Impact of an Endoscopic Quality Improvement Program Focused on Adenoma Detection on Sessile Serrated Adenoma/Polyp Detection.

BACKGROUND: Sessile serrated adenomas/polyps (SSA/P) are an under-recognized disease with a unique malignant pathway. Improved endoscopic recognition and pathological interpretation is needed. AIMS: To determine whether an educational intervention that improved adenoma detection rate (ADR) could improve SSA/P detection rate after reclassification of previously termed "hyperplastic" polyps. METHODS: We reanalyzed data from a prospective randomized trial of an educational intervention aimed at increasing ADR. All hyperplastic polyps ≥6 mm reported in a previously published study were rereviewed and reclassified using standardized criteria for serrated lesions. Detection rates of sessile serrated adenomas/polyps and other clinically relevant serrated polyps were calculated in the baseline and post-training phases of the original study. RESULTS: Of 263 available for rereview, 33 (12.5%) were reclassified as SSA/P (N = 32) or traditional serrated adenoma (TSA) (N = 1). Reclassification was more common in the right colon (18 vs. 8%, p = 0.02). Baseline SSA/P detection rate was 0.7% in the untrained group and 1.3% in the trained group. Post-training, the SSA/P detection rate increased to 2.1 and 1.5%, respectively. The clinically relevant serrated polyp detection rate at baseline was 14.2% in the untrained group and 11.3% in the trained group. After the educational intervention, the clinically relevant serrated polyp detection rates increased to 16.5 and 14.8% in the untrained and trained groups, respectively. The estimated odds of an endoscopist detecting either a SSA/P or other clinically relevant serrated polyp during colonoscopy increased by only 3% with the educational intervention (OR 1.03, 95% CI 0.61-1.74, p = 0.91). CONCLUSIONS: Pathological re-interpretation of larger serrated polyps resulted in the reclassification of 12.5% of lesions. Quality improvement methods focused on adenoma detection did not impact SSA/P detection, and thus specific methods for serrated polyp detection are needed.

An endoscopic quality improvement program improves detection of colorectal adenomas.

OBJECTIVES: Adenoma detection rate (ADR) is a key measure of quality in colonoscopy. Low ADRs are associated with development of interval cancer after "negative" colonoscopy. Uncontrolled studies mandating longer withdrawal time, and other incentives, have not significantly improved ADR. We hypothesized that an endoscopist training program would increase ADRs. METHODS: Our Endoscopic Quality Improvement Program (EQUIP) was an educational intervention for staff endoscopists. We measured ADRs for a baseline period, then randomly assigned half of the 15 endoscopists to undergo EQUIP training. We then examined baseline and post-training study ADRs for all endoscopists (trained and un-trained) to evaluate the impact of training. A total of 1,200 procedures were completed in each of the two study phases. RESULTS: Patient characteristics were similar between randomization groups and between study phases. The overall ADR in baseline phase was 36% for both groups of endoscopists. In the post-training phase, the group of endoscopists randomized to EQUIP training had an increase in ADR to 47%, whereas the ADR for the group of endoscopists who were not trained remained unchanged at 35%. The effect of training on the endoscopist-specific ADRs was estimated with an odds ratio of 1.73 (95% confidence interval 1.24-2.41, P=0.0013). CONCLUSIONS: Our results indicate that ADRs can be improved considerably through simple educational efforts. Ultimately, a trial involving a larger number of endoscopists is needed to validate the utility of our training methods and determine whether improvements in ADRs lead to reduced colorectal cancer.

Assessment of adenoma detection rate benchmarks in women versus men.

