Evaluation of adenomas per colonoscopy and adenomas per positive participant as new quality parameters in screening colonoscopy

doi:10.1016/j.gie.2018.08.013

Gastrointestinal Endoscopy

Volume 89, Issue 3, March 2019, Pages 496-502

https://doi.org/10.1016/j.gie.2018.08.013 Get rights and content

Background and Aims

The primary aim of this study was to evaluate adenomas per positive participant (APP) and adenomas per colonoscopy (APC) as new quality parameters in screening colonoscopy. Furthermore, we wanted to assess whether these parameters differ depending on the setting or profession.

Methods

Colonoscopy records were obtained from the database of the Austrian certificate of quality for screening colonoscopy. The Spearman correlation was calculated to compare the adenoma detection rate (ADR), APC, APP, and advanced ADR. The parameters were compared between surgeons and internists and between private practices and hospitals by using the t test.

Results

A total of 44,142 colonoscopies performed by 202 endoscopists were included. APC showed a strong correlation with ADR (r = 0.94; P < .01), and both showed a similar correlation with the advanced ADR (ADR: r = 0.47; P < 0.01, APC: r = 0.46; P < .01). APP showed weaker correlations compared with all other parameters (ADR: r = 0.36; P < .01; advanced ADR: r = 0.19; P < .01). Private practices did not differ in ADR, APP or APC from hospitals. Among endoscopists with ADRs of ≥25%, 7 (10.3%) had an APP in the lowest quartile, whereas no endoscopists had an APC in the lowest quartile.

Conclusions

APC did not reveal additional information to ADR, and thus there is no need to use it instead of or additionally to ADR. Although the APP identifies endoscopists who find few adenomas per procedure despite acceptable ADRs, this additional information might not be important in regard to sufficient colorectal cancer prevention, because these endoscopists still had high advanced ADRs.

Section snippets

Study population

Database records from the quality certificate for screening colonoscopy were used. The quality certificate for screening colonoscopy was founded in 2007 by the Austrian Society of Gastroenterology and Hepatology, the Austrian Federation of Statutory Insurance Institutions, and Austrian Cancer Aid in order to control and improve the colonoscopy performance of voluntarily participating endoscopists. In order to be part of the program and receive annual benchmarks, endoscopists have to provide

Results

From January 2016 until September 2017, the database of the quality certificate for screening colonoscopy contained 50,578 screening colonoscopy records. In total, 44,142 colonoscopies from 202 endoscopists could be included in the study (Fig. 1). They contained 145 private practices (71.8%), 53 hospitals (26.2%), 4 outpatient clinics (2%), 126 internists (62.4%), 72 surgeons (35.6%), and 4 interdisciplinary departments (2%). Among the internists, 34 endoscopists (27%) were gastroenterologists (

Discussion

In this study, we investigated APP and APC as potential new quality parameters. We found good correlations with other quality parameters and no differences depending on setting and profession.

Two possibilities of increasing the ADR despite poor endoscopic performance have been discussed recently: “indication gaming” by retrospectively describing a colonoscopy with no detected adenoma as no screening colonoscopy16, 22 and stopping to look for further adenomas after having detected the first one.

References (35)

D.K. Rex et al.
Quality indicators for colonoscopy
Gastrointest Endosc
(2015)
D. Lieberman et al.
Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable
Gastrointest Endosc
(2007)
M.E. Martinez et al.
A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy
Gastroenterology
(2009)
M.F. Kaminski et al.
Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death
Gastroenterology
(2017)
J.E. Williams et al.
Polypectomy rate as a quality measure for colonoscopy
Gastrointest Endosc
(2011)
J.E. Williams et al.
Polypectomy rate is a valid quality measure for colonoscopy: results from a national endoscopy database
Gastrointest Endosc
(2012)
B. Denis et al.
The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: a population-based cohort study
Dig Liver Dis
(2014)
H.S. Wang et al.
Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance
Gastrointest Endosc
(2013)
C.J. Kahi et al.
Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience
Gastrointest Endosc
(2014)
B. Denis et al.
Measurement of adenoma detection and discrimination during colonoscopy in routine practice: an exploratory study
Gastrointest Endosc
(2011)

H. Abdul-Baki et al.

Public reporting of colonoscopy quality is associated with an increase in endoscopist adenoma detection rate

Gastrointest Endosc

(2015)

H. Pohl et al.

Colorectal cancers detected after colonoscopy frequently result from missed lesions

Clin Gastroenterol Hepatol

(2010)

J.C. Anderson et al.

Providing data for serrated polyp detection rate benchmarks: an analysis of the New Hampshire Colonoscopy Registry

Gastrointest Endosc

(2017)

T.R. de Wijkerslooth et al.

Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time

Gastrointest Endosc

(2013)

C.J. Kahi et al.

Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy

Clin Gastroenterol Hepatol

(2011)

C.J. Kahi et al.

High colonoscopic prevalence of proximal colon serrated polyps in average-risk men and women

Gastrointest Endosc

(2012)

D.K. Rex et al.

Quality indicators for colonoscopy

Am J Gastroenterol

(2006)

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Endoscopist adenomas-per-colonoscopy detection rates and risk for postcolonoscopy colorectal cancer: Data from the New Hampshire Colonoscopy Registry
2024, Gastrointestinal Endoscopy
Adenomas per colonoscopy (APC) may be a better measure of colonoscopy quality than adenoma detection rate (ADR) because it credits endoscopists for each detected adenoma. There are few data examining the association between APC and postcolonoscopy colorectal cancer (PCCRC) incidence. We used data from the New Hampshire Colonoscopy Registry to examine APC and PCCRC risk.
We included New Hampshire Colonoscopy Registry patients with an index examination and at least 1 follow-up event, either a colonoscopy or a colorectal cancer (CRC) diagnosis. Our outcome was PCCRC defined as any CRC diagnosed ≥6 months after an index examination. The exposure variable was endoscopist-specific APC quintiles of .25, .40, .50, and .70. Cox regression was used to model the hazard of PCCRC on APC, controlled for age, sex, year of index examination, index findings, bowel preparation, and having more than 1 surveillance examination.
In 32,535 patients, a lower hazard for PCCRC (n = 178) was observed for higher APCs as compared to APCs of <.25 (reference): .25 to <.40: hazard ratio (HR), .35; 95% confidence interval (CI), .22-.56; .40 to <.50: HR, .31; 95% CI, .20-.49; .50 to <.70: HR, .20; 95% CI, .11-.36; and ≥.70: HR, .19; 95% CI, .09-.37. When examining endoscopists with an ADR of at least 25%, an APC of <.50 was associated with a significantly higher hazard than an APC of ≥.50 (HR, 1.65; 95% CI, 1.06-2.56). A large proportion of endoscopists—one-fifth (32 of 152; 21.1%)—had an ADR of ≥25% but an APC of <.50.
Our novel data demonstrating lower PCCRC risk in examinations performed by endoscopists with higher APCs suggest that APC could be a useful quality measure. Quality improvement programs may identify important deficiencies in endoscopist detection performance by measuring APC for endoscopists with an ADR of ≥25%.
Comparison of Quality Measures for Detection of Neoplasia at Screening Colonoscopy
2023, Clinical Gastroenterology and Hepatology
Citation Excerpt :
The relative reductions in CRC risk and death for ADR were comparable with those shown in other studies.4,5 Both PDR and APC were highly correlated with ADR, which is in line with previous studies.13,14,16–20 Importantly, we found that ADR, PDR, and APC had similar HRs for CRC risk and well-separated CRC cumulative incidence curves.
The proportion of colonoscopies with at least one adenoma (adenoma detection rate [ADR]) is inversely associated with colorectal cancer (CRC) risk and death. The aim of this study was to examine whether such associations exist for colonoscopy quality measures other than ADR.
We used data from the Polish Colorectal Cancer Screening Program collected in 2000–2011. For all endoscopists who performed ≥100 colonoscopies we calculated detection rates of adenomas (ADR), polyps (PDR), and advanced adenomas (≥10 mm/villous component/high-grade dysplasia [AADR]); and number of adenomas per colonoscopy (APC) and per colonoscopy with ≥1 adenoma (APPC). We followed patients until CRC diagnosed before recommended surveillance, death, or December 31, 2019. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional-hazard models. We used Harrell’s C statistic to compare the predictive power of the quality measures.
Data on 173,287 patients (median age, 56 years; 37.8% male) and 262 endoscopists were used. During a median follow-up of 10 years and 1,490,683 person-years, we identified 395 CRCs. All quality measures were significantly associated with CRC risk and death. The relative reductions in CRC risk were as follows: for ADR ≥24.9% (reference <12.1%; HR, 0.41; 95% CI, 0.25–0.66), PDR ≥42.7% (reference <19.9%; HR, 0.35; 95% CI, 0.24–0.51), AADR ≥9.1% (reference <4.1%; HR, 0.69; 95% CI, 0.49–0.96), APC ≥0.37 (reference <0.15; HR, 0.35; 95% CI, 0.21–0.58), and APPC ≥1.54 (reference <1.19; HR, 0.54; 95% CI, 0.35–0.83). AADR was the only quality measure with significantly lower predictive power than ADR (Harrell’s C, 59.7 vs 63.4; P = .001). Similar relative reductions were observed for CRC death.
This large observational study confirmed the inverse association between ADR and CRC risk and death. The PDR and APC quality measures appear to be comparable with ADR.
