Colonoscopy Quality Indicators Research Articles

FP1.11 - An audit of post colonoscopy Colorectal cancers within a Northern Ireland Health and Social Care Trust

Abstract Background Post colonoscopy colorectal cancer (PCCRC) is defined as colorectal cancer found within 48 months of a colonoscopy in which no cancer was found. The British Society of Gastroenterology (BSG) proposes PCCRC rates as a key quality indicator of colonoscopy. Rates documented vary between 2-8%, with higher rates shown in Inflammatory Bowel disease (IBD). The English National Post Colonoscopy Colorectal Audit was established after recommendations from the World Endoscopy Organisation (WEO). We aim to establish the rates of PCCRC within this Health and Social Care Trust (HSCT). Method All CRCs diagnosed in our HSCT between January 2021 to December 2022 were retrospectively reviewed. Our definition for a PCCRC was one diagnosed between 0-48months after a colonoscopy. Information included whether the colonoscopy was complete, quality of bowel preparation, lesions detected, if resection of lesion was complete and if IBD was present. Results In this timeframe 524 CRCs were diagnosed in this HSCT, with 33(6.3%) having had a colonoscopy within the previous 48 months. Of the 33 PCCRCs, 21(63.6%) had a complete colonoscopy, 22(66.6%) had at least fair/satisfactory bowel preparation, 24(72.7%) had a lesion detected and 3(9%) had a prior diagnosis of IBD. Of those who had a lesion detected (n=24), 13(54%) had a complete resection and 10(41.6%) had a biopsy only or incomplete resection. Conclusions Our PCCRC detection rate is in keeping with previous published literature. Further analysis of the 33 cases should provide information on how we can reduce future PCCRCs.

Analysis of adenoma detection rate of colonoscopy among trainees.

To analyze adenoma detection rate (ADR) and related quality indicators of colonoscopy among trainees and make recommendations for appropriate colonoscopy training. ADR and related indicators of colonoscopies performed by 3 trainees and 5 colonoscopy experts between March and November 2022 were analyzed. These indicators were analyzed in both the entire patients and the screening/surveillance group. In addition, the training period of the 3 trainees was divided into 3 sections, and the changes in these indicators were examined. The mean ADR of the 3 trainees was 50.6%. In the screening/surveillance group, the mean ADR of the 3 trainees was 51.8%, showing no significant difference from the experts' ADR (53.4%). When the training period was divided into 3 sections and analyzed in the screening/surveillance group, the mean ADR of the trainees gradually increased to 49.4%, 52.6%, and 53.6%, respectively; however, the difference was insignificant. Analyzing each trainee's ADR, there was a significant difference among the 3 trainees (58.5% vs. 44.7% vs. 50.2%, P=0.008). However, in the third section of the training period, the 3 trainees' ADRs were 53.0%, 49.2%, and 57.3%, respectively, showing no significant difference (P=0.606). In the early stages of training, the ADR was higher than recommended; however, there were variances in ADR between individuals. As the training period passed, the ADR became similar at the expert level, whereas the difference in ADR between trainees decreased. Therefore, efforts to increase ADR should be made actively from the beginning of training and continued during the training period.

Quality Indicators of Colonoscopy: Are we meeting the standards in Nepal?

BACKGROUND Colonoscopy is an important tool for management of colorectal disorders. Performance of quality colonoscopy requires a trained endoscopist, adequate resources, preparation and evaluation parameters for good outcomes. We conducted this study to emphasize the importance of quality practice in colonoscopy in our country as there is lack of standardization. METHODS This is a retrospective observational study done at a referral center in Western Nepal. All the colonoscopies were done without sedation with two sachets of peglec powder 137.15 grams, each containing polyethylene glycol (118grams) dissolved in 2 liters of clean water each. Data of 1052 colonoscopies done during three years were retrieved from colonoscopy record section and analysed for important quality measures in use. Data entry and analysis was done in Microsoft Excel. RESULTS A total of 1052 colonoscopies were included in this study. Pain abdomen (70.6%) was the commonest indication for colonoscopy and majority were male patients (53.4%). Good bowel preparation was achieved by split dosing of commercially available polyethylene glycol. Cecal and ileal intubation was achieved in 98% and 96% colonoscopies respectively, meeting the current recommendations set by the gastroenterology societies. No major complications occurred during the procedure. CONCLUSION Important quality indicators could be achieved with colonoscopy done without sedation in resource limited settings also. Screening colonoscopy should be promoted for early detection and management of colorectal cancers in low-income countries like Nepal. Quality should be standardized and practiced in routine colonoscopy examination taking into consideration of patient comfort.

