To develop an automated method for Adenoma Detection Rate (ADR) calculation and report card generation using common electronic health records (EHRs).

ADR is the most widely accepted colonoscopy quality indicator and is inversely associated with interval colorectal cancer incidence and mortality. However, ADR is difficult to efficiently measure and disseminate, due to need for data integration from distinct electronic databases.

We migrated data from an endoscopy reporting software (Endosoft) to Epic Reporting Servers where it was combined with anatomic pathology data (Beaker Lab Information System, EPIC Systems). A natural language processing expression was developed to search Beaker pathology reports for accurate identification of adenomatous polyps. A blinded physician manually validated a final cohort of 200 random procedures. ADR report cards were automatically generated utilizing the Crystal Reports feature within EPIC.

Validation of the natural language processing algorithm for ADR showed a sensitivity, specificity, and accuracy of 100%. ADR was automatically calculated for 12 endoscopists over a calendar year. Two thousand two hundred seventy-six screening colonoscopies were performed with 775 procedures having a least one adenoma detected, for a total ADR of 34%. Report cards were successfully generated within the EPIC EHR and distributed to endoscopists by secure e-mail.

We describe an accurate, automated and scalable process for ADR calculation and reporting utilizing commonly adopted EHRs and data integration methods. By integrating the process of ADR collection and streamlining dissemination of reports, this methodology is poised to enhance colonoscopy quality care across health care networks that use it.

Strategies to promote high-quality endoscopy in children require consensus around pediatric-specific quality standards and indicators. Using a rigorous guideline development process, the international Pediatric Endoscopy Quality Improvement Network (PEnQuIN) was developed to support continuous quality improvement efforts within and across pediatric endoscopy services.

This review presents a framework, informed by the PEnQuIN guidelines, for assessing endoscopist competence, granting procedural privileges, audit and feedback, and for skill remediation, when required. As is critical for promoting quality, PEnQuIN indicators can be benchmarked at the individual endoscopist, endoscopy facility, and endoscopy community levels. Furthermore, efforts to incorporate technologies, including electronic medical records and artificial intelligence, into endoscopic quality improvement processes can aid in creation of large-scale networks to facilitate comparison and standardization of quality indicator reporting across sites.

PEnQuIN quality standards and indicators provide a framework for continuous quality improvement in pediatric endoscopy, benefiting individual endoscopists, endoscopy facilities, and the broader endoscopy community. Routine and reliable measurement of data, facilitated by technology, is required to identify and drive improvements in care. Engaging all stakeholders in endoscopy quality improvement processes is crucial to enhancing patient outcomes and establishing best practices for safe, efficient, and effective pediatric endoscopic care.

Adenoma detection rate (ADR) is inversely correlated with the risk of interval colon cancer and is a key target for quality improvement in endoscopy units. We conducted a systematic review and meta-analysis to identify and evaluate the effectiveness of interventions that can be implemented at the endoscopy unit level to improve ADRs.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases between January 1990 and December 2022 to identify relevant studies. Both randomized controlled trials and observational studies were eligible. Data for the primary outcome of ADR were analyzed and reported on the log-odds scale with 95% CIs using a random-effects meta-analysis model using the empiric Bayes estimator.

From 10,778 initial citations, 34 studies were included in the meta-analysis comprising 371,041 procedures and 1501 endoscopists. The provision of report cards (odds ratio [OR], 1.28; 95% CI, 1.13-1.45; P < .001) and the presence of an additional observer to identify polyps (OR, 1.25; 95% CI, 1.09-1.43; P = .002) were associated with significant increases in ADRs whereas multimodal interventions were borderline significant (OR, 1.18; 95% CI, 1.00-1.40; P = .05) and withdrawal time monitoring was not associated significantly with an increase in ADRs (OR, 1.35; 95% CI, 0.93-1.96; P = .11).

The provision of report cards and the presence of an additional observer to identify polyps are associated with improved ADRs and should be considered for implementation in endoscopy facilities.

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear.

We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly.

Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%.

Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Screening-related colonoscopy is a vital component of screening initiatives to both diagnose and prevent colorectal cancer (CRC), with prevention being reliant upon early and accurate detection of pre-malignant lesions. Several strategies, techniques, and interventions exist to optimize endoscopists' adenoma detection rates (ADR).

This narrative review provides an overview of the importance of ADR and other colonoscopy quality indicators. It then summarizes the available evidence regarding the effectiveness of the following domains in terms of improving ADR: endoscopist factors, pre-procedural parameters, peri-procedural parameters, intra-procedural strategies and techniques, antispasmodics, distal attachment devices, enhanced colonoscopy technologies, enhanced optics, and artificial intelligence. These summaries are based on an electronic search of the databases Embase, PubMed, and Cochrane performed on 12 December 2022.

Given the prevalence and associated morbidity and mortality of CRC, the quality of screening-related colonoscopy quality is appropriately prioritized by patients, endoscopists, units, and payers alike. Endoscopists performing colonoscopy should be up to date regarding available strategies, techniques, and interventions to optimize their performance.

Worldwide, the volume and availability of digestive endoscopy have undergone dramatic development in recent years, with increasing attention on quality assurance. We investigated the utilization and quality of digestive endoscopy in China from 2015 to 2019 and developed a quantitative quality evaluation tool for medical institutions.

We invited all tertiary/secondary hospitals in Chinese mainland to participate in the survey annually. The questionnaires included the personnel, annual volume, and quality indicators of endoscopy. An endoscopy quality index (EQI) was developed based on recorded quality indicators using principal component analysis to determine the relative weight.

From 2015 to 2019, 806, 1412, 2644, 2468, and 2541 hospitals were respectively enrolled in this study. The average annual volume of endoscopy increased from 12,445 to 16,206 (1.30-fold) and from 2938 to 4255 (1.45-fold) in tertiary and secondary hospitals, respectively. The most obvious growth was observed in diagnostic colonoscopy (1.44-fold for all hospitals after standardization). The proportion of early cancer among all esophageal and gastric cancers during diagnostic esophagogastroduodenoscopy increased from 12.3% (55,210/448,861) to 17.7% (85,429/482,647) and from 11.4% (69,411/608,866) to 16.9% (107,192/634,235), respectively. The adenoma detection rate of diagnostic colonoscopy increased from 14.9% (2,118,123/14,215,592) to 19.3% (3,943,203/20,431,104). The EQI model included 12 quality indicators, incorporating 64.9% (7.792/12) of the total variance into one comprehensive index. According to the EQI measurements, the quality of endoscopy was higher in tertiary hospitals and hospitals in developed areas with higher volume or more endoscopists than that in other hospitals.

