Sandra Yin

November 07, 2011

November 7, 2011 (National Harbor/Washington, DC) — Intensive training can boost endoscopists' adenoma detection rates, even experienced endoscopists, according to findings from a study presented here at the American College of Gastroenterology (ACG) 2011 Annual Scientific Meeting and Postgraduate Course.

The pilot study found that special training boosted the adenoma detection rate for a randomly selected group of endoscopists.

The adenoma detection rate, or the percentage of patients with at least 1 adenoma among all the patients having colonoscopy, rose to 47% from 36% for the group of endoscopists that got special training, said lead author Susan Coe, MD, a third-year gastroenterology fellow at the Mayo Clinic in Jacksonville, Florida. The adenoma detection rate for the group that did not get special training remained unchanged, at 35%.

The researchers expected to see improvement, Dr. Coe told Medscape Medical News, but "what surprised me the most was that the short focused training program resulted in such a significant improvement." She added that "this was in a group of endoscopists who were already above the national average."

The adenoma detection rate has become an important measure of quality in colonoscopy. A low rate is linked to interval cancer after "negative" colonoscopy.

The prospective randomized trial involved 2 phases. In each, 15 endoscopists completed 1200 procedures. Patient characteristics were similar between study phases and randomized groups.

Half of the endoscopists were randomly assigned to EQUIP training and half were assigned to the control group (endoscopies conducted as usual). At the end of the baseline phase, all endoscopists received their baseline adenoma detection rates and withdrawal times. The second phase of the study began after training was completed.

The training group underwent 2 group training sessions of 1 hour each. The first session focused on the techniques of high adenoma detectors and the subtle characteristics of easy-to-miss polyps such as flat serrated adenomas. The second session focused on the surface and vascular patterns that predict neoplasia.

Only endoscopists in the training group continued to receive personal monthly feedback on adenoma detection rates, withdrawal time, and group averages. Each endoscopist was asked to describe all polyps by shape, location, size, and predicted pathology.

The control group practiced as usual and did not receive intervention or feedback.

Researchers compared adenoma detection rates between the 8 trained endoscopists and the 7 untrained endoscopists, adjusting for baseline levels and for patient age, sex, adequacy of bowel preparation, and indication.

Previous studies have looked at ways to improve adenoma detection, such as increased withdrawal time, more financial penalties, and discussions with low-performing endoscopists, but they did not focus on educational interventions or techniques, Dr. Coe said.

The EQUIP training focused on proven practices, such as looking carefully behind folds, actively taking the tip of the colonoscope and deflecting the fold, and taking the time to look in each little nook and cranny, Dr. Coe explained. Training also looked at the importance of adequate distention and washing and of recognizing subtle or serrated lesions.

"My recommendation for other physicians, given our findings, is to take advantage of the new tools and techniques that are being developed to continuously retrain ourselves to better serve our patients," Dr. Coe said. "I think there's always room for improvement."

Although this pilot study was based on a relatively small population of 15 endoscopists in an academic setting, Dr. Coe said that she is looking forward to validating method with larger groups of endoscopists in other clinical settings. One question that remains to be answered is whether similar short focused training sessions will work in community settings, where most endoscopies are performed.

"I think this is a hugely important area," Jonathan Leighton, MD, FACG, a gastroenterologist at the Mayo Clinic in Scottsdale, Arizona, and chair of the ACG Educational Affairs Committee, told Medscape Medical News.

What this suggests is that if you do formal training, you can improve adenoma detection rates, he said. "I think the next step is to figure out what you have to do to sustain that improvement," he noted. In most cases, he said, some kind of ongoing feedback will be important to sustain the improvements.

This study was an ACG 2011/Olympus Award recipient.

Dr. Susan Coe has disclosed no relevant financial relationships. Dr. Leighton reports financial relationships with Given Imaging, IntroMedic, Procter and Gamble, Abbott, Bristol-Myers Squibb, Capso Vision, Centocor Ortho Biotech Inc., Exagen, and Schering Plough.

American College of Gastroenterology (ACG) 2011 Annual Scientific Meeting and Postgraduate Course: Abstract 5. Presented October 31, 2011.

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