Colen Cancer

[silence] my name is david lieberman. i'm the chief of gastroenterologyat oregon health and science university, and i am honoredto participate in this effort by the centersfor disease control and prevention to improve the qualityof colorectal cancer screening. for those of you who do not know me,i am a past president of the american societyfor gastrointestinal endoscopy and a current memberof the governing board

of the american gastroenterologicalassociation, or the aga. i have been a participant in the national colorectal cancerroundtable for many years. i served as chairof the multisociety task force on colorectal cancer for six years and participated in the development of colorectal cancer screeningand surveillance guidelines. my research has focusedon colorectal cancer screening, surveillance, and quality.

we now have compelling evidencethat colon cancer screening works. it reduces the incidenceand mortality of colorectal cancer, but only if it's performed with high quality. the topics that we're goingto be covering include ensuring that colonoscopyis appropriate and indicated, the importance of a good bowel prepand the role of split dosing, the importance of complete documentationand the role that that plays in communicationwith primary care physicians and patients to determinewhen the next exam is appropriate,

and the need to improvethe quality of colonoscopy in monitoring quality indicators. so let's start outtalking about considerations before you perform a colonoscopyto ensure that the exam is appropriate, it's at the appropriate interval, and that the patient is medicallyappropriate for the procedure. the other elements to think aboutprior to the examination are optimizing the bowel prep and then managing any patientmedications and other conditions.

so is the colonoscopy examappropriate now? and so we haverecommended screening intervals based on the age and family history that we discussed in part 1, and i'll show you an example of howyou can go back to the earlier slide. so for patients that are average risk, we have several screening options,but the recommendation for performing colonoscopyis at ten-year intervals if the baseline examwas a normal examination

and was complete to the cecum. so you can use this methodto go to additional slides, and then when you're donelooking at that slide, those slides will have a "go back" message, and you can just returnto the primary slide show. we also discussed in part 1 the recommended surveillance intervalsfor patients that have had prior polyps, including thosethat have had prior adenomas, and i'll go to the slide that shows that,

which highlightslow- and high-risk individuals. so patients that have one or two adenomas less than ten millimetersin their baseline examination represent a low-risk group,and they can have colonoscopy in five to ten yearsafter that baseline examination, whereas those that havethree or more adenomas or adenomas greater than 10 millimeters or with villous featuresor high-grade dysplasia represent a higher-risk group,

and they should have colonoscopyperformed at three-year intervals. so i encourage you to usethe links provided on this slide set, which enable you to moveto additional slides. if the examination is going to be performed at a different intervalthan guidelines have recommended, we encourage youto include a reason for deviatingfrom the recommended guidelines, and there could bemany good reasons for deviating, but this should be documentedin the medical record.

today many patients are referreddirectly for colonoscopy in so-called direct access,and i'd like to spend a few minutes talking about the circumstances under which you should thinkabout seeing the patient prior to the scheduling of the colonoscopy. so elderly patients have a higher risk, and elderly over 75 have a higher riskassociated with colonoscopy. patients that are gettinganticoagulation and cannot safely stop their medications;patients that have had recent infections

or active cardiac, renal,pulmonary, or liver disease; patients that have hada prior history of difficulty with sedation or anesthesia; patients that have hadpoorly prepped colons in the past-- these are all situations in which you may needto take some special precautions, and you may need to takesome special measures to ensure that you can perform a safe and effectivecolonoscopy examination.

the bowel preparation is perhapsone of the most mundane topics related to colonoscopy,and it is the most important, so i want a spend a few minutes talking about the reasonsthis is so important. the consequences of a poor prep include difficulty actually performingthe colonoscopy itself, prolonged procedure time, reduced rates of completingthe exam to the cecum, the need for repeat proceduresat a shortened interval,

and, most important, a reduced ability to detect important pathologies,such as polyps or cancer. we have evidence that the bowel prepis inadequate in up to 25% of patients undergoing colonoscopyin the united states, and this is an important factorassociated with the possibility of developing interval lesionsafter colonoscopy. there are several types of bowel prep. there are so-calledisosmotic full volume preps, and these isosmotic prepsare basically not absorbed,

and so there's full volume,which is generally four liters, lower volume preps, and then hyperosmotic preps. the important message,though, about the prep is that the instructions need to be clear and they need to be understoodby the patient. so they have to beat an appropriate literacy level. there have been manyinnovative approaches taken to try to improvethe quality of the bowel prep,

and i encourage you to lookat some of these links. one is a youtube video that talks about the preparationfor colonoscopy, and then there are actual examplesfrom several centers showing bowel prep instructionsthat are given to patients. we hope that these additional materialswill be helpful to you in advising your patientsabout bowel preps. there's evidencethat using patient navigators can improve both the adherenceand the quality of screening examinations.

