Individual Endoscopists Research Articles

Adequate Colon Preparation in Screening Colonoscopy

Colorectal cancer (CRC) is one of the most common forms of cancer worldwide, being the fourth most prevalent cancer and the third most common in terms of mortality. A decrease in the incidence and mortality of CRC has been observed among adults over 50 years of age, screening colonoscopy being a contributory factor for this improvement. Adequate preparation of the colon is essential for obtaining accurate results and minimizing the risks associated with the colonoscopy procedure. Both ESGE (European Society of Gastrointestinal Endoscopy) and UEG (United European Gastroenterology) recommend adequate preparation in at least 90% of cases, calculated both at the endoscopy center level and for each individual endoscopist. The purpose of our article is to review the literature on different bowel preparation products for colonoscopy and demonstrate the non inferiority of low-volume preparations over the standard PEG 4L. Preparations containing PEG are the most common in preparation for colonoscopy. A recent meta-analysis suggests that high-volume, mutiple-dose regimens are superior in terms of efficacy to low-volume, multiple- dose regimens, including low-volume PEG with various adjuvants and sodium phosphate, although with lower tolerability. Due to low levels of compliance, tolerability and acceptability, standard 4L single-dose regimens of PEG have been gradually and successfully replaced by newer regimens that include low-volume solutions. An eample of low-volume split-dose preparation is the solution of low-volume PEG4000, sodium sulphate, citric acid, sodium citrate, sodium chloride, potassium chloride and simethicone. In several studies this 2 L low volume preparations ehibit similar effectiveness with safety profiles that are comparable to classic 4 L PEG, with lower incidence of adverse effects and good tolerability. In conclusion, adequate preparation increases the quality of colonoscopy procedures as proper patient preparation is essential to obtain an optimal visualization of the intestinal mucosa. Low-volume bowel preparation is effective, safe and well tolerated by the patients, with higher acceptability compared to the standard volume PEG.

Overall Polyp Detection Rate as a Surrogate Measure for Screening Efficacy Independent of Histopathology: Evidence from National Endoscopy Database.

Adenoma detection rate (ADR) is challenging to measure, given its dependency on pathology reporting. Polyp detection rate (PDR) (percentage of screening colonoscopies detecting a polyp) is a proposed alternative to overcome this issue. Overall PDR from all colonoscopies is a relatively novel concept, with no large-scale studies comparing overall PDR with screening-only PDR. The aim of the study was to compare PDR from screening, surveillance, and diagnostic indications with overall PDR and evaluate any correlation between individual endoscopist PDR by indication to determine if overall PDR can be a valuable surrogate for screening PDR. Our study analyzed a prospectively collected national endoscopy database maintained by the National Institute of Health from 2009 to 2014. Out of 354,505 colonoscopies performed between 2009-2014, 298,920 (n = 110,794 average-risk screening, n = 83,556 average-risk surveillance, n = 104,770 diagnostic) met inclusion criteria. The median screening PDR was 25.45 (IQR 13.15-39.60), comparable with the median overall PDR of 24.01 (IQR 11.46-35.86, p = 0.21). Median surveillance PDR was higher at 33.73 (IQR 16.92-47.01), and median diagnostic PDR was lower at 19.35 (IQR 9.66-29.17), compared with median overall PDR 24.01 (IQR 11.46-35.86; p < 0.01). The overall PDR showed excellent concordance with screening, surveillance, and diagnostic PDR (r > 0.85, p < 0.01, 2-tailed). The overall PDR is a reliable and pragmatic surrogate for screening PDR and can be measured in real time, irrespective of colonoscopy indication.

Assessing Patient Radiation Exposure in Endoscopic Retrograde Cholangiopancreatography: A Multicenter Retrospective Analysis of Procedural Complexity and Clinical Factors.

Endoscopic retrograde cholangiopancreatography (ERCP) procedures can result in significant patient radiation exposure. This retrospective multicenter study aimed to assess the influence of procedural complexity and other clinical factors on radiation exposure in ERCP. Data on kerma-area product (KAP), air-kerma at the reference point (Ka,r), fluoroscopy time, and the number of exposures, and relevant patient, procedure, and operator factors were collected from 2641 ERCP procedures performed at four university hospitals. The influence of procedural complexity, assessed using the American Society for Gastrointestinal Endoscopy (ASGE) and HOUSE complexity grading scales, on radiation exposure quantities was analyzed within each center. The procedures were categorized into two groups based on ERCP indications: primary sclerosing cholangitis (PSC) and other ERCPs. Both the ASGE and HOUSE complexity grading scales had a significant impact on radiation exposure quantities. Remarkably, there was up to a 50-fold difference in dose quantities observed across the participating centers. For non-PSC ERCP procedures, the median KAP ranged from 0.9 to 64.4 Gy·cm2 among the centers. The individual endoscopist also had a substantial influence on radiation dose. Procedural complexity grading in ERCP significantly affects radiation exposure. Higher procedural complexity is typically associated with increased patient radiation dose. The ASGE complexity grading scale demonstrated greater sensitivity to changes in radiation exposure compared to the HOUSE grading scale. Additionally, significant variations in dose indices, fluoroscopy times, and number of exposures were observed across the participating centers.

