Adjusting Detection Measures for Colonoscopy: How Far Should We Go?

The adenoma detection rate (ADR) was proposed as a colonoscopy quality metric in 2002 by the US Multi-Society Task Force (USMSTF).1Rex D.K. Bond J.H. Winawer S. et al.Quality technical performance of and continuous improvement process for colonoscopy: recommendations U.S. on Colorectal Cancer.Am J Gastroenterol. 2002; 97: 1296-1308Crossref PubMed Scopus (834) Google Scholar Subsequently, consistent wide variation ADR among colonoscopists documented2Barclay R.L. Vicari J.J. Doughty A.S. al.Colonoscopic withdrawal times during screening colonoscopy.N Engl Med. 2006; 355: 2533-2541Crossref (1028) Scholar,3Chen S.C. Rex Endoscopist can be more powerful than age male gender predicting at colonoscopy.Am 2007; 102: 856-861Crossref (324) measure validated predictor postcolonoscopy cancer.4Kaminski M.F. Regula J. Kraszewska E. indicators risk interval cancer.N 2010; 362: 1795-1803Crossref (1268) Scholar,5Corley D.A. Jensen C.D. Marks A.R. al.Adenoma colorectal cancer death.N 2014; 370: 1298-1306Crossref (971) is priority measure.6Rex Schoenfeld P.S. Cohen colonoscopy.Gastrointest Endosc. 2015; 81: 31-53Abstract Full Text PDF (513) Table 1 lists alternatives or possible add-ons to measures, descending order their direct relationship desired outcome preventing cancer, together with weaknesses each measure. Asking endoscopists an effort regulate technique. Because this regulatory aspect, from outset1Rex there has been major emphasis using that hard corrupt under prospective use. If easily gamed corrupted, it frustrating all participants lead failure measure, potentially entire effort. In regard, does certain things well. measures endoscopist rather someone else’s performance, which pathologist (Table 1). Second, skill endoscopists, not other skills such size measurement localization lesions colonic segment, both notoriously are inaccurate would subject bias gaming Arguably, widespread acceptance accurately reflects rests these features played role its success.Table 1Alternatives Their Weaknesses, Potential Add-Ons (Serrated Measures)AbbreviationWeaknesses PCCRCLong intervals; Extended follow-up period, large databases neededAdenoma AAMRLarge tandem study required AMRTandem AADRSize errors endoscopists; High interobserver pathologists high-grade dysplasia villous elements APCHarder measure; Could incentivize increased pathology charges ADRSubject indication (solved expanding indications); One-and-done PDRCould corrupted use removal clinically unimportant polypsSerrated SSLDRaThere multiple variations serrated targets, susceptible colon location variation.Measures PSPDRaThere variation.,bSerrated polyp may defined class (sessile lesions, hyperplastic polyps, traditional adenomas).Subject TSPDRaThere adenomas).Incentivizes diminutive rectosigmoid polypNOTE. Adenoma listed decreasing cancer.AADR, advanced rate; AAMR, miss ADR, AMR, APC, adenomas per colonoscopy; PCCRC, cancer; PDR, PSPDR, proximal SSLDR, sessile lesion TSPDR, total rate.a There variation.b Serrated adenomas). Open table new tab NOTE. cancer. AADR, rate. have enormous investigation,6Rex naturally led criticisms suggestions improve it. several commonly discussed questions about improving measures. 3 broad categories indications surveillance, screening, diagnostic. highest then lowest diagnostic (with exception positive fecal tests).7Anderson J.C. Butterly L.F. Goodrich M. al.Differences rates polyps versus surveillance colonoscopies, based New Hampshire Colonoscopy Registry.Clin Gastroenterol Hepatol. 2013; 11: 1308-1312Abstract (69) Scholar,8Rex Ponugoti P.L. Calculating colonoscopies only: necessary? Can gamed?.Endoscopy. 2017; 49: 1069-1074Crossref (40) between diagnostic, combined tends quite close ADR. This principle shown previously,8Rex nicely 2 well-done studies issue Clinical Gastroenterology Hepatology.9Ladabaum U. Shepard Mannalithara A. indication: ADR-ESS (ADR Screening/Surveillance) score.Clin 2021; 19: 1873-1882Abstract (2) Scholar,10Kaltenbach T. Gawron Meyer C.S. irrespective comparable ADR: implications monitoring.Clin 1883-1889Abstract (5) Using results less over time, narrowed CIs around measured ADR.9Ladabaum Changing include return past, because original proposal did restrict colonoscopies.1Rex restriction added 2006,11Rex Petrini J.L. Baron T.H. 101: 873-885Crossref (45) when decided targets had derived studies,1Rex should confined screening. We now enough evidence drop screening-only restriction.8Rex Scholar, 9Ladabaum 10Kaltenbach Including eliminates potential ADR,8Rex decides what after procedure completed (when known whether removed) before creates report. revised definition still exclude patients inflammatory bowel disease polyposis syndromes, tests immunochemical test (FIT) DNA-FIT. FIT-positive runs 15% 20% higher primary minimum ADRs 35% women 45% men were recommended USMSTF.12Robertson D.J. Lee J.K. Boland C.R. al.Recommendations testing screen neoplasia: consensus statement cancer.Gastrointest 85: 2-21 e3Abstract (41) Of (APC) one variants,13Zhao Wang Pan P. al.Magnitude, factors, factors associated systematic review meta-analysis.Gastroenterology. 