Research priority setting in Barrett's oesophagus and gastro-oesophageal reflux disease

Development and validation of a novel Barrett's oesophagus patient reported outcome measure (B-PROM)

Background

Patients with Barrett's oesophagus (BO) carry significant cancer worry, burden of symptoms, and lack disease-specific knowledge. Currently there is no validated BO patient reported outcome measure (PROM) to measure these factors for use in clinical practice and research, hence the aim of this study was to devise a novel, validated BO-specific tool, B-PROM.

Methods

Literature review, quantitative and qualitative research informed the initial item generation. The item bank was refined through a modified Delphi process between May and August 2021. The PROM was then tested through cognitive interviews and validated via multicentre testing between September 2021 and February 2023 with the aim to create a succinct tool which addresses the key important factors to BO patients and has strong psychometric properties.

Findings

B-PROM covers key themes of disease-specific knowledge, trust in clinicians, burden of symptoms, cancer worry and burden of surveillance. Validation results from 387 participants (response rate 40.8%) showed 93.3% of participants completed >95% of B-PROM. All individual items scored a completion rate of >95%. Mean completion time was 5 mins 34s for a sample group. Nineteen items showed a ceiling effect, 3 items showed a floor effect. Internal consistency overall demonstrated a Cronbach Alpha of 0.846, while predetermined subsections showed Cronbach alphas of 0.335, 0.718, 0.736, and 0.896. Inter-item analysis found 2 pairs of items with strong correlation, with only 6 items correlating weakly. Item-total correlation showed 19 items correlated well. Exploratory Factor analysis (EFA) with principal component analysis produced 5 components with Eigenvalues >1 of which 4/5 had satisfactory Cronbach alphas. Test-retest reliability showed no significant differences across single and average measures (p ≤ 0.001).

Interpretation

B-PROM is the first BO-specific PROM to be systematically evaluated. Validation findings show strong internal consistency, short completion time, low missingness and excellent test-retest reliability.

Funding

Medtronic Limited ISR-2016-1077.

Consumer Engagement in Perioperative Clinical Trials

Consumer engagement (patient and public involvement) in perioperative medicine research is in its infancy. The patient experience and family/carer perspectives can provide an extra layer of insight to give more understanding as to what, why, and how we do research. Patients who have undergone surgery have a unique understanding of the issues, concerns, wants, and needs that they learned as a patient-they, therefore, can be considered as a professional given their experience(s)-thus warranting recognition as a partner in research. Knowledge of the consumer engagement literature and availability of resources should support anesthesia researchers aiming to include these perspectives in their research. This includes several existing engagement frameworks and assessment tools. We provide a framework for consumer engagement for adoption into anesthesia and other perioperative research. By incorporating the patient or caregiver into the design, funding application(s), data collection, and interpretation of the findings can be beneficial to all. This includes promoting knowledge and access to clinical trials, the wording of participant consent and information forms, methods of data collection, selection of important outcomes, and dissemination of results.

Developing patient-orientated Barrett's oesophagus services: the role of dedicated services

Introduction

Barrett’s oesophagus (BO) is common and is a precursor to oesophageal adenocarcinoma with a 0.33% per annum risk of progression. Surveillance and follow-up services for BO have been shown to be lacking, with studies showing inadequate adherence to guidelines and patients reporting a need for greater disease-specific knowledge. This review explores the emerging role of dedicated services for patients with BO.

Methods

A literature search of PubMed, MEDLINE, Embase, Emcare, HMIC, BNI, CiNAHL, AMED and PsycINFO in regard to dedicated BO care pathways was undertaken.

Results

Prospective multicentre and randomised trials were lacking. Published cohort data are encouraging with improvements in guideline adherence with dedicated services, with one published study showing significant improvements in dysplasia detection rates. Accuracy of allocation to surveillance endoscopy has been shown to hold cost savings, and a study of a dedicated clinic showed increased discharges from unnecessary surveillance. Training modalities for BO surveillance and dysplasia detection exist, which could be used to educate a BO workforce. Qualitative and quantitative studies have shown patients report high levels of cancer worry and poor disease-specific knowledge, but few studies have explored follow-up care models despite being a patient and clinician priority for research.

