve Prediction of Adenoma Miss Rate Apart from Adenoma Detection Rate

OBJECTIVES

Adenoma detection rate (ADR) cannot distinguish between endoscopists who detect one adenoma and those who detect ≥2 adenomas. Hypothetically, adenoma miss rate (AMR) may be significant for endoscopists with high ADRs who examine the rest of colon with less care after detecting first polyp. Our objective was to evaluate other quality indicators plus ADR vs. ADR alone in prediction of AMR.

METHODS

We conducted a cross-sectional study of asymptomatic participants aged 50-75 years who underwent back-to-back screening colonoscopies by four faculty endoscopists. Each round of colonoscopy was performed by two of the endoscopists in a randomized order. During each round of colonoscopy, all detected polyps were removed. The second endoscopist was blinded to the results of the first. The total number of adenomas per positive participant (APP), the total number of adenomas per colonoscopy (APC), the additional adenomas found after the first adenoma per colonoscopy (ADR-Plus), and ADR were calculated for prediction of AMR.

RESULTS

In all, 200 participants underwent back-to-back colonoscopies. There were no significant differences in ADRs of four endoscopists (44, 50, 54, and 46%). APPs were 1.91, 2.12, 2.19, and 2.43. APCs were 0.84, 1.06, 1.18, and 1.12. ADR-Plus were 0.40, 0.56, 0.64, and 0.66, respectively. AMRs differed significantly between the endoscopists (36, 27, 21, and 13%; P=0.01). There was no correlation between ADR and AMR (r=-0.25; P=0.75). Whereas APP exhibited a strong inverse correlation with AMRs (r=-0.99; P<0.01). APC and ADR-Plus appeared to be inversely correlated with AMR, however this was not statistically significant (r=-0.82; P=0.18 and r=-0.93; P=0.07, respectively).

CONCLUSIONS

Among high-ADR endoscopists, AMRs still varied. APP may be a promising secondary indicator for distinguishing between the one-and-done polyp endoscopist and the meticulous endoscopist. The evaluation of influence of new metrics on colorectal cancer (CRC) prevention requires a larger population-based study.

Impact of endoscopy nurse involvement on polyp detection rates during colonoscopy

AIM: To investigate the impact of endoscopy nurse involvement during colonoscopy on the polyp detection rate (PDR) and adenoma detection rate (ADR).

METHODS: This was a single-center, prospective study. Patients involved were prospectively randomized to a routine colonoscopy group or an endoscopy nurse involvement group. The association of nurse involvement with PDR and ADR was evaluated.

RESULTS: A total of 1192 patients were included in the study. The PDR was significantly higher (33.19% vs 27.81%, P = 0.000) among colonoscopies that included an endoscopy nurse compared with those performed by only a physician, as was the left-sided and the right-sided adenomas detected (P = 0.017). There was no difference in ADR between the two groups (20.88% vs 20.55%, P = 0.889). Nurse participation was associated with a higher detection rate of small (< 5 mm) polyps (P = 0.006).

CONCLUSION: Endoscopy nurse involvement in colonoscopies significantly improves the overall PDR. Involvement of a well-trained nurse in screening colonoscopies may be an effective strategy to increase access.

Usefulness of oil lubrication during colonoscopy: A comparative study with the conventional technique

BACKGROUND

The different forms of lubrication are among the most simple, accessible, and economic techniques that have been implemented for improving the diagnostic performance of colonoscopy.

AIM

To determine whether the use of oil improved the number of complete colonoscopies, facilitated the procedure, reduced pain, or improved the study's diagnostic performance, compared with the conventional lubrication technique.

PATIENTS AND METHODS

One hundred and seventy-five patients referred for colonoscopy were alternately allocated to receive treatment with the standard lubrication method with chlorhexidine gel (group 1) or lubrication with corn oil administered through the working channel (group II). The number of complete colonoscopies, the length of time needed to reach the cecum, the degree of difficulty estimated by the endoscopist and the assistant, the level of pain at the end of the study estimated by the patient, and the endoscopic findings were all determined.

RESULTS

Eighty-eight patients made up group I and 87 made up group II. No statistically significant differences were found between the two groups in relation to general characteristics, the number of complete colonoscopies (93 vs. 97%, respectively), the time needed to reach the cecum (8:00 vs. 8:41min, respectively), the level of pain at the end of the study, or the detection of polyps. The degree of difficulty was slightly lower in group II, but with no statistical significance.

CONCLUSIONS

Lubrication with oil during colonoscopy did not improve the number of complete colonoscopies, did not facilitate the study, nor did it reduce pain or increase the diagnostic performance of the study, when compared with the conventional technique.