Uptake of Colorectal Cancer Screening in 45 to 49 Year Olds: An Early-Inning View from the Endoscopy Suite
2022, Clinical Gastroenterology and Hepatology
High-quality Studies of Artificial Intelligence in Colonoscopy Illuminate a Next Important Step
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Magnitude, Risk Factors, and Factors Associated With Adenoma Miss Rate of Tandem Colonoscopy: A Systematic Review and Meta-analysis
2019, Gastroenterology
Citation Excerpt :
Rationally, ADR represents the ability of colonoscopy to distinguish the presence from the absence of adenomas for all colonoscopies, whereas APPC represents the ability to distinguish the magnitude of adenomas in positive colonoscopy, which could compensate for the weakness of ADR in monitoring the number of adenomas. The >10% of endoscopists with ≥25% ADR being in the lowest quartile of APPC also underscores the different distinguishing ability between ADR and APPC.43,44 Although Gessl et al43 also found a weak correlation (r = 0.19, P < 0.01) between APPC and advanced ADR, their study merely correlated advanced ADR with ADR or APPC, without assessing the value of combining ADR with APPC or the potential value of these indicators in monitoring AMR and AAMR.
We performed a systematic review and meta-analysis to comprehensively estimate adenoma miss rate (AMR) and advanced AMR (AAMR) and explore associated factors.
We searched the PubMed, Web of Science, and Ovid EMBASE databases for studies published through April 2018 on tandem colonoscopies, with AMR and AAMR as the primary outcomes. We performed meta-regression analyses to identify risk factors and factors associated with outcome. Primary outcomes were AMR and AAMR and secondary outcomes were AMR and AAMR for different locations, sizes, pathologies, morphologies, and populations.
In a meta-analysis of 43 publications and more than 15,000 tandem colonoscopies, we calculated miss rates of 26% for adenomas (95% confidence interval [CI] 23%–30%), 9% for advanced adenomas (95% CI 4%–16%), and 27% for serrated polyps (95% CI 16%–40%). Miss rates were high for proximal advanced adenomas (14%; 95% CI 5%–26%), serrated polyps (27%; 95% CI 16%–40%), flat adenomas (34%; 95% CI 24%–45%), and in patients at high risk for colorectal cancer (33%; 95% CI 26%–41%). Miss rates could be decreased by adequate bowel preparation and auxiliary techniques (P = .06; P = .04, and P = .01, respectively). The adenoma detection rate (ADR), adenomas per index colonoscopy, and adenomas per positive index colonoscopy (APPC) were independently associated with AMR (P = .02, P = .01, and P = .008, respectively), whereas APPC was the only factor independently associated with AAMR (P = .006). An APPC value greater than 1.8 was more effective in monitoring AMR (31% vs 15% for AMR P < .0001) than an ADR value of at least 34% (27% vs 17% for AMR; P = .008). The AAMR of colonoscopies with an APPC value below 1.7 was 35%, vs 2% for colonoscopies with an APPC value of at least 1.7 (P = .0005).
In a systematic review and meta-analysis, we found that adenomas and advanced adenomas are missed (based on AMR and AAMR) more frequently than previously believed. In addition to ADR, APPC deserves consideration as a complementary indicator of colonoscopy quality, if it is validated in additional studies.
Ensuring that endoscopists completely clear the colon of adenomas: Perhaps we try more carrots?
2019, Gastrointestinal Endoscopy

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: DISCLOSURE: The project “quality certificate for screening colonoscopy” was conducted in cooperation with the Austrian Society of Gastroenterology and Hepatology, the Main Association of Austrian Social Security Institutions, and Austrian Cancer Aid. The project was funded by § 447h ASVG (fund for preventive check-ups and health promotion). The funding organizations played no role in the design and conduct of the study, in the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the manuscript. All other authors disclosed no financial relationships relevant to this publication.

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Original articleClinical endoscopyEvaluation of adenomas per colonoscopy and adenomas per positive participant as new quality parameters in screening colonoscopy

Background and Aims

Methods

Results

Conclusions

Section snippets

Study population

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Dig Liver Dis

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Quality indicators for colonoscopy

Am J Gastroenterol

Original article
Clinical endoscopy
Evaluation of adenomas per colonoscopy and adenomas per positive participant as new quality parameters in screening colonoscopy