Usefulness of mean number of adenomas per positive screenee for identifying meticulous endoscopists among those who achieve acceptable adenoma detection rates

Abstract

Background Adenoma detection rate (ADR) is a quality indicator for colonoscopy. However, many missed adenomas have subsequently been identified after colonoscopies performed by endoscopists with ADR ≥ 25 %. Adenomas per positive participant (APP; mean number of adenomas detected by an endoscopist among screenees with positive findings) correlates well inversely with adenoma miss rate. This study aimed to evaluate whether APP added additional information on the detection rate for advanced adenomas (AADR) and proximal adenomas (pADR) and among endoscopists with acceptable ADRs (≥ 25 %).

Methods A total of 47 endoscopists performed 7339 screening colonoscopies that were retrospectively reviewed. Using a cutoff APP value of 2.0, endoscopist performance was classified as high or low APP. Endoscopist ADRs were also classified as acceptable (25 % – 29 %), high standard (30 % – 39 %) and aspirational (≥ 40 %). Generalized linear models were used to assess the relationship between AADR or pADR, and ADR and APP, after adjusting for potential confounders.

Results After adjusting for endoscopist performance and patient characteristics, endoscopists with high APP had a significant 2.1 percentage point increase in AADR (95 %CI 0.3 to 3.9; P = 0.02) and a 2.1 percentage point increase in pADR (95 %CI – 0.8 to 5.1; P = 0.15) compared to endoscopists with low APP. In total, 11 (24 %), 18 (38 %), and 18 (38 %) endoscopists were classified as having acceptable, high standard, and aspirational ADRs, respectively. APP values higher than the cutoff were found in 18 %, 44 %, and 72 % of endoscopists with acceptable, high standard, and aspirational ADRs, respectively (P = 0.02).

Conclusion APP is helpful for identifying more meticulous endoscopists who can detect a greater number of advanced adenomas. Endoscopists who achieved an only acceptable ADR had the lowest APP.

Publication History

Received: 03 February 2020

Accepted: 16 June 2020

Accepted Manuscript online:
16 June 2020

Article published online:
01 October 2020

• References

• 1 Nishihara R, Wu K, Lochhead P. et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013; 369: 1095-1105
• 2 Lieberman DA. Clinical practice. Screening for colorectal cancer. N Engl J Med 2009; 361: 1179-1187
• 3 Dominic OG, McGarrity T, Dignan M. et al. American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008. Am J Gastroenterol 2009; 104: 2626-2627 ; author reply 2628-2629
• 4 Singh S, Singh PP, Murad MH. et al. Prevalence, risk factors, and outcomes of interval colorectal cancers: a systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 1375-1389
• 5 Pedersen L, Valori R, Bernstein I. et al. Risk of post-colonoscopy colorectal cancer in Denmark: time trends and comparison with Sweden and the English National Health Service. Endoscopy 2019; 51: 733-741
• 6 Tollivoro TA, Jensen CD, Marks AR. et al. Index colonoscopy-related risk factors for postcolonoscopy colorectal cancers. Gastrointest Endosc 2019; 89: 168-176.e163
• 7 le Clercq CM, Bouwens MW, Rondagh EJ. et al. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 2014; 63: 957-963
• 8 Rex DK, Schoenfeld PS, Cohen J. et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31-53
• 9 Rex DK, Schoenfeld PS, Cohen J. et al. Quality indicators for colonoscopy. Am J Gastroenterol 2015; 110: 72-90
• 10 Rembacken B, Hassan C, Riemann JF. et al. Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012; 44: 957-968
• 11 Sung JJ, Ng SC, Chan FK. et al. An updated Asia Pacific Consensus Recommendations on colorectal cancer screening. Gut 2015; 64: 121-132
• 12 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010; 362: 1795-1803
• 13 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
• 14 Wang HS, Pisegna J, Modi R. et al. Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance. Gastrointest Endosc 2013; 77: 71-78
• 15 Rex DK, Cutler CS, Lemmel GT. et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997; 112: 24-28
• 16 Aniwan S, Orkoonsawat P, Viriyautsahakul V. et al. The secondary quality indicator to improve prediction of adenoma miss rate apart from adenoma detection rate. Am J Gastroenterol 2016; 111: 723-729
• 17 Gessl I, Waldmann E, Penz D. et al. Evaluation of adenomas per colonoscopy and adenomas per positive participant as new quality parameters in screening colonoscopy. Gastrointest Endosc 2019; 89: 496-502
• 18 Lee TJ, Rutter MD, Blanks RG. et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012; 61: 1050-1057
• 19 Castaneda D, Popov VB, Verheyen E. et al. New technologies improve adenoma detection rate, adenoma miss rate, and polyp detection rate: a systematic review and meta-analysis. Gastrointest Endosc 2018; 88: 209-222.e211
• 20 Committee ASoP, Saltzman JR, Cash BD. et al. Bowel preparation before colonoscopy. Gastrointest Endosc 2015; 81: 781-794
• 21 Hilsden RJ, Rose SM, Dube C. et al. Defining and applying locally relevant benchmarks for the adenoma detection rate. Am J Gastroenterol 2019; 114: 1315-1321
• 22 Leung WK, Lo OS, Liu KS. et al. Detection of colorectal adenoma by narrow band imaging (HQ190) vs. high-definition white light colonoscopy: a randomized controlled trial. Am J Gastroenterol 2014; 109: 855-863
• 23 Rex DK, Repici A, Gross SA. et al. High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial. Gastrointest Endosc 2018; 88: 335-344 e332
• 24 Leufkens AM, DeMarco DC, Rastogi A. et al. Effect of a retrograde-viewing device on adenoma detection rate during colonoscopy: the TERRACE study. Gastrointest Endosc 2011; 73: 480-489
• 25 Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol 2014; 109: 1714-1723 ; quiz 1724
• 26 Shaukat A, Rector TS, Church TR. et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology 2015; 149: 952-957
• 27 Lai EJ, Calderwood AH, Doros G. et al. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009; 69: 620-625
• 28 Aronchick CA. Bowel preparation scale. Gastrointest Endosc 2004; 60: 1037-1038 ; author reply 1038-1039
• 29 Parmar R, Martel M, Rostom A. et al. Validated scales for colon cleansing: a systematic review. Am J Gastroenterol 2016; 111: 197-204 ; quiz 205
• 30 Kahi CJ, Vemulapalli KC, Johnson CS. et al. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience. Gastrointest Endosc 2014; 79: 448-454
• 31 Kudo SE, Misawa M, Mori Y. et al. Artificial intelligence-assisted system improves endoscopic identification of colorectal neoplasms. Clin Gastroenterol Hepatol 2019;
• 32 Ahmad OF, Soares AS, Mazomenos E. et al. Artificial intelligence and computer-aided diagnosis in colonoscopy: current evidence and future directions. The lancet Gastroenterol Hepatol 2019; 4: 71-80
• 33 Mori Y, Kudo SE, Misawa M. et al. Real-time use of artificial intelligence in identification of diminutive polyps during colonoscopy: a prospective study. Ann Intern Med 2018; 169: 357-366