Room for Improvement in Barrett Esophagus Care

Megan Brooks

February 08, 2023

Adherence to the Seattle biopsy protocol and recommended endoscopic surveillance intervals ― two established quality indicators (QIs) in Barrett esophagus (BE) ― varies widely by individual endoscopist and center, an analysis of US registry data shows.

"As the GI Quality Improvement Consortium (GIQuIC) registry represents the 'best-case scenario' for adherence, since sites and endoscopists enrolled in this quality registry are aware that their practices are being monitored, these results indicate that there is still room for improvement and better consistency," the researchers write.

The study was published online in The American Journal of Gastroenterology.

Quality care in BE, which is a precursor to esophageal adenocarcinoma (EAC), includes adherence to the Seattle biopsy protocol for sampling the BE segment (four-quadrant biopsies every 2 cm) and to a surveillance interval of 3 to 5 years for patients with nondysplastic BE (NDBE).

Previous studies have found poor adherence to these two Qis, but those studies only provided overall estimates, and individual endoscopists or different sites were not taken into consideration.

Jennifer Kolb, MD, with David Geffen School of Medicine at the University of California, Los Angeles, and colleagues say their study is the first to highlight variation in adherence to these measures at the center and endoscopist levels.

The study is also the first US population-based study to report the dysplasia detection rate (DDR), which is a proposed quality indicator. The findings on this metric also demonstrate marked variability across endoscopists and sites.

Study Details

Using the nationwide GIQuIC registry, the researchers evaluated endoscopist and site-based adherence to the Seattle protocol and surveillance interval advice from January 2018 to May 2021.

Among 255 practices with 1195 endoscopists who performed 20,155 upper endoscopies for suspected or established BE, overall adherence to the Seattle protocol was 86%, which is considerably higher than the 51% reported in a study conducted from 2002 to 2007, Kolb and colleagues note.

When researchers looked specifically at 572 endoscopists for whom there were at least 10 endoscopy records in the registry, they found high variability in adherence to the Seattle protocol (median, 93.8%; interquartile range [IQR], 18.9%).

Adherence to the Seattle protocol was also variable among 153 practices for which there were at least 20 endoscopy records (median, 90%; IQR, 20.1%).

Of the 12,100 upper endoscopies with documented NDBE, 8517 (70.4%) had a guideline-concordant-recommended surveillance interval of 3 to 5 years, with variability at both the endoscopist (median, 82.4%; IQR, 36.3%) and site level (median, 77.2%; IQR, 28.9%).

Endoscopist and site adherence to the Seattle protocol and surveillance guidance generally rose along with volume of upper endoscopies performed.

The overall DDR was 3.1%; it varied among endoscopists and sites (mean, 3.3% for both).

The investigators note that the 95% confidence intervals for each provider for DDR were "highly variable" and ranged from –20% to 119.3%. Notably, increasing upper endoscopy volume had an inconsistent effect on adherence rates and DDR by endoscopists and sites.

The investigators saw no correlation between overall DDR and Seattle protocol adherence among sites and only weak but statistically significant negative correlation between DDR and Seattle protocol adherence among individual endoscopists.

Practical Approaches to Improvement

The researchers say their observations from the GIQuIC database "most accurately represent the real-world experience in Barrett's endoscopy."

The results can serve as a "benchmark for quality initiatives and intervention trials aimed at improving outcomes for patients with BE," they say.

Improving adherence to key QI measures and ensuring more consistent clinical behavior across practice groups and endoscopists are "critical first steps" to ensure high-quality BE care, Kolb and colleagues say.

To that end, they encourage professional societies to emphasize these metrics to their members and to streamline the reporting systems for QIs within the electronic health records used across various practice settings.

Avenues to improve examination quality may include educational interventions, such as online learning platforms that teach dysplasia detection or that highlight best practices, they add. These educational tools should be easy to use and should emphasize quality improvement measures.

"Future efforts are warranted to identify and extinguish predictors of this variability and to determine whether these interventions can improve DDR and adherence rates to QIs among endoscopists doing these examinations with the goal to improve EAC outcomes," they conclude.

The study had no financial support. The authors have disclosed no relevant financial relationships.

Am J Gastroenterol. Published online January 5, 2023. Abstract

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