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Sharma P, Falk GW, Bhor M, Ozbay AB, Latremouille-Viau D, Guérin A, Shi S, Elvekrog MM, Limburg P. Real-world upper endoscopy utilization patterns among patients with gastroesophageal reflux disease, Barrett esophagus, and Barrett esophagus-related esophageal neoplasia in the United States. Medicine (Baltimore) 2023; 102:e33072. [PMID: 36961193 PMCID: PMC10036066 DOI: 10.1097/md.0000000000033072] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/02/2023] [Indexed: 03/25/2023] Open
Abstract
This study fills a gap in literature by providing contemporary real-world evidence on the prevalence of patients with gastroesophageal reflux disease (GERD), Barrett esophagus (BE), and Barrett esophagus-related neoplasia (BERN) and their upper endoscopy utilization patterns in the United States. A retrospective cohort study design was used: adults with GERD, nondysplastic Barrett esophagus (NDBE), and BERN (indefinite for dysplasia [IND], low-grade dysplasia [LGD], high-grade dysplasia [HGD], or esophageal adenocarcinoma [EAC]) were identified from the MarketScan databases (January 01, 2015-December 31, 2019). For each disease stage, prevalence of adults in commercial claims by calendar year, annual number of upper endoscopies per patient and time between upper endoscopies were reported. In 2019, in commercial claims (N = 12,363,227), the annual prevalence rate of GERD was 13.7% and 0.70% for BE/BERN, among which, 87.1% had NDBE, 6.8% had IND, 2.3% had LGD, 1.0% had HGD, and 2.8% had EAC. From 2015-2019, the study included 3,310,385 patients with GERD, 172,481 with NDBE, 11,516 with IND, 4332 with LGD, 1549 with HGD, and 11,676 with EAC. Annual mean number of upper endoscopies was 0.20 per patient for GERD, 0.37 per patient for NDBE, 0.43 for IND, 0.58 for LGD, and 0.87 for HGD. Median time (months) to second upper endoscopy was 38.10 for NDBE, 36.63 for IND, 22.63 for LGD, and 11.90 for HGD. Upper endoscopy utilization increased from GERD to BE to BERN, and time between upper endoscopies decreased as the disease stage progressed from BE to BERN, with less frequent utilization in BERN than what would be expected from guideline recommendations for surveillance.
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Affiliation(s)
- Prateek Sharma
- Department of Gastroenterology, University of Kansas School of Medicine and VA Medical Center, Kansas City, MO
| | - Gary W. Falk
- Perelman School of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Sijben J, Peters Y, van der Velden K, Rainey L, Siersema PD, Broeders MJ. Public acceptance and uptake of oesophageal adenocarcinoma screening strategies: A mixed-methods systematic review. EClinicalMedicine 2022; 46:101367. [PMID: 35399814 PMCID: PMC8987366 DOI: 10.1016/j.eclinm.2022.101367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/14/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
UNLABELLED Oesophageal adenocarcinoma (OAC) is increasingly diagnosed and often fatal, thus representing a growing global health concern. Screening for its precursor, Barrett's oesophagus (BO), combined with endoscopic surveillance and treatment of dysplasia might prevent OAC. This review aimed to systematically explore the public's acceptance and uptake of novel screening strategies for OAC. We systematically searched three electronic databases (Ovid Medline/PubMed, Ovid EMBASE and PsycINFO) from date of inception to July 2, 2021 and hand-searched references to identify original studies published in English on acceptability and uptake of OAC screening. Two reviewers independently reviewed and appraised retrieved records and two reviewers extracted data (verified by one other reviewer). Of the 3674 unique records, 19 studies with 15 249 participants were included in the review. Thematic analysis of findings showed that acceptability of OAC screening is related to disease awareness, fear, belief in benefit, practicalities and physical discomfort. The findings were mapped on the Integrated Screening Action Model. Minimally invasive screening tests are generally well-tolerated: patient-reported outcomes were reported for sedated upper endoscopy (tolerability ++), transnasal endoscopy (tolerability +), tethered capsule endomicroscopy (tolerability +/-), and the Cytosponge-TFF3 test (acceptability ++). In discrete choice experiments, individuals mainly valued screening test accuracy. OAC screening has been performed in trials using conventional upper endoscopy (n = 231 individuals), transnasal endoscopy (n = 966), capsule endoscopy (n = 657) and the Cytosponge-TFF3 test (n = 9679), with uptake ranging from 14·5% to 48·1%. Intended participation in OAC screening in questionnaire-based studies ranged from 62·8% to 71·4%. We conclude that the general public seems to have interest in OAC screening. The findings will provide input for the design of a screening strategy that incorporates the public's values and preferences to improve informed participation. Identification of a screening strategy effective in reducing OAC mortality and morbidity remains a crucial prerequisite. FUNDING This study was funded by the Netherlands Organization for Health Research and Development (ZonMw) under grant 555,004,206.
