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Original article Clinical endoscopy: Editorial| Volume 87, ISSUE 3, P752-754, March 2018

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Adhering to quality metrics in colonoscopy: we can do better

      Abbreviations:

      BBPS (Boston Bowel Preparation Scale), CORI (Clinical Outcomes Research Initiative), USMSTF (U.S. Multi-Society Task Force)
      The Boston Bowel Preparation Scale (BBPS) was first published in Gastrointestinal Endoscopy in a special issue for Colorectal Cancer Awareness Month in March 2009.
      • Lai E.J.
      • Calderwood A.H.
      • Doros G.
      • et al.
      The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research.
      Although the BBPS was not the first validated bowel preparation rating scale—the Aronchick and Ottawa scales were published in 1999 and 2004, respectively—it has become the most widely used because of its objective scoring system and its clinically relevant focus on results after thorough intraprocedural cleansing.
      In this issue of Gastrointestinal Endoscopy, Kluge and colleagues examine the relationship between bowel preparation quality and polyp miss rate using the national Clinical Outcomes Research Initiative (CORI) database.
      • Kluge M.A.
      • Williams J.L.
      • Wu C.K.
      • et al.
      Inadequate Boston Bowel Preparation Scale scores predict the risk of missed neoplasia on the next colonoscopy.
      The study’s greatest strength lies in the diversity of the CORI consortium, which comprises 73% private practices, 18% Veterans Administration hospitals, and 9% academic medical centers.
      • Calderwood A.H.
      • Schroy P.C.
      • Lieberman D.A.
      • et al.
      Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness.
      Within this diverse setting between 2009 and 2014, the investigators identified average-risk individuals aged 50 to 75 who underwent an initial screening colonoscopy followed by second colonoscopy for any indication within 3 years. To be included, individuals must have had an initial colonoscopy that was scored by the BBPS and a second colonoscopy that was scored as adequate either by the BBPS or by a qualitative assessment of “excellent,” “good,” or “adequate” to exclude polyps >5 mm. The authors used the detection of polyps rather than adenomas as the outcome of interest because of the lack of reliable data from pathologic analysis. The primary endpoint was the proportion of colon segments with polyps and large polyps (>9 mm) detected at second colonoscopy among inadequately versus adequately prepared colon segments at initial colonoscopy, which was stratified by findings at initial colonoscopy. Secondary endpoints included similar comparisons at the patient level and by segment location.
      Of the approximately 98,000 average-risk screening colonoscopies that were performed during the study period, the vast majority did not meet the inclusion criteria, and only 755 colon segment pairs and 288 individuals were included in the analysis. For the primary endpoint, among segment pairs in which polyps were not found at initial colonoscopy, segments with initially inadequate BBPS scores were more likely to have polyps found at second colonoscopy than were segments with initially adequate scores (10% vs 5%, P = .04). The detection of large polyps did not differ (2% for both, P = .94). For segment pairs with polyps found on the initial examination, more large polyps were detected at second colonoscopy in segments with initially inadequate versus adequate BBPS scores (20% vs 4%, P = .03), but there was no statistically significant difference in the overall polyp detection rate (33% vs 26%, P = .54). Similarly, for segment pairs with large polyps found on initial colonoscopy, there was a trend toward more large polyps being detected in segments with initially inadequate examinations (25% vs 4%, P = .07) but no statistically significant difference in overall polyp detection (38% vs 30%, P = .67). For the secondary endpoints, patient-level analysis yielded similar results as the segment-level analysis, and no significant differences by segment location were found. Finally, the authors conducted a multivariable logistic regression analysis and found that large polyps at initial colonoscopy predicted large polyps at second colonoscopy (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.1-10.8), but an inadequate BBPS segment score did not (OR, 1.8; 95% CI, 0.6-5.1). Overall, these results add to the growing evidence that polyps—including more clinically relevant large polyps—are more likely to be missed if the examination is judged as inadequate according to the BBPS. Specifically, Kluge and colleagues
      • Kluge M.A.
      • Williams J.L.
      • Wu C.K.
      • et al.
      Inadequate Boston Bowel Preparation Scale scores predict the risk of missed neoplasia on the next colonoscopy.
      demonstrate that similar findings from a recent study of male veterans can be generalized to other populations and practice settings.
      • Clark B.T.
      • Protiva P.
      • Nagar A.
      • et al.
      Quantification of adequate bowel preparation for screening or surveillance colonoscopy in men.
      Although the diversity of the CORI consortium is a notable strength of the study, the incompleteness of endoscopic and pathologic data within the database is also the study’s biggest limitation. The authors use polyps as a surrogate for adenomas, and although the original study comparing polyp and adenoma detection rates showed excellent correlation,
      • Francis D.L.
      • Rodriguez-Correa D.T.
      • Buchner A.
      • et al.
      Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate.
      a more recent study found that the correlation was much less reliable in the distal colon than in the proximal colon.
      • Boroff E.S.
      • Gurudu S.R.
      • Hentz J.G.
      • et al.
      Polyp and adenoma detection rates in the proximal and distal colon.
      Large polyps in this population have an 84% positive predictive value for advanced neoplasia,
      • Lieberman D.A.
      • Holub J.L.
      • Moravec M.D.
      • et al.
      Prevalence of colon polyps detected by colonoscopy screening in asymptomatic black and white patients.
      which still means that 1 in 6 lesions is inaccurately characterized as a high-risk adenoma. Information about the number of polyps, sessile serrated adenomas, and the completeness of polyp resection at initial colonoscopy is unavailable, and incompletely resected polyps could partially explain the elevated risk of large polyps detected at the subsequent procedure. Finally, the use of 3 years as the cutoff interval period for the second colonoscopy does not guarantee that lesions found on the repeated examination were missed rather than de novo polyps, although consistent results from the 1-year sensitivity analysis are reassuring.
