ASGE/ACG Quality Task Force Updates Quality Indicators for Colonoscopy

Douglas K. Rex, MD, MASGE, reviewing Rex DK, et al. Gastrointest Endosc and Am J Gastroenterol 2024 Aug 21.

This is the first update of colonoscopy quality indicators since 2015. Much new evidence has appeared since then.

Some key recommendations from the updated American Society for Gastrointestinal Endoscopy/American College of Gastroenterology guideline document:

• The priority quality indicators that should be measured by all colonoscopists are now the adenoma detection rate (ADR), the sessile serrated lesion detection rate (SSLDR), bowel preparation adequacy rate, and the adherence rate to recommended screening and surveillance intervals.
• The cecal intubation rate should be measured by all colonoscopists (target ≥95%), but this measurement can be intermittent or not at all for colonoscopists who are consistently above the threshold.
• The rate of adequate bowel preparation in outpatients should be ≥90%.
• ADR should now be measured for screening, surveillance, and diagnostic examinations combined. The main exclusions from the ADR measurement are positive fecal tests or other positive screening tests, as well as patients with inflammatory bowel disease (IBD), genetic cancer syndromes, and those undergoing colonoscopy for treatment of known neoplasms. The ADR should include patients aged 45 years or older, and the target for minimum acceptable performance is ≥35%.
• SSLDR should be ≥6%. In centers where all endoscopists are below this threshold, the pathologic diagnosis of SSLDR will need to be reviewed with local pathologists.
• For patients with positive fecal screening tests (fecal immunochemical testing or multitarget stool DNA testing), the recommended ADR is ≥50%
• The new recommended minimum average withdrawal time in normal colonoscopies in persons aged 45 years or older is ≥8 minutes.
• There are 2 new resection indicators: (1) the fraction of resected lesions for which the report documents lesion size, shape, location, and resection method (target ≥98%) and (2) the fraction of 4- to 9-mm lesions removed by cold snare (target ≥90%).
• Postprocedure screening and surveillance interval recommendations should be consistent with the U.S. Multi-Society Task Force on Colorectal Cancer recommendations in ≥90% of cases.
• The proportion of serious adverse events (eg, perforation, delayed bleeding, death) tracked, documented, and reviewed by a quality improvement committee to assess for systemic and clinical areas of improvement should be ≥95%.
• There are 3 indicators related to IBD: (1) the fraction of patients with ulcerative colitis (UC) who undergo a formal assessment of disease activity with a scoring system such as the Mayo Endoscopic Score; (2) the fraction of patients with Crohn’s disease with a formal disease activity score such as the Crohn’s Disease Endoscopic Index of Severity or Rutgeerts score; and (3) adherence to recommended surveillance for dysplasia intervals in chronic UC.

COMMENT

Operator dependence remains a huge issue in colonoscopy. These new recommendations ask colonoscopists to do more in measuring performance quality, of which the biggest changes are the recommendation to measure SSLDR and the modification to the ADR definition. All the major changes are supported by a substantial evidence base, as outlined in the document. Adherence to the recommendations seems likely to advance our central goal in colonoscopy—preventing colorectal cancer.

Note to readers: At the time we reviewed these papers, their publishers noted that they were not in final form and that subsequent changes might be made.