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

Quality indicators in Barrett's endoscopy: Best is yet to come

There is growing interest in establishing quality indicators (QIs) for endoscopic screening and surveillance in Barrett's esophagus (BE). QIs are objective, measurable, and evidence-based metrics that are applicable in a health-care setting to monitor a process and identify key performance indicators (KPIs) to achieve defined goals. In the Barrett's endoscopy setting, QIs can offer a standardized approach to monitor and maintain high-quality endoscopy for BE screening and surveillance that will allow measuring performance of an endoscopist as an individual, a group, or a facility. Since BE is an endoscopically identifiable premalignant condition with histological corroboration, adherence to QIs is paramount for the early and accurate detection of dysplasia and neoplasia. It is the holy grail for BE screening and surveillance. Although several suggested QIs for Barrett's endoscopy exist, issues remain in determining the most appropriate ones. These issues include inconsistent use of terminology, unclear definitions, and a scarcity of studies linking these QIs with relevant patient outcomes, making it difficult for clinicians to understand the concept and clinical importance. Hence, there is an urgent need to determine what should constitute appropriate QIs for Barrett's endoscopy, clearly define items used in the QIs, and identify ways to measure these KPIs. Ultimately, well-defined and validated QIs will contribute to clinically effective, safe, timely, and patient-focused care. In this review, we summarize recent literature and discuss four proposed QIs: (i) neoplasia detection rate; (ii) postendoscopy Barrett's neoplasia; (iii) Barrett's inspection time; and (iv) adherence to the Seattle biopsy protocol.

Dedicated service for Barrett's oesophagus surveillance endoscopy yields higher dysplasia detection and guideline adherence in a non-tertiary setting in the UK: a 5-year comparative cohort study

Objective

Barrett's oesophagus (BO) endoscopic surveillance is performed to varying quality, dedicated services may offer improved outcomes. This study compares a dedicated BO service to standard care, specifically dysplasia detection rate (DDR), guideline adherence and use of advanced imaging modalities in a non-tertiary setting.

Design/method

5-year retrospective comparative cohort study comparing a dedicated BO endoscopy service with surveillance performed on non-dedicated slots at a non-tertiary centre in the UK. All adult patients undergoing BO surveillance between 1 March 2016 and 1 March 2021 were reviewed and those who underwent endoscopy on a dedicated BO service run by endoscopists with training in BO was compared with patients receiving their BO surveillance on any other endoscopy list. Endoscopy reports, histology results and clinic letters were reviewed for DDR and British society of gastroenterology guideline adherence.

Results

921 BO procedures were included (678 patients). 574 (62%) endoscopies were on a dedicated BO list vs 348 (38%) on non-dedicated.DDR was significantly higher in the dedicated cohort 6.3% (36/568) vs 2.7% (9/337) (p=0.014). Significance was sustained when cases with indefinite for dysplasia were excluded: 4.9% 27/533 vs 0.9% 3/329 (p=0.002). Guideline adherence was significantly better on the dedicated endoscopy lists.Factors associated with dysplasia detection in regression analysis included visible lesion documentation (p=0.036), use of targeted biopsies (p=<0.001), number of biopsies obtained (p≤0.001).

Conclusions

A dedicated Barrett's service showed higher DDR and guideline adherence than standard care and may be beneficial pending randomised trial data.

Adherence to guideline recommendations for Barrett's esophagus (BE) surveillance endoscopies: Effects of dedicated BE endoscopy lists

Background and study aims For non-dysplastic Barrett's Esophagus (BE) patients, guidelines recommend endoscopic surveillance every 3 to 5 years with four-quadrant random biopsies every 2 cm of BE length. Adherence to these guidelines is low in clinical practice. Pooling BE surveillance endoscopies on dedicated endoscopy lists performed by dedicated endoscopists could possibly enhance guideline adherence, detection of visible lesions, and dysplasia detection rates (DDRs). Patients and methods Data were used from the ACID-study (Netherlands Trial Registry NL8214), a prospective trial of BE surveillance in the Netherlands. BE patients with known or previously treated dysplasia were excluded. Guideline adherence, detection of visible lesions, and DDRs were compared for patients on dedicated and general endoscopy lists. Results A total of 1,244 patients were included, 318 on dedicated lists and 926 on general lists. Endoscopies on dedicated lists showed significantly higher adherence to the random biopsy protocol (85% vs. 66%, P <0.01) and recommended surveillance intervals (60% vs. 47%, P <0.01) compared to general lists. Detection of visible lesions (8.8% vs. 8.1%, P =0.79) and DDRs were not significantly different (6.9% and 6.6%, P =0.94). None (0.0%) of the patients scheduled on dedicated lists and 10 (1.1%) on general lists were diagnosed with esophageal adenocarcinoma ( P =0.07). In multivariable analysis, dedicated lists were significantly associated with biopsy protocol adherence and adherence to surveillance interval recommendations with odds ratios of 4.45 (95% confidence interval [CI] 2.07-9.57) and 1.64 (95% CI 1.03-2.61), respectively. Conclusions Dedicated endoscopy lists are associated with better adherence to the random biopsy protocol and surveillance interval recommendations.

Effect of biopsy protocol adherence vs non-adherence on dysplasia detection rates in Barrett's esophagus surveillance endoscopies: a systematic review and meta-analysis

Background  Barrett's esophagus (BE) surveillance endoscopies are advised for early diagnosis of esophageal adenocarcinoma (EAC). Current guidelines recommend obtaining four-quadrant random biopsies every 2 centimeters of BE length alongside with targeted biopsies if visible lesions are present. Low adherence rates for this random biopsy protocol are widely reported. The aim of this systematic review and meta-analysis was to assess the effect of adherence versus non-adherence to the four-quadrant biopsy protocol on detection of dysplasia in BE patients. Methods  We searched for studies that reported effects of adherence and non-adherence to the four-quadrant biopsy protocol on dysplasia detection rates in BE patients. Adherence was defined as taking a minimum of 4 quadrant random biopsies per 2 cm of BE segment. Studies with low risk of bias and without applicability concerns were included in a good quality synthesis. Pooled relative risks (RRs) with 95% confidence interval (CI) of dysplasia detection rates were calculated. Results  A total of 1,570 studies were screened and 8 studies were included. Four studies were included in the good quality synthesis. In the pooled good quality analysis, four-quadrant biopsy protocol adherence significantly increased detection of dysplasia compared to non-adherence (RR 1.90, 95 % CI = 1.36-2.64; I2 = 45 %). Pooled RRs for LGD and HGD/EAC were 2.00 (95 % CI = 1.49-2.69; I2 = 0 %) and 2.03 (95 % CI = 0.98-4.24; I2 = 28 %), respectively. Conclusion  This systematic review and meta-analysis demonstrates that four-quadrant biopsy protocol adherence is associated with increased detection of dysplasia in BE patients. Efforts should be made to increase biopsy protocol adherence rates.

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.