Conclusions

Cost–benefit analysis for dedicated services, considering both financial and environmental impacts, and more robust clinical data must be obtained to support this model of care in the wider health service. Greater understanding is needed of the root causes for poor guideline adherence, and disease-specific models of care should be designed around clinical and patient-reported outcomes to address the unmet needs of patients with BO.

Involving stakeholders in research priority setting: a scoping review

BACKGROUND

This scoping review provides a thorough analysis of how stakeholders have so far been involved in research priority setting. The review describes, synthesizes, and evaluates research priority setting projects not only for the field of health-as previous reviews have done-but does so on a much broader scale for any research area.

METHODS

A comprehensive electronic literature search was conducted in the databases PubMed, Scopus, and Web of Science. Reflecting the importance of grey literature, Google Scholar and relevant websites were also screened for eligible publications. A computational approach was then used for the study selection. The final screening for inclusion was done manually.

RESULTS

The scoping review encompasses 731 research priority setting projects published until the end of 2020. Overall, the projects were conducted within the realm of 50 subject areas ranging from agriculture and environment over health to social work and technology. Key learnings include that nearly all priority setting projects aimed to identify research priorities for the field of health (93%), particularly for nursing and care, cancer, pediatrics, and mental, behavioral and neurodevelopmental disorders. Only 6% of the projects were not health-related and 1% identified research priorities at the interface between health and a non-health area. Over time, 30 different stakeholder groups took part in research priority setting. The stakeholders most frequently asked to identify research priorities were doctors, patients, academics/researchers, nurses, allied healthcare professionals, family members, friends, and carers. Nearly two thirds of all projects have been conducted in Europe and North America. Overall, only 9% of the projects emphasized the importance of stakeholders in their goals and rationales and actively involved them. In around a quarter of the projects, stakeholders deliberated on their research priorities throughout the entire process.

CONCLUSION

By mapping out the complex landscape of stakeholder involvement in research priority setting, this review guides future efforts to involve stakeholders effectively, inclusively, and transparently, which in turn may increase the overall value of research for society. As a practical addition to this review, the first worldwide research priority setting database was created: https://ois.lbg.ac.at/en/project-database . The database contains all the projects analyzed for this review and is constantly updated with the latest published research priority setting projects.

Trends and projections in the incidence of oesophageal cancer in the Netherlands: An age-period-cohort analysis from 1989 to 2041

In Western populations, the incidence of oesophageal squamous cell carcinoma (OSCC) has been declining, whereas the incidence of oesophageal adenocarcinoma (OAC) has been increasing. Our study examines temporal trends in the incidence of oesophageal cancer in the Netherlands between 1989 and 2016, in addition to predicting future trends through 2041. Data from the Netherlands Cancer Registry and Statistics Netherlands were collected to obtain incidence trends of OSCC and OAC for the period 1989 to 2016. Age‐period‐cohort (APC) modelling was used to estimate the contribution of age, calendar period and birth cohort on the observed incidence trends. To predict the future numbers of new cases of both OSCC and OAC from 2017 to 2041, log‐linear APC models were fitted to the trends of 1989 to 2016. The age‐standardised incidence rates of OSCC have decreased slightly for men and increased slightly for women. In contrast, a marked increase in the incidence of OAC was observed, ranging from 2.8 per 100 000 persons in 1989 to 10.1 in 2016. This increase in OAC incidence was more prominent in men, and it will result in an increased risk of OAC for successive generations. Future projections indicate that the incidence of OAC will further increase to 13.1 per 100 000 persons in 2037 to 2041, meaning that there will be 13 259 cases of OAC in 2037 to 2041, as compared to 9386 diagnoses in 2017 to 2021. The changing epidemiologic trends in oesophageal cancer in the Netherlands should be reflected in the development of prevention, early detection and treatment strategies.

What's new?

The incidence of esophageal adenocarcinoma (OAC) is on the rise in Western countries. Better understanding of this trend could facilitate critical improvements in OAC prevention, early detection, and treatment strategies. Here, the authors investigated trends in OAC incidence from 1989 to 2016 for successive birth cohorts in the Netherlands. OAC incidence was found to have increased significantly since 1989, with risk rising most noticeably in men. Analyses through 2037‐2041 predict continued growth in OAC cases. The findings highlight the importance of promoting measures to prevent esophageal cancer, particularly those aimed at controlling modifiable risk factors, such as obesity and smoking.