A108 AN EVALUATION OF IMPLEMENTATION OF A CENTRALIZED REFERRAL AND BOOKING PROCESS ON WAIT TIMES FOR COLONOSCOPIES

Abstract Background Colonoscopies in the majority of centres in Ontario are booked by individual endoscopists via their individual offices (practices). As such, wait times for procedures will vary significant from centre to centre, or even from endoscopist to endoscopist at the same centre, depending on individual expertise, experience, procedure types, and local availability of endoscopic resources. This system could lead to significant variability in access to care for patients. Aims This study analyzed the effect of implementing a centralized referral and booking process for colonoscopy, for a specific indication, at a single centre in Ontario. Methods This was a single centre retrospective study analyzing wait times for patients that underwent a colonoscopy at Cambridge Memorial Hospital (CMH) between April 2017 to July 2022 for either positive fecal occult blood test (FOBT) or fecal immunochemistry test (FIT). The province of Ontario transitioned from FOBT to FIT as the primary tool for colon cancer screening in 2019. Prior to this transition, colonoscopy for positive FOBT performed at CMH were booked by individual endoscopists, with wait times from referral to procedure having great variability. In conjunction with Ontario’s transition to FIT for colon cancer screening, all endoscopists at CMH agreed to participate in a centralized referral and booking process specifically for colonoscopy for positive FIT indication. A chart review of all patients undergoing colonoscopy for either FOBT (non central booking) or FIT (central booking). Patients that self-delayed were excluded. Wait times (WT) was calculated as time between date of referral and date of procedure. The effect of the centralized booking system on wait times was then assessed using statistical analysis. Results In total, 344 patients were included for analysis from before March 2019 (non centralized booking process). The average WT in this group was determined to be 99.2 days (range 50-171 days), of which 147 patients had a WT of less than 56 days (42.7%). In contrast, a total 572 patients were included for analysis after March 2019 (centralized booking process), the average WT was determined to be 44.2 days (range 32-59 days), of which, 526 patients had a WT of less than 56 days (92.0%). The centralized booking process reduced average wait times by 55 days (55.4%), and improved procedure WTs meeting mandated time frame of 56 days by 49.3%. This improvement in wait times was most pronounced for endoscopists with the longest wait times in a non centralized system. Conclusions The implementation of a centralized referral and booking process (for a single indication for colonoscopy) was associated with significantly reduced WTs. These findings suggest a centralized referral and booking process (for well defined clinical needs) can potentially significantly improve patient wait times. Funding Agencies None

A143 PATIENT POSITION AND ENDOSCOPIC CHOLANGIOPANCREATOGRAPHY (ERCP) TECHNICAL SUCCESS AMONG PATIENTS WITH SURGICALLY ALTERED FOREGUT ANATOMY: A RETROSPECTIVE ANALYSIS

Abstract Background Patients with surgically altered gastrointestinal anatomy undergoing endoscopic retrograde cholangiopancreatography (ERCP) pose challenges due to anatomical distortions. Factors such as patient positioning, endoscopist experience, and choice of endoscope may influence procedural success. It is unclear how these factors may impact the technical success of ERCP among patients with altered anatomy. Aims We primarily aimed to determine the impact of patient positioning (prone versus left lateral decubitus [LLD]) on technical success of ERCP among patients with surgically altered anatomy. Our secondary aim was to determine the impact of patient positioning on procedural time and immediate bleeding. Methods We conducted a retrospective single-centre study using data from 2010 to 2020 that included patients with hepaticojejunostomy, Roux-en-Y anastomosis, Billroth-1, or Billroth-2 anatomy. The primary outcome was technical success of the ERCP, which we comprehensively defined as of successful navigation to the papilla or surgical anastomosis, selective cannulation and cholangiography, and the realization of the intended therapeutic goals. The secondary outcomes were the presence of immediate bleeding and procedural time. Statistical analysis involved descriptive statistics using mean and standard deviation (SD) and Fisher exact test with relative risk (RR) and 95% confidence interval (95% CI). All statistical tests were two-tailed and considered significant at Pampersand:003C0.05. Results Among 205 patients, there were 179 (87.3%) in the LLD group, and 26 (12.6%) in the prone group. There were no statistically significant differences between the two groups in terms of patient sex, age, type of altered anatomy, or American Society of Anesthesiologist (ASA) classification. We found that there was no significant differences between the two groups in terms of procedural success (RR 1.1, 95% CI: 0.8-1.5), immediate bleeding (RR 1.7, 95% CI: 0.2-14.8), and procedural time (P=0.808). Conclusions We did not find that patient positioning had a significant impact on technical success in ERCP among patients with surgically altered anatomy. The choice of positioning should be tailored to individual patient and endoscopist factors, with a focus on optimizing outcomes in this complex patient subset. Funding Agencies None