so these navigators can be effectivenot only in communicating and helping patientsnavigate through the system, but they can be a wayof helping communicate information about the bowel prep,which, as i said, is so critical to the performance of a high-quality exam. in many studies,there's been evidence that navigatorshelp get patients scheduled. they help get the appropriate tests done and help with transportation,language issues,

and, as i said,bowel prep and getting patients ready. so this is somethingto think about in your practice, and it may helpwith improving the effectiveness of the overall screeningexperience for your patients. so we have a question. what is the preferred bowel prepdosing schedule for colonoscopy? and the answer is that the split-dose prep is clearly now preferredover any other method, and that applies to all of the variousbowel-cleansing preparations.

so it's now recommendedin several guidelines, and the concept hereis that half of the laxative is taken on the eveningprior to the examination, and the remainder is takenin the morning of the procedure. the colonoscopy can be performedtwo to four hours after the last dosing, and it's more effective and better tolerated than the full-dose evening dosingthat used to be used. in studies, it's been demonstratedto be superior for both the isosmotic peg, high and low volume,as well as osmotics.

so it really should be usedfor any form of prep that you are considering,and here's the evidence. this comes from a meta-analysisthat showed that, number one, that the prep cleansingwas better--far superior, number two, patients were less likelyto discontinue the prep, number three,that patients were more willing to repeat it with the prep, and number four,they had fewer side effects. so if you look at this slide,this is a win-win-win-win situation,

and there should be no doubt nowthat split-dose preps should be used in practice. there are potential barriersto split-dosing preps that have been raised that we believeare not significant concerns. one is patient acceptancebecause this may require the patient to wake upin the middle of the night to take the second doseprior to an early-morning procedure. but when patients have been surveyed,more than 85% are willing to get up

in the middle of the nightto take the second dose, and for those that are not, you may want to consider schedulinginto an afternoon procedure. a second concern is, am i going to have difficultyduring the transportation from home to the endoscopy centerto have my procedure and need to make several stopsalong the way? and most of the evidence suggeststhat there is very little difference between taking the full dose in the eveningor having the split-dose prep.

so it's a matter of timingand understanding how far the patient needs to go, and this is where a patient navigatormay be very helpful. there is a potential risk ofaspiration during sedation because patients may still havesome liquid in their stomach. however, the anesthesia guidelinesdo allow for ingestion of clear liquids up until two hours before sedation, and that is more than sufficientfor patients undergoing a bowel prep. so most of these alleged barriersare really not a barrier to split dosing,

and we strongly urgethat split dosing be used in practice. for those patients that are going to havean afternoon examination, the prep can be given--part of it in the evening before and then part of itin the morning before the procedure, ending more than two hours before the scheduled colonoscopyshould begin. what about diet? there are various diet regimensthat have been recommended. the optimal pre-procedure dietis still really not well defined.

most experts would considergoing on a clear liquid diet for 24 hours prior to the examination or having a very lightbut low-fiber breakfast on the day before the procedurefollowed by clear liquids. the important message,i think, to patients is that they need to drink a lotduring that day before the procedure, and that will help make the bowel prep,the laxative, much more effective. how do you predict if somebody'sgoing to have a bad prep? well, clearly, if somebody'shad a bad prep in the past,

they may be likely to have it again, but there are other patient characteristicsthat may help you determine that you need to do somespecial prep considerations. patients that are in the hospitaltend to be difficult to prep, and i think this is partly becausethey're not moving around very much, and they may be on medicationsthat can slow down the gut. the elderly, the obese,patients with lower levels of education tend to have less adequate preps. patients with a history of constipation,patients that are using antidepressants,

particularly those that may havean anticholinergic effect, and patients that are on chronic narcotics-- narcotics slow down the boweland can make prepping very difficult. and then, of course, patients that arenot compliant with their medications may also have difficulty with the prep. this is another area wherehaving a patient navigator can help address some of these issues, but special considerationsmay be needed for some individuals if you can anticipatethat they're going to have a bad prep.

