Clin Endosc.  2022 May;55(3):332-338. 10.5946/ce.2022.037.

Quality indicators in colonoscopy: the chasm between ideal and reality

• Park SB
• Cha JM

• KMID: 2529952
• DOI: http://doi.org/10.5946/ce.2022.037

Abstract

Continuous measurement of quality indicators (QIs) should be a routine part of colonoscopy, as a wide variation still exists in the performance and quality levels of colonoscopy in Korea. Among the many QIs of colonoscopy, the adenoma detection rate, average withdrawal time, bowel preparation adequacy, and cecal intubation rate should be monitored in daily clinical practice to improve the quality of the procedure. The adenoma detection rate is the best indicator of the quality of colonoscopy; however, it has many limitations for universal use in daily practice. With the development of natural language processing, the adenoma detection rate is expected to become more effective and useful. It is important that colonoscopists do not strictly and mechanically maintain an average withdrawal time of 6 minutes but instead perform careful colonoscopy to maximally expose the colonic mucosa with a withdrawal time of at least 6 minutes. To achieve adequate bowel preparation, documentation of bowel preparation with the Boston Bowel Preparation Scale (BBPS) should be a routine part of colonoscopy. When colonoscopists routinely followed the bowel preparation protocols, ≥85% of outpatient screening colonoscopies had a BBPS score of ≥6. In addition, the cecal intubation rate should be ≥95% of all screening colonoscopies. The first step in improving colonoscopy quality in Korea is to apply these key performance measurements in clinical practice.

Keyword

Adenoma detection rate; Colonoscopy; Quality; Screening

Reference

1. Wong MC, Ding H, Wang J, et al. Prevalence and risk factors of colorectal cancer in Asia. Intest Res. 2019; 17:317–329.

2. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993; 329:1977–1981.

3. Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012; 366:687–696.

4. van Rijn JC, Reitsma JB, Stoker J, et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol. 2006; 101:343–350.

5. Pickhardt PJ, Nugent PA, Mysliwiec PA, et al. Location of adenomas missed by optical colonoscopy. Ann Intern Med. 2004; 141:352–359.

6. Heresbach D, Barrioz T, Lapalus MG, et al. Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies. Endoscopy. 2008; 40:284–290.

7. Ahn SB, Han DS, Bae JH, et al. The miss rate for colorectal adenoma determined by quality-adjusted, back-to-back colonoscopies. Gut Liver. 2012; 6:64–70.

8. Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol. 2007; 102:856–861.

9. Hetzel JT, Huang CS, Coukos JA, et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol. 2010; 105:2656–2664.

10. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2015; 110:72–90.

11. Keswani RN, Crockett SD, Calderwood AH. AGA clinical practice update on strategies to improve quality of screening and surveillance colonoscopy: expert review. Gastroenterology. 2021; 161:701–711.

12. Sanaka MR, Gohel T, Podugu A, et al. Adenoma and sessile serrated polyp detection rates: variation by patient sex and colonic segment but not specialty of the endoscopist. Dis Colon Rectum. 2014; 57:1113–1119.

13. 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.

14. 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.

15. 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.

16. Boroff ES, Gurudu SR, Hentz JG, et al. Polyp and adenoma detection rates in the proximal and distal colon. Am J Gastroenterol. 2013; 108:993–999.

17. Imler TD, Morea J, Kahi C, et al. Multi-center colonoscopy quality measurement utilizing natural language processing. Am J Gastroenterol. 2015; 110:543–552.

18. Mehrotra A, Dellon ES, Schoen RE, et al. Applying a natural language processing tool to electronic health records to assess performance on colonoscopy quality measures. Gastrointest Endosc. 2012; 75:1233–1239.

19. Raju GS, Lum PJ, Slack RS, et al. Natural language processing as an alternative to manual reporting of colonoscopy quality metrics. Gastrointest Endosc. 2015; 82:512–519.

20. Park SK, Kim HY, Lee CK, et al. Comparison of adenoma detection rate and adenoma per colonoscopy as a quality indicator of colonoscopy. Scand J Gastroenterol. 2016; 51:886–890.

21. Do A, Weinberg J, Kakkar A, et al. Reliability of adenoma detection rate is based on procedural volume. Gastrointest Endosc. 2013; 77:376–380.

22. Robertson DJ, Lee JK, Boland CR, et al. Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on colorectal cancer. Gastrointest Endosc. 2017; 85:2–21.

23. Yoon JY, Cha JM, Shin JE, et al. An adjusted level of adenoma detection rate is necessary for adults below 50 years old. J Clin Gastroenterol. 2018; 52:703–708.

24. Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med. 2006; 355:2533–2541.

25. Chaptini L, Laine L. Can I improve my adenoma detection rate? J Clin Gastroenterol. 2015; 49:270–281.

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. Barclay RL, Vicari JJ, Greenlaw RL. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008; 6:1091–1098.

28. Vavricka SR, Sulz MC, Degen L, et al. Monitoring colonoscopy withdrawal time significantly improves the adenoma detection rate and the performance of endoscopists. Endoscopy. 2016; 48:256–262.

29. Kaminski MF, Thomas-Gibson S, Bugajski M, et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. United European Gastroenterol J. 2017; 5:309–334.

30. Butterly L, Robinson CM, Anderson JC, et al. Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry. Am J Gastroenterol. 2014; 109:417–426.

31. Moritz V, Bretthauer M, Ruud HK, et al. Withdrawal time as a quality indicator for colonoscopy: a nationwide analysis. Endoscopy. 2012; 44:476–481.

32. Jung Y, Joo YE, Kim HG, et al. Relationship between the endoscopic withdrawal time and adenoma/polyp detection rate in individual colonic segments: a KASID multicenter study. Gastrointest Endosc. 2019; 89:523–530.

33. Bianco MA, Cipolletta L, Rotondano G, et al. Prevalence of nonpolypoid colorectal neoplasia: an Italian multicenter observational study. Endoscopy. 2010; 42:279–285.

34. Munoz Garcia-Borruel M, Hervas Molina AJ, Rodriguez Peralvarez ML, et al. Post-colonoscopy colorectal cancer: characteristics and predictive factors. Med Clin (Barc). 2018; 150:1–7.

35. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol. 2002; 97:1296–1308.

36. Larsen M, Hills N, Terdiman J. The impact of the quality of colon preparation on follow-up colonoscopy recommendations. Am J Gastroenterol. 2011; 106:2058–2062.

37. Calderwood AH, Jacobson BC. Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc. 2010; 72:686–692.

38. 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.

39. Johnson DA, Barkun AN, Cohen LB, et al. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi-society task force on colorectal cancer. Gastrointest Endosc. 2014; 80:543–562.

40. Clark BT, Protiva P, Nagar A, et al. Quantification of adequate bowel preparation for screening or surveillance colonoscopy in men. Gastroenterology. 2016; 150:396–405.

41. Kilgore TW, Abdinoor AA, Szary NM, et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. Gastrointest Endosc. 2011; 73:1240–1245.

42. Kim J, Kim HG, Kim KO, et al. Clinical comparison of low-volume agents (oral sulfate solution and sodium picosulfate with magnesium citrate) for bowel preparation: the EASE study. Intest Res. 2019; 17:413–418.

43. Shin SH, Kwon KA. Oral sulfate solution is as effective as 2 L polyethylene glycol plus ascorbic acid. Clin Endosc. 2020; 53:503–504.

44. Hassan C, Bretthauer M, Kaminski MF, et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2013; 45:142–150.

45. Woo DH, Kim KO, Jeong DE, et al. Prospective analysis of factors associated with inadequate bowel preparation for colonoscopy in actual clinical practice. Intest Res. 2018; 16:293–298.

46. Lee TJ, Rutter MD, Blanks RG, et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut. 2012; 61:1050–1057.

47. Baxter NN, Sutradhar R, Forbes SS, et al. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology. 2011; 140:65–72.

48. Rex DK, Chen SC, Overhiser AJ. Colonoscopy technique in consecutive patients referred for prior incomplete colonoscopy. Clin Gastroenterol Hepatol. 2007; 5:879–883.

49. Park SH, Hong KI, Park HC, et al. Colon polyp detection in primary health care institutions of Korea: detection rate and issues with following the guidelines. Korean J Gastroenterol. 2021; 78:328–336.

50. Kim DH, Lee SY, Choi KS, et al. The usefulness of colonoscopy as a screening test for detecting colorectal polyps. Hepatogastroenterology. 2007; 54:2240–2242.

51. Choi JH, Cha JM, Yoon JY, et al. The current capacity and quality of colonoscopy in Korea. Intest Res. 2019; 17:119–126.

52. Bretthauer M, Kaminski MF, Loberg M, et al. Population-based colonoscopy screening for colorectal cancer: a randomized clinical trial. JAMA Intern Med. 2016; 176:894–902.

53. Yoon JY, Cha JM, Jeen YT, et al. Quality is the key for emerging issues of population-based colonoscopy screening. Intest Res. 2018; 16:48–54.