Post written by Wladyslaw Januszewicz, MD, from the Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, and the Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland, and the MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom.
The focus of our study was to develop, test and validate a new quality parameter for the upper GI endoscopy–the endoscopist biopsy rate (EBR). This parameter represents a proportion of endoscopies with at least a single biopsy for histological assessment obtained in all performed upper-GI endoscopies performed by a single operator. We then aimed to see if there is an association between EBR parameters and the gastric premalignant conditions detection (defined as atrophic gastritis, gastric intestinal metaplasia, or gastric dysplasia), the risk for a missed gastric cancer (defined as cancer diagnosed after 1 month and within 3 years of an upper endoscopy), and the rate of “negative biopsies” (defined as gastric biopsies without significant histologic pathologic changes).
Esophagogastroduodenoscopy (EGD) has become a primary tool in detecting early neoplasia; however, its diagnostic accuracy for early cancer and precancerous conditions is highly operator-dependent. A recent meta-analysis has shown that over 11% of upper-GI cancers are missed during endoscopy (Menon S, et at. Endosc Int Open 2014), hence quality indicators for EGD are of paramount importance to improve routine practice. The importance of high-quality performance measures has already been shown in the field of colonoscopy. The primary quality indicator for screening colonoscopy, adenoma detection rate (ADR), is associated with prognostic clinical outcomes, such as increased interval colon cancer incidence (Kaminski MF, et al. N Eng J Med 2010) and mortality (Corley DA, et al. N Eng J Med 2014). To date, no comparable quality indicator for EGD has been described. There is an increased level of awareness about the importance of quality indicators for the EGD, but an overall lack of high-quality evidence in the published literature. The objective of our study was to fill this existing gap with high-quality evidence for new performance measures in upper-GI endoscopy.
First of all, we have shown that the rate of obtaining biopsies (EBR) is highly variable between endoscopists, and this was shown both in the derivation cohort of endoscopists, whereby the EBR varied between 22.4% and 65.8%, and in the independent validation cohort (22.0%- 52.9%). We think that this variability of EBR represents a difference in performance between endoscopists and lack of standardization in practice. We believe that in the setting of a routine outpatient endoscopy unit, EBR could be an adjunct quality parameter being used to monitor the performance of endoscopists in combination with other parameters such as procedural time, completeness, and quality of photo-documentation, the rate of D2 intubation, etc. We have shown that EBR is highly correlated with the detection of gastric premalignant conditions (rs=0.835, P< .001) and the rate of missed gastric cancers (81% of all missed cancers in the cohort were attributed to endoscopists with an EBR below median). On the other hand, the increasing rate of EBR is correlated with the increasing number of “negative” biopsies. This increases the cost burden of upper-GI endoscopy with no clinical benefit. The most accurate range of EBR should, therefore, represent the best balance between detection accuracy and costs. This should be the aim for further, preferably prospective, trials.
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