A Randomized Controlled Trial of an Endoscopic Quality Improvement Program (EQUIP) Results in Improved Detection of Colorectal Adenomas: ACG /Olympus Award

Abstract

Purpose: Adenoma detection rate (ADR) has become a key measure of quality in colonoscopy with low ADR linked to interval cancer after “negative” colonoscopy. Previous studies mandating longer withdrawal time, and other incentives, have not been shown to improve ADR. We hypothesized that an intensive endoscopist training program would result in an increase in overall adenoma detection. Methods: The EQUIP study was a prospective randomized trial completed in two phases. In the first phase, baseline adenoma detection rates were measured. One half of endoscopists were then randomly assigned to EQUIP training and one half continued with routine practice in the second phase. Phase II data collection began once training was completed by those randomized to receive it. The training group also received personal monthly feedback on ADR, withdrawal time, and group averages. Each endoscopist was asked to describe all polyps according to shape, location, size and predicted pathology. The ADRs of the 8 trained endoscopists were compared to those of the 7 untrained endoscopists, adjusting for baseline levels and for patient age, sex, adequacy of bowel preparation (Boston Bowel Preparation Score), and indication (screening, surveillance or other). Results: 1200 procedures were completed in each phase of study by 15 endoscopists. Patient characteristics were similar between each study phase and between randomization groups. The overall ADR in phase I was 36% for both the “EQUIP trained” and “untrained” groups of endoscopists. In phase II, the group of endoscopists randomized to training had an overall increase in ADR to 47% whereas the ADR in the untrained endoscopists remained unchanged at 35%. The improvement in ADR with training at the endoscopist level was significant with an estimated odds ratio of 1.74 (95% CI 1.22 to 2.49, p=0.0022) (Figure 1). Conclusion: This is the first study to our knowledge to prospectively show that ADR can be significantly improved through an intensive structured endoscopist training program. We believe our efforts will provide a model for improvement efforts in colonoscopy. Our goal is to use this pilot data to develop a larger multi-center trial to evaluate these effects on a larger scale, and to validate long term clinical improvements in colorectal cancer prevention.