A resource utilization projection study of EUS

Current status of quality control in screening esophagogastroduodenoscopy and the emerging role of artificial intelligence

Esophagogastroduodenoscopy (EGD) screening is being implemented in countries with a high incidence of upper gastrointestinal (UGI) cancer. High-quality EGD screening ensures the yield of early diagnosis and prevents suffering from advanced UGI cancer and minimal operational-related discomfort. However, performance varied dramatically among endoscopists, and quality control for EGD screening remains suboptimal. Guidelines have recommended potential measures for endoscopy quality improvement and research has been conducted for evidence. Moreover, artificial intelligence offers a promising solution for computer-aided diagnosis and quality control during EGD examinations. In this review, we summarized the key points for quality assurance in EGD screening based on current guidelines and evidence. We also outline the latest evidence, limitations, and future prospects of the emerging role of artificial intelligence in EGD quality control, aiming to provide a foundation for improving the quality of EGD screening.

Upstream and downstream revenue of upper gastrointestinal endoscopic ultrasound determined with an episode-of-care approach

Background and study aims  Upper gastrointestinal endoscopic ultrasound (EUS) has clinical advantages that can lead to improved patient outcome. This study seeks to characterize and quantify the upstream and downstream healthcare utilizations and revenues. Patients and methods  A retrospective claims data analysis of upper gastrointestinal EUS procedures was conducted at a large health system. Types of care and total revenues associated with each episode of care were characterized by descriptive statistics. Comparisons were made between patients who had Medicare Advantage and commercial plans as well as those with and without cancer diagnoses during the downstream period. Results  A total of 436 cases were identified. The most frequent downstream healthcare utilizations consisted of radiology (31 %), pathology services (28 %), and high-revenue services including chemotherapy and inpatient admissions. The most common upstream utilizations included radiology (18 %) and lab services (22 %). Average total downstream revenue was $ 34 231 (95 %CI: $ 28 561 - $ 39 901) per case, and average total upstream revenue was $4373 (95 %CI: $3227 - $ 5519). Average total revenue per case did not differ significantly between Medicare Advantage and commercial plan members. However, patients who were diagnosed with cancer at or immediately following EUS (20 %) were associated with significantly higher total revenue compared to those without cancer diagnosis ( P  < 0.0001). Conclusions  This episode-of-care approach to quantifying the revenue impact of upper gastrointestinal EUS to the providers suggests there are substantial downstream as well as upstream revenues associated with upper gastrointestinal EUS procedures, driven by patients who are diagnosed with cancer by the EUS procedures and subsequently require oncologic care.

The Use of a Stylet in Endoscopic Ultrasound With Fine-Needle Aspiration: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is the most efficacious way to collect specimens from a solid lesion adjacent to the gastrointestinal tract and is performed with an internal stylet during puncture. However, its reinsertion into the needle is time-consuming. Controversy surrounds whether quality of cytology specimen improves with stylet use. We performed a meta-analysis comparing the use of stylet versus no stylet with EUS-FNA of gastrointestinal-related masses.

METHODS

Multiple databases were searched from inception until April 28, 2016. Discordant findings from independent extractions were reviewed by at least 2 investigators. Methods were executed as per the standards of the Cochrane Collaboration. Primary outcomes assessed were diagnostic adequacy of individual specimen samples, accuracy, and yield. Secondary outcomes included overall diagnostic accuracy of per-malignant lesion, cellularity, contamination, and bloodiness of the sample, and adverse events.

RESULTS

Five randomized control trials were identified comparing stylet versus no stylet use, which enrolled 504 patients, evaluated 537 lesions, and 1914 distinct specimens. There was no difference in diagnostic adequacy [risk ratio (RR)=1.00; 95% confidence interval (CI), 0.95-1.07], accuracy (RR=0.98; 95% CI, 0.90-1.06), or yield (RR=0.96; 95% CI, 0.89-1.03). No stylet use was favored in per-lesion malignant diagnosis (RR=0.85; 95% CI, 0.76-0.96). There was no difference in representative cellularity, contamination, or bloodiness of specimens obtained with or without stylet use.

