Adenoma detection rate is necessary but insufficient for distinguishing high versus low endoscopist performance

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. Design: 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 (up arrow ADR/up arrow ADR-Plus); (2) one and done (up arrow ADR/down arrow ADR-Plus); (3) all or none (down arrow ADR/up arrow ADR-Plus); (4) none and done (down arrow ADR/down arrow ADR-Plus). Setting: Tertiary-care teaching hospital and 3 nonteaching facilities servicing the same patient pool. Patients: A total of 3318 VA patients who underwent screening between 2005 and 2009. Main Outcome Measurements: 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). Limitations: External generalizability, nonrandomized study. Conclusion: 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. (Gastrointest Endosc 2013;77:71-8.)