Introduction

Adenoma detection rate (ADR) has been criticised as a colonoscopy key performance indicator (KPI), for excluding significant serrated polyps, being dependent on histological data and fostering a “one-and-done” attitude. A case-mix adjusted Mean Number of Polyp (aMNP) was selected as preferred KPI in the NED-APRIQOT study Delphi process.(1,2) We hypothesised that aMNP would address the criticisms of ADR, providing a more tailored and comprehensive assessment of quality and across the whole colon. UK endoscopy centre quality indicators include post-colonoscopy colorectal cancer (PCCRC) rates and a quality Global Rating Scale assessed by the UK Joint Advisory Group for endoscopy (JAG) when accrediting endoscopy units.

Aims & Methods

We aimed to develop an aMNP using the National Endoscopy Database (NED) and assess its relationship with traditional KPI, post-colonoscopy colorectal cancer (PCCRC) and broader markers of endoscopy quality using the National Endoscopy Database (NED).
We extracted colonoscopy procedure data from NED for 1/1/2019-4/4/2019. Multiple negative binomial regression was undertaken to estimate the effects of patient age, sex and procedure indication on MNP, and generate an aMNP using the formulae:
Expected number of polyp for each procedure = e^{(constant +∑incidence ratio rates age, sex and indication)}
Expected MNP = (∑expected number of polyps per procedure) ÷ number of colonoscopies
Case-mix adjusted MNP per 100 procedures (aMNP) = Observed MNP ÷ Expected MNP x National MNP x 100
Associations between aMNP and polyp detection rate (PDR), proximal polypectomy rate (PPR), Trust PCCRC rate and endoscopy unit accreditation score were explored.

Results

92,892 complete colonoscopies were analysed. Patient age, sex and procedure indication were all significantly associated with MNP. At endoscopist level, aMNP strongly correlated with PDR (Spearman rho=0.834, p<0.001) and PPR (rho=0.709, p<0.001).

Table Distribution of aMNP, PDR and PPR per endoscopist.

Conclusion

We have demonstrated a method to compute a new case-mix adjusted KPI, aMNP, which is significantly associated with other detection KPI of PDR, PPR, PCCRC and JAG endoscopy unit quality standards. Subsequently the NED-APRIQOT study has demonstrated endoscopy unit aMNP also correlates with ADR (Spearman r=0.65, 95%CI 0.61 to 0.70)(Paper under review). aMNP addresses some limitations of traditional detection KPI, allowing consideration of warranted variation in detection, and therefore improving the face validity of detection data for endoscopists, potentially addressing engagement in audit and feedback processes. We propose it should be considered a candidate gold standard KPI for reporting endoscopy quality.

References

1. Catlow J, Sharp L, Kasim A, et al. The National Endoscopy Database (NED) Automated Performance Reports to Improve Quality Outcomes Trial (APRIQOT) randomized controlled trial design. Endosc Int Open 2020;08:E1545–52. doi:10.1055/a-1261-3151
2. Catlow J, Sharp L, Rutter M. ACCEPTABILITY OF KEY PERFORMANCE INDICATORS (KPI) IN THE NATIONAL ENDOSCOPY DATABASE (NED) AUTOMATED PERFORMANCE REPORTS TO IMPROVE QUALITY OUTCOMES TRIAL (APRIQOT), A DELPHI PROCESS. In: ESGE Days. © Georg Thieme Verlag KG 2020. ePP228. doi:10.1055/s-0040-1704620

Introduction

Bowel cleansing completion time is one of the important factors for optimal bowel preparation. The recommended completion time is within 3-8 hours of colonoscopy.

Aims & Methods

In this randomized study, we investigated the optimal bowel preparation completion time between short interval and long interval. Study participants were randomized into two groups: short interval, bowel preparation completion time (2-4 hours of colonoscopy); long interval (4-8 hours of colonoscopy). The primary endpoint was successful bowel cleansing assessed by Boston bowel preparation (BBPS) scale. Secondary endpoint included Aronchick scale and patient’s tolerability investigated by sleep disturbance and patients’ satisfaction. Bowel preparation was performed using 4 L polyethylene glycol.

Results

​A total of 504 individuals were included (short interval, 255; long interval, 249). Mean time for bowel preparation finish time was 2.99 and 5.12 hours respectively. The rate for successful preparation was comparable between the two groups (short interval, 97.6% and long interval, 95.2%, p=0.136). Total BBPS score was 8.22 in the short interval group, which was higher than that of long interval group (7.82, p<0.001). Regional score for Rt. colon (2.65 vs 2.44, p < 0.001) and Lt. colon (2.65 vs 2.56, p=0.057) of short interval group was higher than that of long interval group. Regional score for T-colon (2.92 vs 2.82, p = 0.002) and was comparable between the two groups. Sleep disturbance was higher in the long interval group. Safety did not differ between the two groups.

Conclusion

The rate for successful preparation were similar for the two groups. Total BBPS score and regional scores for Rt. colon and T-colon were higher in the short interval group. For better bowel cleansing, bowel preparation finish time is recommended 2-4 hours of colonoscopy.

