As new quality indicators surrounding colonoscopies are introduced, the onus to meet the new guidelines will fall on individual gastroenterologists.
Several experts spoke on this subject at the American Gastroenterological Association's postgraduate course earlier this year. On Sept. 19, Medscape released four key takeaways from the experts on improving colonoscopy performance:
1. Tackling inadequate preparation. While numerous factors are regularly considered in identifying patients at high risk for improper prep — including comorbidities, tobacco use, bowel activity and prior abdominal or pelvic surgery, among others — Brian Jacobson, MD, associate professor of medicine at Harvard Medical School in Boston questioned the effectiveness of models using this data. According to Medscape, he said that these models do not actually indicate whether knowing about or addressing these risks actually leads to improved bowel preparation.
Rather, he advocated for maximizing prep for all patients. This includes using verbal and written instructions for all components of prep, phoning or virtual messaging patients to help navigate the process, low-fiber or all-liquid diets a full day before a colonoscopy and a split-dose 2-liter prep regimen.
AI could also help identify patients who are at high risk for poor prep and create personalized, interactive plans to help patients navigate their preparation.
2. Enhancing polyp detection. Tonya Kaltenbach, MD, professor of clinical medicine at the University of California in San Francisco said in the report that technique is a major factor in achieving successful polyp detection rates, alongside the use of new adjunct and AI-based tools.
Improving the technical, cognitive and recognition skills that are required for more precise colonoscopies starts with having the correct mindset, Dr. Kaltenbach said. This means having a "reflexive recognition of deconstructed patterns of normal," alongside utilization of adjunctive tools. This mindset and skill application is important even alongside the help of AI, Dr. Kaltenbach said, as real-world studies using AI and computer-assisted detection have had "mixed results." This means that true success ultimately comes down to the skill and performance of the physician, with or without the help of AI.
Another physician in the Medscape report further suggested that gastroenterologists and endoscopists should be cautious with AI, as it can create a false sense of comfort or "alarm fatigue." Tools should be developed with the provider in mind with the goal of enhancing the physician's skills instead of creating total reliance on the technology.
3. Sticking to polyp surveillance intervals. The U.S. Multi-Society Task Force on Colorectal Cancer offered recommendations for follow-up after colonoscopy and polypectomy, which provide rationale for determining surveillance levels for individuals. But some uncertainty may still exist in some cases where patients fall into gray areas of risk and physicians are hesitant to bring them in for unnecessary procedures.
Rajesh Keswani, MD, associate professor of medicine at the Northwestern University Feinberg School of Medicine in Chicago said that recent studies have found that clinicians may estimate imprecise polyp measurements and don't often follow evidence-based guidelines. He said that providing additional education and instituting automated surveillance calculators alongside guideline adherence could help manage these gray area cases.
"Why do we ignore the guidelines? There's this perception that a patient has risk factors that aren't addressed by the guidelines, with regards to family history or a distant history of a large polyp that we don't want to leave to the usual intervals," Dr. Keswani said in the report. "We feel uncomfortable, even with our meticulous colonoscopy, telling people to come back in 10 years."
4. Minimizing environmental impacts. A recent audit of waste in endoscopy rooms found that providers generate 1 to 3 kilograms of waste per procedure. This comes from procedure-related equipment, administration, education, travel of patients and staff and facility infrastructure. The GI Multisociety Strategic Plan on Environmental Sustainability recommends a five-year initiative to cut down on waste across clinical settings, education, research, society efforts, intersociety efforts, industry and advocacy.
This may also look like cutting down on unnecessary procedures, adhering more strictly to guidelines and considering alternative tests when appropriate.