Relative Efficacies of Interventions to Improve the Quality of Screening-related Colonoscopy: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials
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BACKGROUND & AIMS: Significant variability exists in colonoscopy quality indicators including adenoma detection rate (ADR). We synthesized evidence from randomized trials in a network meta-analysis on interventions to improve colonoscopy quality. METHODS: We included trials from database inceptions to September 25, 2023 of patients undergoing screening-related colonoscopy and presented efficacies of interventions within domains (periprocedural parameters, endoscopist-directed interventions, intraprocedural techniques, endoscopic technologies, distal attachment devices, and additive substances) compared to standard colonoscopy. The primary outcome was ADR. We employed a Bayesian random effects model using Markov-chain Monte-Carlo simulation, with 10,000 burn-ins and 100,000 iterations. We calculated odds ratios with 95% credible intervals and presented surface under the cumulative ranking (SUCRA) curves. RESULTS: We included 124 trials evaluating 37 interventions for the primary outcome. Nine interventions resulted in statistically significant improvements in ADR compared to standard colonoscopy (9-minute withdrawal time, dual observation, water exchange, iScan™, linked color imaging, computer-aided detection, Endocuff™, Endocuff Vision™, and oral methylene blue). Dual observation (SUCRA=0.84) and water exchange (SUCRA=0.78) ranked highest among intraprocedural techniques, iScan™ (SUCRA=0.95), linked color imaging (SUCRA=0.85), and computer-aided detection (SUCRA=0.78) among endoscopic technologies, WingCap (SUCRA=0.87) and Endocuff™ (SUCRA 0.85) among distal attachment devices, and oral methylene blue (SUCRA= 0.94) among additive substances. No interventions improved detection of advanced adenomas, and only narrow-band imaging improved detection of serrated lesions (odds ratio 2.94, 95% credible interval 1.46 to 6.25). CONCLUSIONS: Several interventions are effective in improving adenoma detection and overall colonoscopy quality, many of which are cost-free. These results can inform endoscopists, unit managers, and endoscopy societies on relative efficacies.
