Table 1:

Barriers and possible solutions to optimize care for patients with complex polyps

Barriers	Possible solutions
Inaccurate visual diagnosis. Presumption of malignancy based on size. Lack of confidence in assessment of submucosal invasion. Uncertainty regarding which lesions are eligible for endoscopic resection.	Develop educational programs in visual diagnosis for practicing endoscopists who perform screening colonoscopy. Automatic prompts for gross morphology (Paris classification) and surface morphology (e.g. NICE) for all polyps ≥ 20mm. Increased emphasis on visual diagnosis on GI board exams. Creation of new standardized methods of information transfer for consulting physician to review high resolution endoscopic images.
Expectation that all polyps can and should be resected during initial screening procedure. Assumption that all colonoscopists should be proficient in EMR.	Inform patients that if a large polyp is found, a separate procedure may be needed to remove it. Develop competency criteria to perform EMR.
Ingrained habits and referral patterns. Assumption that surgery is the only alternative to polypectomy at time of screening exam.	Creation of guidelines for management of patients with complex polyps to drive high quality care. Better promotion of EMR centers of excellence by GI societies.
Limited availability of EMR experts Inability to search for EMR experts by region Distance to nearest tertiary center	Training programs such as ASGE STAR program Creation of a searchable database of endoscopic resection centers of excellence Shared decision-making with patients regarding willingness to travel to avoid surgery
Poor compensation for EMR procedures	Payers endorse and pay for a second opinion by an expert prior to approval of surgery for benign colonic lesions. Payers endorse and pay for a second therapeutic colonoscopy when complex polyps are found at a screening exam. Payers provide time-based reimbursement for complex resections, especially prolonged EMR and ESD (endoscopic submucosal dissection) procedures. Reimbursement schemes that place equal value on endoscopic and surgical resection of benign polyps.
Absence of quality metrics for management of complex polyps	Creation of practice-level quality metrics such as proportion of benign polyps ≥20mm removed endoscopically. EMR experts should track performance, such as case volume, complication rates, and residual neoplasia rates at follow-up.