Digestive endoscopy in China has developed considerably in recent years in terms of both volume and quality. The EQI is a promising tool to quantify the quality of endoscopy at different hospitals.

Measuring the adenoma detection rate (ADR) is critical to providing quality care, however it is also challenging. We aimed to develop a tool using pre-existing electronic health record (EHR) functions to accurately and easily measure total ADR and to provide real-time feedback for endoscopists. We utilized the Epic EHR. With the help of an Epic analyst, using existing tools, we developed a method by which endoscopy staff could mark whether an adenoma was detected for a given colonoscopy. Using these responses and all colonoscopies performed by the endoscopist recorded in the EHR, ADR was calculated in a report and displayed to endoscopists within the EHR. One endoscopist piloted the tool, and results of the tool were validated against a manual chart review. Over the pilot period the endoscopist performed 145 colonoscopies, of which 78 had adenomas. The tool correctly identified 76/78 colonoscopies with an adenoma and 67/67 of colonoscopies with no adenomas (97.4% sensitivity, 100% specificity, 98% accuracy). There was no difference in ADR as determined by the tool compared to manual review (53.1% vs. 53.8%, p = 0.912). We successfully developed and pilot tested a tool to measure ADR using existing EHR functionality.

Background and study aims  First case start (FCS) time is often a key metric used to gauge efficiency in an endoscopy suite. There are limited data on tools and methods to improve the FCS time in the endoscopy suite. Methods  A prospective observational cohort study was conducted in an academic tertiary care endoscopy suite examining the effect of badge sign-in (Period 2) and badge sign-in coupled with report cards (Period 3) compared to an initial observational period (Period 1). Results  After the badge sign-in reader was introduced in P2, the unit experienced a mean time savings of 5 ± 18 minutes in FCS delays compared to P1 ( P  = .03). In P3, an 8 ± 17-minute time savings in FCS time delay was observed compared to P1 ( P  = 0.0006). Sign-in compliance significantly increased for the overall unit between P2 and P3 (49 % vs. 59 %, P  = .002). Increases in first case on-time start (FCOTS) rates compared to P1 were observed for the unit, with a 14% absolute increase in P2 ( P  < .0001) and a 17 % absolute increase in P3 ( P  < .0001). FCS delays for on-time badge sign-ins were significantly lower compared to FCS delays for missed badge sign-ins and late badge sign-ins ( P  < .0001). Conclusions  The use of badge sign-in and report cards improve endoscopy unit efficiency as it can increase FCOTS rates and decrease FCS time delays.

Monitoring of key performance indicators (KPIs) is a vital element of endoscopy quality improvement. Adenoma detection rate (ADR) is considered the best marker for colonoscopic quality as it inversely correlates with subsequent colonic cancer incidence and mortality, while polyp detection rate (PDR) is an easier-to-calculate surrogate for ADR. This study assessed whether regular feedback to individual endoscopists about their KPIs improved departmental performance.

Individual KPIs were calculated for a period of 8 years (January 2012-December 2019) and fed back to all endoscopists at 6 monthly intervals, alongside anonymised indicators for other endoscopists, aggregate departmental performance data and benchmarks. An automated natural language processing software (EndoMineR) was used to identify adenomas in pathology reports and calculate ADR. Linear regressions were calculated for departmental ADR, PDR and other KPIs at 6 monthly intervals.

39 359 colonoscopies (average 2460 in every 6-month period, range 1799-3059) were performed by an average of 42 (range 34-50) endoscopists. A continuous improvement in collective performance including ADR (12.7%-21.0%, R² 0.92, p<0.001) and PDR (19.0%-29.6%, R² 0.77, p<0.001) was observed throughout the study. Other KPIs showed similar improvement. The detection of non-neoplastic polyps did not increase. When analysed separately, ADR and PDR appeared to improve for gastroenterologists and nurse endoscopists but not for surgeons.

Regular feedback with individual and departmental KPIs was associated with improved ADR and overall performance throughout the 8-year study period. Concomitant monitoring of ADR and PDR may prevent 'gaming' behaviour and ensure that genuine improvement is achieved.

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

Background and study aims  Colonoscopy inspection quality (CIQ) assesses skills (fold examination, cleaning, and luminal distension) during inspection for polyps and correlates with adenoma detection rate (ADR) and serrated detection rate (SDR). We aimed to determine whether providing individualized CIQ feedback with instructional videos improves quality metrics performance. Methods  We prospectively studied 16 colonoscopists who already received semiannual benchmarked reports of quality metrics (ADR, SDR, and withdrawal time [WT]). We randomly selected seven colonoscopies/colonoscopist for evaluation. Six gastroenterologists graded CIQ using an established scale. We created instructional videos demonstrating optimal and poor inspection techniques. Colonoscopists received the instructional videos and benchmarked CIQ performance. We compared ADR, SDR, and WT in the 12 months preceding ("baseline") and following CIQ feedback. Colonoscopists were stratified by baseline ADR into lower (≤ 34 %) and higher-performing (> 34 %) groups. Results  Baseline ADR was 38.5 % (range 26.8 %-53.8 %) and SDR was 11.2 % (2.8 %-24.3 %). The proportion of colonoscopies performed by lower-performing colonoscopists was unchanged from baseline to post-CIQ feedback. All colonoscopists reviewed their CIQ report cards. Post-feedback, ADR (40.1 % vs 38.5 %, P  = 0.1) and SDR (12.2 % vs. 11.2 %, P  = 0.1) did not significantly improve; WT significantly increased (11.4 vs 12.4 min, P  < 0.01). Among the eight lower-performing colonoscopists, group ADR (31.1 % vs 34.3 %, P  = 0.02) and SDR (7.2 % vs 9.1 %, P  = 0.02) significantly increased post-feedback. In higher-performing colonoscopists, ADR and SDR did not change. Conclusions  CIQ feedback modestly improves ADR and SDR among colonoscopists with lower baseline ADR but has no effect on higher-performing colonoscopists. Individualized feedback on colonoscopy skills could be used to improve polyp detection by lower-performing colonoscopists.