Priorities of patients, caregivers and health-care professionals for health research - A systematic review

Background

Based on subjective experience, patients can identify research priorities important for health services research. A systematic method for priority setting has been developed by the James Lind Alliance.

Objective

This article reviews the literature on the research priorities of patients, caregivers and health‐care professionals and presents the prioritized research themes and prioritization methods used.

Search strategy

Three electronic databases were searched on 22 May 2018. The search was not limited to any time period or language.

Inclusion criteria

The included studies reported the identification and prioritization of research priorities involving patients, relatives and caregivers. Each included paper addressed a specific ICD‐coded health problem, and at least one‐third of the sample involved in the prioritization process was affected by the health problem.

Data extraction and synthesis

The 10 top‐ranked research priorities were included in the thematic analysis. With an inductive approach, a system of identified themes and subthemes was developed from the research priorities. Each research priority was assigned to one research theme.

Main results

The priority lists of 34 publications involving 331 research priorities were included. Nine main themes represent the content of the research priorities. The most frequently represented main themes are ‘Treatment’, ‘Patients’ and ‘Health condition’. The distribution of the research priorities varied depending on the health conditions and prioritization methods.

Discussion and conclusions

This review provides a comprehensive overview of the overarching research themes in research priorities of affected individuals. The results can guide future patient‐oriented research.

It takes two to tango: carers' reflections on their participation and the participation of people with dementia in the James Lind Alliance process

Background

Worldwide, patient and public involvement (PPI) in health research has grown steadily in recent decades. The James Lind Alliance (JLA) is one approach to PPI that brings patients, carers and clinicians together to identify priorities for future research in a Priority Setting Partnership (PSP). Our study aim was to describe the reflections of informal carers of people with dementia on the possibility of participating in the JLA’s PSP process, for both themselves and the recipients of their care. In addition, we wanted to explore barriers to and facilitators of their participation.

Methods

We conducted four focus groups with 36 carers of people with dementia. Thematic analysis was applied to analyse the data.

Results

An overarching theme emerged from the participants’ reflections: “Creating empowering teams where all voices are heard”. The overarching theme incorporates the participants’ suggestions about the importance of equivalence in power, mutual agreement with and understanding of the goals, adequate support, openness about each partner’s tasks and the bonds needed between the partners to sustain the enterprise, and expectations of positive outcomes. From the overarching theme, two main themes emerged: “Interaction of human factors, the PSP process and the environment” and “The power of position and knowledge”. The overall results indicated that carers are willing to participate in PSP processes and that they thought it important for people with dementia to participate in PSP processes as well, even if some might need extra support to do so. The carers also identified the need for research topics that influence their everyday lives, policy development and healthcare services.

Conclusions

Both carers and the people with dementia for whom they care are able to contribute to the PSP process when given sufficient support. The involvement of these groups is important for setting healthcare research agendas, developing research projects that increase awareness and knowledge about their circumstances and improving health professionals’, researchers’ and policymakers’ understanding of and insight into their unique situations.

The James Lind Alliance process approach: scoping review

OBJECTIVE

To summarise study descriptions of the James Lind Alliance (JLA) approach to the priority setting partnership (PSP) process and how this process is used to identify uncertainties and to develop lists of top 10 priorities.

DESIGN

Scoping review.

DATA SOURCES

The Embase, Medline (Ovid), PubMed, CINAHL and the Cochrane Library as of October 2018.

STUDY SELECTION

All studies reporting the use of JLA process steps and the development of a list of top 10 priorities, with adult participants aged 18 years.

DATA EXTRACTION

A data extraction sheet was created to collect demographic details, study aims, sample and patient group details, PSP details (eg, stakeholders), lists of top 10 priorities, descriptions of JLA facilitator roles and the PSP stages followed. Individual and comparative appraisals were discussed among the scoping review authors until agreement was reached.

RESULTS

Database searches yielded 431 potentially relevant studies published in 2010-2018, of which 37 met the inclusion criteria. JLA process participants were patients, carers and clinicians, aged 18 years, who had experience with the study-relevant diagnoses. All studies reported having a steering group, although partners and stakeholders were described differently across studies. The number of JLA PSP process steps varied from four to eight. Uncertainties were typically collected via an online survey hosted on, or linked to, the PSP website. The number of submitted uncertainties varied across studies, from 323 submitted by 58 participants to 8227 submitted by 2587 participants.