Effectiveness of switching endoscopists for repeat surveillance colonoscopy: a retrospective study

BackgroundSurveillance colonoscopy decreases colorectal cancer mortality; however, lesions are occasionally missed. Although an appropriate surveillance interval is indicated, variations may occur in the methods used, such as scope manipulation or observation. Therefore, individual endoscopists may miss certain areas. This study aimed to verify the effectiveness of performing repeat colonoscopies with a different endoscopist from the initial procedure.MethodsWe retrospectively reviewed a database of 8093 consecutive colonoscopies performed in the Omori Red Cross Hospital from January 1st 2018 to June 30th 2021. Data from repeat total colonoscopies performed within three months were collected to assess missed lesions. The patients were divided into two groups according to whether the two examinations were performed by different endoscopists (group D) or the same endoscopist (group S). The primary outcome in both groups was the missed lesion detection rate (MLDR).ResultsOverall, 205 eligible patients were analyzed. In total, 102 and 103 patients were enrolled in groups D and S, respectively. The MLDR was significantly higher in group D (61.8% vs. 31.1%, P < 0.0001). Multivariate logistic regression analysis for the detection of missed lesions identified performance by the different endoscopists (odds ratio, 3.38; 95% CI, 1.81–6.30), and sufficient withdrawal time (> 6 min) (odds ratio, 3.10; 95% CI, 1.12–8.61) as significant variables.ConclusionsOverall, our study showed a significant improvement in the detection of missed lesions when performed by different endoscopists. When performing repeat colonoscopy, it is desirable that a different endoscopist perform the second colonoscopy.Trial registrationThis study was approved by the Institutional Review Board of the Omori Red Cross Hospital on November 28, 2022 (approval number:22–43).

Long-Term Follow-Up of Colonoscopy Quality Monitoring.

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear. We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly. Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%. Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Evaluation of the quality of colonoscopies performed by Alberta North Zone surgeons, family physicians and internists: a quality improvement initiative.

In Canada, endoscopy is primarily performed by gastroenterologists and surgeons, and some studies report that colonoscopies performed by nongastroenterologists have more complications and higher rates of future colorectal cancer. Our objective was to determine whether rural-based nongastroenterologist endoscopists are achieving quality benchmarks in colonoscopy. This quality improvement initiative prospectively evaluated 6 key performance indicators (KPIs) (cecal intubations, polyp detection [males and females; for first-time colonoscopies on patients aged ≥ 50 yr], bowel preparations, patient comfort and withdrawal times) on consecutive colonoscopies performed by participating Alberta North Zone endoscopists. The study period was June 2018 to March 2020. Overall and individual endoscopist's KPIs were compared with standard benchmarks. Additional performance indicators included mean number of polyps per colonoscopy and an exploration of study-defined sedation-related level of consciousness. Data were collected on 6212 colonoscopies performed by 16 endoscopists (9 surgeons, 5 family physicians and 2 internists) in 6 hospitals. All 6 KPI benchmarks were achieved when results were pooled over all endoscopists in the study. Overall, cecal intubation occurred in 6006 of 6209 (96.7%, 95% confidence interval 94.5%-99.0%) cases. Polyp detection was 65.9% (592/898) and 49.8% (348/699) for male and female patients, respectively, aged 50 years or older. Variability in individual endoscopist results existed, especially for the mean number of polyps per 100 colonoscopies and sedation-related level of consciousness. Overall, Alberta North Zone endoscopists are performing high-quality colonoscopies, collectively achieving all 6 KPIs. To understand endoscopic performance and encourage individual and group reflection on endoscopic practices, Canadian endoscopists are encouraged to participate in similar colonoscopy quality initiative studies.

Variation in the rate of detection of minute and small early gastric cancers at diagnostic endoscopy may reflect the performance of individual endoscopists

ObjectiveThe documented variation in gastric cancer (GC) detection among endoscopists has often been dismissed as a coincidental artefact of the low incidence of gastric neoplasms; it is not considered associated...

Endoscopist volume and the quality of colonoscopy of the Korean National Cancer Screening Program.

