Effect of a computer-aided quality feedback system on colonoscopists’ adenoma detection rate in Denmark: a multicentre, stepped-wedge, cluster-randomised, controlled trial

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BACKGROUND: Colonoscopy is a frequently performed procedure to diagnose and treat colorectal cancer. However, endoscopist competence varies considerably. Adenoma detection rate (ADR) is the most established indicator of colonoscopy quality. We aimed to evaluate the effect of a computer-aided quality (CAQ) feedback and monitoring system on the ADR of endoscopists. METHODS: We conducted a cluster-randomised, controlled trial with stepped-wedge randomisation among patients aged 50-74 years with a positive faecal immunochemical test (FIT) result across three university hospitals in Denmark (Hilleroed University Hospital [site A], Bispebjerg University Hospital [site B], and Herlev University Hospital [site C]). The unit of randomisation was defined as the hospital site, resulting in three clusters. Patients received standard-of-care colonoscopies by endoscopists during the control period. During the intervention period, endoscopists received CAQ feedback according to the Copenhagen Colonoscopy Concept (CCC) after each colonoscopy on the following quality metrics: colonoscopy retraction score (retraction distance, tip retraction, and efficiency), cecal intubation rate, intubation time, number of polyps detected, withdrawal time, and distance to cecum. The primary outcome measure was ADR, analysed at individual colonoscopy level. The secondary outcome measures were polyp detection rate (PDR), adenomas per colonoscopy, polyps per colonoscopy, adenocarcinoma detection rate (ACDR), and withdrawal time. This trial is registered at ClinicalTrials.gov (NCT04862793) and is complete. FINDINGS: Between Feb 23, 2022, and April 19, 2024, 1109 patients in the intervention group (site A: 710, site B: 65, and site C: 334 patients) and 1001 patients in the control group (site A: 446, site B: 127, and site C: 428 patients) were enrolled and included in the final analysis (935 [44·3%] patients were female; 1175 [55·7%] were male). 17 endoscopists (site A: four endoscopists, site B: three endoscopists, and site C: ten endoscopists) participated and acted as their own controls. The intervention period had a higher ADR (539 [48·6%] vs 434 [43·4%]; odds ratio 1·24, 95% CI 1·02-1·52; p=0·032), PDR (54·2% vs 50·7%; 1·22, 1·00-1·49; p=0·048), ACDR (8·9% vs 6·5%; 1·51, 1·06-2·15; p=0·027), and withdrawal time (960 s vs 915 s; incident rate ratio (IRR; 1·11, 95% CI 1·06-1·17; p=0·003) than the control period. Per colonoscopy, there was no significant difference between the intervention period and control period for mean number of detected adenomas (1·00 [SD 1·58] vs 0·85 [1·34]; IRR 1·15, 95% CI 0·99-1·33; p=0·069), tubular adenomas (0·93 [1·51] vs 0·80 [1·33]; 1·15, 0·99-1·35; p=0·078), tubulovillous adenomas (0·02 [0·16] vs 0·02 [0·16]; 1·06, 0·54-2·06; p=0·86), sessile serrated adenomas (0·04 [0·48] vs 0·03 [0·17]; 1·11, 0·48-2·60; p=0·79), and polyps (1·36 [2·07] vs 1·27 [2·03]; 1·10, 0·95-1·27; p=0·22). INTERPRETATION: Implementation of the CCC CAQ-feedback system improved ADR, PDR, and ACDR, and prolonged the withdrawal time. Future studies should assess whether this implementation leads to a decrease in post-colonoscopy colorectal cancer and explore the effect in centres that do not use FIT-based screening. FUNDING: EU Horizon, Danish Cancer Society, Capital Region of Denmark, Danish Cancer Research Foundation, Vissing Foundation, Aase and Ejnar Danielsens Foundation, and Ambu.

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