so how can you improve the prep for patients that have hada prior poor prep? well, there are really no good studies, but there is evidence thatthe navigator and patient education work. you can increase the total volume of thelaxative solution from two to four liters if it's a low dose, or four to six litersif it's a higher dose. split dosing, as i mentioned,is very effective. ensuring adequate hydrationis absolutely important, and then potentiallyadding other agents

such as magnesium citrate or miralaxthe evening before beginning the prep, so that would be two daysbefore the procedure, may help with the bowel prep. adding bisacodyl or sennato help with evacuation can help some patientsthat have constipation, and then extending the periodof diet modification from 24 hours to 48 hours. so these are all individualconsiderations that you should think about in patients

where there's eithera past history of poor prep or you anticipate a poor prepfor the reasons that we have talked about. other things to think about prior to the colonoscopyare special precautions, and we have a link to slidesfor each one of these areas. so, for example,if somebody is on anticoagulants, you need to think about whetherthey can be safely stopped over a period of several daysor whether the patient has to be bridged. for patientsthat are taking diabetes medications,

we generally recommend that theywill be taking half of their medication on that day before the procedure becausethey're not going to be eating any food. antibiotic prophylaxis,we rarely need to do, but there are certain circumstances, and each one of these itemshas a link to a slide that will take youto the established recommendations. one area where i think is very important are patients that are takingoral iron for any reason. iron is very difficultto clear during the prep,

and so we recommend thatoral iron medications be stopped at least seven to ten days beforethe patient has their colonoscopy. and cardiac devices, we have a coupleof slides describing the management, and you should be working closelywith your cardiology colleagues to help manage some of these devicesat the time of the procedure to make sure that all precautions are taken. what about sedation? well, there are several optionsfor sedation, including conscious sedationand deeper sedation with propofol.

propofol has become popularin the united states because it has a very rapid onset of actionand a very rapid recovery. so patients sleep during the procedure, and then they wake up very quicklyafter the procedure is completed. it's probably necessaryfor a small fraction of patients who cannot be effectively sedatedwith moderate sedation or are at increased risk for sedation,for moderate sedation. so these could be individuals that have a prior history of difficultywith moderate sedation,

cannot tolerate those medications,or are on chronic narcotics and, therefore, would be difficult to sedatewith moderate sedation. major limitation with propofolis the possibility of moving from deep sedation into general anesthesiawith respiratory depression. in most states, there's a requirementthat anesthesia personnel be available, and that could substantially increasethe cost of the procedure. propofol is not covered by all insurersand often only for specific indications. so what are those indications? and they can include patientsthat have dependence on opiates

and sedatives, like benzodiazepines, that have significantneuropsychiatric disorders, that have had a negative experiencewith prior sedation efforts, drug or alcohol abuse. the extremes of age,very young and very old patients, may benefit from havingcareful sedation with propofol. pregnancy, morbid obesitybecause of the difficulties of managing these patientswith conscious sedation, and anybody thatis going to be uncooperative

or if the procedureis going to be complex or lengthy, at least you should thinkabout the use of propofol. finally, increased risk of airwayobstruction should be also considered as a potential reasonfor considering propofol. so we're going to move onto some of the quality elements of the colonoscopy report,and so the question posed here is, what elements should bedocumented in every report? and the quick and simple answer to this is,these are elements that will be communicatedto other physicians and to the patient

and will help direct the subsequentmanagement of that individual, including the appropriate intervalfor the next examination. so the documentation,which seems like a fairly simple step, becomes a very important stepas part of a quality practice, and we should ensurethat all the key elements are noted because it facilitates communicationwith physicians and the patient, and also allows monitoring of performanceto compare with other practices. so what are some of these elements? well, we have triedto define these elements

in a paper that we publishedseveral years ago, and the link to this paperis provided on this slide. this was designed after the developmentof similar reporting systems for radiology and mammography. and so it's a fairly simple systemthat includes key elements from the pre-procedure, intra-procedure,and post-procedure periods, and so we're going to talkabout each one of those. so in the pre-procedure report elements, the endoscopistshould document the informed consent,

the patient demographics,such as age, sex, and race, and then any appropriate measuresthat are needed for management of anticoagulation,cardiac devices, and diabetes so that these elements of precaution are carefully documentedin the medical record. there should be some assessmentof the patient risk comorbidity. many physiciansuse the anesthesia classification, which definesfive different groups of patients, and most patients that have endoscopywill be either asa class 1, 2, or 3.

