In Colonoscopy, Quality Indicators Aren’t Optional

This transcript has been edited for clarity. 
Hello. I’m Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. 
Quality matters. We know that as gastroenterologists, as do the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE), who have updated their quality indicators for gastrointestinal endoscopic procedures.
Today I’d like to focus on their recommendations around colonoscopy, which represents approximately 80% of our endoscopic volume. Recommendations for quality colonoscopy were first developed by the ACG/ASGE in 2006, updated in 2015, and now updated again with the most recent evidence. 
Before we get into the highlights of these recommendations, many of which are actionable now, I would like to say that if you do not have a quality performance program evaluation in your endoscopic unit, you need to. It’s not a suggestion — it’s an absolute standard of care.
The ACG/ASGE’s latest recommendations identify several priority quality indicators for colonoscopy, including one around the rate of bowel prep adequacy. 
In their initial guidelines in 2014, the US Multi-Society Task Force recommended that at least 85% of outpatient colonoscopies should have an adequate bowel preparation. The new recommendation from the ACG/ASGE is a target of 90% or, ideally, even higher. 
The authors recommend reporting preparation of the colonoscopy using the validated instrument of the Boston Bowel Preparation Scale, which has been used in the majority of studies looking at this outcome. It records adequacy as a score of ≥ 2 in all three colon segments, which should be measured after endoscopic washing and cleaning. 
It’s highly clinically relevant that if you have an inadequate prep, you document it endoscopically. The authors recommend repeating the colonoscopy within a year [for patients with inadequate prep] — and certainly sooner should you see any evidence of dysplasia, adenoma, or other suggestive findings. 
Cecal intubation rate is a priority indicator in so many quality benchmarks. 
In earlier years, the target performance for cecal intubation rate was 90%, but that’s been raised to ≥ 95% in the latest recommendations. 
For the majority of us achieving or exceeding that performance, the cecal intubation rate measurement can be discontinued and performed intermittently or not at all if the track record is consistent. That could be one thing that’s less burdensome to your quality assessment, allowing you to perhaps focus on other factors more relevant and subject to other variabilities. 
The adenoma detection rate (ADR) is the most clinically relevant and best validated quality indicator in colonoscopy. 
In 2002, the ADR threshold was arbitrarily set at 20% (25% in men and 15% in women). This has been incrementally raised in recent years, with the newest ACG/ASGE guideline recommending a performance target of ≥ 35%.
Other modifications to the ADR were made after a higher adenoma prevalence was detected among those aged 45-49 years old, which is now only a little bit lower than in those aged 50-54 years old. 
The definition of the ADR has also been expanded to include not only index screening exams but also surveillance and diagnostic exams, with the exception of a positive fecal immunochemical test (FIT), which we’ll discuss next. 
If you’re not meeting the ≥ 35% performance benchmark for the ADR, then you need to have some type of remediation strategy in your unit. There are several ways to go about that. I invite those readers to whom this applies to review the ACG/ASGE recommendations for remediation strategies. It’s necessary to measure the ADR, but it’s critically important to respond to that measurement if it’s inadequate, because quality matters. 
In FIT-positive patients, evidence suggests that the ADR may be as high as 70%. The ADR is even higher when the cutoff level of hemoglobin per gram of feces is higher. The current standard guideline is 20 µg hemoglobin per gram of feces, which is frequently used in FIT assays. The ADR is 10%-15% higher among FIT-positive men than in women. 
Based on the latest available evidence, the authors recommend a blended ADR of 50% (55% in men, 45% in women) among FIT-positive patients. This includes positive stool DNA tests as well. Although there’s less evidence around these tests, it’s nonetheless included in the recommendation. 
It’s critically important that you raise those thresholds in a positive fecal screening test. 
The latest recommendations offer a new priority quality indicator around the issue of the sessile serrated lesion (SSL) detection rate. 
SSL detection rates do correlate with the ADRs, but not explicitly and absolutely. There are also some variances based on the interpretation by your local pathologist. However, the SSL detection rate has become more of a standard. 
The new priority indicator recommendation is for an SSL detection rate of ≥ 6%, which encompasses combined screening, surveillance, and diagnostic exams. This is independent of whether there is a positive FIT or stool DNA test, which doesn’t really detect SSLs. 
If you’re not achieving a ≥ 6% performance target, be aware that the confidence intervals may be broad. This is because you’re starting with a lower incidence of SSLs when you begin looking at these detection rates. As you build your SSL database, the confidence intervals should narrow and become more discriminant over time.
We were all impressed with the 2006 study in The New England Journal of Medicine that reported a 6-minute withdrawal time. However, the new ACG/ASGE recommendations suggest a withdrawal time of 8 minutes, which is based on the latest evidence around detection. Eight minutes is an average number, not one derived from a single study. 
Withdrawal time itself is not an adequate measure of skill, but the concordance with increased ADRs and SSL detection rates is recognized. 
There is some evidence that mucosal-exposure devices, specifically the Endocuff Vision, may shorten that interval of withdrawal. 
Average withdrawal time is something you should be measuring and using as a benchmark if you see that your ADRs or SSL detection rates are low. 
The recommendations support the new norm of employing a cold snare to resect 4- to 9-mm lesions, which is associated with reduced incremental risk. The performance target for this recommendation is ≥ 90%. 
If you have a lesion that is ≤ 2 mm, it’s reasonable to use a cold forceps, which a lot of providers do. However, in lesions ≥ 3 mm, the numbers do not support cold forceps as a resection method. 
The recommendations also discuss new approaches in the treatment of patients with inflammatory bowel disease (IBD). 
For the assessment of disease extent and activity, the use of validated instruments for ulcerative colitis (eg, the Mayo Endoscopic score) and Crohn’s disease (eg, the Rutgeerts score) is recommended, with a performance target of ≥ 90%. Given that these tools may not be built into your standard electronic medical record, you may need to look into this further. 
The other recommendation related to IBD calls for the use of high-definition imaging combined with an ancillary enhancement, whether it be dye spray or electronic chromoendoscopy. This is especially the case when performing a targeted biopsy of any suspicious lesions.
When it comes to aligning with the guidelines around screening and surveillance recommendations, we’re doing fairly poorly. This is based on evidence that [17%-25.7% of screening colonoscopies are not being repeated] within the timeframes identified by national guidelines. 
The ACG/ASGE offers specific recommendations on using appropriate screening and surveillance intervals.
We clearly need to do better here. That begins by looking at your performance characteristics, identifying the potential overuse of these procedures, and becoming more concordant with guidelines as a key quality indicator. 
In summary, improving performance begins with the measurement of colonoscopy quality. 
We’ve certainly seen recent changes in this area related to targets for ADRs and SSL detection rates. Cecal intubation rates may be abandoned if you’re truly aligned with a high performance in this area. As it relates to concordance with national screening guidelines, we need to do a better job. For IBD, you should employ validated instruments. You should also to aim to achieve adequacy of bowel preparation at rates of ≥ 90%. 
By following these recommendations, we can all improve quality. 
As a last resort, the guideline authors recommend the removal of privileges to perform colonoscopy if satisfactory performance cannot be achieved. We know that colonoscopy quality matters greatly when it comes to improving key patient outcomes, particularly the incidence and relative mortality of post-colonoscopy colon cancer. These recommendations apply to all providers of colonoscopies across all specialties. 
These are not suggestions. We really need to take these to heart and implement them now. 
I’m Dr David Johnson. Thanks again for listening.
David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.