BACKGROUND: Current guidelines suggest screening adenoma detection rates (ADRs) of 15% for average-risk women and 25% for average-risk men. OBJECTIVE: Determine average-risk screening ADRs and the prevalence of adenomas by location, size, shape, and degree of dysplasia in each sex. DESIGN: Post hoc analysis of prospectively collected data. SETTING: Academic center, ambulatory center. PATIENTS: A total of 864 average-risk patients. INTERVENTION: Screening colonoscopy. MAIN OUTCOME MEASUREMENTS: By using a prospectively collected colonoscopy database, we determined the ADRs for each sex and compared them to current medical society guidelines. In patients with adenomas detected, we compared the percentage of proximally located, large, and advanced-pathology adenomas between sexes. RESULTS: The overall average-risk screening ADR was 33.7% for both sexes combined. Average risks for women and men were significantly higher than guidelines (women: 25.4% vs 15%; P = .0003; men: 41.2% vs 25%; P < .0001). The ADR remained significantly higher for men versus women (P < .0001). Overall advanced-pathology adenoma detection was 12.2% for both sexes combined. There was a significantly higher advanced-pathology ADR for men (15.3%) versus women (8.7%) (P = .003). There was no significant difference between the sexes when age was considered in both advanced-pathology and average-risk ADRs. LIMITATIONS: Data from the study focused on improving ADRs in an academic setting. CONCLUSION: The ADR in our study was higher than current benchmarks for both sexes. In patients with at least one adenoma, advanced-pathology adenomas were detected equally among men and women. Although the benefits of achieving supra-benchmark ADRs are unknown, high ADRs may lead to more effective colonoscopy.

Colonoscopy: new approaches to better outcomes.

PURPOSE OF REVIEW: Prevention of colorectal cancer relies on the detection and removal of colorectal neoplasia. Recent advances in mucosal imaging and inspection techniques have increased the detection of small and diminutive colorectal polyps with unknown clinical impact. The ability to accurately predict whether a polyp is neoplastic may allow for an optical triage approach to polyp management, improving efficiency while reducing the cost and risk of polypectomy. RECENT FINDINGS: High-definition white light colonoscopy, cap-fitted colonoscopy, and dye-based pan-chromoendoscopy have each shown to increase polyp detection. Virtual chromoendoscopy, although not beneficial for polyp detection, allows for accurate in-vivo prediction of polyp pathology. Endoscopists' behaviors, independent of patient factors, strongly influence adenoma detection. Training methods focused on the techniques of high adenoma detectors also increase adenoma and polyp detection. SUMMARY: Advances in mucosal imaging and improvements in inspection technique have allowed us to detect more polyps and to predict their pathology with greater accuracy. An optical triage approach to either 'diagnose and discard' or 'diagnose and leave behind' has the potential to reduce the risk and cost of polypectomy.

Colorectal surveillance interval assignment based on in vivo prediction of polyp histology: impact of endoscopic quality improvement program.

BACKGROUND: Validated training methods are needed before in vivo optical diagnosis can be used to guide colorectal cancer surveillance interval assignments. OBJECTIVES: To assess the impact of endoscopist training on accuracy of surveillance intervals based on in vivo optical diagnosis. DESIGN: Prospective, randomized study. SETTING: Tertiary referral center. PATIENTS: A total of 1231 patients with colorectal polyps (before training, n = 577; after training, n = 654). INTERVENTIONS: Endoscopists were randomized to either participate or not participate in two 1-hour training sessions. Endoscopists' in vivo pathology predictions were recorded for all resected polyps. The accuracy of in vivo prediction-guided surveillance intervals were compared with pathology-guided intervals as the criterion standard. Surveillance interval accuracy before and after training were analyzed. MAIN OUTCOME MEASUREMENTS: Surveillance interval accuracy based on in vivo polyp predictions with pathology-guided intervals as criterion standard before and after a training intervention. RESULTS: Optically predicted surveillance intervals for the trained group of endoscopists had an overall accuracy of 84% (242/287) before training and 82% (261/317) after training. There was little evidence to suggest that training had a meaningful impact on the accuracy of optically predicted surveillance intervals (odds ratio 1.20; 95% CI, 0.76-1.89, P = .44). LIMITATIONS: Limitations include small sample size, lack of endoscopist prediction confidence levels, and optional use of narrow-band imaging. CONCLUSIONS: Surveillance interval accuracy did not meet published thresholds (>90%) to use in vivo optical diagnosis without pathologic confirmation. Larger studies, focused specifically on the impact of training, are needed to validate methods to improve polyp diagnosis and surveillance predication accuracy.

An evaluation of risk factors for inadequate cytology in EUS-guided FNA of pancreatic tumors and lymph nodes.