Effect of artificial intelligence implementation to the latest generation 4K colonoscopy.

<b>Indroduction:</b> Colonoscopy is an acclaimed screening test to detect colorectal cancer (CRC). The most important quality indicators for colonoscopy are adenoma detection rate (ADR), cecal intubation rate (CIR), withdrawal time (WT), and bowel preparation (Boston Bowel Preparation Scale; BBPS). In modern endoscopy practice, the human eye is enhanced by highdefinition white-light visualization and advanced imaging technology. The main limitation of this procedure is the detection rate of suspicious lesions. The next generation of endoscopes with 4K resolution and computer-aided detection (CADe) based on artificial intelligence (AI) may be the next step to improve the quality of tests performed.<b>Aim:</b> The aim was to assess the effect of CADe implementation in the environment of the latest generation of endoscopes and 4K visualization in retrospective analysis.<b>Methods:</b> The study included 2,000 patients over 18 years old who underwent colonoscopy for various indications. Olympus Endo-Aid CADe AI system was used, together with the latest X1 series endoscope set using LED lighting and 4K ultra high-resolution technology. Group I consisted of 1,000 consecutive tests performed using Endo-Aid CADe, and group II the first 1,000 consecutive tests without the CADe system. ADR, Advanced adenoma detection rate (AADR), polyp detection rate (PDR), and mean polyp per patient score (MPP) were assessed in each group<b>Results:</b> A total of 2,000 participants were included in the analysis, divided into two groups regarding CADe implementation. The overall PDR was similar in the analyzed groups (AI: 46.7% <i>vs.</i> non-AI: 44.9%, P = 0.419). Both ADR (29.7 <i>vs.</i> 28.9%, P = 0.694) and AADR (6.9 <i>vs.</i> 7.1%, P = 0.861) changed unremarkably. However, a significant elevation in MPP was noted. The MPP rose from 0.85 in the non-AI group to 1.26 in the AI group (P<0.001). The comparative analysis conducted separately for each segment of the bowel revealed that PDR remarkably increased in the left colon (29.3 <i>vs.</i> 18.0%, P<0.001), with no difference for other segments and other parameters. Investigating the MPP separately in each segment showed a significant difference for the right colon (0.33 <i>vs.</i> 0.23, P = 0.032) and the left colon (0.47 <i>vs.</i> 0.28, P<0.001). When adjusted to bowel preparation the PDR and MPP were constantly higher in the AI group (29.3 <i>vs.</i> 19.0%, P<0.001, and 0.48 <i>vs.</i> 0.30, P<0.001, respectively). In addition, the significant impact of AI implementation on MPP faded in the right colon (0.33 <i>vs.</i> 0.24, P = 0.051) when compared with the overall analysis.<b>Conclusions:</b> Although recently published evidence is optimistic regarding AI efficiency in improving the quality of colonoscopy, the provided results widen the overall perspective. Prospective randomized controlled trials (RCTs) including procedures performed with newest generation scopes should elucidate the role of AI in high-resolution colonoscopy.

Comparison of One-Person Technique and Two-Person Technique for Colonoscope Insertion: A Randomized Controlled Trial.

