Quality in Colonoscopy- Colonoscopist’s Adenoma Detection Rate(ADR)

While colonoscopy and polypectomy reduced incidence of bowel cancer in 76% and reduced bowel cancer related mortality in 53% in a cohort of post-polypectomy pa- tients ( National bowel cancer study), the magnitude of such prevention depends on your colonoscopist’s adenoma detection rate (ADR). Colonoscopist’s ADR is de- fined as the percentage of consecutive screening (asymptomatic) patients who had at least one adenoma removed. A colonoscopist’s ADR is inversely proportional to post-colonoscopy missed cancers and adenomas. Higher the ADR less the missed colorectal cancers (CRC) and polyps (adenomas) for these patients in the post – polypectomy years.

Prevalence rates of adenomas in colonoscopy screening studies have been consist- ently over 25% in men and over 15% in females of more than 50 years of age. Hence the recommended ADR for colonoscopists is 30% for males and 20% for fe- males..My ADR is 61% for males and 51% for females which is within the top 10% globally. The attributes that affect ADR are quality of bowel prepara- tion, colonoscopist’s technique and tools and equipments.

Quality of bowel preparation is paramount for a good colonoscopy. Majority of poor bowel preparation are due to failure to follow the printed instructions for bow- el lavage. Patients whose colonoscopy is compromised due to poor bowel prepara- tion should repeat colonoscopy, where possible, after a brief consultation with the colonoscopist who can discuss and rectify what went wrong with the first colonos- copy.

Colonoscopist’s technique of introduction of the endoscope to caecum and its careful withdrawl back to rectum over a minimal of 6 minutes is of paramount im- portance. In one large study of 314,872 colonoscopies by 136 colonoscopists at 17 medical centres, ADR ranged between as low as 7.3% to as high as 52.5%.

Tools and equipment: We, at Southcoast Digestive, use state of the art Olympus high definition dual focus 190 series equipement with narrow band imaging which high lights subtle mucosal characteristics of polyps not easily visible with stand- ard white light . Other adjuncts include use of caps mount for endoscopes and chromoendoscopy( dye spray to high light subtle polyps).

Other factors: Colonoscopist’s fatigue plays a role. The longer the list of patients to do the likelier it is for the colonoscopist to miss polyps towards the end of his/her list. I find adenomas in 50-60% of my last 5 patients of the day indicating I am still awake!

New frontier: It has been proposed that number of polyps found and removed in ndividual patients is also taken into account in determining the colonoscopist’s adenoma detection rate. Clearly the colonoscopist who averages 3-4 polyps in each patient found to have polyps is looking harder than the colonoscopist who

finds one or two polyps in each patient with polyps.

Navigate the Maize of Endoscopy Fees

While quality in endoscopy is second to none at Southcoast Di- gestive Diseases Centre (hence this article on adenoma detec- tion rate today), we are fully cognisant of your need to under- stand endoscopy fees for your patient.

All endoscopist’s, anaesthetist’ and pathologist’s fees are rebated or billed directly to medicare or patients’ health fund regardless of whether they are uninsured or insured.

All uninsured patients pays a theatre fee regardless of creative marketing elsewhere. This is true for all providers of endosco- py services on the coast. This pays for wages and overheads.

Our theatre fees, at Southcoast Digestive Diseases Centre, has been the lowest on the coast and have remained so for the last 18 years.

Insured patients are not out of pocket for theatre fees which is paid by their Health fund. However, if a patient has an agreed excess (in exchange for a lower yearly premium) with their health fund, their fund would want that paid at the time of the endoscopy or any hospital service provided. This is exactly like paying an excess to your car insurer when making a claim.

As you know, we schedule high risk patients, such as those with American Anaesthesiology Society Classification 3 and upwards to lists in Pindara and Allamanda hospitals and such fees there are dictated by the respective Hospitals.

When you have a specially disadvantaged patient, please pick up the phone and speak with Cathy, Karen or Lyn for discounted fees. Thank you.


Bhaskar Chakravarty

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