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An Endoscopic Quality Improvement Program Improves Detection of Colorectal Adenomas

Coe, Susan G MD1; Crook, Julia E PhD2; Diehl, Nancy N BS2; Wallace, Michael B MD, MPH1

American Journal of Gastroenterology: February 2013 - Volume 108 - Issue 2 - p 219–226
doi: 10.1038/ajg.2012.417

OBJECTIVES: Adenoma detection rate (ADR) is a key measure of quality in colonoscopy. Low ADRs are associated with development of interval cancer after “negative” colonoscopy. Uncontrolled studies mandating longer withdrawal time, and other incentives, have not significantly improved ADR. We hypothesized that an endoscopist training program would increase ADRs.

METHODS: Our Endoscopic Quality Improvement Program (EQUIP) was an educational intervention for staff endoscopists. We measured ADRs for a baseline period, then randomly assigned half of the 15 endoscopists to undergo EQUIP training. We then examined baseline and post-training study ADRs for all endoscopists (trained and un-trained) to evaluate the impact of training. A total of 1,200 procedures were completed in each of the two study phases.

RESULTS: Patient characteristics were similar between randomization groups and between study phases. The overall ADR in baseline phase was 36% for both groups of endoscopists. In the post-training phase, the group of endoscopists randomized to EQUIP training had an increase in ADR to 47%, whereas the ADR for the group of endoscopists who were not trained remained unchanged at 35%. The effect of training on the endoscopist-specific ADRs was estimated with an odds ratio of 1.73 (95% confidence interval 1.24–2.41,P=0.0013).

CONCLUSIONS: Our results indicate that ADRs can be improved considerably through simple educational efforts. Ultimately, a trial involving a larger number of endoscopists is needed to validate the utility of our training methods and determine whether improvements in ADRs lead to reduced colorectal cancer.

1 Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida, USA

2 Section of Biostatistics, Mayo Clinic, Jacksonville, Florida, USA

Correspondence: Michael B. Wallace, MD MPH, Department of Gastroenterology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, Florida 32224, USA. E-mail:

SUPPLEMENTARY MATERIAL accompanies this paper at,,

Received 12 June 2012; accepted 21 August 2012

The material in this manuscript was presented at the ACG Annual Scientific Meeting in Washington DC, in October 2011 as a Presidential Plenary oral presentation and won a 2011 ACG/Olympus Colorectal Cancer prevention award.

published online 8 January 2013

© The American College of Gastroenterology 2013. All Rights Reserved.
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