Background: The one-person technique (OPT) for colonoscope insertion is recommended by professional societies and regarded as standard practice. However, the two-person technique (TPT) has shown several advantages over the OPT. The aim of this study was to evaluate the performance of the TPT compared to the OPT. Methods: In this prospective study, consecutive individuals presenting for outpatient colonoscopy were randomized to undergo colonoscopy by OPT or by TPT. The colonoscopies were performed by six endoscopists, two of whom were beginners, two with intermediate skills, and two who were experts. The primary endpoints were quality indicators for colonoscopy, including adenoma detection rate, cecal intubation rate, cecal insertion time, and total colonoscopy time. A secondary outcome was procedure tolerability, as assessed by both the patients and the endoscopists. Results: Two hundred and four subjects (117 males, mean age 54.3) were randomized to either one- (n = 102) or two-person (n = 102) colonoscopy. The adenoma detection rate was 30.4% in OPT group and 34.3% in TPT group. (p = 0.55). No significant differences between the two groups were found in terms of cecal intubation rate (98/102 vs. 98/102), insertion time (411 vs. 381 s), and total examination time (1426 vs. 1296 s). However, patients receiving the TPT had lower pain scores than patients receiving the OPT. Endoscopist fatigue measured with the FACIT-F was also significantly lower in the TPT group. Conclusion: The two-person colonoscopy method was not shown to be technically or clinically inferior. Rather, the TPT can improve patient tolerance and reduce endoscopist fatigue.

Adenoma detection rate of screening colonoscopy among age 40–75 years: Implications for lowering the age for colorectal cancer screening

AbstractIncidence of early‐onset colorectal cancer is on the rise, prompting updated international guidelines recommending screening for average‐risk individuals starting at age 45. Adenoma detection rate (ADR) serves as a crucial quality indicator for colonoscopy (CFS), with a current benchmark of 25% for screening CFS starting at age 50. However, the impact of lowering the screening age on ADR remains uncertain. This study aimed to assess the ADR in average‐risk individuals who undergo screening colonoscopy at an age older than 40. Participants who underwent a complete colonoscopy for health examination at a medical center between January 2014 and February 2020 were enrolled in this study. We excluded colonoscopies performed on individuals younger than 40 years of age or older than 75 years of age, as well as those conducted for surveillance purposes. ADR was defined as the percentage of colonoscopies with at least one colorectal adenoma detected. We calculated the ADR for different age groups, including 40–44, 45–49, 50–54, and 55–75, to understand the age‐specific ADR of screening colonoscopy. Additionally, we evaluated the ADR among participants who started screening colonoscopy at ages ≥40, ≥45, and ≥50 to understand the impact of starting age on ADR. A p value <.05, determined by the chi‐square test, was considered significant. Among the 33 073 CFS completed during the study period, 5852 CFS examined in patients aged younger than 40 years, 344 CFS examined in patients aged older than 75, and 6881 CFS with surveillance indication were excluded, leaving 19 996 CFS enrolled for analysis. The mean age of the participants was 53, with 57% being male and 43% being female. The ADR for the age groups of 40–44, 45–49, 50–54, and 55–75 were 28.0% (1058/3778), 31.8% (1191/3741), 35.6% (1387/3891), and 44.2% (3794/8586), respectively, with a statistically significant difference (p < .01). The ADR for age ≥40, ≥45, and ≥50 were 37.2% (7430/19996), 40.1% (6372/15874), and 41.5% (5181/12477), respectively, with a statistically significant difference (p < .01). The findings of our study indicate that there are notable differences in ADR among various age groups. Lowering the screening age might result in a decrease in the overall ADR. However, our results suggest that even if CRC screening begins at age 40 or 45, the current benchmark of 25% ADR for screening colonoscopy may still be maintained. These findings provide valuable insights into the age‐ and gender‐specific prevalence of adenomas in colonoscopy screening and can be used to inform future screening guidelines and recommendations.

Adenoma detection rate as a quality indicator for colonoscopy.