CONCLUSIONS

Stylet use confers no significant advantage in diagnostic adequacy, accuracy, yield, contamination, bloodiness, or cellularity over no stylet. We reinforce that no stylet use may be used preferentially in EUS-FNA as a more convenient technique and is favored with a higher per-lesion malignant diagnosis.

Training in Endoscopy: Endoscopic Ultrasound

Endoscopic ultrasound (EUS) has been recently established as an indispensable modality for the diagnosis and management of pancreatobiliary and gastrointestinal (GI) disorders. EUS proficiency requires both cognitive and technical abilities, including an understanding of the appropriate indications, the performance of appropriate evaluations before and after the procedure, and the management of procedure-related complications. An increasing demand for skills to handle a growing range of interventional EUS procedures and a continual shortage of EUS training programs are two major obstacles for EUS training. Acquiring the skills necessary to comprehend and conduct EUS often requires training beyond the scope of a standard GI fellowship program. In addition to traditional formal EUS training and preceptorships, regular short-term intensive EUS training programs that provide training at various levels may help EUS practitioners improve and maintain EUS-related knowledges and skills. Theoretical knowledge can be acquired from lectures, textbooks, atlases, slides, videotapes, digital video discs, interactive compact discs, and websites. Informal EUS training is generally based on 1- or 2-day intensive seminars, including didactic lectures, skills demonstrated by expert practitioners through live video-streaming of procedures, and hands-on learning using animal or phantom models.

Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography: Can they be successfully combined?

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) have much in common, including their main indications (biliopancreatic disorders), powerful therapeutic capacities and a steep learning curve. Over the years they have evolved from novel diagnostic procedures to interventional therapeutic techniques, but along different paths (different scopes or devices and endoscopists specializing exclusively in one or the other technique). However, EUS has gradually developed into a therapeutic technique that requires skills in the use of ERCP devices and stents, leading some ERCP specialists to explore the therapeutic potential of EUS. The corresponding literature, which has grown exponentially, includes recent experiments on combining the two techniques, which have gradually come to be used in routine care in a number of centers, with positive technical, clinical and financial outcomes. We review EUS and ERCP as individual or combined procedures for managing biliopancreatic disorders.

Comparison of the outcomes of endoscopic ultrasound based on community hospital versus tertiary academic center settings

OBJECTIVE

Endoscopic ultrasound (EUS) is an established tool in the management of gastrointestinal diseases. The majority of EUS procedures are performed in tertiary care hospitals but the technology has also disseminated to community hospitals. The data from community hospitals are limited and there are no published studies comparing EUS-fine needle aspiration (FNA) outcomes in community versus tertiary settings. Our objective is to compare EUS procedures performed in these two separate settings.

METHODS

EUS procedures performed for pancreatobiliary indications in an academic tertiary care hospital and a community hospital were retrospectively reviewed and compared. The patient demographics, procedure time, procedure indications, FNA performed, pass counts, needle size, rapid onsite evaluation (ROSE) and final cytological diagnosis were compared between the two centers. Cytological diagnosis was categorized as satisfactory and unsatisfactory samples.

RESULTS

There was no significant difference in patient age, gender, indications, procedure time, FNA performed, needle size, or pass counts between the tertiary hospital (n = 361) and community hospital (n = 119). ROSE was a significant determinant factor for adequacy of sample. There was a positive linear relationship between adequacy of the sample and number of pass counts. After performing a logistic regression and adjusting for target site, the overall odds of having an unsatisfactory specimen were not significantly different at the two centers (OR 0.51, CI 0.23-1.17, p = 0.11). Percentages of unsatisfactory samples were not significantly different at the two centers for solid lesions (7.4 vs. 3.1%, p = 0.33), cysts (33.3 vs. 23.8%, p = 0.31,) or lymph nodes (25.0 vs. 0%, p = 0.063).