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Affiliation(s)
- Jasmijn Sijben
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud university medical center, Geert Grooteplein-Zuid 8, Nijmegen 6500 HB, the Netherland
- Corresponding author.
| | - Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud university medical center, Geert Grooteplein-Zuid 8, Nijmegen 6500 HB, the Netherland
| | - Kim van der Velden
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud university medical center, Geert Grooteplein-Zuid 8, Nijmegen 6500 HB, the Netherland
| | - Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein-Zuid 8, Nijmegen 6500 HB, the Netherland
| | - Peter D. Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud university medical center, Geert Grooteplein-Zuid 8, Nijmegen 6500 HB, the Netherland
| | - Mireille J.M. Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein-Zuid 8, Nijmegen 6500 HB, the Netherland
- Dutch Expert Centre for Screening, Wijchenseweg 101, Nijmegen 6538 SW, the Netherland
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Racial Disparities in Adherence to Quality Indicators in Barrett's Esophagus: An Analysis Using the GIQuIC National Benchmarking Registry. Am J Gastroenterol 2021; 116:1201-1210. [PMID: 33767105 DOI: 10.14309/ajg.0000000000001230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Racial disparities in outcomes in esophageal adenocarcinoma are well established. Using a nationwide registry, we aimed to compare clinical and endoscopic characteristics of blacks and whites with Barrett's esophagus (BE) and adherence to defined quality indicators. METHODS We analyzed data from the Gastrointestinal Quality Improvement Consortium Registry between January 2012 and December 2019. Patients who underwent esophagogastroduodenoscopy with an indication of BE screening or surveillance, or an endoscopic finding of BE, were included. Adherence to recommended endoscopic surveillance intervals of 3-5 years for nondysplastic BE and adherence to Seattle biopsy protocol were assessed. Multivariate logistic regression was conducted to assess variables associated with adherence. RESULTS A total of 100,848 esophagogastroduodenoscopies in 84,789 patients met inclusion criteria (blacks-3,957 and whites-96,891). Blacks were less likely to have histologically confirmed BE (34.3% vs 51.7%, P < 0.01), had shorter BE lengths (1.61 vs 2.35 cm, P < 0.01), and were less likely to have any dysplasia (4.3% vs 7.1%, P < 0.01). Although whites were predominantly male (62.2%), about half of blacks with BE were female (53.0%). Blacks with nondysplastic BE were less likely to be recommended appropriate surveillance intervals (OR 0.78; 95% CI 0.68-0.89). Adherence rates to the Seattle protocol were modestly higher among blacks overall (OR 1.12, 95% CI 1.04-1.20), although significantly lower among blacks with BE segments >6 cm. DISCUSSION The use of sex as a risk factor for BE screening may be inappropriate among blacks. Fewer blacks were recommended appropriate surveillance intervals, and blacks with longer segment BE were less likely to undergo Seattle biopsy protocol.