Objective: To determine the quality of colonoscopy in terms of adenoma detection rate in the existing local settings. Study Design: Cross-sectional study. Setting: Department of Gastroenterology, Liaquat National Hospital, Karachi, Pakistan. Period: February 2022 to August 2022. Methods: We analyzed patients having age 18 years or older, of any gender, and who had colonoscopy indications and were required to have a screening colonoscopy for diagnostic purposes. The number of procedures with at least one polyp or adenoma was classified as the polyp detection rate (PDR) and adenoma detection rate (ADR). Result: Total 210 patients were enrolled into the study with median age of 41.5 (29.8-56.3) years and majority were males (n=46, 69.5%). The most frequent indication for colonoscopy was constipation (n=72, 34.3%) followed by bleeding (n=78, 37.1%), chronic diarrhea (n=36, 17.1%), both constipation and diarrhea (n=21, 10%) and altered bowel habits (n=3, 1.4%). PDR and ADR were 16.2% (n=34) and 10% (n=21) respectively. Age was significantly higher among patients who were found to have polyp (p<0.001) and adenomas (p<0.001). Frequency of polyps (p=0.010) and adenomas (p=0.007) were significantly higher in male patients. Conclusion: The current research discovered a low rate of adenoma detection in people receiving colorectal cancer screening, and it did not meet the quality benchmarks that have been associated with higher rates of early diagnosis and cancer prevention.

Quality Indicators for Colonoscopy.

Quality Indicators for Colonoscopy.

Relative Efficacies of Interventions to Improve the Quality of Screening-Related Colonoscopy: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Significant variability exists in colonoscopy quality indicators, including adenoma detection rate (ADR). We synthesized evidence from randomized trials in a network meta-analysis on interventions to improve colonoscopy quality. We included trials from database inceptions to September 25, 2023, of patients undergoing screening-related colonoscopy and presented efficacies of interventions within domains (periprocedural parameters, endoscopist-directed interventions, intraprocedural techniques, endoscopic technologies, distal attachment devices, and additive substances) compared to standard colonoscopy. The primary outcome was ADR. We used a Bayesian random-effects model using Markov-chain Monte Carlo simulation, with 10,000 burn-ins and 100,000 iterations. We calculated odds ratios with 95% credible intervals and present surface under the cumulative ranking (SUCRA) curves. We included 124 trials evaluating 37 interventions for the primary outcome. Nine interventions resulted in statistically significant improvements in ADR compared to standard colonoscopy (9-minute withdrawal time, dual observation, water exchange, i-SCAN [Pentax Ltd], linked color imaging, computer-aided detection, Endocuff [Olympus Corp], Endocuff Vision [Olympus Corp], and oral methylene blue). Dual observation (SUCRA, 0.84) and water exchange (SUCRA, 0.78) ranked highest among intraprocedural techniques; i-SCAN (SUCRA, 0.95), linked color imaging (SUCRA, 0.85), and computer-aided detection (SUCRA, 0.78) among endoscopic technologies; WingCap (A&A Medical Supply LLC) (SUCRA, 0.87) and Endocuff (SUCRA, 0.85) among distal attachment devices and oral methylene blue (SUCRA, 0.94) among additive substances. No interventions improved detection of advanced adenomas, and only narrow-band imaging improved detection of serrated lesions (odds ratio, 2.94; 95% credible interval, 1.46-6.25). Several interventions are effective in improving adenoma detection and overall colonoscopy quality, many of which are cost-free. These results can inform endoscopists, unit managers, and endoscopy societies on relative efficacies.

