Usefulness of mean number of adenomas per positive screenee for identifying meticulous endoscopists among those who achieve acceptable adenoma detection rates

What are the priority quality indicators for colonoscopy in real-world clinical practice?

Colonoscopy is widely used as a colorectal cancer (CRC) screening tool. The effectiveness of a screening colonoscopy is associated with a decreased risk of CRC. However, colonoscopy is an operator-dependent procedure, and endoscopists' quality performance varies widely. This article reviewed the priority metrics and practices that contribute to high-quality screening colonoscopy in real-world clinical practice. With growing evidence, quality indicators have been subject to intense research and associated with reducing postcolonoscopy CRC incidence and mortality. Some quality metrics can reflect an endoscopy unit-based practice (i.e. quality of bowel preparation and withdrawal time). Other quality indicators primarily reflect individuals' skill and knowledge (i.e. cecal intubation rate, adenoma detection rate, and appropriately assigned follow-up colonoscopy interval). Measurement and improvement of priority quality indicators for colonoscopy should be made at both the endoscopist and unit levels. Substantial evidence supports the impact of high-quality colonoscopy in reducing the incidence of postcolonoscopy CRC.

Computer-aided detection, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized controlled trial

BACKGROUND AND AIMS

Computer-aided detection (CADe) and a mucosal exposure device can improve adenoma detection rate (ADR). Potential benefits of combining the 2 modalities have never been studied. This study aimed to compare ADR differences among CADe alone, endocuff-assisted colonoscopy (EAC) alone, and the combination of CADe and EAC (CADe+EAC) with standard colonoscopy.

METHODS

This prospective randomized controlled study included 1245 participants who underwent screening colonoscopy. Participants were randomized to CADe, EAC, CADe+EAC, and standard colonoscopy as a control. The primary outcome was ADR. Secondary outcomes were proximal ADR (pADR), advanced ADR (AADR), and the number of adenomas per colonoscopy (APCs).

RESULTS

ADRs from the control, CADe, EAC, and CADe+EAC groups were 41.9%, 52.2%, 54.0%, and 58.8%, respectively; pADRs were 25.2%, 33.3%, 34.9%, and 37.0%, respectively; AADRs were 7.7%, 8.3%, 8.3%, and 13.6%, respectively; and APCs were .76, 1.11, 1.18, and 1.31, respectively. Significant increases in ADR and pADR were observed between the intervention and control groups (P < .05 in all comparisons). The AADR was significantly higher only in the CADe+EAC group than in the control group (P = .02). The adjusted incidence rate ratios of APCs were significantly higher in the intervention groups versus the control group (P < .01 in all comparisons).

CONCLUSIONS

CADe+EAC significantly improve ADR and AADR over standard colonoscopy. However, although CADe or EAC alone can substantially increase the detection of adenomas, they do not lead to increased detection of advanced adenomas unless used in combination. (Clinical trial registration number: TCTR20200929003.).

Measuring and Improving Quality of Colonoscopy for Colorectal Cancer Screening

Colorectal cancer (CRC) is largely preventable, yet it remains a major public health issue as it is the third most common and deadly malignancy in the United States. While there are many ways to screen for CRC, colonoscopy remains the gold standard as it is the only test that is both cancer-detecting and cancer-preventing through removal of precancerous polyps. Through identifying and removing neoplastic lesions, colonoscopy reduces CRC incidence by 31%-91% and CRC mortality by 65%-88%. However, colonoscopy is not an infallible test-there is a chance for missed lesions during the exam and there is substantial variation in outcomes among endoscopists. To enhance the quality of colonoscopic exams, and ultimately to improve CRC outcomes, quality indicators have been developed for measuring endoscopists' performance. In this review, we describe the colonoscopic quality indicators and benchmarks recommended by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy for screening colonoscopies in average-risk individuals. Measuring and monitoring endoscopists' performance on these measures are critical first steps in striving toward conducting high quality exams. We also review the evidence for interventions that aim to improve critical measures including adenoma detection rate, withdrawal time, cecal intubation, and bowel preparation quality. Finally, we provide a preview of the forthcoming Advancing Care for Appropriate Colon Health Merit-Based Incentive Payment System Value Pathway by the Centers for Medicare & Medicaid Services and its potential impact on clinical practice.

Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial

BACKGROUND AND AIMS

By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCI+EAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy.

METHODS

This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCI+EAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR ≥35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC).

RESULTS

One thousand participants were included in the study. The LCI+EAC group provided the highest ADR and pADR. The ADRs in the LCI+EAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and .89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCI+EAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P = .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P < .009 for all comparisons).

CONCLUSIONS

The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers. (Clinical trial registration number: TCTR20190319001.).