6627 Background: The Korean government established the National Cancer Screening Program (KNCSP). The KNCSP has provided annual faecal immunochemical test (FIT) for adults aged 50 years or older, and colonoscopy or a double-contrast barium enema test to those with positive results from the FIT. High-quality screening colonoscopy is mandatory to achieve maximum possible CRC prevention. The case volume has been shown to correlate with outcomes in surgical specialties. In contrast, relevant data on colonoscopy is limited. This study aimed to assess the quality indicators of organized CRC screening according to annual colonoscopy volume using KNCSP data. Methods: We used the KNCSP data from 2018 to 2020, which accounted for 378,354 colonoscopy examinations. We used cancer registration data of an extended health insurance program using ICD-11 codes (C18-20). A total of 12,109 CRC patients were registered within 1 year of the date of colonoscopy. We calculated the annual number of colonoscopy examinations by an individual endoscopist. We excluded endoscopists who had a very low or high number of examinations with the highest 1% or lowest 1% as outliers. The final number of endoscopists was 16,552 and colonoscopy examinations were 331,231 during 2018–2020. The annual colonoscopy volume by individual endoscopists was divided into four groups (2–12, 13–24, 25–36, and 37 or more examinations). Multiple linear regression analysis was performed to confirm the association between test accuracy indicators and colonoscopy frequency using a generalized linear model (GLM). We calculated the estimates of the rates for each indicator by adjusting the year. Results: The positive and false positive rates, sensitivity, specificity, and positive predictive value were 4.09%, 1.07%, 83.53%, 98.93%, and 74.68%, respectively. The cancer detection and interval cancer rates were 30.53‰ and 6.29‰, respectively. Quality indicators were related to the annual colonoscopy volume of the endoscopist. Endoscopists with a higher annual colonoscopy volume were more likely to have higher sensitivity, specificity, and positive predictive value than those with a lower annual colonoscopy volume. Endoscopists with higher annual colonoscopy volumes were more likely to have lower positive rates, cancer detection rates, false positive rates, and interval cancers rate than those with lower annual colonoscopy volumes. Conclusions: This study found that the annual volume of colonoscopy examinations was associated with better colonoscopy quality in an organized CRC screening program. A high colonoscopy load could be a sign of substantial experience and lead to better outcomes, as has been shown for surgery. The relationship between quality indicators and case volume is logical and plausible; therefore, more research is required to determine the number of cases that need to be performed in a year to adequately maintain high colonoscopy quality.

One-year review of real-time artificial intelligence (AI)-aided endoscopy performance.

Colonoscopies have long been the gold standard for detection of pre-malignant neoplastic lesions of the colon. Our previous study tried real-time artificial intelligence (AI)-aided colonoscopy over a three-month period and found significant improvements in collective and individual endoscopist's adenoma detection rates compared to baseline. As an expansion, this study evaluates the 1-year performance of AI-aided colonoscopy in the same institution. A prospective cohort study was conducted in a single institution in Singapore. The AI software used was GI Genius™ Intelligent Endoscopy Module, US-DG-2000309 © 2021 Medtronic. Between July 2021 and June 2022, polypectomy rates in non-AI-aided colonoscopies and AI-aided colonoscopies were calculated and compared. Some of the AI-aided colonoscopies were recorded and video reviewed. A "hit" was defined as a sustained detection of an area by the AI. If a polypectomy was performed for a "hit," its histology was reviewed. Additional calculations for polyp detection rate (PDR), adenoma detection rate (ADR), and adenoma detection per colonoscopy (ADPC) were performed. Cost analysis was performed to determine cost effectiveness of subscription to the AI program. 2433 AI-aided colonoscopies were performed between July 2021 and June 2022 and compared against 1770 non-AI-aided colonoscopies. AI-aided colonoscopies yielded significantly higher rates of polypectomies (33.6%) as compared with non-AI-aided colonoscopies (28.4%) (p < 0.001). Among the AI-aided colonoscopies, 1050 were reviewed and a final 843 were included for additional analysis. The polypectomy to "hit" ratio was 57.4%, PDR = 45.6%, ADR = 32.4%, and ADPC = 2.08. Histological review showed that 25 polyps (3.13%) were sessile-serrated adenomas. Cost analysis found that the increased polypectomy rates in AI-aided colonoscopes led to an increase in revenue, which covered the subscription cost with an excess of USD 20,000. AI-aided colonoscopy is a cost effective means of improving colonoscopy quality and may help advance colorectal cancer screening in Singapore.

Colonoscopy performance monitoring: do we need to adjust for case mix?

Introduction Overall caecum intubation rate(oCIR) and overall polyp detection rate(oPDR) have been proposed as performance indicators, but varying complexity in case mix among endoscopists may potentially affect validity. The study aims to explore the effect of adjusting for case mix on individual endoscopist performance by calculating case mix-adjusted performance estimates (cmCIR and cmPDR) and comparing them to overall performance estimates (oCIR and oPDR). The study also provides an R program for case mix analysis. Methods Logistic regression associated endoscopist, colonoscopy indication, patient age and patient gender with the binary outcomes of cecum intubation and polyp detection. Case mix-adjusted performance indicators were calculated for each endoscopist based on logistic regression and bootstraps. Endoscopists were ranked from best to worst by overall and case mix-adjusted performance estimates, and differences were evaluated using percentage points(pp) and rank changes. Results The dataset consisted of 7376 colonoscopies performed by 47 endoscopists. The maximum rank change for an endoscopist comparing oCIR and cmCIR was eight positions, interquartile range (IQR 1–3). The maximum change in CIR was 1.95 percentage point (pp) (IQR 0.27–0.86). The maximum rank change in the oPDR versus cmPDR analysis was 17 positions (IQR 1.5–8.5). The maximum change in PDR was 11.21 pp (IQR 2.05–6.70). Three endoscopists improved their performance from significantly inferior to within the 95% confidence interval (CI) range of performance targets using case mix-adjusted estimates. Conclusions The majority of endoscopists were unaffected by adjustment for case mix, but a few unfortunate endoscopists had an unfavourable case mix that could invite incorrect suspicion of inferior performance.