CONCLUSION

Cytological yield of EUS-FNA in a community hospital is similar to that of a tertiary hospital. Community hospitals can provide EUS services with reasonable success.

Downstream hospital charges generated from endoscopic ultrasound procedures are greater than those from colonoscopies

BACKGROUND & AIMS

Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies.

METHODS

We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures.

RESULTS

Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036).

CONCLUSIONS

Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.

Utility of a repeated EUS at a tertiary-referral center

BACKGROUND

The utility of a repeated EUS by experts is not known.

OBJECTIVE

To define the utility of a repeated EUS for the same indication.

DESIGN

A retrospective case series.

SETTING

Tertiary-referral hospital in Indianapolis, Indiana.

PATIENTS

Consecutive subjects, with and without cancer, who, between January 2000 and September 2006, underwent an initial EUS elsewhere within 6 and 12 weeks of a repeated EUS at our hospital.

INTERVENTIONS

A repeated EUS.

MAIN OUTCOME MEASUREMENTS

Clinical impact of a repeated EUS.

RESULTS

Of 8936 EUS examinations, 73 repeated procedures (0.8%) were identified, and 24 were excluded. The 49 initial EUS procedures (26 men, median age 59 years) were done in Indiana (n = 44) or another state (n = 5) by one of 15 physicians in private practice (n = 48) or at a teaching hospital (n = 1). An EUS-guided FNA (EUS-FNA) was performed during an initial EUS in 21 patients (no biopsy diagnostic for cancer) and was not attempted in 14 patients. The principle indication for a repeated EUS (n = 35) was for an EUS-FNA after the initial tissue sampling was benign, nondiagnostic, or not done. A second EUS had no clinical impact in 18 patients (37%). In the remaining 31 patients (63%), a repeated EUS provided a new or changed clinical diagnosis (n = 12), the initial diagnosis of primary pancreatic cancer (n = 5) or GI stromal tumor (GIST) (n = 1) after a previous nondiagnostic biopsy; or the initial diagnosis of primary (n = 4) or metastatic (n = 2) pancreatic cancer, metastatic esophageal cancer (n = 1), hilar cholangiocarcinoma (n = 1), GIST (n = 1), or pancreatic neuroendocrine tumor (n = 1), or an initial aspiration of a pancreatic cyst (n = 3) after a previous EUS-FNA was not able to be performed.

LIMITATIONS

A retrospective design; a small number of nonpancreatic indications.

CONCLUSIONS

In this study, a repeated EUS at a tertiary-referral center had a clinical impact in 63% of patients when performed by experts for a similar clinical indication.

Current utilization and performance status of endoscopic ultrasound in a community hospital

OBJECTIVE

Endoscopic ultrasound (EUS) is an essential tool for cancer staging and investigating gastrointestinal diseases. Although it is not a widespread skill, as its expanded indications became much more advanced so did its popularity and hospital acceptance. We aimed to study the utilization and indications of upper EUS in a Hong Kong community hospital. The secondary aim was to assess our accuracy in staging of esophageal and gastric cancer and in evaluating submucosal tumors.

METHODS

All patients who had undergone upper EUS in Tuen Mun Hospital from January 2002 to December 2006 were recruited. Their background data, indications, radiological investigations, upper endoscopy and operation records and histopathologic results were retrieved for analysis. The accuracy of EUS in esophageal cancer staging, gastric cancer staging and evaluating submucosal tumors was assessed by comparing surgical and histopathologic findings.

RESULTS

A total of 645 upper EUS examinations were performed and there has been a steady increase in EUS utilization in our hospital. The most common indications were evaluating submucosal tumors and staging esophageal and gastric cancer. The accuracy of T and N staging of esophageal cancer was 71.2 and 79.7%, respectively and for gastric cancer was 64.0 and 74.7%, respectively. Endoscopic ultrasound was 70% accurate in identifying lesions arising from the submucosal layer and 100% accurate in identifying lesions from the muscularis propria.

