Quality Indicators for EGD

Walter G Park MD, MS; Nicholas J Shaheen MD, MPH; Jonathan Cohen MD; Irving M Pike MD; Douglas G Adler MD; John M Inadomi MD; Loren A Laine MD; John G Lieb MD; Maged K Rizk MD; Mandeep S Sawhney MD, MS; Sachin Wani MD

Disclosures

Am J Gastroenterol. 2015;110(1):60-71.

Conclusion

This update on quality indicators for EGD incorporates new information to provide a relevant list for endoscopists who want to perform high-quality upper endoscopy. Similar to those from the original version published in 2006, the indicators are classified as preprocedure, intra-procedure, and postprocedure indicators, and this is summarized in Table 4. The proposed indicators vary in the level of supporting evidence, and several are based solely on expert opinion. For practical and ethical reasons, some indicators may be impossible to validate, such as performing and documenting informed consent and patient monitoring during moderate sedation. The absence of evidence does not equate to evidence of no benefit.

For EGD, the proposed quality measures are predominantly process measures. Many of these process measures are good surrogates of outcomes, based on evidence that links them to clinically recognized outcomes. The future direction of quality indicator development will include relevant outcome measures and a more robust evidence base to support proposed performance targets. The proposed research questions address this deficit of evidence.

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Abbreviations
ACG, American College of Gastroenterology; ASGE, American Society for Gastrointestinal Endoscopy; BE, Barrett's esophagus; ESD, endoscopic submucosal dissection; PPI, proton pump inhibitor

Table 1. Grades of recommendation ^a
Grade of recommendation	Clarity of benefit	Methodologic strength supporting evidence	Implications
1A	Clear	Randomized trials without important limitations	Strong recommendation; can be applied to most clinical settings
1B	Clear	Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws)	Strong recommendation, likely to apply to most practice settings
1C+	Clear	Overwhelming evidence from observational studies	Strong recommendation; can apply to most practice settings in most situations
1C	Clear	Observational studies	Intermediate-strength recommendation; may change when stronger evidence is available
2A	Unclear	Randomized trials without important limitations	Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values
2B	Unclear	Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws)	Weak recommendation; alternative approaches may be better under some circumstances
2C	Unclear	Observational studies	Very weak recommendation; alternative approaches likely to be better under some circumstances
3	Unclear	Expert opinion only	Weak recommendation, likely to change as data become available

^aAdapted from Guyatt G, Sinclair J, Cook D, et al. Moving from evidence to action. Grading recommendations—a qualitative approach. In: Guyatt G, Rennie D, editors. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599–608.

Table 2. Summary of proposed quality indicators common to all endoscopic proceduresa ^a (23)
Quality indicator	Grade of recommendation	Measure type	Performance target (%)
Preprocedure
1. Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications, and the indication is documented (priority indicator)	1C+	Process	>80
2. Frequency with which informed consent is obtained and fully documented	3	Process	>98
3. Frequency with which preprocedure history and directed physical examination are performed and documented	3	Process	>98
4. Frequency with which risk for adverse events is assessed and documented before sedation is started	3	Process	>98
5. Frequency with which prophylactic antibiotics are administered only for selected settings in which they are indicated (priority indicator)	Varies	Process	>98
6. Frequency with which a sedation plan is documented	Varies	Process	>98
7. Frequency with which management of antithrombotic therapy is formulated and documented before the procedure (priority indicator)	3	Process	N/A
8. Frequency with which a team pause is conducted and documented	3	Process	>98
9. Frequency with which endoscopy is performed by an individual who is fully trained and credentialed to perform that particular procedure	3	Process	>98
Intraprocedure
10. Frequency with which photodocumentation is performed	3	Process	N/A
11. Frequency with which patient monitoring among patients receiving sedation is performed and documented	3	Process	>98
12. Frequency with which the doses and routes of administration of all medications used during the procedure are documented	3	Process	>98
13. Frequency with which use of reversal agents is documented	3	Process	>98
14. Frequency with which procedure interruption and premature termination because of oversedation or airway management issues is documented	3	Process	>98
Postprocedure
15. Frequency with which discharge from the endoscopy unit according to predetermined discharge criteria is documented	3	Process	>98
16. Frequency with which patient instructions are provided	3	Process	>98
17. Frequency with which the plan for pathology follow-up is specified and documented	3	Process	>98
18. Frequency with which a complete procedure report is created	3	Process	>98
19. Frequency with which immediate adverse events requiring interventions are documented	3	Process	>98
20. Frequency with which immediate adverse events requiring interventions including hospitalization occur	3	Outcome	N/A
21. Frequency with which delayed adverse events leading to hospitalization or additional procedures or medical interventions occur within 14 days	3	Outcome	N/A
22. Frequency with which patient satisfaction data are obtained	3	Process	N/A
23. Frequency with which communication with referring providers is documented	3	Process	N/A

N/A, Not available.
^aThis list of potential quality indicators is meant to be a comprehensive list of measurable endpoints. It is not the intention of the task force that all endpoints be measures in every practice setting. In most cases, validation may be required before a given endpoint may be adopted universally.