Colorectal Cancer Screening Programs in Latin America

Colorectal cancer (CRC) is a leading cause of cancer-related mortality globally, with increasing incidence and mortality in Latin America. CRC screening programs can reduce disease burden, but information on screening programs in Latin America is limited. To describe characteristics (eg, type of program, uptake, neoplastic yield) of CRC screening programs in Latin America. PubMed, Ovid MEDLINE, EMBASE, Cochrane, PsycINFO, Web of Science Core Collection, LILACS, and SciELO were searched from inception to February 2023. Relevant references from bibliographies, conference proceedings, and gray literature were considered. The search strategy included English, Spanish, and Portuguese terms. Included were studies of CRC screening programs in Latin America using fecal immunochemical test (FIT) or colonoscopy as the primary screening method. Four reviewers independently assessed study eligibility based on titles, with review of abstracts and full texts as needed. Guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed for data abstraction and quality assessment. Descriptive information was extracted, and data were pooled using a random-effects model. Program performance indicators included rates of participation and FIT positivity, adenoma detection rate (ADR), advanced adenoma detection rate (AADR), CRC detection rate, and colonoscopy quality indicators. There were 17 studies included from upper middle-income and high-income countries in Latin America with a total of 123 929 participants. Thirteen studies used FIT as the initial screening method, whereas 4 used screening colonoscopy. The participation rate in FIT-based programs was 85.8% (95% CI, 78.5%-91.4%). FIT positivity rates were 15.2% (95% CI, 9.6%-21.8%) for the 50-ng/mL threshold and 9.7% (95% CI, 6.8%-13.0%) for the 100-ng/mL threshold. For FIT-based studies, the pooled ADR was 39.0% (95% CI, 29.3%-49.2%) and CRC detection rate was 4.9% (95% CI, 2.6%-7.9%); for screening colonoscopy-based studies, the pooled ADR was 19.9% (95% CI, 15.5%-24.8%) and CRC detection rate was 0.4% (95% CI, 0.1%-0.8%). This systematic review and meta-analysis suggests that CRC screening in upper middle-income countries in Latin America is feasible, detecting rates of neoplasia comparable with those of high-income regions. Population-based screening programs should be developed or enhanced in these settings. There is a knowledge gap regarding feasibility and yield of screening programs in lower middle-income countries.

Strategies to improve screening colonoscopy quality for the prevention of colorectal cancer.

The incidence and mortality of colorectal cancer (CRC) have decreased through regular screening colonoscopy, surveillance, and endoscopic treatment. However, CRC can still be diagnosed after negative colonoscopy. Such CRC is called interval CRC and accounts for 1.8-9.0% of all CRC cases. Most cases of interval CRC originate from missed lesions and incompletely resected lesions. Interval CRC can be minimized by improving the quality of colonoscopy. This has led to a growing interest in and demand for high-quality colonoscopy. It is important to reduce the risk of CRC and its associated mortality by improving the quality of colonoscopy. In this review article, we provide an overview of colonoscopy quality indicators, including bowel preparation adequacy, the cecal intubation rate, the adenoma detection rate, the colonoscopy withdrawal time, appropriate polypectomy, and complication of the procedure. Because colonoscopy is a highly endoscopist-dependent procedure, colonoscopists should be well-acquainted with quality indicators and strive to apply them in daily clinical practice for the prevention of CRC.

Screening colonoscopy as an effective way to prevent colorectal cancer

Introduction. Colorectal cancer (CRC) is one of those cancer types which have many worldwide organized screening programs. Those screening programs help to reduce colorectal cancer morbidity and mortality. Aim. To evaluate the results of screening colonoscopy with simultaneous removal of benign epithelial formations on an outpatient basis using “cold” methods, as well as its effectiveness in the prevention of CRC. Materials and methods. A retrospective analysis of the results of colonoscopy in outpatient conditions performed at the N. I. Pirogov Government City Clinic (Orenburg) for the period 2018–2021 was performed. The study included indicators of screening colonoscopy performed in asymptomatic patients. The main evaluated parameters are: the type of polyp according to the Paris classification, the results of histological examination, the frequency of complications, as well as the quality indicators of colonoscopy (preparation according to the Boston scale, the time of removal of the device, adenoma detection rate (ADR), polyp detection rate (PDR)). Results. A total of 4,588 screening colonoscopies were performed, frequency of adenomas detection – 35,3 %, 1,041 neoplasms were removed (of which 456 (44 %) neoplasms were removed with biopsy forceps, 585 (56 %) neoplasms were removed with a cold loop as a single block). In 622 (59,7 %) cases, the macroscopic form of neoplasms is type 0–IIa, in 326 (31.3 %) – type 0–Is, in 93 (9 %) – type IIa + IIc. According to the results of histological examination, the sessile type of structure was diagnosed in 158 (15.2 %) cases, non – sessile – in 883 (84.8 %). In 276 (26.5 %) cases, were detected adenomas with micro-foci of adenocarcinoma (tumor in situ). During the study period (2018–2021), one complication (0.09 %) of outpatient polypectomy by the “cold” method was observed. This complication was manifested by automatically stopped bleeding. Conclusion. Screening colonoscopy is one of the most effective diagnostic methods to detect CRC in asymptomatic patients. The “cold” polypectomy method has an important role in the prevention of CRC, as it is a safe procedure which can be performed on an outpatient basis.