Practice Patterns and Outcomes of Patients with Retained Gastric Food Content Encountered during Endoscopy.

Retained gastric food content encountered during upper endoscopy may reduce diagnostic accuracy and increase the risk of aspiration. To evaluate endoscopists' practice patterns and clinical outcomes in patients with retained gastric food content encountered during endoscopy. Consecutive patients with retained gastric food content during first-time endoscopy at Loma Linda University Health (1/2016-3/2021) were identified. Primary endpoints were complete examination (deep duodenal intubation) and 30-day post-procedural respiratory adverse events. Of 17,868 patients undergoing endoscopy, 629 (3.5%) (mean age 55+17 years) met inclusion criteria. Moderate sedation was used in 506 (80.4%), anesthesiologist-assisted sedation in 16 (2.5%), and general anesthesia in 107 (17.0%) patients. 534 (84.9%) patients received complete examination, and endoscopist-specific completion rates varied by quintile among 26 endoscopists (range 70.3-98.0%, P<0.0001). Large food gastric content decreased (AOR=0.3, 95%CI 0.2-0.4) while obtaining mucosal biopsies increased (AOR=2.5, 95%CI 1.4-4.7) the likelihood of complete examination after adjusting for endoscopist-specific completion rates. Subsequently, 58 (9.2%) patients required repeat endoscopy within 30 days. During follow-up, 41 (6.5%) patients developed respiratory adverse events including 21 (3.3%) requiring ventilatory support. Hospitalized patients (AOR=37.8, 95%CI 4.9-289.0) compared to outpatients and large compared to small gastric food content (AOR=2.1, 95%CI 1.1-4.2) increased the likelihood of respiratory adverse events. Although deep duodenal intubation was achieved in most patients receiving endoscopy, the rate of complete examination varied among individual endoscopists and the extent of food burden. Respiratory adverse events occurred almost exclusively in hospitalized patients and were associated with high morbidity including half developing respiratory failure.

Sessile serrated lesion detection rates continue to increase: 2008-2020.

Background and study aims We assessed sessile serrated lesion detection rate (SSLDR) at a large academic medical center from 2008 to 2020 and modeled a local, aspirational target SSLDR. We also assessed SSLDRs among all gastroenterology fellows to better understand the relationship between SSLDRs and total colonoscopies performed. Patients and methods SSL-positive pathology results were flagged from a dataset composed of all screening colonoscopies for average-risk patients from 2008 to 2020. Unadjusted SSLDRs were calculated for individual endoscopists by year. A mixed effects logistic regression was used to estimate the log odds of SSL detection, with one model estimating division-wide predictors of SSL detection and a second model focused exclusively on colonoscopies performed by fellows. Model-adjusted SSLDRs were estimated for all 13 years and across both categories of all endoscopists and fellows only. Results Adjusted SSLDRs showed a consistent improvement in SSLDR from a low of 0.37 % (95 % confidence interval [CI]: 0.10-0.63) in 2008 to a high of 7.94 % (95 % CI: 6.34-9.54) in 2020. Among fellows only, the odds of SSL detection were significantly lower during their first year compared to their second year (OR: 0.80, 95 % CI: 0.66-0.98) but not significantly higher in their third year compared to their second year (OR: 1.09, 95 % CI: 0.85-1.4). Conclusions SSLDR increased steadily and significantly throughout our study period but variance among endoscopists persists. The peak SSLDR from 2020 of 7.94 % should serve as the local aspirational target for this division's attendings and fellows but should be continuously reevaluated.