an evaluation of the airway has been recommendedby our anesthesia colleagues, and then some documentation thatthere's been a recent history and physical so that if thereare any new medical problems, we're aware of those problems. there are several categoriesfor the indication for the procedure. screening refers to patientswho are asymptomatic, who do not have a personal historyof either adenomas or colorectal cancer. this could include patientswith or without a family history

of colorectal cancer or adenomas, but also include patientsthat are asymptomatic but have had some otherpositive screening tests, such as a fecal occult blood test,fecal immunochemical test, sigmoidoscopy, barium enema,stool dna, or ct colonography. these patients are still asymptomatic,but if those tests are positive, that is an indication for a colonoscopy. a second major categoryfor indication would be surveillance. patients that had a prior personal historyof either colorectal cancer or adenomas

and, if possible, the detailsabout when those diagnoses were made and what was found on prior examinations help guide the subsequent managementfor that individual. this also includes patientsthat have chronic ulcerative colitis and crohn's disease, and the intervals for performing thoseexams should be at about every two years after the patientshave had disease for eight years. finally, the diagnostic category. these are patientsthat have had signs or symptoms,

that of lower gi disease that could includecolorectal cancer and/or other diseases. in this case, the specific signs or symptomsshould be specified in the medical record. the other pre-procedure elementsthat should be documented would be any prior colonoscopy historyand a detailed family history, and the rationalefor the family history, as i mentioned, is that it could identify patients that are going to needmore frequent examinations based on the ageof the index family member that had canceror high-risk polyps.

if there is an indicationthat does not seem to fit into guidelines or the exam is being performedbefore the recommended interval, this deviation from the guidelinesshould just be documented. there are many good reasonsfor deviating from guidelines, but the important message is that it shouldbe documented in the medical record. during the procedure itself,there are certain elements that should be documented,including the bowel prep type and some assessment of bowel prep. so was the final bowel prepgood enough, good, or excellent,

for each segment of the colon, and, if not, was every effort made to tryto convert a fair prep into a good prep during the withdrawal of the instrumentand cleaning during the procedure. so this is an important partof the documentation of the procedure. so how to rate the bowel prep,and there have been several methods used. one is just an excellent,good, fair, and poor examination, with "fair" being defined as adequate to detect polypsgreater than five millimeters after cleaning. the second methodhas been to simplify this

by just saying it was either adequate todetect lesions greater than five millimeters or inadequate to detect lesionsgreater than five millimeters. there's a more rigorous methodthat has been developed called the boston bowel prep score,and this is a scoring system that's used after the bowel has been cleanedduring the withdrawal of the instrument. the important thingabout this scoring system is that it has been linkedto what happens after the procedure, the development of polyps later,and the development of interval cancers, and so this is a report that i think allowsyou to assess each segment of the colon,

so you give a grading systemfor three different segments of the colon, and you can differentially assess whether you've seen allor part of the colon adequately. finally, there should be somedocumentation of the extent of the exam. ideally, there should bephoto documentation of the cecum that includes the appendiceal orificeand the ileocecal valve. the photo shown hereshows the ileocecal valve at the very topat around twelve o'clock in this photograph. if you did not reach the cecum,

you should document how far you gotby anatomic segment, and if the cecum is not reached, a reason should be providedfor not reaching the cecum. also, there should be documentationof the sedation used, the dosage, and the withdrawal timeafter you've reached the cecum. the reasonfor documenting withdrawal time is that there has been a relationshipbetween the withdrawal time and the adenoma detection rate. and so having an adequate withdrawalof at least six minutes

is recommended by most experts. finally, it's been recommendedby most experts to perform retroflexion in the rectum and to document thatto be able to see perianal pathology. the other elements include a descriptionof all the findings in enough detail that a readercan understand what was found. so, for example, for polyp descriptors, that would includemeasuring the size of the polyp or an estimate of the size of the polypbased on endoscopy, the location,and the appearance of the polyp.

so this is an exampleof some of the descriptors that one might think about, showing an exampleof a pedunculated polyp, a sessile polyp, and thena very flat polyp shown on the bottom. so these descriptorsshould be included in the report. the method of removing polypsshould also be documented so that if a snare was used,was cautery used or not? was injection used to raise the lesion? was the resection complete?

