The adenoma detection rate (ADR) is an indicator for quality colonoscopy. However, many missed adenomas have been found in colonoscopies performed by endoscopists with an ADR ≥25%. Adenomas per positive participant (APP) correlates well with the adenoma miss rate. This study aimed to evaluate whether APP added additional information on the detection rate for advanced adenomas (AADR) and proximal adenomas (pADR) and among endoscopists with acceptable ADRs (≥25%).
A total of 47 endoscopists performed 7,339 screening colonoscopies that were retrospectively reviewed. Using a cutoff APP value of 2.0, endoscopist performance was classified into a high APP group and a low APP group. Endoscopist performance was also classified as acceptable ADR (25-29%), high-standard ADR (30-39%) and aspirational ADR (≥40%). Generalized linear models were used to assess the relationship between AADR and pADR, and ADR, after adjusting for potential confounders.
After adjusting for endoscopist performance and patient characteristics, endoscopists with high APP had a significant 2.1% increase AADR (95% CI, 0.3% – 3.9%; p=0.02) and 2.1% increase pADR (95% CI, -0.8% – 5.1%; p=0.15) when compared to endoscopists with low APP. Eleven (24%), 18 (38%) and 18 (38%) endoscopists were classified as having acceptable ADRs, high-standard ADRs and aspirational ADRs, respectively. Eighteen percent of acceptable ADRs, 44% of high-standard ADRs and 72% of aspirational ADRs had APP values higher than the cutoff (p=0.02).
APP is helpful for identifying more meticulous endoscopists who can detect more advanced adenomas. Endoscopists who only achieved an acceptable ADR had the lowest APP.

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