CONCLUSION

Endoscopic ultrasound is an accurate method and its demand is increasing. The performance in a community hospital can be further improved and its utilization should expand to other indications.

Endoscopic ultrasound of the upper gastrointestinal tract and mediastinum: diagnosis and therapy

Endoscopic ultrasound (EUS) has developed significantly over the last two decades and has had a considerable impact on the imaging and staging of mass lesions within or in close proximity to the gastrointestinal (GI) tract. In conjunction with conventional imaging such as helical computed tomography and magnetic resonance imaging, the indications for EUS include (1) differentiating between benign and malignant lesions of the mediastinum and upper GI tract, (2) staging malignant tumors of the lung, esophagus, stomach, and pancreas prior to surgery or oncological treatment, (3) excluding common bile duct stones before laparoscopic cholecystectomy, thereby avoiding the need for endoscopic retrograde cholangiopancreatography (ERCP) in some patients, and (4) assessing suspected lesions that are either equivocal or not seen on conventional imaging. In recent years, EUS has charted a course similar to that taken by ERCP, evolving from a purely diagnostic modality to one that is interventional and therapeutic. These indications include (5) obtaining a tissue diagnosis by EUS-guided fine-needle aspiration or trucut-type needle biopsy and (6) providing therapy such as coeliac plexus neurolysis and pancreatic pseudocyst drainage--in many cases, more accurately and safely than conventional techniques. Emerging investigational techniques include EUS-guided enteric anastomosis formation and fine-needle injection therapy for malignant disease.

Can U.S. GI fellowship programs meet American Society for Gastrointestinal Endoscopy recommendations for training in EUS? A survey of U.S. GI fellowship program directors

BACKGROUND

American Society for Gastrointestinal Endoscopy (ASGE) EUS training and credentialing guidelines exist, but the capability of U.S. GI fellowships to meet these guidelines has not been assessed.

OBJECTIVE

To ascertain the capability of U.S. GI fellowship programs to meet ASGE guidelines for EUS training in the context of 3-year and advanced GI fellowships.

METHODS

U.S. GI fellowship programs were surveyed for the presence or the absence, type, and extent of EUS training. Demographics regarding the programs and the program directors were obtained.

MAIN OUTCOME MEASUREMENTS

Data on the annual total EUS volume and data on EUS performed by 3-year and/or advanced-year fellows were collected and analyzed.

RESULTS

Ninety-one of 142 contactable GI programs responded (64%); 72% of programs performed >200 EUS/y and thus could train >or=1 EUS trainee/y. For 3-year GI fellows, 55% received less than 3 months of training, with 43% not receiving actual "hands-on" EUS experience, and 61% not learning EUS-guided FNA. The median EUS performed by 3-year fellows was 50 (0-350). Programs that offer advanced endoscopy fellowship had a median advanced-trainee EUS volume of 200 procedures (range, 50-1100 procedures). Of advanced fellows, 20% failed to receive "hands-on" training and 52% performed <200 procedures. We observed a significant difference in the median EUS volume performed by 3-year versus advanced-year fellows (P<.001). Program director variables did not correlate with training EUS volumes.

CONCLUSIONS

The majority of U.S. GI fellowship programs have established the EUS volume to train at least 1 EUS fellow, per ASGE guidelines; however, most 3-year and many advanced fellows are currently receiving insufficient EUS training.

Practice patterns and attitudes toward the role of endoscopic ultrasound in staging of gastrointestinal malignancies: a survey of physicians and surgeons

BACKGROUND AND AIMS

It is unknown how physician specialties other than gastroenterologists that manage gastrointestinal (GI) malignancies utilize endoscopic ultrasound (EUS) in their practices. The aim of this study was to (i) assess the proportion of gastroenterologists, oncologists, and surgeons that utilize EUS for staging of GI malignancies; (ii) assess the general availability of EUS; and (iii) determine which factors are associated with the use and availability of EUS.

