Association between improved adenoma detection rates and interval colorectal cancer rates after a quality improvement program

Published:February 21, 2020DOI:

      Background and Aims

      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.


      ADR (adenoma detection rate), CI (confidence interval), CRC (colorectal cancer), iCRC (interval colorectal cancer), ICD (International Classification of Diseases), RR (relative risk), QI (quality improvement), WT (withdrawal time)
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      Linked Article

      • Connecting colonoscopy quality improvement initiatives with reduced rates of interval colorectal cancers
        Gastrointestinal EndoscopyVol. 92Issue 2
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          The dominant strategy for colorectal cancer (CRC) screening in the United States has been opportunistic colonoscopy. CRC incidence and mortality rates have declined since the introduction of screening programs; yet, it remains the second leading cause of cancer-related death in the United States.1,2 For many years, variations in the efficacy to prevent CRC incidence and mortality have been well described in colonoscopy screening studies. For instance, Baxter et al3 showed a total reduction in all CRC-related deaths of 31%, but in that Canadian cohort, colonoscopy failed to show a beneficial effect in preventing death resulting from CRC of the right segment of the colon.
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