Endoscopists' Written Communication After Surveillance Colonoscopy in Older Adults Is Often Unclear

Background and AimsCurrent guidelines recommend that the decision to pursue surveillance colonoscopy in older adults with polyps be individualized, yet how these recommendations are communicated has not been characterized. We aimed to evaluate the effectiveness of endoscopist recommendations after colonoscopy in communicating the need for future surveillance in older adults. MethodsWe performed a single-center, retrospective chart review of adults age ≥ 75 years who underwent colonoscopy for polyp surveillance or screening during which polyps were detected. We performed content analysis of the recommendations from both colonoscopy reports and post-pathology follow-up letters. Recommendations were classified as optimal or less optimal based on whether they were clear, contained a rationale, and maintained consistency between the report and follow-up letter. ResultsBetween 2012 and 2019, there were 1428 colonoscopies performed by 17 endoscopists, of which 874 (61%) were optimal and 554 (39%) were less optimal. Among the less optimal recommendations, 76 (14%) lacked a recommendation, 233 (42%) were unclear, and 409 (74%) lacked a rationale. Among the 954 post-pathology follow-up letters, 80 (8%) were inconsistent with the original colonoscopy report recommendation, of which 30 (38%) resulted in a change in management. The frequency of less optimal recommendations ranged from 0% to 50% by endoscopist. ConclusionFollowing colonoscopy in older adults, we found that roughly one-third of the reports were less than optimal, and there was sizable variation in individual endoscopist performance. Discrepancies between colonoscopy reports and patient follow-up letters could be minimized by avoiding providing recommendations on future colonoscopy before pathologic interpretation.

S288 Long-Term Follow-Up of Colonoscopy Quality Monitoring

Introduction: High-quality colonoscopy is paramount to effective prevention of colorectal cancer. A variety of interventions have been proposed to monitor and improve colonoscopy quality at operator and institutional levels. Since 2009, endoscopists at our university-affiliated, Veterans Affairs Medical Center (VAMC) have received a quarterly report card summarizing individual colonoscopy quality indicators. This intervention was associated with short-term improvement in adenoma detection rate (ADR). However, long-term effects of this monitoring on colonoscopy quality metrics, and appropriate monitoring frequency, are unclear. Methods: We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at a VAMC from April 1, 2012 to August 31, 2019. Anonymized reports included individual endoscopists’ ADR, cecal intubation rates, and withdrawal time. We included endoscopists who had contributed at least 50 colonoscopies per year, and at least 4 consecutive quarters during the study time frame. Linear regression models were used to determine and test slopes over time for each quality metric by physician, and to determine if slopes differed for data above vs below the median for each metric. Analyses were performed for quarterly and yearly data to assess whether there are significant differences based on monitoring frequency. Results: Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%), while the mean yearly ADR was 47.2% (±13.8%). Over the study time frame, there was a small increase in overall ADR based on both quarterly and yearly measurements (slope + 0.6%, p=0.02; and slope +2.7%, p < 0.001, respectively). However, most endoscopists had no significant change in their ADRs (Table). Overall cecal intubation rates and withdrawal times did not change significantly. Analysis of standard deviation of ADRs (to represent outcome variability over time within a physician) showed no significant difference between yearly and quarterly measurements (p=0.064). Individual endoscopists’ ADR standard deviation differences between yearly and quarterly measurement ranged from -4.7% to +6.8%. Conclusion: Long-term colonoscopy quality monitoring was paralleled with modest improvement in overall ADR, likely due to temporal trends. For endoscopists with baseline high ADR, intensive monitoring and reporting of colonoscopy quality metrics is not necessary and could be performed annually. Table 1. - Mean ADR and slopes of ADR for yearly and quarterly measurement Quarterly Yearly Physician Mean (± SD) Slope SE p-value Mean (± SD) Slope SE p-value All 51.7% (+ 11.7%) 0.6% 0.2% 0.021 47.2% (+ 13.8%) 2.7% 0.4% < .001 Physician A 48.5% (+ 7.8%) 1.1% 2.6% 0.689 49.3% (+ 5.7%) -3.0% 2.3% 0.314 Physician B 39.4% (+ 5.4%) 0.2% 0.5% 0.628 36.8% (+ 9.4%) 1.6% 1.4% 0.306 Physician C 66.3% (+ 6.0%) 1.6% 0.7% 0.022 64.1% (+ 7.6%) 2.3% 1.2% 0.113 Physician D 53.4% (+ 9.2%) 1.2% 0.8% 0.155 47.9% (+ 13.3%) 3.5% 1.7% 0.084 Physician E 33.8% (+ 11.5%) 4.7% 10.8% 0.692 21.0% (+ 15.0%) 13.6% 6.3% 0.275 Physician F 46.4% (+ 6.3%) 0.6% 2.0% 0.761 48.2% (+ 4.8%) 1.8% 2.3% 0.531 Physician G 48.0% (+ 11.5%) 0.1% 1.1% 0.948 39.6% (+ 9.1%) 1.9% 1.3% 0.201 Physician H 60.3% (+ 8.6%) 1.2% 0.8% 0.118 54.0% (+ 13.3%) 3.6% 1.6% 0.070 Physician I 55.1% (+ 6.2%) -1.3% 0.9% 0.167 53.2% (+ 9.1%) 1.4% 2.3% 0.589 Physician J 51.8% (+ 7.5%) 0.4% 1.5% 0.802 48.9% (+ 12.2%) 3.6% 3.9% 0.431 Physician K 38.5% (+ 11.0%) -1.4% 1.3% 0.290 35.5% (+ 12.2%) 1.6% 2.4% 0.533 Physician L 50.1% (+ 8.1%) 14.2% 3.4% 0.052 35.9% (+ 14.9%) -21.0% Physician M 48.2% (+ 11.3%) 11.8% 3.8% 0.026 38.6% (+ 15.3%) 7.1% 13.6% 0.692 Physician N 60.0% (+ 7.5%) 2.0% 2.9% 0.506 59.7% (+ 2.8%) 0.8% 2.7% 0.819 Physician O 52.9% (+ 6.4%) 1.3% 1.2% 0.277 52.1% (+ 5.2%) 1.9% 1.6% 0.302 Physician P 59.1% (+ 10.4%) 6.0% 2.5% 0.043 59.2% (+ 8.6%) 5.6% 2.6% 0.160 Physician Q 55.2% (+ 10.7%) 0.4% 1.1% 0.747 48.5% (+ 13.6%) 3.0% 1.9% 0.169