References

Gastrointest Endosc 2015;81:31-53
Gastroenterology 2016;150:396–405
WJGE 2013 February 16; 5(2): 39-46
Endoscopy. 2019;51(8):775-794

Introduction

Adequate bowel cleansing is essential for colonoscopy quality. A novel 1L polyethylene glycol plus ascorbate (1L PEG+ASC) solution has been recently introduced. Nevertheless, the efficacy of 1L PEG+ASC as compared to that of high-volume bowel preparation in both inpatients and outpatients is still unclear.

Aims & Methods

This single-blinded, non-inferiority RCT aims to compare the efficacy, safety, and tolerability of 1L PEG+ASC versus a high-volume 4L PEG-based preparation in both inpatients and outpatients. The primary endpoint was the overall cleansing success. Secondary endpoints were excellent cleansing and high-quality cleansing of the right colon, as well as lesions detection rate, patient compliance, and safety.

Results

Overall, 478 patients (mean age 59.3 ± 14.9 years) were randomized to 1L PEG+ASC (N = 236) or 4L PEG (N = 242). The 1L PEG+ASC showed higher cleansing success rate as compared to 4L PEG preparation (91.8% vs 83.6%; OR = 2.207; 95% CI: 1.2-4.0; P = 0.01), as well as higher excellent cleansing (39.1% vs 27.7; OR, 1.67; 95% CI: 1.1-2.5; P= 0.001) and high-quality cleansing of the right colon (52.3% vs 38.5%; OR, 1.75; 95% CI: 1.194-2.564; P = 0.004). As compared to the high volume, 1L PEG+ASC achieved a higher cleansing success rate in out-patients (96.3%% vs 88.6%; P = 0.018) and a similar success among the in-patients (84.7% vs 76.7%; P = 0.18). No significant differences in colonoscopy performance, including caecal intubation rate (97.3% vs 96.2%, P= 0.5), withdrawal time (9.6 ± 3.2 vs 9.9 ± 4.1, P=0.3) and adenoma detection rate (25.5% vs 23.5%, P= 0.6) were found between 1L PEG+ASC and 4L PEG preparation, respectively. The 1L PEG+ASC and 4L PEG preparation did not differ significantly in terms of tolerability, as documented by the similar rate of patients reporting total adverse events (AEs) (75.1% vs 77.8%, P = 0.5), mild AEs (68.0% vs 70.3%, P = 0.6) and moderate to severe AEs (32.0% vs 29.5%, P = 0.6) after bowel preparation.

Conclusion

Data of this randomized study showed that quality of bowel preparation for colonoscopy achieved with 1L PEG+ASC solution is not inferior as compared to that of 4L PEG. No differences in the tolerability and safety were detected. (Registration/protocol: EudraCT Number 2018-004543-24).

Disclosure

Roberto Vassallo received consultation fees from AlfaSigma and Norgine. Marcello Maida and Roberto Di Mitri served as advisory board member and received lecture grants from Norgine. Other authors have no proprietary, financial, professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of this manuscript.

Introduction

Currently, we can reliably and non-invasively determine steatosis and liver fibrosis by CAP/ATI/PDFF and ET/2D-SWE/MRE, respectively. However, it is not possible to accurately determine the inflammatory component without biopsy. In addition to 2D-SWE and Attenuation Imaging, some new multiparametric US devices incorporate the tissue viscosity-dependent 2D-SWD dispersion slope parameter. The liver is not a purely elastic but a viscoelastic organ, so that 2D-SWD measurement could be useful in the determination of necroinflammation. Our aim was to evaluate the correlation of SWD with the inflammatory component of MAFLD.

Aims & Methods

Prospective study. Immediately prior to liver biopsy (Tru-Cut 16G) in patients with suspected MAFLD, SWD (Canon Aplio i800) was performed. Exclusion criteria were: liver biopsy length <1.5 cm/<11 portal tracts, absence of MAFLD on final biopsy result (steatosis <5%). MAFLD was classified according to NASH-CRN. Normally distributed quantitative variables were described using the mean; otherwise, the median was calculated.

Results

112 patients were included: age 53 years, women 55%, BMI 30.9 kg/m², diabetes 39%, GPT 62 U/L. Biopsy: 2.5 cm, 14 portal spaces. Fibrosis distribution was: F0 53 (46%), F1/F2 37 (32%), F3/F4 25 (22%). Steatosis distribution was: S1 35 (34%), S2 30 (29%), S3 39 (37%). Steatohepatitis: definite 52 (45%), absent 47 (41%), indeterminate 16 (14%). SWD values showed statistically significant differences between patients without steatohepatitis/indeterminate vs. steatohepatitis (13 (m/s)/KHz vs. 13.750 (m/s)/KHz; p=0.015). A positive linear correlation was also observed between SWD and NAS score (rho = 0.216; p=0.028). For the lobular inflammation component, a value of 14.5 (m/s)/KHz had Esp 89.5%, PPV 93.1%, while 10.5 (m/s)/KHz had Sens 90.5%, NPV 80.9%.

Conclusion

The SWD dispersion parameter determined by mulparametric ultrasound could be useful in the non-invasive assessment of liver inflammation and the diagnosis of steatohepatitis in MAFLD patients.