Colonoscopy withdrawal times and adenoma detection rates in a large, multi-site colorectal surgery practice.

433 Background: Colonoscopy withdrawal times (CWT) and adenoma detection rates (ADR) have been extensively correlated in medical literature. The American College of Gastroenterology (ACG) 2021 guidelines recommend measuring quality indicators for screening colonoscopy that achieve minimum benchmarks for ADR (>=25%) and CWT (>=6 minutes). In October 2022, M Desai et al reported in a sample of 1142 patients (46% screening and 54% surveillance), ADR increased as withdrawal time increased from 6 to 13 minutes. Results demonstrated a 6% increase per minute in the likelihood of detecting an additional patient with at least 1 adenoma. Texas Colon and Rectal Specialists routinely reviews ADR’s and CWT’s. This retrospective descriptive study presents a concise review of the correlation between CWT’s and ADR’s in a homogenous set of screening and surveillance patients. Methods: We examined 7164 abstracted colonoscopy records from 31 colorectal surgeons. Diagnostic colonoscopies were excluded. We studied patients between 45 and 84 years of age at the time of the colonoscopy. Each patient was noted for the colonoscopy CWT as well as whether at least one adenomatous polyp was detected. These data were reported in a scatter plot of ADR over CWT as well as a bubble chart of ADR over CWT by each surgeon. A two-sample t-test confirmed a statistical difference between the mean CWT of the adenoma-positive patients and those that were not positive. Results: Consistent with the literature, ADR increased with CWT. The mean CWT was 14.2 minutes in the group where an adenoma was detected (n=3289) and 10.6 minutes in the group where an adenoma was not detected (n=3875), (p<0.05 and CI of 95%). Mean CWT was 12.3 minutes, mode was 7 minutes, median was 10.25 minutes, and the mean ADR was 45.9%. The best ADR performance was 62.5% at a mean of 26.8 minutes CWT and the worst performance was 27.7% at 10 minutes CWT. A bubble chart demonstrates the relationship between CWT and ADR by surgeon with the bubbles representing individual colonoscopy volumes. Consistent with the literature, ADR increased with CWT. The mean CWT was 14.2 minutes in the group where an adenoma was detected (n=3289) and 10.6 minutes in the group where an adenoma was not detected (n=3875), (p<0.05 and CI of 95%). Mean CWT was 12.3 minutes, mode was 7 minutes, median was 10.25 minutes, and the mean ADR was 45.9%. The best ADR performance was 62.5% at a mean of 26.8 minutes CWT and the worst performance was 27.7% at 10 minutes CWT. Conclusions: Our data indicate a significant relationship between CWT and ADR, and may suggest that CWT well beyond six minutes may yield better ADR’s. Furthermore, scope volume appears to play a role in the achievement of higher ADR’s, though this would require further investigation for optimal CWT, minimum expected ADR, optimal techniques and bowel prep, and emerging assistive technology.

Post-colonoscopy rectal cancer in Swedish patients with Crohn's disease 2001-2015: a population-based case review study.

Post-colonoscopy colorectal cancer (PCCRC) is a key quality indicator of colonoscopy, and PCCRC rates are high in the IBD population. Rectal cancer, an important risk factor for PCCRC among patients with Crohn's disease (CD), has not previously been examined. Swedish adult patients with CD who underwent a colonoscopy within 36 months before a rectal cancer diagnosis between 2001 and 2015 were identified through the National Patient and Cancer registers. Their medical records were reviewed and a root-cause analysis and a sub-categorization according to the World Endoscopic Organization (WEO) were performed. Of 24 patients with CD and PCCRC in the rectum, 79% were men and the median age was 50 (IQR 45-59) years. The median disease duration was 21.5 (IQR 19-30) years. The cancer was located in the distal 5 cm of the rectum in 63% of the cases. Retroversion in the rectum was reported in only one case. The most common plausible explanation for PCCRC was 'possible missed lesion, prior examination adequate' (63%); when adding retroversion in the rectum, instead 77% of examinations were considered negative but deemed as inadequate. The most common PCCRC sub-category was non-interval type C (54%) and B (37%). Among those with type C, 38% should have been included in surveillance according to present guidelines. Better adherence to surveillance guidelines and more meticulous follow-up is warranted. The importance of performing rectal palpation and retroversion in the rectum is underscored and we suggest that this is included in the WEO algorithm.