High-quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children.

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopists. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

The PEnQuIN working group achieved consensus on 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with 7 corresponding indicators that can be used to identify high-quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high-quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (≥90%) and terminal ileal intubation rate (≥85%).

It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.

Screening colonoscopy effectiveness depends on procedure quality; however, knowledge about colonoscopy quality in rural and underserved areas is limited. This study aimed to describe the characteristics and quality of colonoscopy and to examine predictors of colonoscopy quality at rural and underserved hospitals.

Adults undergoing colonoscopy from April 2017 to March 2019 at rural or underserved hospitals across the Illinois Surgical Quality Improvement Collaborative were prospectively identified. The primary outcome was colorectal adenoma detection, and secondary outcomes included bowel preparation adequacy, cecum photodocumentation, and withdrawal time. Performance was benchmarked against multisociety guidelines, and multivariable logistic regression was used to examine patient, physician, and procedure characteristics associated with adenoma detection.

In total, 4217 colonoscopy procedures were performed at 8 hospitals, including 1865 screening examinations performed by 19 surgeons, 9 gastroenterologists, and 2 family practitioners. Physician screening volume ranged from 2 to 218 procedures (median 50; IQR 23-74). Adenoma detection occurred in 26.6% of screening procedures (target: ≥ 25%), 90.7% had adequate bowel preparation (target: ≥ 85%), 93.1% had cecum photodocumentation (target: ≥ 95%), and mean withdrawal time was 8.1 min (target: ≥ 6). Physician specialty was associated with adenoma detection (gastroenterologists: 36.9% vs. surgeons: 22.5%; OR 2.30, 95% CI 1.40-3.77), but adequate bowel preparation (OR 1.15, 95% CI 0.76-1.73) and cecum photodocumentation (OR 1.56, 95% CI 0.91-2.69) were not.

Colonoscopies performed at rural and underserved hospitals meet many quality metrics; however, quality varied widely. As physicians are scarce in rural and underserved areas, individualized interventions to improve colonoscopy quality are needed.

Quality metrics and standardization has become critical as the Affordable Care Act mandates that the Center for Medicare and Medicaid Services change reimbursement from volume to a value-based system. While the most commonly used quality indicators are related to that of colonoscopy, quality metrics for other procedures and endoscopy units have been developed mainly by the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy. Data to show that these quality metrics, especially in the field of advanced endoscopy as well as in the era of COVID-19 pandemic, can improve patient outcomes, are anticipated.

Mortality from colorectal cancer is reduced through screening and early detection; moreover, removal of neoplastic lesions can reduce cancer incidence. While understanding of the risk factors, pathogenesis, and precursor lesions of colorectal cancer has advanced, the cause of the recent increase in cancer among young adults is largely unknown. Multiple invasive, semi- and non-invasive screening modalities have emerged over the past decade. The current emphasis on quality of colonoscopy has improved the effectiveness of screening and prevention, and the role of new technologies in detection of neoplasia, such as artificial intelligence, is rapidly emerging. The overall screening rates in the US, however, are suboptimal, and few interventions have been shown to increase screening uptake. This review provides an overview of colorectal cancer, the current status of screening efforts, and the tools available to reduce mortality from colorectal cancer.

Adenoma detection rate (ADR) is the colonoscopy quality metric with the strongest association to interval or "missed" cancer. Accurate measurement of ADR can be laborious and costly.

Our aim was to determine if administrative procedure codes for colonoscopy and text searches of pathology results for adenoma mentions could estimate ADR.

We identified US Veterans with a colonoscopy using Current Procedure Terminology (CPT) codes between January 2013 and December 2016 at ten Veterans Affairs sites. We applied simple text searches using Microsoft SQL Server full-text searches to query all pathology notes for "adenoma(s)" or "adenomatous" text mentions to calculate ADRs. To validate our identification of colonoscopy procedures, endoscopists of record, and adenoma detection from the electronic health record, we manually reviewed a random sample of 2000 procedure and pathology notes from the 10 sites.

Structured data fields were accurate in identification of colonoscopies being performed (PPV = 0.99; 95% CI 0.99-1.00) and identifying the endoscopist of record (PPV of 0.95; 95% CI 0.94-0.96) for ADR measurement. Simple text searches of pathology notes for adenoma mentions had excellent performance statistics as follows: sensitivity 0.99 (95% CI 0.98-1.00), specificity 0.93 (95% CI 0.92-0.95), NPV 0.99 (95% CI 0.98-1.00), and PPV 0.93 (0.91-0.94) for measurement of ADR. There was no clinically significant difference in the estimates of overall ADR vs. screening ADR (p > 0.05).

Measuring ADR using administrative codes and text searches from pathology results is an efficient method to broadly survey colonoscopy quality.

The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.

Colonoscopy withdrawal time (CWT) is a key performance indicator affecting polyp detection rate (PDR) and adenoma detection rate (ADR). However, studies have shown wide variation in CWT and ADR between different endoscopists. The National Endoscopy Database (NED) was implemented to enable quality assurance in all endoscopy units across the UK and also to reduce variation in practice. We aimed to assess whether CWT changed since the introduction of NED and whether CWT affected PDR.

We used NED to retrospectively collect data regarding CWT and PDR of 25 endoscopists who performed (n=4459 colonoscopies) in the four quarters of 2019. We then compared this data to their performance in 2016, before using NED (n=4324 colonoscopies).

Mean CWT increased from 7.66 min in 2016 to 9.25 min in 2019 (p=0.0001). Mean PDR in the two periods was 29.9% and 28.3% (p=0.64). 72% of endoscopists (18/25) had CWT>6 min in 2016 versus 100% (25/25) in 2019, the longer CWT in 2019 positively correlated with the PDR (r=0.50, p=0.01). Gastroenterology consultants and trainee endoscopists had longer CWT compared with colorectal surgeons both before and after using NED.

NED usage increased withdrawal times in colonoscopy. Longer withdrawal times were associated with higher PDR. A national colonoscopy audit using data from NED is required to evaluate whether wide variations in practice across endoscopy units in the UK still exist and to ensure minimum colonoscopy quality standards are achieved.