CONCLUSIONS

JLA-based PSP makes a useful contribution to identifying research questions. Through this process, patients, carers and clinicians work together to identify and prioritise unanswered uncertainties. However, representation of those with different health conditions depends on their having the capacity and resources to participate. No studies reported difficulties in developing their top 10 priorities.

Developing population health research priorities in Asian city state: Results from a multi-step participatory community engagement

OBJECTIVES

To identify a broad range of research priorities to inform the studies seeking to improve population health outcomes based on the engagement of diverse stakeholders.

METHODS

A multi-step, participatory and mixed-methods approach was adopted to solicit and structure the investigative themes from diverse stakeholders. The priority setting exercise involved four key phases: (1) feedback from community leadership; (2) interim ranking survey and focus group discussions during the population health symposium; (3) individual in-depth interviews with stakeholders in the community; and (4) synthesis of the research priorities from the multistep process.

RESULTS

Diverse stakeholders in Singapore, comprising community partnership leaders, health care and social service providers, users of population health services, patients and caregivers, participated in the research priority setting exercise. Initial 14 priorities were identified from six community leadership feedback, 42 survey responses, two focus groups (n = 16) and 95 in-depth interviews. The final integrated research agenda identified six priorities: empower residents and patients to take charge of their health; improve care transition and management through relationship building and communication; enhance health-social care interface; improve respite care services for long-term caregivers; develop primary care as a driving force for care integration; and capacity building for service providers. Selected research questions in each priority area were also generated to develop novel models of care, foster collaboration, implement optimal services and enhance understanding of the end users' care needs.

CONCLUSIONS

This study illuminates that greater community engagement in research priority setting for population health can facilitate the formulation of evidence-based research agendas that matter to the care providers and service users in the community. The outcomes derived from this exercise will help focus researchers' efforts through which meaningful gains can be made for population health.

Dedicated service improves the accuracy of Barrett's oesophagus surveillance: a prospective comparative cohort study

OBJECTIVES

Standards for Barrett's oesophagus (BO) surveillance in the UK are outlined in the British Society of Gastroenterology (BSG) guidelines. This study aimed to assess the quality of current surveillance delivery compared with a dedicated service.

DESIGN

All patients undergoing BO surveillance between January 2016 and July 2017 at a single National Health Service district general hospital were included. Patients had their endoscopy routed to a dedicated BO endoscopy list or a generic service list. Prospective data were analysed against the BSG guidelines and also compared with each patient's prior surveillance endoscopy.

RESULTS

361 patients were scheduled for surveillance of which 217 attended the dedicated list, 78 attended the non-dedicated list and 66 did not have their endoscopy. The dedicated list adhered more closely to the BSG guidelines when compared with the non-dedicated and prior endoscopy, respectively; Prague classification (100% vs 87.3% vs 82.5%, p<0.0001), hiatus hernia delineation (100% vs 64.8% vs 63.3%, p<0.0001), location and number of biopsies recorded (99.5% vs 5.6% vs 6.9%, p<0.0001), Seattle protocol adherence (72% vs 42% vs 50%, p<0.0001) and surveillance interval adherence (dedicated 100% vs prior endoscopy 75%, p<0.0001). Histology results from the dedicated and non-dedicated list cohorts revealed similar rates of intestinal metaplasia (79.8% vs 73.1%, p=0.12) and dysplasia/oesophageal adenocarcinoma (4.3% vs 2.6%, p=0.41).

CONCLUSIONS

The post-BSG guideline era of BO surveillance remains suboptimal in this UK hospital setting. A dedicated service appears to improve the accuracy and consistency of surveillance care, although the clinical significance of this remains to be determined.

Identifying top 10 primary care research priorities from international stakeholders using a modified Delphi method

BACKGROUND

High quality primary care is fundamental to achieving health for all. Research priority setting is a key facilitator of improving how research activity responds to concrete needs. There has never before been an attempt to identify international primary care research priorities, in order to guide resource allocation and to enhance global primary care. This study aimed to identify a list of top 10 primary care research priorities, as identified by members of the public, health professionals working in primary care, researchers, and policymakers.

METHODS

We adapted the James Lind Alliance Priority Setting Partnership process, to conduct multiple rounds of stakeholder recruitment and prioritization. The study included an online survey conducted in three languages, followed by an in-person priority setting exercise involving primary care stakeholders from 13 countries.