BACKGROUND: The factors associated with maximizing the cytological adequacy of EUS-guided FNA (EUS-FNA) in pancreatic tumor evaluation are not well-known. OBJECTIVE: To examine associations of physician and procedural factors with the endpoint: the presence of an adequate cytological specimen found by using EUS-FNA in patients with pancreatic tumors and lymph nodes. DESIGN: Retrospective cohort study. SETTING: A U.S. tertiary care center. PATIENTS: Patients undergoing EUS-FNA of pancreatic masses and lymph nodes. INTERVENTIONS: Analysis of EUS-FNA procedures performed in our institution from 1997 to 2007. MAIN OUTCOME MEASUREMENTS: Associations were evaluated between the primary endpoint of cytological adequacy and factors including the endoscopist, needle gauge, the number of needle passes attempted, the pathologist, and the presence of an onsite cytotechnologist to confirm an adequate specimen. EUS-FNA adequacy was determined by a pathologist based on the presence of definite benign or malignant tissue. RESULTS: EUS-FNA was performed in 247 pancreatic masses and 276 lymph nodes. An adequate cytological sample was obtained in 240 (97%) pancreatic tumors (95% CI, 94%-99%) and 252 (91%) lymph nodes (95% CI, 87%-94%). For pancreatic tumors, there was no evidence of any associations between factors and cytological adequacy. For lymph nodes, cytological adequacy was improved when an onsite cytotechnologist was present (96% vs 84%, P = .002); no other factors showed statistically significant associations with cytological adequacy. LIMITATIONS: Retrospective study, low power to detect associations. CONCLUSIONS: The presence of an onsite cytotechnologist is an important factor in achieving successful EUS-FNA of suspicious lymph nodes in patients with pancreatic masses.

Quality in EUS: an assessment of baseline compliance and performance improvement by using the American Society for Gastrointestinal Endoscopy-American College of Gastroenterology quality indicators.

BACKGROUND: An American Society for Gastrointestinal Endoscopy-American College of Gastroenterology (ASGE-ACG) task force recently developed quality indicators for the preprocedure, intraprocedure, and postprocedure phases of each endoscopic procedure. Benchmark rates and clinical significance of compliance have not been determined. OBJECTIVES: To establish baseline compliance rates to the preprocedure and intraprocedure quality indicators in our EUS cases, identify indicators with the lowest compliance rates, and establish change in compliance rates with a targeted performance improvement plan. METHODS: We measured baseline compliance to each of the preprocedure and intraprocedure EUS quality indicators in the EUS procedures performed at Mayo Clinic Jacksonville from March 1996 through August 2006. We developed a performance improvement plan that targeted the 4 indicators with the lowest compliance over the entire time period. Compliance rates in the year after plan implementation were compared with those from January 2004 to August 2006, when adjusting for endoscopist and direct access. RESULTS: We demonstrated areas of high quality as well as areas for improvement in compliance with the ASGE-ACG quality metrics in a large cohort of EUS cases. We achieved improvement in all 4 areas targeted for quality improvement, statistically significant at the 5% level for two of the quality indicators. LIMITATIONS: Limitations included our retrospective design and the use of unstructured procedure dictations that may limit application of our results. It is also unclear whether compliance was truly synonymous with performance. CONCLUSIONS: We established reference levels of compliance rate within our practice and showed that a targeted performance improvement plan that consisted of awareness, individual accountability, and documentation can result in improvement.

Cushing's syndrome due to ectopic adrenocorticotropic hormone production secondary to hepatic carcinoid: diagnosis, treatment, and improved quality of life.

INTRODUCTION: We describe a previously healthy 40-year-old woman with Cushing's syndrome caused by adrenocorticotropic hormone (ACTH) secretion from metastatic carcinoid. CASE REPORT: Over a 2-year period, the patient had multiple hospitalizations for uncontrolled hypertension, hyperglycemia, and hypokalemia. She had transient flushing, rashes, and a rapid weight gain. In addition, she developed anasarca and had a nontraumatic hip fracture 1 month before presentation. Subsequently, a hypertensive crisis resulted in admission to the intensive care unit and fine-needle aspiration of a liver lesion. DISCUSSION: A diagnosis of metastatic carcinoid was established. She was transferred to our hospital for further evaluation and management. On arrival, she had the signs of Cushing's syndrome. Despite extensive evaluation, her primary carcinoid tumor was not localized. She was treated successfully with bilateral adrenalectomy and octreotide. CONCLUSION: This case illustrates how early recognition of the signs and symptoms of excess ACTH is important for prompt and appropriate treatment.

Quality in colonoscopy reporting: an assessment of compliance and performance improvement.

BACKGROUND: An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined. AIMS: To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention. METHODS: 300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance. RESULTS: Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16). CONCLUSION: This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.