S293 Validation of an Automated Adenoma Detection Rate

Introduction: Adenoma detection rate (ADR) is an internationally recognized benchmark in the performance of colonoscopy, representing an important endoscopist quality metric. While ADR is a simple and widely accepted measure, the process of determining ADR is labor intensive. With the advent of endoscopy software within electronic health record (EHR) systems, ADR can be calculated automatically. However, the method of ADR calculation is inaccurate and therefore we aimed to compare automated ADR based on coding parameters from Lumens software within EPIC with manually calculated ADR. Methods: We performed an IRB approved analysis of colonoscopy data from 2/1/22-5/10/22 at our institution. All outpatient colonoscopies were evaluated for indication, endoscopic findings, and histology. Manual ADR calculation was performed as per the CMS 2019 definition. We also extracted ADR data and the previously validated cecal withdrawal times available within the EHR. Automated ADR was performed within the EHR by extracting exams performed for the z12.11 and z12.12 indications. Data from individual endoscopists was made anonymous then normalized and compared with a single sample T-test; aggregate ADR rates were compared using Chi-squared analysis. Results: Over this 98-day period, there were 1,737 colonoscopies performed. After identifying screening exams as per CMS guidelines and exclusion of seven endoscopists with less than 30 colonoscopies performed over this period, the manual calculation of ADR included 688 colonoscopies performed in patients ≥45 and 505 colonoscopies in patients ≥50. The automated ADR calculations in the EHR included a total of 503 exams in individuals ≥50. An adequate prep was seen in 92.2% of cases with an average BBPS of 7.3. Average cecal withdrawal time in screening exams was 9 minutes, 37 seconds and was not correlated with ADR. While ADR is reported in individuals ≥50 years as per CMS, the overall ADR between those ≥50 was 4.0% higher when compared to ≥45 (35.8% vs 31.8%, respectively), though this did not meet statistical significance (95%CI -1.4% to 9.4%). Comparison of manual ADR and automated ADR by endoscopist showed no significant differences. A comparison of manual ADR (35.8%) showed no significant difference from the automated ADR calculation (34.9%), p=0.79. (Table) Conclusion: An automated ADR will not strictly adhere to CMS definitions of ADR, but this index appears to be an adequate surrogate marker of ADR, simplifying an otherwise time-intensive process. Table 1. - Comparison of the absolute values of manually calculated ADR ("True ADR") with the EHR-derived "Automated ADR" Endoscopist True ADR Automated ADR 1 41.5% 27.0% 2 34.3% 25.0% 3 40.0% 42.4% 4 37.5% 45.5% 5 31.7% 43.2% 6 37.5% 44.8% 7 28.9% 21.7% 8 30.0% 18.8% 9 42.9% 54.2% 10 30.4% 44.1% 11 47.6% 29.4% 12 25.6% 26.4% Combined 35.8% 34.9% While individual differences are present, these differences were statistically insignificant. Furthermore, when all data was combined, the two values were within one percentage point.T-statistic =0.846 (p = 20.8).

Endoscopists performance in optical diagnosis of colorectal polyps in artificial intelligence studies.

