A Little Training Goes a Long Way in Improving Colonoscopy

David A. Johnson, MD


July 24, 2023

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia.

Adenoma detection rate (ADR) has served as the marker of quality colonoscopy over the past several years. This recognition was driven in part by researchers from Kaiser Permanente, who noted that ADR correlated with a reduction in both colon cancer disease and colon cancer–related mortality.

Kudos to Dr Doug Corley and colleagues for taking this a step further in a recent publication in which they describe the development, testing, and validation of a training tool employed throughout a Kaiser Permanente organization.

The tool consists of a 30-minute interactive, remotely accessible online training program. It features education on the value of colonoscopy, including a focus on the importance of miss rates, what factors contribute to overlooking adenomas and sessile serrated lesions, and a review of the optimal examination techniques.

Training Enhanced by Expert Contributors

Expert speakers involved in this training video include Dr Doug Rex from Indiana University School of Medicine. I love it when Doug lectures on anything related to colonoscopy.

In this video, he provides a detailed analysis of the withdrawal technique.

He also discusses the concept of a three-dimensional–shaped lumen. Doug advises that you look at all areas of the lumen and, as he says, "work the folds," going back and forth in order to expose and view the proximal side of the folds.

He further advises to "aim small, miss small." If you're going to miss something, it's going to be very small, so target those lesions in particular. This will make your range of misses very narrow, as you're not going to miss big lesions.

These are fundamental tenets for Doug, which really drive the best possible examination. It's critical that we do this.

The video also includes Dr Gottumukkala S. Raju from MD Anderson Cancer Center, who provided several excellent videos looking at amplification of imaging via mucosal caps, indigo carmine, injection techniques, and narrow-band imaging.

There was a particular focus on flat lesions, meaning adenomas or sessile serrated lesions, and identifying not only when they're present but also the necessary margin for adequate resection.

The video includes a discussion about some of the pure concepts of what quality colonoscopy means and how these programs methodologically place an emphasis on patient enhancement and prioritization of quality.

A Brief Training Video Produces Big Results

The authors explored the use of their online training system within the Kaiser Permanente Northern California organization. They obtained a 100% participation rate from 86 eligible colonoscopists at 21 endoscopy centers, who all met certain criteria related to training. Screening examinations were performed on patients ≥ 50 years of age. Endoscopists were assessed to determine ADR before and after undertaking the online training. They were further stratified according to whether they were below or above the median ADR of 29.2% before their online training.

The investigators found that after undergoing training with this 30-minute video, there was an immediate absolute ADR increase across all the colonoscopies of 3.13%, with an estimated relative risk reduction for colon cancer prevention within the next 3 years of 12.5%.

For the endoscopists with a lower ADR — that is, below the median pretraining threshold of 29.2% — there was an immediate absolute increase in ADR of 4.89%. This would equate to a 19.6% risk reduction over the next 3 years.

For the endoscopists above that pretraining threshold, there was a smaller absolute risk reduction of 0.73%, which nonetheless resulted in an estimated risk reduction of 2.9% over the next 3 years.

But the risk estimates were dramatically improved for the endoscopists with the lower-end ADR. Those in this group who were able to increase their ADR by ≥ 10% saw their patients experience a 55% risk reduction for development of colon cancer.

However, it's worth repeating that improvements were seen in endoscopists across all categories of pretraining ADR. The absolute increase was most evident among the endoscopists with the lower-end ADR but also was noted for those on the higher end.

A Freely Accessible Program

Among the advantages of this training program is that it's only 30 minutes, accessible online, and free. I would put it high on your prioritization list and recommend it for every office and department that involves colonoscopy.

I would encourage not only endoscopists but also their full endoscopy team, including the nurses and the nursing assistants involved in these procedures, to undergo this training. It should be very easy — a no-brainer — for endoscopists to use with their team. Clearly, the more eyes on the screen, the better. It will lead to better engagement and education, which will enhance results. There are no relative downsides.

This video represents a vital way to achieve quality improvement. The absolute risk reductions are dramatic. These results show that the "not so good" got much better, but even the "good" got better. And, ultimately, the patients are the benefactors. It's a way of achieving greater patient satisfaction while also preventing cancer.

Please review and incorporate this training to help your patients. It's an incredibly valuable tool.

I'm Dr David Johnson. Thanks again for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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