Gastrointestinal endoscopic quality is operator-dependent. To ensure the endoscopy quality, we constructed an endoscopic audit and feedback system named Endo.Adm and evaluated its effect in a form of pretest and posttest trial.

Endo.Adm system was developed using Python and Deep Convolutional Neural Ne2rk models. Sixteen endoscopists were recruited from Renmin Hospital of Wuhan University and were randomly assigned to undergo feedback of Endo.Adm or not (8 for the feedback group and 8 for the control group). The feedback group received weekly quality report cards which were automatically generated by Endo.Adm. We then compared the adenoma detection rate (ADR) and gastric precancerous conditions detection rate between baseline and postintervention phase for endoscopists in each group to evaluate the impact of Endo.Adm feedback. In total, 1,191 colonoscopies and 3,515 gastroscopies were included for analysis.

ADR was increased after Endo.Adm feedback (10.8%-20.3%, P < 0.01,

DISCUSSION

Endo.Adm feedback contributed to multifaceted gastrointestinal endoscopic quality improvement. This system is practical to implement and may serve as a standard model for quality improvement in routine work (http://www.chictr.org.cn/, ChiCTR1900024153).

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Esophagogastroduodenoscopy (EGD) is commonly performed in patients with gastroesophageal reflux disease (GERD). An EGD report should document pertinent findings such as esophagitis, a columnar-lined esophagus (CLE), the location of the squamo-columnar and gastroesophageal junctions, the size and type of a hiatal hernia and the number and location of any biopsies. The aim of this study was to evaluate how commonly these findings were noted in the EGD reports of patients referred for antireflux surgery.

A retrospective review was performed of patient charts from 2012 to 2015 to identify 100 consecutive EGD reports from different endoscopists in different patients. Each EGD report was reviewed for pertinent findings and the use of a classification system for esophagitis (Savory-Miller or Los Angeles) and for reporting a CLE (Prague).

In 100 EGD reports, esophagitis was noted in 33 patients, but was graded in only 14 (42%). A CLE was noted in 28 patients, but the length was reported in only 16 (57%) and no report used the Prague classification system. A hiatal hernia was noted in 61 patients, measured in 31 (51%) and the type classified in 26%. A biopsy was taken in 93 patients and the location noted in 86 patients (93%). The number of biopsies was recorded in only 20 patients (22%). In 12 patients the EGD was for Barrett's surveillance, yet a Seattle biopsy protocol was reported to be used in only 3 patients.

Endoscopy reports frequently do not include the use of a grading system for esophagitis or the Prague system for CLE. This hampers the assessment of change with therapy or over time. The size of a hiatal hernia was typically reported in a subjective fashion and only infrequently was the type specified. Lack of clarity about the presence of a paraesophageal hernia can impede evaluation of acute symptoms. In patients with Barrett's esophagus a standard biopsy protocol was infrequently reported to be used. These findings raise concern about the quality of upper endoscopy, both in the performance of the procedure and the documentation of findings. A consistent reporting system is recommended for routine use with upper endoscopy.

Adenoma detection rate (ADR) is one of the most important quality indicators of colonoscopy. Monitoring endoscopists and providing feedback has shown to improve ADR. We performed a systematic review of the literature and meta-analysis to determine the effect of any form of feedback on ADR.

A literature search for comparative studies that employed any form of feedback to assess the impact on ADR before and after the feedback was done on MEDLINE, EMBASE, and Cochrane Database. The primary outcome of interest was ADR. Secondary outcomes included polyp detection rate, advanced adenoma detection rate, sessile serrated adenoma detection rate, withdrawal time, and cecal intubation rate. Cochrane Revman 5.3 software was used for statistical analysis.

A total of 12 studies met the inclusion criteria for the analysis of primary outcomes. There were 78,355 subjects (45.42% male) with a mean age of 59.52 years. There was a significant improvement in ADR after any form of feedback compared to no feedback: 36.18% vs. 26.75%; pooled odds ratio 1.51, 95% confidence interval 1.37-1.66; P<0.001. There was a substantial heterogeneity (I2=82%). ADR improved in both active or passive feedback, irrespective of whether endoscopists knew about being monitored for their performance or not.

Monitoring and providing feedback to endoscopists in any form leads to improvement in ADR. Feedback is an easy and effective way of improving the ADR of endoscopists, especially in those not achieving the recommended benchmarks.

Measuring adherence to ERCP quality indicators (QIs) is confounded by variability in indications, maneuvers, and documentation styles. We hypothesized that incorporation of mandatory, structured data fields within reporting software would permit accurate measurement of QI adherence rates and facilitate generation of a provider ERCP report card.

At two referral centers, endoscopy documentation software was modified to generate provider alerts prior to finalizing the note. The alerts reminded the provider to document the following components in a standardized manner: indication, altered anatomy, prior interventions, and QIs deemed high priority by society consensus, study authors, or both. Adherence rates for each QI were calculated in aggregate and by provider via data extraction directly from the procedure documentation software. Medical records were reviewed manually to measure the accuracy of automated data extraction. Accuracy of automated measurement for each QI was calculated against results derived by manual review.

During the 9-month study period, 1,376 ERCP procedures were completed by 8 providers. Manual medical record review confirmed high (98-100%) accuracy of automatic extraction of ERCP QIs from the endoscopy report, including cannulation rate of the native papilla and complete extraction of common bile duct stones. An ERCP report card was generated, allowing for individual comparison of adherence to ERCP QIs with colleagues at their institution and others.

In this pilot study, use of mandatory, structured data fields within clinical ERCP reports permit the accurate measurement of high priority ERCP QIs and the subsequent generation of interval report cards.

Colonoscopy quality indicators such as adenoma detection rate (ADR) are surrogates for the effectiveness of screening-related colonoscopy. It is unclear whether endoscopist feedback on these indicators improves performance. We performed a meta-analysis to determine whether associations exist between endoscopist feedback and colonoscopy performance.

We conducted a search through May 2019 for studies reporting on endoscopist feedback and associations with ADR or other colonoscopy quality indicators. Pooled rate ratios (RRs) and weighted mean differences were calculated using DerSimonian and Laird random effects models. Subgroup, sensitivity, and meta-regression analyses were performed to assess for potential methodological or clinical factors associated with outcomes.

