Updated Colonoscopy Guidelines Have Implications on Doctors, Patients Alike

The American College of Gastroenterology (ACG) and American Society for Gastrointestinal Endoscopy (ASGE) published their updated guidelines regarding the quality indicators surrounding colonoscopy in August 2024.

Although these guidelines are outlined in the new document, it remains unclear how they will affect the ways in which endoscopists approach their colonoscopies and how patients will receive their colonoscopies in the future. What is known is that these guidelines introduce new quality indicators for a colonoscopy and update previous guidelines to illustrate the best ways to measure the effectiveness of a colonoscopy.

What Has Changed and What Has Stayed the Same

Colonoscopies remain the primary mode of prevention of colorectal cancer (CRC), as they have been shown to be effective in detecting CRC at earlier stages compared with more recent stool testing. Colonoscopies should be performed for adults 45 years and older who have an increased risk of CRC due to family history or inherited diseases that affect the bowels.¹ Colonoscopy can also be performed in patients who have an abnormal Cologuard or fecal immunology test to detect CRC. The guidelines are aimed at standardizing the measures used to determine the quality of the colonoscopy performed.

Several major updates regarding the guidelines for colonoscopies were introduced, including new quality indicators for measuring the quality of a colonoscopy. According to the report of the guidelines,² these include adding bowel preparation adequacy rate and sessile serrated lesion detection rate to the list of priority quality indicators that should be measured consistently when performing a colonoscopy.³

Douglas K. Rex, MD | Image credit: American Society for Gastrointestinal Endocsopy

“These guidelines are created by a joint task force of the [ACG and ASGE], and they were first published in 2006 and the second version was published in 2015, 9 years later,” said Douglas K. Rex, MD, professor at Indiana University School of Medicine and coauthor of the new guidelines. “So it was about time to repeat them…There’s been a lot of new evidence in the last 9 years, so we felt that there some new things to say.”

Rex stated that the guidelines are meant to not simply cover every aspect of quality but to make recommendations on measuring certain aspects of quality, which can number between 12 and 15 indicators depending on which guidelines you looked at. Priority indicators, he said, were introduced to specify which indicators are the most important to measure, given the inability for certain doctors and endoscopists to measure all 12 to 15 indicators.

“There’s no legal mandate to do it. There aren’t necessarily requirements from insurance companies to make these quality measure. But that’s the purpose of the priority indicators,” said Rex.

There were also some changes to the guidelines that were less of a headliner compared with adding priority quality indicators. Reid Ness, MD, MPH, AGAF, associate professor of medicine at Vanderbilt University Medical Center and Vanderbilt-Ingram Cancer Center, emphasized that there were also changes made to the thresholds that some of the indicators are held to, including to adenoma detection rate (ADR).

“The [ADR] has been dramatically changed,” said Ness. “What I mean by that is, they increased the ADR acceptance level from 30% to 35% but significantly changed the population of assessed cases from screening only to all procedures except those performed in patients with an underlying hereditary cancer syndrome, [inflammatory bowel disease], or a known positive colon cancer screening test.”

ADR, he said, measures the quality of colonoscopy and has been tied to the rate of cancer in the patients, as a higher ADR from an endoscopist is associated with a lower rate of CRC in the patients who have had a colonoscopy from that endoscopist. By raising the acceptable ADR, this might be able to determine which doctors are giving their patients the best chance of not being diagnosed with CRC.

Ness also pointed to the new priority quality indicator of sessile serrated lesion detection rate as being of particular interest, as there were scant data on the usefulness of this measure. This can lead to practitioners having to defend themselves against this in multiple settings, he said.

“A lot of people that put together guidelines find it difficult not to make a recommendation, an active recommendation, in an area, even if the data are lacking,” he said. “This was a level 2C recommendation, which means this is a very weak recommendation…I tend to favor, if you don’t have the data available, don’t make a guideline.”

Rex, however, said that several studies have come out in the past few years that demonstrate that doctors performing colonoscopy had an adequate ADR but a low sessile serrated lesion detection rate between 13% and 15%, which can contribute to the occurrence of cancers appearing after a colonoscopy. He acknowledged that it is hard to create a detection target for serrated lesions, however.

“Those studies, which were the first studies really to evaluate this, are pretty consistent in their results,” he said. “So we felt that, on the basis of that, it was important to create this sessile serrated lesion detection rate parameter.”