did it need to be performedin several pieces, so-called piecemeal resection. any suspicious lesion in the colon, and by this i would mean any lesiongreater than two centimeters, should be tattooed with india ink and so that it will be easyto go back and reinspect that area on a subsequent examination. the only exceptions to tattoowould be if the lesion is in the cecum itself, where you have other anatomic landmarks,like the appendix and the ileocecal valve

or in the rectum itself,where you know exactly where you are. the other questionthat should be addressed in the report is whether the polyp was actually retrievedfor pathological examination. so when we retrieve polyps, we need to give our pathologistsimportant information about the pathology specimen, and pathologists need to know the colon descriptionof the lesion that we removed, the morphology, whether we thinkit was completely removed,

and what portion of the colonit was taken from. and we provide some examples hereof descriptors that might be used to communicate to your pathologists. so it's important that they haveas much information as we have at the time that they're examining this. there's some controversyabout whether pathology specimens can be pooled into one jar. most experts would say that if a polypis greater than five millimeters, it should probablybe placed in its own vial.

there are situationswhere there's a cluster of polyps in one portion of the colonthat are all diminutive-- less than five millimeters--and some experts believe that it's reasonable to poolsome of those polyps into one jar to reduce the costs of the pathology. after the procedure, it's important to provide recommendationsfor follow-up based on the patient's history, their age, their comorbidity,and the colonoscopic findings. in many cases,this is going to have to be delayed

until after the pathology resultsare available and you know what type of polypthat you are dealing with. the recommendations for follow-up should be consistentwith evidence-based guidelines, but if for some reason you think that the examinationshould be performed at a different interval, then you should provide a reasonfor deviating from those guidelines. those recommendationsand results should be communicated very clearly to both the patientand to the referring provider,

and ideally,there should be a follow-up for any adverse eventsoccurring after the procedure's completed. in terms of recommendingappropriate follow-up, one of the issuesthat should appear in every report so that any reader can look at it is,was the exam complete to the cecum, was the bowel prep adequate,and were the polypectomies complete? because if they were not,then that may be reason that there will need to bea shorter interval for the next examination. and that shorter interval would be exams

that would be performed intwo to six months after the procedure. in patients wherethe cecum was not reached who are average risk,should those patients have yet another colonoscopyor some other examination? and the answer is not clear. these patientsare still average risk, so they may benefit from havinga high-sensitivity guaiac fobt or fecal immunochemical test. many physicians would useanother examination like ct colonography

to view that portion of the colonthat was not adequately seen, and so i think the individual-- the management of these patientsshould be individualized. in the next slide,we discuss the appropriate follow-up for an incomplete examination, and there are several optionsfor patients that-- for those patientsthat had an adequate bowel prep but it just wasn't technically possibleto complete the exam due to a tortuous colonor prior surgery, adhesions,

or various colon diseases. the options include using a capsulethat can be swallowed, the so-called pillcam colonthat allows a visualization of the colon, or performing ct colonographyto visualize that portion of the colon that was not adequately seen. in patientswhere the exam was incomplete due to ineffective sedation, that's an examthat might be repeated in the future using deeper sedation with propofoland other sedation medications.

the key point is that if a high-qualityexam is completed and it's negative, the patient does not needto have another exam again for ten years if they're average risk. the next slide poses a question. in an average-risk patient who hasa complete colonoscopy with no findings, should you recommend an interim stool test before his or her next colonoscopyis due in ten years? the key message here is that patients that have a negativecolonoscopy who are average risk

have a very low risk of developingany serious colon pathology for ten years or more, and therefore, they probably do not needany screening during that ten-year period. there is no evidence that supportsthe performance of an interim test, such as fecal occult blood testingor fecal immunochemical testing prior to the next colonoscopy. there are other groupswhere the management of these patients might be different, and so patients that have a family historywith a first-degree relative

who had cancer at age less than 60, those individuals should have examinationsat five-year intervals. and then we've talked earlierabout patients that have adenomas, serrated polyps,or a history of colon cancer. those patients will haveexaminations at shorter intervals based on the significance of the lesionthat was found on their examination. what about patientsthat had only a fair prep at the baseline colonoscopy? here we have little or no publishedguidance or evidence to guide us,

and so it comes down to clinical judgment. the follow-up for these individualsshould be individualized based on the patient's age,their comorbidities, and the goals of the procedureas well as the risk. so, for example, an elderly patient-- it may be that the goal of that procedureis to detect important lesions, and you might be satisfiedif you felt that the exam was sufficient to detect important polypsor growths in the colon. then that patient,even though the prep was fair,

may not need another examination. in selected cases,it may be very appropriate to recommend that the patient return earlierthan the interval recommended, and this could include younger patients who have a much longerlife span ahead of them and may be more likely to benefitfrom a high-quality exam. if the exam was only fair, though,then it's worth considering whether these patients will need to havespecial prep instructions to assure that that next exam is reallyan excellent or good bowel prep.