From 1326 initial studies, 12 studies were included in the meta-analysis for ADR, representing 33,184 colonoscopies. Endoscopist feedback was associated with an improvement in ADR (RR, 1.21; 95% confidence interval [CI], 1.09-1.34). Low performers derived a greater benefit from feedback (RR, 1.62; 95% CI, 1.18-2.23) compared with moderate performers (RR, 1.19; 95% CI, 1.11-1.29), whereas high performers did not derive a significant benefit (RR, 1.06; 95% CI, 0.99-1.13). Feedback was not associated with increases in withdrawal time (weighted mean difference, +0.43 minutes; 95% CI, -0.50 to +1.36 minutes) or improvements in cecal intubation rate (RR, 1.00; 95% CI, 0.99-1.01).

Endoscopist feedback is associated with modest improvements in ADR. The implementation of routine endoscopist audit and feedback should be considered alongside other quality improvement interventions in institutions dedicated to the provision of high-quality screening-related colonoscopy.

Background and study aims  The quality of screening-related colonoscopy depends on several physician- and patient-related factors. Adenoma detection rate (ADR) varies considerably between endoscopists. Educational interventions aim to improve endoscopists' ADRs, but their overall impact is uncertain. We aimed to assess whether there is an association between educational interventions and colonoscopy quality indicators. Methods  A comprehensive search was performed through August 2019 for studies reporting any associations between educational interventions and any colonoscopy quality indicators. Our primary outcome of interest was ADR. Two authors assessed eligibility criteria and extracted data independently. Risk of bias was also assessed for included studies. Pooled rate ratios (RR) with 95 % confidence intervals (CI) were reported using DerSimonian and Laird random effects models. Results  From 2,253 initial studies, eight were included in the meta-analysis for ADR, representing 86,008 colonoscopies. Educational interventions were associated with improvements in overall ADR (RR 1.29, 95 % CI 1.25 to 1.42, 95 % prediction interval 1.09 to 1.53) and proximal ADR (RR 1.39, 95 % CI 1.29 to 1.48), with borderline increases in withdrawal time, ([WT], mean difference 0.29 minutes, 95 % CI - 0.12 to 0.70 minutes). Educational interventions did not affect cecal intubation rate ([CIR], RR 1.01, 95 % CI 1.00 to 1.01). Heterogeneity was considerable across many of the analyses. Conclusions  Educational interventions are associated with significant improvements in ADR, in particular, proximal ADR, and are not associated with improvements in WT or CIR. Educational interventions should be considered an important option in quality improvement programs aiming to optimize the performance of screening-related colonoscopy.

There is marked variability in colonoscopy quality, limiting its effectiveness in colorectal cancer prevention. Multiple indicators have been established as markers for colonoscopy quality; however, there are conflicting data on the effects of quality reporting programs on endoscopist performance. In this study, we investigate the impact of a multicenter quarterly report card initiative on colonoscopy quality metric performance.

Data were collected from 194 endoscopists at 10 participating sites throughout New York City using a Qualified Clinical Data Registry from January 2013 to December 2014. Adenoma detection rate (ADR), cecal intubation rate, withdrawal time, bowel preparation quality and appropriate interval recommendations were tracked. Report cards were distributed to each site on a quarterly basis and technical assistance was provided as needed. Performance trends were analyzed using the Cochran-Armitage trend and analysis of variance tests.

37,258 screening colonoscopies were performed during the study period. There was a positive performance trend for ADR over time from the first quarter of 2013 to the last quarter of 2014 (15.6-25.7%; p < 0.001). There were also increases in cecal intubation rates (78.2-92.6%; p < 0.001), bowel preparation adequacy rates (77.5-92.8%; p < 0.001), and adherence to appropriate screening intervals (28.0-55.0%; p < 0.001). There was no clinically significant change in mean withdrawal time.

The implementation of a quarterly report card initiative resulted in statistically significant improvements in adenoma detection, cecal intubation, bowel preparation adequacy rates, and appropriate recommended screening intervals.

Although colonoscopy reduces colorectal cancer (CRC) risk, interval CRCs (iCRCs) still occur. We aimed to determine iCRC incidence, assess the relationship between adenoma detection rates (ADRs) and iCRC rates, and evaluate iCRC rates over time concomitant with initiation of an institutional colonoscopy quality improvement (QI) program.

We performed a retrospective cohort study of patients who underwent colonoscopy at an academic medical center (January 2003 to December 2015). We identified iCRCs through our data warehouse and reviewed charts to confirm appropriateness for study inclusion. iCRC was defined as a cancer diagnosed 6 to 60 months and early iCRC as a cancer diagnosed 6 to 36 months after index colonoscopy. We measured the relationship between provider ADRs and iCRC rates and assessed iCRC rates over time with initiation of a QI program that started in 2010.

A total of 193,939 colonoscopies were performed over the study period. We identified 186 patients with iCRC. The overall iCRC rate was .12% and the early iCRC rate .06%. Average-risk patients undergoing colonoscopy by endoscopists in the highest ADR quartile (34%-52%) had a 4-fold lower iCRC risk (relative risk, .23; 95% confidence interval, .11-.48) than those undergoing colonoscopy by endoscopists in the lowest quartile (12%-21%). After QI program initiation, overall iCRC rates improved from .15% to .08% (P < .001) and early iCRC rates improved from .07% to .04% (P = .004).

We confirmed that iCRC rate is inversely correlated with provider ADR. ADRs increased and iCRC rates decreased over time, concomitant with a QI program focused on split-dose bowel preparation, quality metric measurement, provider education, and feedback. iCRC rate measurement should be considered a feasible, outcomes-driven institutional metric of colonoscopy quality.