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Wani S, Williams JL, Falk GW, Komanduri S, Muthusamy VR, Shaheen NJ. An Analysis of the GIQuIC Nationwide Quality Registry Reveals Unnecessary Surveillance Endoscopies in Patients With Normal and Irregular Z-Lines. Am J Gastroenterol 2020; 115:1869-1878. [PMID: 33156106 DOI: 10.14309/ajg.0000000000000960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Population-based estimates of adherence to Barrett's esophagus (BE) guidelines are not available. Using a national registry, we assessed surveillance intervals for patients with normal and irregular Z-lines based on the presence or absence of intestinal metaplasia (IM) and among patients with suspected or confirmed BE. METHODS We analyzed data from the GI Quality Improvement Consortium Registry. Endoscopy data, including procedure indication, demographics, endoscopy and histology findings, and recommendations for further endoscopy, were assessed from January 2013 through December 2019. Patients with an indication of BE screening or surveillance or an endoscopic finding of BE were included. Biopsy and surveillance practices were assessed based on the length of columnar epithelium (0 cm, <1 cm, 1-3 cm, and >3 cm) and diagnosis based on histology findings. RESULTS A total of 1,907,801 endoscopies were assessed; 135,704 endoscopies (7.1%) performed in 114,894 patients met the inclusion criteria (men 61.4%, Whites 91%, and mean age of 61.7 years [SD 12.5]). Among patients with normal Z-lines, surveillance endoscopy was recommended for 81% of patients with IM and 20% of individuals without IM. Among patients with irregular Z-lines, surveillance endoscopy was recommended for 81% with IM and 24% without IM. Approximately 30% of patients with confirmed nondysplastic BE (lengths 1-3 and >3 cm) had recommended surveillance intervals of <3 years. DISCUSSION An analysis of data from a nationwide quality registry demonstrated that patients without BE are receiving recommendations for surveillance endoscopies and many patients with nondysplastic BE are reexamined too soon.
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Affiliation(s)
- Sachin Wani
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Gary W Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Cotton CC, Shaheen NJ. Overutilization of Endoscopic Surveillance in Barrett's Esophagus: The Perils of Too Much of a Good Thing. Am J Gastroenterol 2020; 115:1019-1021. [PMID: 32618650 DOI: 10.14309/ajg.0000000000000650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A cost-utility analysis in the current issue of AJG examines the ramifications of the overuse of surveillance endoscopy in Barrett's esophagus (BE). This study suggests that excess surveillance is expensive, increasing costs by 50% or more, with only nominal increases in quality-adjusted life expectancy. This study joins a growing literature of cost-utility analyses that suggest that more is not likely better when it comes to surveillance endoscopy. Given the plentiful literature showing overutilization of surveillance endoscopy in BE, the authors argue for a focus on the quality of endoscopy rather than increased frequency of surveillance to improve returns on our healthcare investment.
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Affiliation(s)
- Cary C Cotton
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Holmberg D, Ness-Jensen E, Mattsson F, Lagergren J. Adherence to clinical guidelines for Barrett's esophagus. Scand J Gastroenterol 2019; 54:945-952. [PMID: 31314608 DOI: 10.1080/00365521.2019.1641740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and aim: Clinical guidelines recommend endoscopy surveillance at given intervals or endoscopic therapy for Barrett's esophagus with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). Whether these guidelines are followed in clinical practice is unknown and was assessed in this study. Methods: This nationwide Swedish cohort study included patients with Barrett's esophagus with histologically verified LGD or HGD from 50 centers in 2006-2013. These patients were followed up using nationwide registers. Adherence to clinical guidelines was explored. Eight potential risk factors for deviation from guidelines were assessed using multivariable logistic regression, providing adjusted odds ratios (OR) with 95% confidence intervals (95%CI). Results: Among 211 patients with Barrett's esophagus (mean age 67.0 years, standard deviation 9.7 years, 81% male), 71% had LGD and 29% had HGD. During median 3.9 years of follow-up, 84% underwent a follow-up endoscopy, 17% received endoscopic therapy and 8% underwent esophagectomy. The clinical management deviated from guidelines in 60% of all patients (69% in LGD and 39% in HGD), which was mainly due to under-surveillance (86%). Risk factors for deviation from guidelines were LGD compared to HGD (OR 3.4, 95%CI 1.7-6.8), longer Barrett's segment length (OR 2.0, 95%CI 1.0-3.9, comparing ≥3 cm with <3 cm), and treatment at gastroenterology compared to surgery departments (OR 2.3, 95%CI 1.2-4.4). Age, sex, calendar period and university hospital status were not associated with deviation from surveillance guidelines. Conclusions: Adherence to guidelines for dysplastic Barrett's esophagus is poor, particularly for LGD. Efforts to implement clinical guideline recommendations are needed.
