title: Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance.
abstract: BACKGROUND
  Endoscopist quality is benchmarked by the adenoma detection rate (ADR)-the proportion of cases with 1 or more adenomas removed. However, the ADR rewards the same credit for 1 versus more than 1 adenoma.
  
  
  OBJECTIVE
  We evaluated whether 2 endoscopist groups could have a similar ADR but detect significantly different total adenomas.
  
  
  METHODS
  We retrospectively measured the ADR and multiple measures of total adenoma yield, including a metric called ADR-Plus, the mean number of incremental adenomas after the first. We plotted ADR versus ADR-Plus to create 4 adenoma detection patterns: (1) optimal (↑ADR/↑ADR-Plus); (2) one and done (↑ADR/↓ADR-Plus); (3) all or none (↓ADR/↑ADR-Plus); (4) none and done (↓ADR/↓ADR-Plus).
  
  
  METHODS
  Tertiary-care teaching hospital and 3 nonteaching facilities servicing the same patient pool.
  
  
  METHODS
  A total of 3318 VA patients who underwent screening between 2005 and 2009.
  
  
  METHODS
  ADR, mean total adenomas detected, advanced adenomas detected, ADR-Plus.
  
  
  RESULTS
  The ADR was 28.8% and 25.7% in the teaching (n = 1218) and nonteaching groups (n = 2100), respectively (P = .052). Although ADRs were relatively similar, the teaching site achieved 23.5%, 28.7%, and 29.5% higher mean total adenomas, advanced adenomas, and ADR-Plus versus nonteaching sites (P < .001). By coupling ADR with ADR-Plus, we identified more teaching endoscopists as optimal (57.1% vs 8.3%; P = .02), and more nonteaching endoscopists in the none and done category (42% vs 0%; P = .047).
  
  
  CONCLUSIONS
  External generalizability, nonrandomized study.
  
  
  CONCLUSIONS
  We found minimal ADR differences between the 2 endoscopist groups, but substantial differences in total adenomas; the ADR missed this difference. Coupling the ADR with other total adenoma metrics (eg, ADR-Plus) provides a more comprehensive assessment of adenoma clearance; implementing both would better distinguish high- from low-performing endoscopists.
authors.affiliation: Department of Medicine, Division of Gastroenterology, VA Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA.
authors.forename: Hank S
authors.initials: HS
authors.lastname: Wang
authors.forename: Joseph
authors.initials: J
authors.lastname: Pisegna
authors.forename: Rusha
authors.initials: R
authors.lastname: Modi
authors.forename: Li-Jung
authors.initials: LJ
authors.lastname: Liang
authors.forename: Mary
authors.initials: M
authors.lastname: Atia
authors.forename: Minh
authors.initials: M
authors.lastname: Nguyen
authors.forename: Hartley
authors.initials: H
authors.lastname: Cohen
authors.forename: Gordon
authors.initials: G
authors.lastname: Ohning
authors.forename: Martijn
authors.initials: M
authors.lastname: van Oijen
authors.forename: Brennan M R
authors.initials: BM
authors.lastname: Spiegel
mesh_terms: D000236:Adenoma / Q000175:diagnosis* / Q000473:pathology; D003113:Colonoscopy / Q000379:methods / Q000592:standards*; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000473:pathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009378:Neoplasms, Multiple Primary / Q000175:diagnosis; D012189:Retrospective Studies