Background and study aims  Adenoma detection rate (ADR), the proportion of an endoscopist's screening colonoscopies in which at least one adenoma is found, is an established quality metric. Several publications have suggested that a technique referred to as "one and done," where less attention is paid to additional polyp detection following discovery of one likely adenoma, may be occurring 1 2 3 . To investigate whether this practice occurs and provide additional context to the significance of ADR, we examined ADR by single and multiple adenomas in the statewide New Hampshire Colonoscopy Registry (NHCR). Patients and methods  A total of 25,324 NHCR patients receiving screening colonoscopies between 2009 and 2014 by 69 endoscopists were analyzed. ADR was dichotomized into high (≥ 20 %) and low (< 20 %) based on 2006 recommended targets in place during the time of the study. ADR-plus (the average number of adenomas in colonoscopies with > 1 adenoma) was dichotomized at mean values into high (≥ 1.5) and low (< 1.5). As suggested by others, a high ADR but low ADR-plus was used to indicate the "one and done" approach. Results  Among endoscopists with an ADR ≥ 20 %, only 5 (7.2 %) had low ADR-plus values and were classified as "one and done." Results for serrated polyp detection were similar. ADR and ADR-plus decreased monotonically with increasing years since residency ( P values for trend ADR = 0.02; ADR-plus = 0.003) after adjusting for patient risk factors. Conclusion  "One and done" infrequently occurred among endoscopists with high ADR in a large statewide registry. The need to replace ADR with other polyp detection metrics (such as ADR-plus) to accurately ascertain performance quality is not supported by these findings.

Ineffective polypectomy technique may lead to incomplete polyp resection, high complication rates, interval colorectal cancer, and costly referral to surgery. Despite its central importance to endoscopy, training in polypectomy is not standardized nor has the most effective training approach been defined. Polypectomy competence is rarely reported and quality metrics for this skill are lacking. Use of tools and measurements to assess polypectomy outcomes is low. There is a need for standardization of training and remediation in polypectomy; defining standards of competent polypectomy and how it is feasibly measured; and integration of polypectomy quality metrics into training programs and the accreditation process.

To investigate effects of bowel preparation, experience level of colonoscopists, and colonoscopy withdrawal time (CWT) on the quality of an individual opportunistic screening colonoscopy, according to adenoma detection rate (ADR).Data were retrospectively analyzed from opportunistic screening colonoscopies (n = 16,951) at 4 hospitals of various care levels in China.The ADR positively correlated with the experience level of the colonoscopist. The individualized CWT varied, depending on the quality of bowel preparation and the number of colonoscopies performed previously by the colonoscopist. In a setting of adequate bowel preparation, the mean CWT decreased with the increased experience of the colonoscopist. With poor and inadequate bowel preparation, no colonoscopist at any level of experience could obtain a satisfactory ADR.For adequately prepared colonoscopies, minimum CWTs have been determined. Repeat colonoscopy is strongly recommended for patients with poor bowel preparation, regardless of the colonoscopist's experience.

Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied.

To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days.

A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices.

Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated.

A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician's fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician's higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician's specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors.

Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

Polypectomy competency varies significantly among providers. Poor polypectomy technique may lead to interval cancer and/or adverse events. Our aim was to determine the effect of a polypectomy skills report card on subsequent polypectomy performance.

We conducted a 3-phase, prospective, single-blinded study. In phase 1 ("baseline"), we graded 10 polypectomies per endoscopist using the Direct Observation of Polypectomy Skills (DOPyS) tool (scores 1-4); mean overall scores ≥3 are competent. In phase 2 ("pre-report card"), we selected 10 additional polypectomies per endoscopist. We subsequently gave endoscopists a report card with baseline scores and instructional videos demonstrating optimal polypectomy technique. In phase 3 ("post-report card"), 10 additional polypectomies per endoscopist were selected. Raters, blinded to study phase, graded 10 pre- and 10 post-report card polypectomies per endoscopist. We compared mean DOPyS scores and rate of competent polypectomy in the pre- and post-report card phases.

We graded 110 pre- and 110 post-report card polypectomies performed by 11 endoscopists. The mean DOPyS score increased between the pre- and post-report card phases (2.7 ± .9 vs 3.0 ± .8, P = .01); this improvement was seen for diminutive (P < .0001) but not for small-to-large polyps. Rate of competent polypectomy significantly improved from the pre- to post-report card phase (56% vs 69%, P = .04); this improvement was seen for diminutive (57% vs 81%, P = .001) but not for small-to-large polyps (55% vs 36%, P = .2).

Report cards with educational videos effectively improved polypectomy technique, primarily because of improvements in resecting diminutive polyps. The improved competency and decreased piecemeal resection may reduce the risk of polyp recurrence. Further education is needed to improve larger polyp resection.

Adenoma detection rate (ADR) and serrated polyp detection rate (SDR) vary significantly among colonoscopists. Colonoscopy inspection quality (CIQ) is the quality with which a colonoscopist inspects for polyps and may explain some of this variation. We aimed to determine the relationship between CIQ and historical ADRs and SDRs in a cohort of colonoscopists and assess whether there is variation in CIQ components (fold examination, cleaning, and luminal distension) among colonoscopists with similar ADRs and SDRs.

We conducted a prospective observational study to assess CIQ among 17 high-volume colonoscopists at an academic medical center. Over 6 weeks, we video-recorded >28 colonoscopies per colonoscopist and randomly selected 7 colonoscopies per colonoscopist for evaluation. Six raters graded CIQ using an established scale, with a maximum whole colon score of 75.

We evaluated 119 colonoscopies. The median whole-colon CIQ score was 50.1/75. Whole-colon CIQ score (r=0.71; P<.01) and component scores (fold examination r=0.74; cleaning r=0.67; distension r=0.77; all P<.01) correlated with ADR. Proximal colon CIQ score (r=0.67; P<.01) and component scores (fold examination r=0.71; cleaning r=0.62; distension r=0.65; all P<.05) correlated with SDR. CIQ component scores differed significantly between colonoscopists with similar ADRs and SDRs for most of the CIQ skills.

In a prospective observational study, we found CIQ and CIQ components to correlate with ADR and SDR. Colonoscopists with similar ADRs and SDRs differ in their performance of the 3 CIQ components-specific, actionable feedback might improve colonoscopy technique.

Although adenoma prevalence is lower in younger people compared with screening-aged adults 50 years old and above, there is no adjustment recommendation for the target adenoma detection rate (ADR) in young people. Herein, we estimated a different target ADR for adults below 50 years old based on screening colonoscopy findings.