METHODS

A self-administered questionnaire was mailed out to 1,200 randomly selected gastroenterologists, oncologists, and surgeons throughout the United States.

RESULTS

The data was analyzed from 521 (43%) responses. There were 60% respondents who had EUS available within their practices. There was greater availability of EUS within the practices of surgeons (81%; p < 0.001), within academic practices (87%; p= < 0.001), and in practices that serve a population >500,000 (p < 0.001). The majority of respondents (71%) utilized EUS in their practices. There was a similar utilization of EUS across specialties (p= NS). There was greater utilization of EUS in academic centers (82%; p < 0.001), in practices that served a community of >500,000 (p= 0.003), and among respondents who had been in practice for less than 5 yr (p= 0.005). Employing logistic regression models for utilization of EUS, lesser number of years in practice, and availability of EUS were found to be the only significant predictors of utilization.

CONCLUSIONS

The majority of practitioners utilized EUS in management of GI malignancies. There was similar utilization of EUS across specialties. EUS is available to the majority of practitioners who manage GI malignancies.

Present and future of endoscopic ultrasonography

Endoscopic ultrasonography and endoscopic ultrasonography-guided fine needle aspiration are well-established techniques, encompassing a variety of diagnostic and therapeutic applications. Along with traditional indications that constitute everyday clinical practice in all endoscopic ultrasonography centres, new indications are emerging that resemble the continuing research carried on in this field. Some of these are innovative applications, developed by highly experienced endosonographers and with a putative role for clinical practice in the near future. Others are merely experimental applications, carried out on in animal models or in highly selected groups of patients, opening up new fascinating areas of research but not for imminent introduction in clinical practice. The purpose of this review, after summarising the present indications of endoscopic ultrasonography, is to focus on the future applications and try to establish their possible advent, either in the near or in the far future.

Endoscopic ultrasound in the diagnosis, staging, and management of gastrointestinal and adjacent malignancies

Endoscopic ultrasound (EUS) is a superior modality for local staging of gastrointestinal cancer. In interventional endosonography linear array echoendoscopes permit real-time EUS-guided puncture of target lesions for cytologic evaluation of such lesions. This article describes the basic principles of EUS, established indications pertaining to gastrointestinal cancer and other malignancies, and emerging indications for this minimally invasive technology.

Chronic pancreatitis

The pathogenesis of idiopathic chronic pancreatitis remains poorly understood despite the high expectations for ascribing the pancreatic damage in affected patients to genetic defects. Neither mutations in the cationic trypsinogen gene nor mutations of the cystic fibrosis conductance regulator gene account for the chronic pancreatitis noted in most patients with idiopathic chronic pancreatitis. Attempts to find an autoimmune basis for the pancreatitis in these patients have not been very successful. The diagnosis of small duct idiopathic chronic pancreatitis remains a great source of frustration for clinicians. Such patients with negative results of radiographic studies often cannot be diagnosed unless a hormone stimulation test such as a secretin test is performed. Although the porcine biologic form of secretin, which has been used to diagnose chronic pancreatitis, became unavailable because of widespread use in the treatment of children with autism, a synthetic form of porcine secretin has now been approved by the US Food and Drug Administration and is available. The true value of endoscopic ultrasonography in diagnosing small duct chronic pancreatitis remains to be fully defined. Endoscopic ultrasonography is becoming the test of choice in detecting radiographic abnormalities in both the parenchyma and ducts of the pancreas. Endoscopic ultrasonography-guided celiac plexus block can be performed relatively easily and very safely. It can provide excellent short-term pain relief in some patients, but reliable predictors of which patients will be successful with this therapy are not yet available. Because long-term follow-up data on the use of endoscopic ultrasonography in this respect are not available, and because the pain of chronic pancreatitis is, indeed, chronic, the role of endoscopic ultrasonography-guided celiac plexus block should be limited to treating those patients with chronic pancreatitis whose pain has not responded to other modalities.