      The study by Kluge and colleagues
      • Kluge M.A.
      • Williams J.L.
      • Wu C.K.
      • et al.
      Inadequate Boston Bowel Preparation Scale scores predict the risk of missed neoplasia on the next colonoscopy.
      also highlights 3 important areas for improvement in the practice of colonoscopy. First, national uptake of validated bowel preparation scores such as the BBPS remains insufficient. The BBPS was published at the beginning of the study period and incorporated into the CORI website and endoscopic software. Nevertheless, only 11% of the total procedures during the study period had a recorded BBPS score, and the authors allowed both BBPS and qualitative assessments of bowel preparation quality for the second colonoscopies in their analysis so they could maintain an adequate sample size. There is always an understandable delay from evidence to guideline to practice, but as we approach the 10-year anniversary of the BBPS and have reached general consensus on its superiority over qualitative scales, no valid excuse remains for endoscopists who have yet to integrate the scale into clinical practice. At this point, the BBPS should be considered the lingua franca for describing bowel preparation, and all endoscopists should be fluent users.
      Second, endoscopists have accepted individual responsibility for quality metrics such as adenoma detection rate, cecal intubation rate, and withdrawal time, but the adequacy of bowel preparation is often regarded as a patient-dependent outcome that is beyond the physician’s control. In fact, several interventions have been shown to improve the success rate and tolerability of bowel preparation, including split-dose and low-volume regimens, low-residue diet, oral and written patient education, and patient navigation.
      • Johnson D.A.
      • Barkun A.N.
      • Cohen L.B.
      • et al.
      Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi-society task force on colorectal cancer.
      For patients with an aversion to standard oral bowel preparation, our experience in using a colonic irrigation device as an alternative same-day preparation method has been promising. For patients who present with poor bowel preparation, endoscopic cleansing devices and through-the-scope enema techniques can also be effective salvage options.
      • Hoffman A.
      • Murthy S.
      • Pompetzki L.
      • et al.
      Intraprocedural bowel cleansing with the JetPrep cleansing system improves adenoma detection.
      • Horiuchi A.
      • Nakayama Y.
      • Kajiyama M.
      • et al.
      Colonoscopic enema as rescue for inadequate bowel preparation before colonoscopy: a prospective, observational study.
      More importantly, because the BBPS should be assessed only after thorough intraprocedural cleansing, it is imperative that endoscopists are diligent to routinely use standard cleansing techniques to wash the colonic mucosa and, when possible, to convert an inadequate bowel preparation to an adequate one. This is a critically important physician-level factor in ensuring that the bowel cleansing and the BBPS score are optimal. The U.S. Multi-Society Task Force (USMSTF) issued a strong recommendation in 2014 that the rate of adequate bowel preparation for each endoscopist should be 85% or higher,
      • Johnson D.A.
      • Barkun A.N.
      • Cohen L.B.
      • et al.
      Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi-society task force on colorectal cancer.
      the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy concurred in its guideline in 2015,
      • Rex D.K.
      • Schoenfeld P.S.
      • Cohen J.
      • et al.
      Quality indicators for colonoscopy.
      and the European Society of Gastrointestinal Endoscopy elevated the standard in 2017 by recommending a minimum of 90% and a target of 95% or higher.
      • Kaminski M.F.
      • Thomas-Gibson S.
      • Bugajski M.
      • et al.
      Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.
      Because ensuring a high rate of adequate bowel preparation is crucial for providing excellent and cost-effective care, endoscopists should take greater ownership of this key quality metric.
      Third, there is substantial overuse of colonoscopy and nonadherence to evidence-based screening and surveillance interval recommendations. Among individuals in the study with adequate bowel preparation at initial colonoscopy, the median time to the second examination was 374 days, and the interquartile range was 188 to 525 days. This means that 75% of individuals with an adequate initial examination underwent a repeated colonoscopy in less than 1.5 years. Among those with an adequate initial examination, indications for the second procedure were 68% surveillance, 19% diagnostic, 8% therapeutic/follow-up, and 5% screening. Of the procedures listed as surveillance, it is possible that a small percentage of them appropriately required a shorter follow-up interval for colonoscopy because of larger polyps that underwent incomplete piecemeal resection, more than 10 adenomas removed, or a diagnosis of Lynch syndrome or serrated polyposis syndrome. However, it is likely that for the majority of the 73% of screening and surveillance colonoscopies, the USMSTF guidelines recommending the interval for repeated examination of 3 or more years would have been applicable.
      • Lieberman D.A.
      • Rex D.K.
      • Winawer S.J.
      • et al.
      Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
      Even though one may assume that endoscopists who use the BBPS would also have high adherence to guideline-recommended examination intervals, these data suggest otherwise. Therefore, continued efforts to educate the endoscopy community are necessary, and mandating the reporting of appropriate quality metrics such as adequate preparation and surveillance intervals may provide additional motivation for adhering to guidelines.
      Optimizing care in the practice of colonoscopy is not conceptually difficult, but supplanting old habits with evolving best practice standards can be challenging. If all endoscopists simply strive to implement the BBPS in routine practice, take greater responsibility for the quality of their patients’ bowel preparations, and rigorously apply recommended screening and surveillance intervals, then we will have done a great service for both our patients and our healthcare system.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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