Table 3. Indications and contraindications for EGD (6)
1. EGD is generally indicated for evaluating:
A. Upper abdominal symptoms, which persist despite an appropriate trial of therapy
B. Upper abdominal symptoms associated with other symptoms or signs suggesting serious organic disease (e.g., anorexia and weight loss) or in patients aged >45 years
C. Dysphagia or odynophagia
D. Esophageal reflux symptoms, which are persistent or recurrent despite appropriate therapy
E. Persistent vomiting of unknown cause
F. Other diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, or chronic nonsteroidal anti-inflammatory drug therapy for arthritis and those with cancer of the head and neck
G. Familial adenomatous polyposis syndromes
H. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
1. Suspected neoplastic lesion
2. Gastric or esophageal ulcer
3. Upper tract stricture or obstruction
I. GI bleeding:
1. In patients with active or recent bleeding
2. For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy result is negative
J. When sampling of tissue or fluid is indicated
K. In patients with suspected portal hypertension to document or treat esophageal varices
L. To assess acute injury after caustic ingestion
M. Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy)
N. Banding or sclerotherapy of varices
O. Removal of foreign bodies
P. Removal of selected polypoid lesions
Q. Placement of feeding or drainage tubes (peroral, PEG, or percutaneous endoscopic jejunostomy)
R. Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems by using guidewires)
S. Management of achalasia (e.g., botulinum toxin, balloon dilation)
T. Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent placement)
U. Endoscopic therapy for intestinal metaplasia
V. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery)
W. Management of operative adverse events (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances)
2. EGD is generally not indicated for evaluating:
A. Symptoms that are considered functional in origin (there are exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy)
B. Metastatic adenocarcinoma of unknown primary site when the results will not alter management
C. Radiographic findings of:
1. Asymptomatic or uncomplicated sliding hiatal hernia
2. Uncomplicated duodenal ulcer that has responded to therapy
3. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy
3. Sequential or periodic EGD may be indicated:
A. Surveillance for malignancy in patients with premalignant conditions (ie, Barrett's esophagus)
4. Sequential or periodic EGD is generally not indicated for:
A. Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, or prior gastric operations for benign disease
B. Surveillance of healed benign disease such as esophagitis or gastric or duodenal ulcer
C. Surveillance during repeated dilations of benign strictures unless there is a change in status

Table 4. Summary of proposed quality indicators for EGD ^a
Quality indicator	Grade of recommendation	Type of measure	Performance target (%)
Preprocedure
1. Frequency with which EGD is performed for an indication that is included in a published standard list of appropriate indications, and the indication is documented	1C+	Process	>80
2. Frequency with which informed consent is obtained, including specific discussions of risks associated with EGD, and fully documented	3	Process	>98
3. Frequency with which appropriate prophylactic antibiotics are given in patients with cirrhosis with acute upper GI bleeding before EGD (priority indicator)	1B	Process	>98
4. Frequency with which appropriate prophylactic antibiotics are given before placement of a PEG tube	1A	Process	>98
5. Frequency with which a PPI is used for suspected peptic ulcer bleeding (priority indicator)	1B	Process	>98
6. Frequency with which vasoactive drugs are initiated before EGD for suspected variceal bleeding	1B	Process	>98
Intraprocedure
7. Frequency with which a complete examination of the esophagus, stomach, and duodenum, including retroflexion in the stomach, is conducted and documented	3	Process	>98
8. Among those with nonbleeding gastric ulcers, frequency with which gastric biopsies are done to exclude malignancy	2C	Process	>80
9. Frequency with which Barrett's esophagus is appropriately measured when present	2C	Process	>98
10. Frequency with which biopsies are obtained in cases of suspected Barrett's esophagus	2C	Process	>90
11. Frequency with which type of upper GI bleeding lesion is described, and the location is documented	3	Process	>80
12. Frequency with which, during EGD examination revealing peptic ulcers, at least one of the following stigmata is noted: active bleeding, nonbleeding visible vessels (pigmented protuberance), adherent clot, flat spot, and clean-based	1A	Process	>98
13. Frequency with which, unless contraindicated, endoscopic treatment is given to ulcers with active bleeding or with nonbleeding visible vessels (priority indicator)	1A	Process	>98
14. Frequency with which achievement of primary hemostasis in cases of attempted hemostasis of upper GI bleeding lesions is documented	3	Process	>98
15. Frequency with which a second treatment modality is used (e.g., coagulation or clipping) when epinephrine injection is used to treat actively bleeding or nonbleeding visible vessels in patients with bleeding peptic ulcers	1A	Process	>98
16. Frequency with which variceal ligation is used as the first modality of treatment for the endoscopic treatment of esophageal varices	1A	Process	>98
17. Frequency with which at least 4 intestinal biopsies are done from patients in whom celiac disease is suspected	1C	Process	>90
Postprocedure
18. Frequency with which PPI therapy is recommended for patients who underwent dilation for peptic esophageal strictures	1A	Process	>98
19. Frequency with which patients diagnosed with gastric or duodenal ulcers are instructed to take PPI medication or an H2 antagonist	1A	Process	>98
20. Frequency with which plans to test for H pylori infection are documented for patients diagnosed with gastric or duodenal ulcers (priority indicator)	1A	Process	>98
21. Frequency with which patients with evidence of rebleeding from peptic ulcer disease after endoscopic treatment undergo repeat upper endoscopy	1B	Process	>98
22. Frequency with which patients are contacted to document the occurrence of adverse events after EGD	3	Process	N/A

PPI, proton pump inhibitor.
^aThis list of potential quality indicators was meant to be a comprehensive listing of measurable endpoints. It is not the intention of the task force that all endpoints be measured in every practice setting. In most cases, validation may be required before a given endpoint may be universally adopted.

Table 5. Priority quality indicators for EGD ^a
Frequency with which, unless contraindicated, endoscopic treatment is performed for ulcers with active bleeding or with nonbleeding visible vessels.
Frequency with which plans to test for Helicobacter pylori infection are documented for patients diagnosed with gastric or duodenal ulcers.
Frequency with which appropriate prophylactic antibiotics are given in patients with cirrhosis with acute upper GI bleeding who undergo EGD.
Frequency with which a proton pump inhibitor is used for suspected peptic ulcer bleeding.

^a See text for specific targets and discussion.

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