2019; 156: 1661-1674 e11Abstract (111) Scholar,14Wang H.S. Pisegna Modi R. necessary but insufficient distinguishing high low performance.Gastrointest 77: 71-78Abstract (79) arguably best candidate replace done gaming, resects get credit toward examines remaining carefully. One instance documented,14Wang although likely reimbursement system pays only first polypectomy, APC mostly good correlation,2Barclay indicating one-and-done rare. better clearing whole colon, provides greater separation ADR.2Barclay might valuable populations prevalence neoplasia FIT-positive, whom yet prevention, very thorough needed lesions. clear probably establish APC.15Rex Detection considerations rate, thresholds, times, updates measures.J Clin 2020; 54: 130-135Crossref It used across indications, different small adenomas.16Rex Repici Gross S.A. al.High-definition Endocuff EndoRings full-spectrum endoscopy multicenter randomized trial.Gastrointest 2018; 88: 335-344 e2Abstract (64) Reasons switch following: expensive practice placing separate bottle pathology, tedious measuring problem considering cost already deterrent measurement. Given established seems reasonable await artificial intelligence programs eventually will make automatic. recent endorsement Americans 45,17Davidson K.W. Barry M.J. al.US Preventive Services ForceScreening cancer: recommendation statement.JAMA. 325: 1965-1977Crossref (63) we change 50 years older 45 older? purpose identify signal need improvement, plenty older, do change. decision could reasonably go either way. I suspect want starting coincide change, targets? regard 45- 49-year group same 50- 54-year group.18Butterly Siegel Fedewa al.Colonoscopy outcomes average-risk equivalent young adults: data Registry.Am 116: 171-179Crossref (18) Adding calculation, assuming they show up substantial numbers, pull most endoscopists’ down bit. relevant note set somewhat arbitrarily, is, bit below mean available studies.1Rex thought greatest benefit accrue moving worst performers above mean. also choosing level target everyone inadequate, well accepted. history, leave where are, minor adjustments. huge issue. current thresholds considered acceptable remedial work undertaken threshold 5% 2015,6Rex response report Corley al.5Corley choice increase again involved value judgments feasibility perceived fraction who fall threshold. However, data5Corley Scholar,19Shaukat Rector T.S. Church T.R. al.Longer time reduced incidence colonoscopy.Gastroenterology. 149: 952-957Abstract (101) showing prevention continued given rise idea aspirational thresholds,20Hilsden R.J. Bridges Dube C. al.Defining benchmarks undergoing due test.Am 2016; 111: 1743-1749Crossref (29) represent achievable population. Thus, involve consensus-based judgments, detectors association high-level further prevention. thus advantageous targets. (SSLs) important. Creating SSL challenging pathologic differentiation SSLs definitions constitutes SSL, similar high. some reports, centers reported no SSLs.21Payne S.R. Wandell al.Endoscopic identification adenomas/polyps vary basis center.Clin 12: 1119-1126Abstract (93) expert endoscopists,22Abdeljawad K. Vemulapalli K.C. Kahi C.J. al.Sessile determined colonoscopist experienced pathologist.Gastrointest 517-524Abstract (110) Scholar,23IJspeert J.E. de Wit van der Vlugt al.Prevalence, distribution center pathologists.Endoscopy. 48: 740-746Crossref (54) necessitate evaluation understand performance. Another approach local institution (within less), minimally endoscopists. question directly adjusted, formulate postpolypectomy recommendations. Hepatology, Waldmann al24Waldmann Kammerlander A.A. Gessl I. al.Association characteristics mortality colonoscopy.Clin 1890-1898Abstract (3) predict previously result.25Wieszczy Loberg al.Colonoscopist stratify surveillance: two nationwide observational studies.Gastroenterology. 160: 1067-1074 e6Abstract (7) USMSTF dealt saying intervals assumes complete examination, adequate preparation, thresholds.26Gupta Lieberman D. Anderson polypectomy: update Cancer.Gastrointest 91: 463-485 e5Abstract (44) That incorporating into determinations. Although makes perfect sense adjust fairness challenge fee-for-service payment system. perform poorly rewarded performing frequently. meaningful financial incentives high-quality colonoscopy. functioned detection, changes Expanding examinations exclusive appears justified valuable.9Ladabaum concept adding thresholds20Hilsden carries important message. continue minimize avoid costs complexities keep cancers.