Implementing The Guidelines Nationwide

With the new guidelines, making sure they are followed and used consistently is a big factor in determining the usefulness of such guidelines in making colonoscopies more effective and of higher quality.

When it comes to making sure that hospitals and clinics follow the guidelines, Rex said that the guidelines will mostly be implemented through the goodwill of endoscopists and endoscopy units to measure the quality effectively. Not measuring for optimal priority quality indicators is still a challenge within the space, when it comes to making sure that all patients receive the best care.

“We don’t have a government mandate, we don’t have an insurance mandate,” said Rex. “I think that CMS is perfectly aware of the recommendations that we have made and they have, at times, created incentives for measurement of different quality parameters, but the way that is set up, depending on where you practice, the health care system may be able to meet those quality requirements without actually measuring anything that has to do with any [gastrointestinal] outcomes.”

Reid Ness, MD, MPH | Image credit: Vanderbilt University Medical Center

Ness noted that there are software systems that can help to input measurements into a patient’s electronic health record but noted that the new guidelines would make old data incomparable to the new measure. This specifically could become an issue when it comes to ADR, where the number of patients evaluated has changed to include more patients outside of the screening patients.

“It sounds like it’s the same measure, but it’s not. So the old data [become] incomparable to the new data, and you’re going to have to build this new database,” said Ness. “I think it’s going to be difficult for systems to change over to the new measure. It’s going to take time and, in some cases as they mentioned themselves with certain systems, years.”

These indicators can help patients to be more comfortable in asking their endoscopists questions about their measurements in the past, Rex believes. This includes measurements, such as ADR, to determine how effective they are before making an appointment for a colonoscopy. Overall, he says, the goal is to improve the outcomes for patients by encouraging endoscopists to study the recommendations and adopt their processes to be able to provide their patients with assurance of efficacy in the operating room.

Ness believes that the measurements of quality guidelines will start to become common knowledge and sent to the government to compare results through the Freedom of Information Act. However, he warned of doctors “gaming the system” to improve their own quality measurements, specifically when it comes to ADR.

“The number of adenomas that should be found per colonoscopy, they said it should be 0.6. The issue is then, if I’m not as ethical as I should be, then what I can do is if I find an adenoma or find something I think is an adenoma, I stop looking. [Or] I don’t stop looking, but I don’t look as carefully because I found my adenoma,” said Ness. “That can be gaming the system when there’s a guideline buried in there…People can do that with guidelines. That’s why guidelines…may not be measuring what you choose to measure.”

Both Rex and Ness noted that although Merit-Based Incentive Payment System (MIPS) and Quality Payment Program use measurements for colonoscopy to provide reimbursement, it’s unclear how these new guidelines will be implemented in such a method. Reimbursement likely won’t change with these new guidelines, Ness concluded, but should MIPS start looking at ADR, it might change some aspects of reimbursement.

“Whether something is going to change from what’s currently used as a result of this update, I don’t know, and that’s not something that we take into consideration at this level when we’re creating the guidelines,” said Rex. “The guidelines are created…to get the best outcome for patients and the rest of that follows on the other groups that are considering these guidelines.”

Updating registries to include the new guideline measurements will be the first step in getting more clinics and hospitals to report on the priority quality measurements. Tying the indicators to reimbursement, said Ness, might be a way to get more endoscopists and endoscopy clinics to get the measurements done quickly. However, according to Rex, the ACG and ASGE are not capable of enforcing the measurement of these quality indicators beyond recommending them.

Making sure that these measurements are accounted for and measured during and after a colonoscopy should be a primary goal after the publication of these recommendations. Efforts to make sure that the priority quality indicators are accounted for during colonoscopy will take a lot of effort from endoscopists, clinics, software, and insurance to encourage clinicians to provide the best outcomes for patients.

References

1. Colonoscopy. Cleveland Clinic. Updated November 30, 2022. Accessed September 11, 2024. https://my.clevelandclinic.org/health/diagnostics/4949-colonoscopy

2. Rex DK, Anderson JC, Betterly LF, et al. Quality indicators for colonoscopy. Am J Gastroenterol. Published online August 21, 2024. doi:10.14309/ajg.0000000000002972

3. Bonavitacola J. New recommendations, quality indicators for colonoscopy released. AJMC^®. Published August 22, 2024. Accessed September 11, 2024. https://www.ajmc.com/view/new-recommendations-quality-indicators-for-colonoscopy-released