Dramatic Improvement in Adenoma Detection Rate (ADR) after Enlisting All Room Staff in Polyp Detection

Abstract

Purpose: To determine whether enlisting all endoscopy room staff as active observers in the process of identifying polyps during screening colonoscopy would cause a significant improvement in adenoma detection rates. Methods: Using Pentax high resolution colonoscopes unaided by other technologies, adenoma and sessile serrated adenoma location and occurrence per 100 patients screened (ADR and SSADR) were measured retrospectively in 970 asymptomatic patients undergoing first time screening colonoscopy during two consecutive quarters of 2010-2011 (Group I). The results were compared with ADR and SSADR in 1,050 patients (Group II) and 767 patients (Group III) screened during respective quarters of 2011-2012 (Group II) and 2012-2013 (Group III) by endoscopists fully aware of the intent to measure performance. For six months prior to Group II and continually thereafter, all endoscopy room staff were asked to focus on polyp detection. During endoscopy all were taught polyp morphology and encouraged to participate with the intent of creating a cohesive, highly effective team. Colonoscopies were performed in a single privately owned endoscopy center with a procedure completed in each room every 30 minutes. Greater than 90% of adenomas were classified by a single GI pathologist. Polyps proximal to the splenic flexure were classified as right colon polyps. Withdrawal time (WT) from cecum to rectum was measured in all patients. Data were calculated with a linear or logistic model with physician operator as the random effect to account for repeated measures over the three time periods. Results: See Table 1. The data sets for Groups I, II, and III, respectively, are as follows: Endoscopist Mean (SD) SSADR were 6.2% (4.2%), 7.7% (2.8%), and 13.4% (3.9%). Endoscopist Mean (SD) ADR were 34.0% (9.9%), 41.3% (11.6%), and 52.0% (8.5%). Center ADR for males were 40.3%, 43.1%, and 58.0%. Center ADR for females were 27.2%, 34.7%, and 46.7%. Patients with only right colon polyps were 11.2%, 17.1%, and 24.1%. Patients with polyps who had only right colon polyps were 33.3%, 44.1%, and 47.6%. The p-values for each data set were <0.001.Table 1: ADR by Study Time PeriodConclusion: 1. Enlisting all room staff in the task of polyp detection led to markedly increased adenoma detection rates in a high volume efficient endoscopy center. 2. These detection rates are far above the present thresholds and standards of care for colonoscopic screening. 3. No special equipment (e.g., enhanced imaging, contrast dyes) was required to realize this improvement in ADR and SSADR. 4. Minimal increase in procedure time but no decrement in endoscopy center efficiency occurred with these process improvement measures. 5. Screening sigmoidoscopy strategy would have missed at least one half of adenoma patients in this population.