Asymptomatic, average-risk adults below 50 years old who underwent screening colonoscopy were enrolled at 12 endoscopy centers in Korea between February 2006 and March 2012. Screening colonoscopies were stratified into low or high ADR groups with ADR levels of 20% and 25%, respectively.

The ADRs from 12 endoscopy centers ranged from 12.1% to 43.8% (median ADR, 24.1%) based on 5272 young adults receiving screening colonoscopies. Using 20% as an ADR level, the risks for metachronous adenoma and advanced adenoma were significantly higher in the low ADR group than the high ADR group (35.4% vs. 25.7%, P<0.001; 8.3% vs. 3.7%, P=0.001, respectively). However, using ADR level of 25%, the risk for metachronous neoplasia was similar in the high and low ADR groups in young adults according to screening colonoscopy. In subgroup analysis, similar findings were found in males, but not in females.

Optimal target ADR may be different between younger and older populations, and the adoption of a 20% target ADR could be used as a performance indicator for young populations.

Bone marrow biopsy (BMB) is crucial for the diagnosis, staging, and monitoring of a variety of hematologic diseases. Obtaining an adequate BMB can be challenging given the need to balance patient comfort with acquisition of high quality specimens. We had observed variable BMB quality at our institution with poor quality specimens sometimes affecting diagnosis. We thus undertook this quality improvement (QI) project to improve the quality of diagnostic BMB specimens.

We used an A3 QI process to identify factors possibly influencing BMB quality. We collected baseline data on 211 BMB, with short and long-term follow-up data on a further 382 cases. We used clinical conferences to discuss data, perform peer comparisons and identify strategies to create a sustainable improvement in BMB quality.

Baseline data showed that BMB length was influenced most by the individual performer, with some influence of needle gauge. Other factors such as sedation, BMB indication were noncontributory. BMB lengths improved following performer education and individual performer data comparisons (15.2 mm post vs 12.8 mm baseline, P < .0001) and with use of an 8- rather than 11-gauge needle (18.3 mm 8-gauge vs 13.3 mm 11-gauge P < .0001), and were sustained over the long term.

Education on BMB standards, sharing of performer data, and changing needle gauge are relatively straightforward methods to improve BMB quality, leading to easier pathology diagnosis.

Adenoma detection rate (ADR) is a quality indicator for screening colonoscopy, but its calculation is time-consuming. Polyp detection rate (PDR) has been found to correlate with ADR; however, its use as a quality indicator has been criticized out of concern for endoscopists artificially inflating the PDR. We aim to evaluate whether active monitoring affects PDR.

In March 2015, 14 endoscopists were made aware that their personal PDRs would be tracked monthly as a quality improvement project. Endoscopists received a report of their individual monthly and cumulative PDR, departmental averages, and a benchmark PDR. Following the intervention, data were collected for consecutive patients undergoing average risk screening colonoscopy for six months. PDR, ADR, and adenoma to polyp detection ratio quotient (APDRQ) were compared to a six-month pre-intervention period.

2203 patients were included in the study. There was no statistically significant difference in PDR when comparing pre- and post-intervention (44 vs. 45%, OR 1.04; 95% CI 0.77-1.36). No statistically significant difference in ADR was observed when comparing pre- and post-intervention (29 vs. 30%, OR 1.03; 95% CI 0.64-1.52). There was no statistically significant difference in APDRQ when comparing pre- and post-intervention (0.67 vs. 0.66, OR 0.99; 95% CI 0.69-1.33).

Monthly report cards did not result in a change in PDR or APDRQ. In some environments, PDR can be used as a surrogate marker of ADR, despite endoscopist awareness that PDR is being measured.

Inadequate polypectomy leads to incomplete resection, interval colorectal cancer, and adverse events. However, polypectomy competency is rarely reported, and quality metrics are lacking. The primary aims of this study were to assess polypectomy competency among a cohort of gastroenterologists and to measure the correlation between polypectomy competency and established colonoscopy quality metrics (adenoma detection rate and withdrawal time).

We conducted a prospective observational study to assess polypectomy competency among 13 high-volume screening colonoscopists at an academic medical center. Over 6 weeks, we made video recordings of ≥28 colonoscopies per colonoscopist and randomly selected 10 polypectomies per colonoscopist for evaluation. Two raters graded the polypectomies by using the Direct Observation of Polypectomy Skills, a polypectomy competency assessment tool, which assesses individual polypectomy skills and overall competency.

We evaluated 130 polypectomies. A total of 83 polypectomies (64%) were rated as competent, which was more likely for diminutive (70%) than small and/or large polyps (50%, P = .03). Overall Direct Observation of Polypectomy Skills competency scores varied significantly among colonoscopists (P = .001), with overall polypectomy competency rates ranging between 30% and 90%. Individual skills scores, such as accurately directing the snare over the lesion (P = .02) and trapping an appropriate amount of tissue within the snare (P = .001) varied significantly between colonoscopists. Polypectomy competency rates did not significantly correlate with the adenoma detection rate (r = 0.4; P = .2) or withdrawal time (r = 0.2; P = .5).

Polypectomy competency varies significantly among colonoscopists and does not sufficiently correlate with established quality metrics. Given the clinical implications of suboptimal polypectomy, efforts to educate colonoscopists in polypectomy techniques and develop a metric of polypectomy quality are needed.

Patient comfort is an important part of endoscopy and reflects procedure quality and endoscopist technique. Using the validated, Nurse Assisted Patient Comfort Score (NAPCOMS), this study aimed to determine whether the introduction of NAPCOMS would affect sedation use by endoscopists.

The study was conducted over 3 phases. Phase One and Two consisted of 8 weeks of endoscopist blinded and aware data collection, respectively. Data in Phase Three was collected over a 5-month period and scores fed back to individual endoscopists on a monthly basis.

NAPCOMS consists of 3 domains - pain, sedation, and global tolerability. Comparison of Phase One and Two, showed no significant differences in sedative use or NAPCOMS. Phase Three data showed a decline in fentanyl use between individual months ( P  = 0.035), but no change in overall NAPCOMS. Procedures involving trainees were found to use more midazolam ( P  = 0.01) and fentanyl ( P  = 0.01), have worse NAPCOMS scores, and resulted in longer procedure duration ( P  < 0.001). Data comparing gastroenterologists and general surgeons showed increased fentanyl use ( P  = 0.037), decreased midazolam use ( P  = 0.001), and more position changes ( P  = 0.002) among gastroenterologists.