the communication with patientsand referring physicians about subsequent recommendationscannot be emphasized enough. there should be clear communicationabout what was found and the implications of those resultsin terms of next steps. so a summary of the findingsshould be provided for both the patientand for the referring physician, and a recommendation,a very clear recommendation, for the next examinationshould be included with that note to both the patientand the referring provider.

after the colonoscopy,when the patient is awake, it's important to discussthe major findings of the procedure, whether it was adequate,whether polyps were removed and when those results will be availableand what to do in the following days in terms of diet,medications, driving, et cetera, and what to look out for, particularlyany complications of a procedure, such as bleedingor perforation or pain should be-- the patient should understandwith clear instructions what to do if those things were to happen.

the patient should be givenwritten discharge instructions that tell the patient what to do should any of theseserious adverse events occur. if possible,capturing what happens to the patient over the next 30 days should be done. we realize that this is not feasiblein many clinical practices, but it would certainly be valuable to know if patients had any serious eventsoccur within the 30 days after they've completed a colonoscopy.

finally, this communicationshould occur in writing so that there's no misunderstandingof what was being found and what is being recommended to boththe patient and the referring provider. so the communication with patientsshould be in a written form, ideally, that provides them information about when they need to returnbased on their risk level. depending on the findings,it may be important to encourage the patientto talk to their family members about the importance of these findings

because it may have implicationsfor the family member. so, for example,if the patient has colorectal cancer, they should be notifyingtheir family members because those family membersare going to be at increased risk for colorectal cancer themselves and should be initiating screeningat a younger age and more intensively. so as part of the communicationwith the patient, encouraging them to speakto their family about the findings is an important part of that communication.

finally, reminder systemsare very important, and they work. we have very good evidencefrom a variety of studies that getting patients backat appropriate intervals using computerized reminder systemsare very effective, but what's also effective is making surethat the patient knows when they need to come back,and because patients may leave a practice or they may leave a cityand go somewhere else during a five- or ten-year period,it's important that the patient understand when they are due for their nextexamination so that it's done appropriately.

moving on to the quality of colonoscopyand how to monitor quality, a few questions to think aboutas we discuss this section. first, are some endoscopistsbetter than others at finding adenomas? what is the minimumadenoma detection rate that you should achieve for screeningexaminations in average-risk individuals? and what should you doif the bowel prep quality is only fair or poorin more than 10% of your patients? so the need to improvethe quality of colonoscopy has been highlightedby variation in practice.

we know from a variety of studies thatthere is wide variation among endoscopists who are performing screening examinationsin similar types of patients where we would expect to haverather consistent results. so the variationincludes the detection of polyps, the ability to reach the cecum,the quality of the bowel prep, the appropriateness of the screeningand surveillance recommendations after the procedure,and the completeness of reporting. so there's room to improve quality. how can it be improved?

and there are several methods, but certainly, having a continuous qualityimprovement program within your practice will enable you to monitor performanceof the endoscopists in your practice, compare with benchmarksand national targets, and then take steps to improveperformance when it is needed. the recommendationsfrom the u.s. multisociety task force on colorectal cancer as well asthe national colorectal cancer roundtable about elements that should be measuredand, very recently, a new publication in 2014on the quality indicators for colonoscopy

are included in the linksprovided on this slide set. so what should be monitored? and the highest-priority itemsinclude the adenoma detection rate, the cecal intubation rate,the quality of the bowel prep, and the use of appropriate intervals after screeningand surveillance is completed. and some of these have now becomemeasures of cms quality programs such as the physician qualityreporting system, or so-called pqrs, that many of us need to provide reports to.