Widespread adoption of optical diagnosis of colorectal neoplasia is prevented by suboptimal endoscopist performance and lack of standardized training and competence evaluation. We aimed to assess diagnostic accuracy of endoscopists in optical diagnosis of colorectal neoplasia in the framework of artificial intelligence (AI) validation studies.Literature searches of databases (PubMed/MEDLINE, EMBASE, Scopus) up to April 2022 were performed to identify articles evaluating accuracy of individual endoscopists in performing optical diagnosis of colorectal neoplasia within studies validating AI against a histologically verified ground‐truth. The main outcomes were endoscopists' pooled sensitivity, specificity, positive and negative predictive value (PPV/NPV), positive and negative likelihood ratio (LR) and area under the curve (AUC for sROC) for predicting adenomas versus non‐adenomas.Six studies with 67 endoscopists and 2085 (IQR: 115–243,5) patients were evaluated. Pooled sensitivity and specificity for adenomatous histology was respectively 84.5% (95% CI 80.3%–88%) and 83% (95% CI 79.6%–85.9%), corresponding to a PPV, NPV, LR+, LR− of 89.5% (95% CI 87.1%–91.5%), 75.7% (95% CI 70.1%–80.7%), 5 (95% CI 3.9%–6.2%) and 0.19 (95% CI 0.14%–0.25%). The AUC was 0.82 (CI 0.76–0.90). Expert endoscopists showed a higher sensitivity than non‐experts (90.5%, [95% CI 87.6%–92.7%] vs. 75.5%, [95% CI 66.5%–82.7%], p < 0.001), and Eastern endoscopists showed a higher sensitivity than Western (85%, [95% CI 80.5%–88.6%] vs. 75.8%, [95% CI 70.2%–80.6%]). Quality was graded high for 3 studies and low for 3 studies.We show that human accuracy for diagnosis of colorectal neoplasia in the setting of AI studies is suboptimal. Educational interventions could benefit by AI validation settings which seem a feasible framework for competence assessment.

Accuracy and Inter-observer Agreement Among Endoscopists for Visual Identification of Colorectal Polyps Using Endoscopy Images.

It is essential to accurately distinguish small benign hyperplastic colon polyps (HP) from sessile serrated lesions (SSL) or adenomatous polyps (TA) based on endoscopic appearances. Our objective was to determine the accuracy and inter-observer agreements for the endoscopic diagnosis of small polyps. High-quality endoscopic images of 30 small HPs, SSLs, and TAs were used randomly to create two-timed PowerPoint slide sets-one with and another one without information on polyp size and location. Seven endoscopists viewed the slides on two separate occasions 90days apart, identified the polyp type, and graded their confidence level. Overall and polyp-specific accuracies were assessed for the group and individual endoscopists. Chi-square tests and Kappa (κ) statistics were used to compare differences as appropriate. When polyp size and location were provided, overall accuracy was 67.1% for TAs, 50.0% for SSLs, and 41.4% for HPs; the corresponding accuracies were 60%, 44.3%, and 34.3% when polyp size and location were withheld (p < .001). Inter-observer agreement was moderate for TAs (κ = 0.50) and fair for SSLs (κ = 0.26) and HPs (κ = 0.29); the corresponding inter-observer agreements were 0.44, 0.31, and 0.17 with polyp size and location withheld. Accuracy was not affected by knowledge of polyp size, location, or confidence level. Endoscopists with ≥ 10years (vs. < 10years) of colonoscopy experience had marginally higher (56% vs. 40%, p = 0.05) accuracy for SSL diagnosis. The ability to distinguish between small TAs, SSLs, and HPs on their endoscopic appearance is poor regardless of the endoscopists' knowledge of polyp size and location.

Real-time artificial intelligence (AI)-aided endoscopy improves adenoma detection rates even in experienced endoscopists: a cohort study in Singapore.

BackgroundColonoscopy is a mainstay to detect premalignant neoplastic lesions in the colon. Real-time Artificial Intelligence (AI)-aided colonoscopy purportedly improves the polyp detection rate, especially for small flat lesions. The aim of this study is to evaluate the performance of real-time AI-aided colonoscopy in the detection of colonic polyps.MethodsA prospective single institution cohort study was conducted in Singapore. All real-time AI-aided colonoscopies, regardless of indication, performed by specialist-grade endoscopists were anonymously recorded from July to September 2021 and reviewed by 2 independent authors (FHK, JL). Sustained detection of an area by the program was regarded as a “hit”. Histology for the polypectomies were reviewed to determine adenoma detection rate (ADR). Individual endoscopist’s performance with AI were compared against their baseline performance without AI endoscopy.ResultsA total of 24 (82.8%) endoscopists participated with 18 (62.1%) performing ≥ 5 AI-aided colonoscopies. Of the 18, 72.2% (n = 13) were general surgeons. During that 3-months period, 487 “hits” encountered in 298 colonoscopies. Polypectomies were performed for 51.3% and 68.4% of these polypectomies were adenomas on histology. The post-intervention median ADR was 30.4% was higher than the median baseline polypectomy rate of 24.3% (p = 0.02). Of the adenomas excised, 14 (5.6%) were sessile serrated adenomas. Of those who performed ≥ 5 AI-aided colonoscopies, 13 (72.2%) had an improvement of ADR compared to their polypectomy rate before the introduction of AI, of which 2 of them had significant improvement.ConclusionsReal-time AI-aided colonoscopy have the potential to improved ADR even for experienced endoscopists and would therefore, improve the quality of colonoscopy.Graphical abstract