The introduction of a patient comfort scoring system resulted in a decrease in fentanyl use, although with minimal clinical significance. Additional studies are required to determine the role of patient comfort scores in quality control in endoscopy. Procedures completed with trainees used more sedation, were longer, and had worse NAPCOMS scores, the implications of which, for teaching hospitals and training programs, will need to be further considered.

The purpose of this review is to summarize the current state of endoscopic quality measurement and use of measures in enhancing the value of endoscopic services.

Initially, quality measurement of endoscopic procedures was claims based or included small unit or practice-specific efforts. Now we have a mature national registry and large electronic medical or procedural records that are designed to yield valuable data relevant to quality measurement.

With the advent of better measures, we are beginning to understand that initial process and surrogate outcome measures (adenoma detection rate) can be improved to provide a better reflection of endoscopic quality. Importantly, however, even measures currently in use relate to important patient outcomes such as missed colon cancers. At a federal level, older cumbersome pay-for-performance initiatives have been combined into a new overarching program named the quality payment program within the centers for medicare and medicaid services. This program is an additional step toward furthering the progress from volume-to-value-based reimbursement. The legislation mandating the movement toward outcomes-linked (value) reimbursement is the medicare access and children's health insurance program reauthorization act, which was passed with overwhelming bipartisan support and will not be walked back by alterations of the affordable care act. Increasing portions of medicare reimbursement (and likely commercial to follow) will be linked to quality metrics, so familiarity with the underlying process and rationale will be important for all proceduralists.

Adenoma detection rate (ADR) is an important measure of colonoscopy quality, as are polyp, advanced ADR, and adenocarcinoma detection rates. We investigated whether performance report cards improved these outcome measures.

Endoscopists were given report cards comparing their detection rates to the institutional mean on an annual basis. Detection rates were evaluated at baseline, 1 year after report cards (Year 1), and 2 years after report cards (Year 2). Endoscopists were unaware of the study and received no other interventions. The primary outcome was ADR and secondary outcomes were polyp detection rate (PDR), advanced ADR, and adenocarcinoma detection rate. Multivariate regression was performed to adjust for temporal trends in patient, endoscopists, and procedural factors.

 Seventeen physicians performed 3,118 screening colonoscopies in patients with positive FOBT or family history of colon cancer. The ADR increased from 34.5 % (baseline) to 39.4 % (Year 1) and 41.2 % (Year 2) ( P  = 0.0037). The PDR increased from 45 % (baseline) to 48.8 % (Year 1) and 51.8 % (Year 2) ( P  = 0.011). There was no significant improvement in advanced ADR or adenocarcinoma detection rates. On multivariate analysis, the ADR increased by 22 % in Year 1 ( P  = 0.03) and 30 % in Year 2 ( P  = 0.008). Among physicians with a baseline ADR < 25 %, improvement in ADR was even greater, increasing 2.2 times by the end of the study ( P  = 0.004). Improvements in ADR were not correlated with specialty although gastroenterologists were 52 % more likely to find an adenoma than general surgeons.

 Annual performance report cards increased adenoma detection rates, especially among physicians with low ADR < 25 %.

Diminutive (1-5 mm) and small (6-9 mm) polyps comprise 90% of detected lesions during colonoscopy and rarely contain advanced histology or colorectal cancer (CRC). Routine removal of these lesions results in a significant burden to colonoscopy programs. At the same time, the risk for progression of these polyps to CRC is unclear. We performed a systematic review to explore the natural history of diminutive and small colorectal polyps.

We searched MEDLINE and EMBASE for studies investigating the natural history of colorectal polyps. Studies were considered eligible when they assessed patients with 1- to 9-mm polyps that were not treated with polypectomy and that underwent follow-up. We excluded studies in patients with inflammatory bowel disease, polyposis syndromes, and previously diagnosed CRC. We independently extracted study characteristics and evaluated CRC and advanced adenoma (size ≥ 10 mm, containing high-grade dysplasia or villous features) as outcome parameters.

Of 8775 retrieved studies, 9 studies with 721 patients were included that prospectively evaluated the evolution of 1- to 9-mm polyps. In 7 studies the average duration of observation was 2 to 3 years. There was only 1 study in which 1 small polyp might have progressed to cancer. Of 1034 adenomas sized 1 to 9 mm in those studies, 6% progressed to advanced adenomas over time.

Based on this systematic review, it appears that some 1- to 9-mm adenomas progress to advanced adenomas within 2 to 3 years. No information on long-term CRC transition rates was found. Defining the biologic significance of these polyps is needed to balance between benefits and harm of polypectomy. (PROSPERO database registration number: CRD42016036577.).

Quality performance measures for screening colonoscopy vary among endoscopists. The impact of practice setting is unknown.

We aimed to (1) compare screening colonoscopy performance measures among three different US practice settings; (2) evaluate factors associated with adenoma detection; and (3) assess a scorecard intervention on performance metrics.

This multi-center prospective study compared patient, endoscopist, and colonoscopy characteristics performed at a tertiary care hospital (TCH), community-based hospital (CBH), and private practice group (PPG). Withdrawal times (WT), cecal intubation, and adenoma detection rates (ADR) were compared by site at baseline and 12 weeks following scorecard distribution. Generalized linear mixed models identified factors associated with adenoma detection.

Twenty-eight endoscopists performed colonoscopies on 1987 asymptomatic, average-risk individuals ≥50 years. Endoscopist and patient characteristics were similar across sites. The PPG screened more men (TCH: 42.8%, CBH: 45.0%, PPG: 54.2%; p < 0.0001). Preparation quality varied with good/excellent results in 70.6, 88.3, and 92% of TCH, CBH, and PPG cases, respectively (p < 0.0001). Male ADRs, cecal intubation, and WT exceeded recommended benchmarks despite variable results at each site; female ADRs were <15% at the PPG which screened the fewest females. Performance remained unchanged following scorecard distribution. Adenoma detection was associated with increasing patient age, male gender, WT, adequate preparation, but not practice setting.

Each practice performed high-quality screening colonoscopy. Scorecards did not improve performance metrics. Preparation quality varies among practice settings and can be modified to improve adenoma detection.