HIGH-TECH Enhanced scope technology may be the key to improved adenoma detection.

The secret to a "good" adenoma detection rate? Most gastroenterologists will say it comes down to 2 key variables: the clinician's level of care and the withdrawal time ("At least 6 minutes," is the common refrain). Even so, high-tech tools designed to improve visualization — high-resolution imaging, accessories for peering into the tough-to-see spaces behind mucosal folds, and full-spectrum cameras offering far superior wall-to-wall views — can change the game in a GI doc's favor.

"Our future in endoscopy is in technology," says gastroenterologist Vincent Jabour, MD, of the Wooster (Ohio) Ambulatory Surgery Center. "It will lead us to better detection rates. Just look at how much scopes have improved in the last 10 years. We've had a dramatic improvement in terms of flexibility and visualization. Right now, most of us are looking at a 180- to 240-degree view, and in time it will be an even better view."

Although there are no adequate substitutes for training and conscientious technique, physicians now have more tools than ever to reach, and even exceed, the ADR gold standard, which currently stands at 30% for male patients and 20% for females. ADR is defined as the percentage of first-time patients in which at least 1 adenoma has been detected during a screening. Here are 4 trends that can help GI centers improve their ADR rate.

• Improved visualization. Just as it has in other areas of medicine, high-definition imaging has turned endoscopists' world on its ear: superior image quality for discovering and treating adenomas that might otherwise have gone undetected; faster cecal intubation times; and increased contrast for examining mucosal tissue. For example, visualization systems that employ narrow band imaging (NBI) can drive up ADR because NBI enhances the visibility of vessels and other tissue on the mucosal surface.

Wide-angle and full-spectrum colonoscopes, as well as ancillary devices with side-viewing cameras and powerful light sources, have significantly expanded the effective view of the colon — as much as 330 degrees, compared to the standard 170-degree view of traditional forward-viewing colonoscopes, which might not easily show adenomas in mucosal folds. A 2015 study in the World Journal of Gastroenterology showed that endoscopists achieved an ADR of 44% using an accessory device equipped with a panoramic view.

THE ECONOMICS OF ADR
How ADR Drives Revenue

INDICATIVE Besides measuring how well you're screening patients, ADR can indicate the potential for financial growth.

Ask Reed B. Hogan II, MD, and he'll share his secret to improving his adenoma detection rate, just one of the metrics his facility has been measuring for nearly a decade. It's a simple formula: time plus pressure equals success. For time, it's a 6-minute minimum for withdrawal. For pressure, he's referring to the "reward of peer pressure" he and his fellow doctors share in diligently screening each patient.

"We're a group of 30 doctors, and nobody wants to be the last guy [in terms of ADR]," says Dr. Hogan, a senior partner in GI Associates & Endoscopy Center of Flowood, Miss. "It's all about raising the level — measuring withdrawal times, slowing people down and stacking ourselves up against each other."

Such competition ultimately benefits the patient.

"If a doctor has a 10% ADR, that means he's probably not a very good doctor," he says. "By virtue of his low ADR, those patients who see him have an increased risk of death [from colon cancer]."

And while ADR may measure a center's effectiveness in screening at-risk patients, it can also indicate the potential for financial growth.

"ADR is a moneymaker," says Dr. Hogan, adding that all of his facility's doctors have ADRs above the national average. "It drives revenue ancillary to pathology. It fills up the schedule. It fills up the future. But few people talk about it as a revenue promoter."

Say a physician sees 1,000 patients a year and has a 10% ADR. Those 100 patients would be invited back for follow-up screenings within the next 3 to 5 years, but the other 90% — 900 patients — would not be invited back for 10 years. Translation: A higher ADR not only measures how well you're screening patients, it also feeds your bottom line.

— Bill Donahue

NEW VIEW Side-viewing cameras offer wall-to-wall views of the mucosa. An adenoma can be seen here in the right lateral view.

IN CONTROL Can ergonomic controller designs address the musculoskeletal complaints common among endoscopists?

ACCESSORIZE Accessories such as the endoscopic cuff are designed to enhance visualization of the mucosa.

"Almost without a doubt, we will have side-viewing scopes here within the next 3 to 5 years," says Reed B. Hogan II, MD, senior partner in GI Associates & Endoscopy Center of Flowood, Miss. "When they're at the right price, I think the majority of us will go for it because it will improve care and it's a way to increase ADR."

• A closer look. While the retroflexion technique can improve detection of polyps, particularly in the distal rectum, a number of disposable accessory devices let endoscopists enjoy better visualization of the mucosa throughout the colon. Example: The endoscopic cuff, which slides over the distal tip of the colonoscope, features flexible finger-like projections designed to flatten the walls of the colon. According to a May 2015 study published in the Journal of Clinical Gastroenterology, ADR increased 14% when performing a colonoscopy with an endoscopic cuff, while the number of polyps detected per patient climbed by 63%.

The issue of cost may be prohibiting broad acceptance of such devices, especially as reimbursements slide and profit margins get sliced thinner and thinner. Regardless of its effectiveness in visualizing the tissue in the mucosal folds, Dr. Hogan considers the device — at a little more than $20 each, by his estimate — to be cost-prohibitive. "For a company like ours, doing 20,000 colonoscopies per year, that would have cost us about $460,000 a year," he says. "We can buy a set of scopes for that much."

• Ergonomically speaking. Musculoskeletal complaints are common among endoscopists, according to a 2014 study from the Journal of Clinical Gastroenterology, with cervical disk injuries and carpal tunnel syndrome often reported as side effects of performing a lot of colonoscopies. As a result, manufacturers have looked to ease strain through more contemporized designs, including lightweight controllers with joystick-style handling. The thinking here: More comfortable controllers might work to prevent fatigue during a colonoscopy, thereby helping the physician to maintain his focus for the duration of the withdrawal process.
• Preparation is key. As Dr. Hogan says, "If you don't have a good prep, you don't have a good ADR." Some surgical facilities have moved toward split-dose liquid preps, with patients beginning the process the night before and then finishing the cleanse the day of their procedure. Regardless of the method, keep a close eye on patient compliance. If patients consistently fail, take a closer look at protocol, says Joyce Mackler, RN, MSN, CASC, the administrator of Seaford (Del.) Endoscopy Center. "There's more than one way to clean a colon," she says. "How many people do you have to bring back because of a bad prep? The more complicated you make it, the less success you'll likely have."

Although new technology, tools and techniques can each play an important role in improving ADR, clinicians agree that a quality colonoscopy — and a good ADR — comes down to a sole defining factor: the skill of the endoscopist. OSM