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EQUIP-3: Endoscopic quality improvement program increases ADR
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HONOLULU — In the third trial of an endoscopic quality improvement program, adenoma detection rates were shown to increase after training in a multicenter clinical practice setting, but not significantly compared with a control intervention, according to data presented at ACG 2015.
“In our original trial … called EQUIP-1, … we performed a single-center, randomized, controlled trial at the Mayo Clinic in Florida,” Michael B. Wallace, MD, from the division of gastroenterology and hepatology at Mayo Clinic in Jacksonville, Fla., said during his presentation. “There was a significant increase in adenoma detection rate in the group of physicians … that received supplemental education that included regular feedback, lectures on detection of flat and otherwise subtle polyps, and showing both the individual and the group adenoma detection rate throughout the course of feedback, whereas the control group received no other feedback or intervention.
Michael B. Wallace
“In the current study design we performed a prospective, randomized, controlled clinical trial using the same EQUIP educational intervention,” he said. “The main hypothesis was that an endoscopic training program would increase adenoma detection rate. The methods were the same as in our single-center trial, although in this case we randomized by center.”
Wallace and colleagues randomly assigned five large clinical centers to receive supplemental, in-person EQUIP training with active feedback, and four control sites to receive no additional training and no active feedback.
Adenoma detection rates (ADRs) and other quality measures were evaluated during a 6-month baseline period, and during a 6-month post-training period using the GIQuIC quality monitoring system. All participants were unmasked to the evaluation of ADRs and other factors.
Overall, there were 22,316 patients, who underwent colonoscopy during the study period. ADRs increased significantly from 32% to 38% after training at the intervention centers compared with and insignificant increase of 35% to 39% at the control centers, but the difference between groups was not significant (OR = 1.03; 95% CI, 0.84-1.25).
“We observed that ADR increased significantly after training. There was a small but nonsignificant increase in the control group, but there was no significant difference between the intervention and control group,” Wallace said. “We saw the greatest gains in screening examinations in physicians who had baseline low ADR.
“In conclusion, we believe that there are beneficial gains in ADR for both groups. We speculate that there was a possible Hawthorne effect, meaning just by knowing that you are being monitored you improve your behaviors, and we believe that national efforts, particularly GIQuIC, are ongoing and encouraged.” – by Adam Leitenberger
Reference:
Wallace MB, et al. Abstract 10. Presented at: ACG 2015; Oct. 19-21, 2015; Honolulu, HI.
Disclosures: The researchers report no relevant financial disclosures.
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Kenneth R. DeVault, MD, FACG
During the Presidential Plenary session, there was an outstanding study that used a database jointly supported by the ACG and the ASGE — GIQuIC, which currently has over 2 million colonoscopies in its database, which is phenomenal.
Wallace received a grant from the ACG Institute and this allowed him to go around the country and train gastroenterologists to improve their ability to find polyps, and he found two things. One, installing GIQuIC actually improves your ability to find polyps, probably because we are competitive people and we like to do better than our neighbors, and that’s called the Hawthorne effect; if you measure it, it will necessarily get better.
But he also found that if we actually provide some training and mentoring to physicians, we can improve their ability to find polyps. Finding small polyps and removing those seems to correlate with the finding of large polyps and cancers and improves the quality. So, in addition to people getting a colonoscopy, they need a high quality colonoscopy.
I think the partnership between our two societies in developing GIQuIC, the research institute funding Wallace’s study and our ability to present it at this meeting really hit a home run.
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John R. Saltzman, MD, FACG
This is, in my opinion, maybe the best study design of any of the trials that were presented here —prospective, randomized, controlled, multicenter — it’s not easy to conduct these trials. It was randomized by center, and the intervention is a standard treatment directed by Michael Wallace, MD, who is a leader in the field and an outstanding educator.
Wallace has shown previously in a single center that the intervention improves adenoma detection rate, but the current study is a negative study. It is surprising in that there was not a statistically significant difference between those who received the training and those who didn’t, although both improved over time.
Wallace stated that these results may be explained by the Hawthorne effect — that the physicians know they are being watched over time and since that they are being watched, they have altered their behaviors.
I think the central to this study is the questions of what do physicians need to understand in order to improve their own performance? Is it somebody watching them, watching videos or viewing an educational PowerPoint presentation? Are they not adherent to the current recommended guidelines in practice? Are there new bowel preps or regimens such as split-dosing that improved over time and such that now everyone’s adenoma detection rate went up?
This is an important study although it is a negative study, and negative studies are important to present and be published in the literature. But to me it suggests there is something else we need to be doing in addition to this in order to improve physicians’ adenoma detection rates.
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