so let's talkabout the adenoma detection rate. what is it? it's really the rate of finding adenomasin average-risk screening examinations. the current target that is recommendedin the 2014 recommendations are that it should be greaterthan 30% for men who are undergoingscreening examinations and greater than 20% for womenundergoing screening examinations. why is it important? it's importantbecause it has been linked directly

to the development of interval cancersin subsequent years after a colonoscopy. so perhapsthe most important quality indicator would be the rate of interval cancers,which is difficult to measure. but this is an excellent surrogate marker which has been shownto have a direct relationship so that patientsthat are high detectors-- above these targets--have low rates of interval cancers in the next three to five yearsamongst their patients, whereas patients that have low--that are low--

physicians who are low detectors, their patients have higher ratesof interval cancer in the three to five yearsafter their colonoscopy is completed. that is why this is important. that is why all us should knowwhat our adenoma detection rate is. the targets highlighted in this slide are new targets that were justpublished recently in 2014 and represent the most recent datafor screening examinations. what else should be monitored?

well, the cecal intubation raterepresents an estimate of whether the exam is a complete exam,and if the exam is not complete, then important pathology may be missed. so it's really definedas the percentage of exams in which the cecum was reachedwhen it was intended to reach the cecum. the target for all examinationsis greater than 90%. the target for screening and surveillanceexaminations is greater than 95%. and again, the reason this is so important is because important lesions can be missedif the colonoscopy is not complete.

how do you know if it's complete? i think thatmost of the guidelines and experts recommendthat there be photo documentation that demonstrates at leastone of these features, the ileocecal valveor the appendiceal orifice, to demonstrate completeness of the exam. quality of the bowel prep-- we talked about qualityof the bowel prep several times, and it remainsone of the most important targets

and one of the most important barriersto a highly effective colonoscopy. we recommend that all practicesmonitor the quality of their bowel prep and the adequacy with a targetof achieving greater than 90% either good, excellent, or adequate todetect lesions greater than five millimeters. we mentioned that a poor bowel prepresults in missed lesions, a need for repeat examinationsat shorter intervals, which drives up the risk to patientsas well as the cost. we recommend that if a practicehas less than 90% of exams that are good that you should look very carefullyat the processes

that are involved in patient instructionsand the type of prep that you're giving. so the prepshould all be split-dose preps. the instructions should be very clear,and you may want to consider the use of a patient navigatorto help the patient, guide the patientthrough this process of the bowel prep, which is so criticalto a high-quality examination. finally, the appropriateness of the screeningand surveillance recommendations should also be monitoredso that you have an idea

of how often you're deviatingfrom the published guidelines that are based on evidence. we know that in certain situations, the exams are performedat shorter intervals than are recommended, which has the potentialfor wasting resources as well as the potentialfor harm with little benefit. and then there are other circumstances where a procedureshould be performed more often in patients with higher-risk lesionsor incompletely removed lesions,

and those patients would be at riskfor development of cancer. so adhering to evidence-based guidelinesshould be a quality metric, and reasons for deviatingfrom that guideline should be providedas part of a high-quality report. the other things that should be monitoredwould be some of the descriptors, whether or not the reporting elementsare included in the report. so does the reportindicate the polyp descriptors? is the polyp retrieval rate documented? is the rate of repeat examinationsin less than a year

for poor or inadequate prep documented? are tattoos placedfor large or suspicious lesions except in the cecum and rectum? so these are other parametersthat can be followed as part of a high-qualitycolonoscopy practice. a paper was published several years ago to assist physicians in what questionsthat they might ask their endoscopists about the qualityof their colonoscopy examinations. and so this paper is provided hereas a reference for you,

and the source documentcan be obtained to enable you to know what questions to be askingabout colonoscopy quality. so a few final take-home points from this sectionof our discussion: first, that we should be following evidence-based screeningand surveillance guidelines to ensure that colonoscopyis performed at the appropriate time in the appropriate patientbased on the personal and family history; second, that we should beworking and striving

for good-to-excellent bowel prepsin all patients; split-dose prepsare strongly recommended; that every effort should be madeduring the examination itself to convert a fair prep into a good prepwith cleaning during the procedure even though that takes additional timeduring the procedure; and if the bowel prep qualityis inadequate in more than 10% of patients, then it's important for practicesto look at their procedures to see if they can improvetheir educational materials, if they can improvethe navigation process for their patients.

complete colonoscopy reports are essential for clear communication with bothpatients and referring providers so that the appropriate next stepscan be taken at the proper interval. and the quality of colonoscopyis highly variable, and therefore, it's importantfor all of us to monitor performance with quality indicators and quality metrics and then take steps to remediatewhen the benchmarks are not achieved. i want to thank all of you for viewingand participating in this course. i want to remind youthat we have many resources

embedded in these documentsso that you can click on links that will take youto many wonderful source documents.