Artificial intelligence–assisted real-time monitoring of effective withdrawal time during colonoscopy: a novel quality marker of colonoscopy

Background and aimsThe importance of withdrawal time during colonoscopy cannot be overstated in mitigating the risk of missed lesions and post-colonoscopy colorectal cancer. We evaluated a novel colonoscopy quality metric called the effective withdrawal time (EWT), which is an artificial intelligence (AI) derived quantitative measure of quality withdrawal time and their association with various colonic lesions detection rates, as compared with standard withdrawal time (SWT). MethodsA total of 350 video recordings of colonoscopy withdrawal (from caecum to anus) were assessed by the new AI model. The primary outcome was adenoma detection rate (ADR) according to different quintiles of EWT. Multivariate logistic regression, adjusting for baseline covariates, was used to determine the adjusted odd ratios (OR) for EWT on lesion detection rates, with the lowest quintile as reference. The area under the receiver operating characteristic curve (AUC) of EWT was compared with SWT. ResultsThe crude ADR in different quintiles of EWT, from lowest to highest, was 10.0%, 31.4%, 33.3%, 53.5%, and 85.7%, respectively. The ORs of detecting adenoma and polyp were significantly higher in all top 4th quintiles when compared to the lowest quintile. Each minute increase in EWT was associated with a 49% increase in ADR (aOR, 1.49; 95% CI, 1.36 to 1.65). The AUC of EWT was also significantly higher than SWT on adenoma detection (0.80 [95%CI: 0.75 – 0.84] vs 0.70 [95%CI: 0.64-0.74], p <0.01). ConclusionsThe AI-derived EWT monitoring is a promising novel quality indicator for colonoscopy, which is more associated with ADR than SWT.

What Is the Optimal Bowel Preparation for Capsule Colonoscopy and Pan-intestinal Capsule Endoscopy? A Systematic Review and Meta-Analysis

BackgroundThe rate of adequate cleansing (ACR) and complete examinations (CR) are key quality indicators in capsule colonoscopy (CC) and pan-intestinal capsule endoscopy (PCE).AimsTo evaluate the efficacy of bowel preparation protocols regarding ACR and CR.MethodsWe conducted a systematic review and meta-analysis, search terms regarding colon capsule preparation, publication date from 2006/01, and date of search 2021/12, in six bibliographic databases. Multiple steps of the cleansing protocol were assessed: diet, adjunctive laxatives, purgative solution, use of prokinetic agents, and “booster”. The meta-analytical frequency of ACR and CR was estimated, and subgroup analyses performed. Strategies associated with higher ACR and CR were explored using meta-analytical univariable and multivariable regression models.ResultsTwenty-six observational studies and five RCTs included (n = 4072 patients). The pooled rate of ACR was 72.5% (95% C.I. 67.8–77.5%; I2 = 92.4%), and the pooled rate of CR was 83.0% (95% C.I. 78.7–87.7%; I2 = 96.5%). The highest ACR were obtained using a low-fibre diet [78.5% (95% C.I. 72.0–85.6%); I2 = 57.0%], adjunctive laxatives [74.7% (95% C.I. 69.8–80.1%); I2 = 85.3%], and split dose < 4L polyethylene glycol (PEG) as purgative [77.5% (95% C.I. 68.4–87.8%); I2 = 47.3%]. The highest CR were observed using routine prokinetics prior to capsule ingestion [84.4% (95% C.I. 79.9–89.2%); I2 = 89.8%], and sodium phosphate (NaP) as “booster” [86.2% (95% C.I. 82.3–90.2%); I2 = 86.8%]. In univariable models, adjunctive laxatives were associated with higher ACR [OR 1.81 (95% C.I. 1.13; 2.90); p = 0.014]. CR was higher with routine prokinetics [OR 1.86 (95% C.I. 1.13; 3.05); p = 0.015] and split-dose PEG purgative [OR 2.03 (95% C.I. 1.01; 4.09), p = 0.048].ConclusionsMain quality outcomes (ACR, CR) remain suboptimal for CC and PCE. Despite considerable heterogeneity, our results support low-fibre diet, use of adjunctive sennosides, split dose < 4L PEG, and routine prokinetics, while NaP remains the most consistent option as booster.

