Quality Measures for Colonoscopy: A Critical Evaluation
Quality Measures for Colonoscopy: A Critical Evaluation
Proximal serrated polyp detection rate (PSP-DR) is defined as the proportion of patients undergoing screening colonoscopy in whom at least one serrated polyp (hyperplastic polyp, sessile serrated adenoma/polyp, traditional serrated adenoma) is identified proximal to the splenic flexure. Interest in the PSP-DR has been rising in relation to the concerns about the limited protective effect of colonoscopy in the right colon and the emerging appreciation of the role of the serrated pathway in colorectal neoplasia.
The range of PSP-DR is more striking compared with ADR, varying 5-fold to 18-fold among endoscopists in clinical studies, as opposed to approximately 3-fold to 4-fold variation for the ADR. Potential contributing factors are the more subtle endoscopic features of serrated polyps and the lower quality of bowel preparation in the right colon, particularly without split dosing. A review of 6681 colonoscopies showed a PSP-DR range of 1%–18% among 15 academic gastroenterologists (mean, 13%). Other studies have reported detection ranges of 1.4%–7.6% and 6%–22%.
The strong correlation between ADR and PSP-DR suggests that PSP-DR can be considered a valid measure of quality for colonoscopy. This is an intuitive conclusion, because endoscopists who conduct a meticulous colon mucosa inspection are expected to be high-level adenoma detectors as well as detect other types of colon lesions such as serrated polyps. However, the strong correlation also implies redundancy between ADR and PSP-DR. In fact, despite the links between interval cancer and the serrated pathway, there are no studies showing an independent association between the PSP-DR and the risk of interval CRC. There are other obstacles to the PSP-DR becoming an independent quality metric. There are no benchmarks defined by gastroenterology professional societies at this time, although the current targets for ADR have been shown to correspond to PSP-DR of 4.5% for both men and women, with a suggested benchmark of 5%. Another limitation is the high variability in serrated polyp classification among pathologists. Furthermore, measuring and reporting the PSP-DR are not practical because this requires a fairly detailed pathologic review and neglects the left colon. The ADR can be used as surrogate for both adenomatous and serrated polyps, but high-level adenoma detectors who are motivated to obtain a comprehensive assessment of quality can consider measuring PSP-DR as a complementary quality metric.
Proximal Serrated Polyp Detection Rate
Proximal serrated polyp detection rate (PSP-DR) is defined as the proportion of patients undergoing screening colonoscopy in whom at least one serrated polyp (hyperplastic polyp, sessile serrated adenoma/polyp, traditional serrated adenoma) is identified proximal to the splenic flexure. Interest in the PSP-DR has been rising in relation to the concerns about the limited protective effect of colonoscopy in the right colon and the emerging appreciation of the role of the serrated pathway in colorectal neoplasia.
The range of PSP-DR is more striking compared with ADR, varying 5-fold to 18-fold among endoscopists in clinical studies, as opposed to approximately 3-fold to 4-fold variation for the ADR. Potential contributing factors are the more subtle endoscopic features of serrated polyps and the lower quality of bowel preparation in the right colon, particularly without split dosing. A review of 6681 colonoscopies showed a PSP-DR range of 1%–18% among 15 academic gastroenterologists (mean, 13%). Other studies have reported detection ranges of 1.4%–7.6% and 6%–22%.
The strong correlation between ADR and PSP-DR suggests that PSP-DR can be considered a valid measure of quality for colonoscopy. This is an intuitive conclusion, because endoscopists who conduct a meticulous colon mucosa inspection are expected to be high-level adenoma detectors as well as detect other types of colon lesions such as serrated polyps. However, the strong correlation also implies redundancy between ADR and PSP-DR. In fact, despite the links between interval cancer and the serrated pathway, there are no studies showing an independent association between the PSP-DR and the risk of interval CRC. There are other obstacles to the PSP-DR becoming an independent quality metric. There are no benchmarks defined by gastroenterology professional societies at this time, although the current targets for ADR have been shown to correspond to PSP-DR of 4.5% for both men and women, with a suggested benchmark of 5%. Another limitation is the high variability in serrated polyp classification among pathologists. Furthermore, measuring and reporting the PSP-DR are not practical because this requires a fairly detailed pathologic review and neglects the left colon. The ADR can be used as surrogate for both adenomatous and serrated polyps, but high-level adenoma detectors who are motivated to obtain a comprehensive assessment of quality can consider measuring PSP-DR as a complementary quality metric.
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