Culture of quality key to improved ADRs

Colonoscopy remains an effective method of colorectal cancer (CRC) screening and has been shown to reduce CRC deaths by around 50 percent through detection and removal of precancerous lesions. But adenoma detection rates (ADRs) — defined as the percentage of exams with at least one adenoma detected — vary widely. In a large, retrospective study, Kaiser Permanente researchers found that among 136 endoscopists, ADRs ranged from 7.4 to 52 percent (9.7 to 60.5 percent for male patients and 3.9 to 39.9 percent for female patients).

In January 2015, the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology increased their ADR target to at least 25 percent overall (30 percent for men and 20 percent for women).

The Kaiser study, which appeared in 2014 in The New England Journal of Medicine, proved that higher targets are needed. Each 1 percent increase in the ADR was associated with a 3 percent reduced risk of interval cancer. Over 10 years, patients of physicians with the highest ADRs — 33 to 52 percent across all colonoscopies — developed CRC at a rate of about 0.05 percent a year compared with 0.1 percent a year for patients of physicians whose ADRs ranged from 7 to 19 percent.

The EQUIP trials

Michael B. Wallace, M.D., a gastroenterologist at Mayo Clinic's campus in Jacksonville, Florida, says Mayo is committed to improving the quality of colonoscopy through ADR measurement.

"There is a broad consensus that ADR is a good way of measuring quality. It's a surrogate marker that is very tightly linked with the prevention of colon cancer," he says. "In the mid-2000s, we started looking at our ADR, which was pretty good, but we thought we could do better. So we initiated a series of studies in which 15 endoscopists who routinely performed colonoscopies in our ambulatory practice were randomized to an Endoscopic Quality Improvement Program (EQUIP)."

The simple educational intervention led to significantly improved adenoma and polyp detection rates. At baseline, the ADR for all endoscopists was 36 percent. Post-training, the ADR for the EQUIP group increased to 47 percent but remained virtually unchanged for untrained endoscopists. Polyp detection also increased, from 51 to 65 percent in the EQUIP group, but just 53 to 54 percent among untrained physicians. The results were published in 2013 in The American Journal of Gastroenterology.

Later, in phase III of that study, the trained endoscopists were prospectively followed for five months after the intervention. Their ADRs remained statistically unchanged, showing that improvements obtained through EQUIP are durable. Study results appeared in the September 2014 issue of The American Journal of Gastroenterology.

Dr. Wallace says ADRs are still monitored throughout the practice. "We continue to observe extremely high rates of polyp detection — 52 to 80 percent — which exceed the highest threshold that has been reported," he observes. "Sixty to 65 percent of those are adenomatous polyps, and that has been validated in our data, in data from Mayo Clinic's Rochester campus and in the entire Medicare population."

He attributes this in large part to a culture of quality. "The whole group is focused on maximizing quality. We are very open to looking critically at quality and any areas of deficiency, and we improve through an active, open and positive process, not a punitive one," he explains. "On the practical level, we have posters in every endoscopy suite explaining what constitutes high-quality colonoscopy and what to look for. Nurses are very much part of the team, too. We don't just have doctors looking, because we know that having both doctors and nurses looking improves ADR. We have at least four eyes on the screen in every case."

The future of quality

Dr. Wallace and colleagues have developed a national endoscopic quality improvement program, enrolling 10 centers across the U.S.

"We looked at 30,000 colonoscopies and the quality is quite good nationwide, but there are exceptions," he says. "The ones that are doing well have created cultures of quality where they measure ADR, identify areas for improvement and openly discuss how to achieve it. Those that don't do well don't have a quality improvement program, and many of the physicians performing colonoscopies weren't trained in gastroenterology."

EQUIP was also recently expanded to all Veterans Affairs and New York public hospitals. "We've come a long way in 10 years in learning how to measure ADR, improving in more centers and undertaking more studies. It's all making a huge difference," Dr. Wallace says.

For more information

Corley DA, et al. Adenoma detection rate and risk of colorectal cancer and death. The New England Journal of Medicine. 2014;370:1298.

Coe SG, et al. An endoscopic quality improvement program improves detection of colorectal adenomas. The American Journal of Gastroenterology. 2013;108:219.

Ussui V, et al. Stability of increased adenoma detection at colonoscopy. Follow-up of an endoscopic quality improvement program-EQUIP-II. The American Journal of Gastroenterology. 2014 online.