Impact of a Time-Related Benchmark on the Adenoma Detection Rate in Surveillance Colonoscopy: A STROBE Statement-Oriented Cross-Sectional Cohort Study.

Colorectal adenomas are precursor lesions of globally increasing colorectal cancer. Hence, a high adenoma detection rate in colonoscopy is pivotal. We investigated the clinical impact of stratified colonoscopy observation time combined with observation time/intubation time ratio on the detection of colorectal adenomas. We conducted a single-center retrospective study including 369 consecutive patients who underwent colonoscopy following fecal immunochemical tests between May 2021 and April 2022. The primary outcome measure was the impact of the stratified observation time and observation time/ intubation time ratio (category 1: <6.0 minutes and <1.0, category 2: <6.0 minutes and ≥1.0, category 3: ≥6.0 minutes and <1.0, and category 4: ≥6.0 minutes and ≥1.0) on adenoma detection rate. Cecum intubation was obtained in 367 patients (99.5%). Adenomas were detected in 226 patients (61.2%). From the univariate analysis, age ≥53 years, habitual alcohol intake, colonoscopy attachment (+), and observation time with observation time/intubation time ratio categories 3 and 4 were determined as significant factors for adenoma detection rate. From the logistic regression analysis, age ≥ 53 years (odds ratio: 4.86, 95% CI: 2.25-10.52), habitual alcohol intake (odds ratio: 2.26, 95% CI: 1.33-3.82), category 3 (odds ratio: 3.66, 95% CI: 1.81-7.45), and category 4 (odds ratio: 5.60, 95% CI: 2.92-10.73) were significant factors for adenoma detection rate. We propose the observation time with observation time/intubation time ratio combined benchmark (with categories' thresholds based on observation time >6 minutes and scope withdrawal time exceeding intubation time [observation time/intubation time ratio > 1]) as a novel colonoscopy quality indicator. These findings represent an important educational message for endoscopists.

An Accurate and Automated Method for Adenoma Detection Rate and Report Card Generation Utilizing Common Electronic Health Records.

To develop an automated method for Adenoma Detection Rate (ADR) calculation and report card generation using common electronic health records (EHRs). ADR is the most widely accepted colonoscopy quality indicator and is inversely associated with interval colorectal cancer incidence and mortality. However, ADR is difficult to efficiently measure and disseminate, due to need for data integration from distinct electronic databases. We migrated data from an endoscopy reporting software (Endosoft) to Epic Reporting Servers where it was combined with anatomic pathology data (Beaker Lab Information System, EPIC Systems). A natural language processing expression was developed to search Beaker pathology reports for accurate identification of adenomatous polyps. A blinded physician manually validated a final cohort of 200 random procedures. ADR report cards were automatically generated utilizing the Crystal Reports feature within EPIC. Validation of the natural language processing algorithm for ADR showed a sensitivity, specificity, and accuracy of 100%. ADR was automatically calculated for 12 endoscopists over a calendar year. Two thousand two hundred seventy-six screening colonoscopies were performed with 775 procedures having a least one adenoma detected, for a total ADR of 34%. Report cards were successfully generated within the EPIC EHR and distributed to endoscopists by secure e-mail. We describe an accurate, automated and scalable process for ADR calculation and reporting utilizing commonly adopted EHRs and data integration methods. By integrating the process of ADR collection and streamlining dissemination of reports, this methodology is poised to enhance colonoscopy quality care across health care networks that use it.

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.

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.