FINDINGS

Participants identified a list of top 10 international primary care research priorities. These were focused on diverse topics such as enhancing use of information and communication technology, and improving integration of indigenous communities' knowledge in the design of primary care services. The main limitations of the study related to challenges in engaging an adequate diversity and number of appropriate stakeholders, particularly members of the public, in aggregating the diverse set of responses into coherent categories representative of the participants' perspectives and in adequately representing the diversity of submitted responses while ensuring research priorities on the final list are sufficiently actionable to guide resource allocation.

CONCLUSIONS

The top 10 identified research priorities have the potential to guide research resource allocation, supporting funding agencies and initiatives to promote global primary care research and practice.

Model for Identifying Individuals at Risk for Esophageal Adenocarcinoma

BACKGROUND & AIMS

The prognosis for most patients with esophageal adenocarcinoma (EAC) is poor because they present with advanced disease. Models developed to identify patients at risk for EAC and increase early detection have been developed based on data from case-control studies. We analyzed data from a prospective study to identify factors available to clinicians that identify individuals with a high absolute risk of EAC.

METHODS

We collected data from 355,034 individuals (all older than 50 years) without a prior history of cancer enrolled in the UK Biobank prospective cohort study from 2006 through 2010; clinical data were collected through September 2014. We identified demographic, lifestyle, and medical factors, measured at baseline, that associated with development of EAC within 5 years using logistic regression analysis. We used these data to create a model to identify individuals at risk for EAC. Model performance was assessed using area under the receiver operating characteristics curve (AUROC), sensitivity, and specificity analyses.

RESULTS

Within up to 5 years of follow up, 220 individuals developed EAC. Age, sex, smoking, body mass index, and history of esophageal conditions or treatments identified individuals who developed EAC (AUROC, 0.80; 95% CI, 0.77-0.82). We used these factors to develop a scoring system and identified a point cut off that 104,723 individuals (29.5%), including 170 of the 220 cases with EAC, were above. The scoring system identified individuals who developed EAC with 77.4% sensitivity and 70.5% specificity. The 5-year risk of EAC was 0.16% for individuals with scores above the threshold and 0.02% for individuals with scores below the threshold.

CONCLUSION

We combined data on several well-established risk factors that are available to clinicians to develop a system to identify individuals with a higher absolute risk of EAC within 5 years. Studies are needed to evaluate the utility of these factors in a multi-stage, triaged, screening program.

Decline in perception of acid regurgitation symptoms from gastroesophageal reflux disease in diabetes mellitus patients

Objectives

To determine if a discrepancy exists between subjective symptoms and the grade of endoscopic gastroesophageal reflux disease (GERD) in diabetes mellitus (DM) patients.

Methods

All 2,884 patients who underwent esophagogastroduodenoscopy completed the modified Gastrointestinal Symptom Rating Scale (GSRS), an interview-based rating scale consisting of 16 items including a question on acid regurgitation. Patients were divided into DM and non-DM groups (1,135 and 1,749 patients, respectively). GERD was diagnosed endoscopically and graded according to the Los Angeles classification. Grade B or more severe GERD was defined as severe endoscopic GERD. The intergroup GSRS score was compared statistically.

Results

In severe endoscopic GERD patients, the prevalence of patients with a positive GSRS score in the acid regurgitation question was statistically lower in DM patients than non-DM patients. Of the 60 non-DM patients with severe endoscopic GERD, 40 patients (67%) had a positive GSRS score for acid regurgitation; however, of the 51 DM patients with severe endoscopic GERD, 23 patients (45%) had a positive GSRS score. Multivariate analysis showed that severe endoscopic GERD (OR: 2.01; 95% CI: 1.21–3.33; p = 0.0066), non-DM (OR: 0.74; 95% CI: 0.54–0.94; p = 0.0157), younger age (OR: 0.98; 95% CI: 0.97–0.99; p = 0.0125), and hiatal hernia (OR: 1.46; 95% CI: 1.12–1.90; p = 0.0042) were associated with acid regurgitation symptoms.

Conclusions

There is a discrepancy between subjective symptoms and endoscopic GERD grade in DM patients. The ability of DM patients to feel acid regurgitation may be decreased.