There are plenty of metrics you can use to measure the effectiveness of the colonoscopies your GI docs perform, but none are more important than adenoma detection rate (ADR) — the rate in patients 50 and older undergoing first-time colonoscopy screenings who have 1 or more adenomas detected and removed.

Studies (osmag.net/PpX9Jy) show that ADR is inversely correlated to the rates of interval colorectal cancer risk (iCRC) — those cancers that may develop due to missed or incompletely resected polyps. Let's look at how your endoscopists can get ADR above the recommended minimum, which the American Society for Gastrointestinal Endoscopy (ASCE) and the American College of Gastroenterology's (ACG) Taskforce on Quality in Endoscopy put at 25% for all patients (30% for men; 20% for women).

1. Technique is tantamount. As innovations in colonoscopy tech continue to emerge, it may be tempting to rely too heavily on the stunning HD-quality imagery, nearly 360-degree angle, wall-to-wall views of the colon or even artificial intelligence during screenings, but technology will never replace technique. Physicians must be competent, confident and consistent at detecting and removing polyps. What do all gastroenterologists with above average ADR rates have in common? "They come into every procedure with a very detailed understanding of what precancerous lesions look like in the colon," says gastroenterologist Douglas K. Rex, MD, a professor at Indiana University-Purdue University in Indianapolis. "They understand what serrated and adenomatous polyps look like," adds Dr. Rex. And the physicians who don't? They're likely missing critical methods for adenoma detection. These are the GI docs who don't expose all of the mucosa when they're passing the scope through the haustral fold, who don't realize the fold has hidden some mucosa from view and don't work at going back in and poking the tip of the scope in between those folds and exposing that mucosa, says Dr. Rex.

To prevent missed adenomas: Adhere to a minimum withdrawal time of 6 minutes. That metric comes from the ASGE/ACG Taskforce. "This is a process measure of the amount of time you spent looking for polyps during a colonoscopy," says Rajesh N. Keswani, MD, medical director of quality at Northwestern Medicine Digestive Health Center in Chicago, Ill., a facility that does approximately 18,000 colonoscopies each year. "It's a surrogate measure of how careful you are during screenings looking for polyps, it highly correlates with the risk of developing cancer after colonoscopy and it's relatively easy to populate in your unit," adds Dr. Keswani.

Another proven way to boost your ADR rates is to compare your physicians' performances and focus on the outliers for improvement. At Northwestern, this is accomplished through semi-annual ADR report cards. "Every colonoscopist in our unit gets a report card with their 6-month ADR rate that's benchmarked to their peers who have a similar population of patients," says Dr. Keswani. "If someone's ADR is just 10% and their peers are at 30%, they know there's an issue that needs to be addressed."

These physicians, the outlier performers whose ADR is less than 20%, are the ones to focus your efforts on, whether it's through remediation, additional scope training or even reassessing the privileges they're allowed to have in endoscopy. "Getting people's ADR from 42% to 45% may have little to no effect," says Dr. Keswani, "but if you look at all the studies, the relative risk of your patient developing cancer if they get scoped by a person with a fair or a very low ADR compared to someone with a high ADR is quite significant. It's almost 5 times higher."

2. Split-prep is the only prep. At many facilities, split-prep bowel treatment — taking half the prep drink the night before the procedure and the other half the morning of (say 5 hours prior to the colonoscopy) — is the standard. But if you're not doing split prep, you need to start. "You need to make sure all patients coming in for a colonoscopy are getting split-dose bowel preparations," says Dr. Keswani.

"It's another structural thing you can implement in your lab that markedly improves the overall quality of the colonoscopy." And this improved quality translates to higher ADR. "Using split-prep bowel preparation has been shown in randomized trials to improve ADR," says Dr. Rex. This is a fundamental part of achieving high-quality colonoscopy, but for whatever reason, there are still a fair number of people who don't appreciate the importance of using split prep, adds Dr. Rex.

High-quality colonoscopy that translates to above average ADRs essentially comes down to equipping skilled, knowledgeable endoscopists with high-definition scopes, measuring and benchmarking their performance, and ensuring that all patients use split-bowel preparations. If you do these things, there's no reason all your GI docs won't meet the minimum 25% adenoma detection rate. But why not aspire for more? "For any endoscopy doctors who are interested in high-quality colonoscopy, which should be all of us, that target ADR should be closer to 35%," says Dr. Keswani. "That 25% is sometimes called the "basement' ADR and that 35% the "aspirational' ADR. That's where we should all strive to be." OSM