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Affiliation(s)
- Dag Holmberg
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Eivind Ness-Jensen
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.,Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology , Levanger , Norway.,Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust , Levanger , Norway
| | - Fredrik Mattsson
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London , London , UK
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Over-Utilization of Repeat Upper Endoscopy in Patients with Non-dysplastic Barrett's Esophagus: A Quality Registry Study. Am J Gastroenterol 2019; 114:1256-1264. [PMID: 30865017 DOI: 10.14309/ajg.0000000000000184] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Guidelines recommend that patients with non-dysplastic Barrett's esophagus (NDBE) undergo surveillance endoscopy every 3-5 years. Using a national registry, we assessed compliance to recommended surveillance intervals in patients with NDBE and identified factors associated with compliance. METHODS We analyzed data from the GI Quality Improvement Consortium registry. Data abstracted include procedure indication, demographics, endoscopy/pathology results, and recommendations for future endoscopy. Patients with an indication of Barrett's esophagus (BE) screening or surveillance, or an endoscopic finding of BE, with non-dysplastic intestinal metaplasia on pathological examination, were included. Compliance was defined as a recommendation to undergo subsequent endoscopy between 3 and 5 years. Multivariate logistic regression was conducted to assess variables associated with compliance. RESULTS Of 786,712 endoscopies assessed, 58,709 (7.5%) endoscopies in 53,541 patients met inclusion criteria (mean age 61.3 years, 60.4% men, 90.2% white, mean BE length was 2.3 cm). Most cases were performed by Gastroenterologists (92.3%) with propofol (78.7%). A total of 29,978 procedures (55.8%) resulted in pathology-confirmed BE. Among procedures with NDBE (n = 25,945), 29.9% were noncompliant with the 3-year threshold; most (26.9%) recommended surveillance at 1- to 2-year intervals. Patient factors such as extremes of age, black race, geographic region, type of sedation, and increasing BE length were associated with noncompliance. DISCUSSION Approximately 30% of patients with NDBE are recommended to undergo surveillance endoscopy too soon. Patient factors associated with inappropriate utilization include extremes of age, black race, and increasing BE length. Compliance with appropriate endoscopic follow-up as a quality measure in BE is poor.
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Tavakkoli A, Appelman HD, Beer DG, Madiyal C, Khodadost M, Nofz K, Metko V, Elta G, Wang T, Rubenstein JH. Use of Appropriate Surveillance for Patients With Nondysplastic Barrett's Esophagus. Clin Gastroenterol Hepatol 2018; 16:862-869.e3. [PMID: 29432922 PMCID: PMC5962402 DOI: 10.1016/j.cgh.2018.01.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 01/09/2018] [Accepted: 01/28/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Guidelines recommend that patients with nondysplastic BE (NDBE) undergo surveillance endoscopy every 3-5 years. We aimed to identify factors associated with surveillance endoscopy of patients with NDBE and identify trends in appropriate surveillance endoscopy of NDBE at a large tertiary care center. METHODS We performed a retrospective analysis of data from a Barrett's Esophagus Registry, identifying patients with NDBE who underwent endoscopy in 2002 or later. We identified patients with NDBE and collected data on length of BE segment, esophageal lesions, demographic features, medications, histology findings, comorbidities, development of EAC, and dates of follow-up endoscopies. We defined appropriate surveillance as 3-5 years between 2nd and 3rd endoscopies, over-utilizers as patients who had less than 3 years between their 2nd and 3rd endoscopies, under-utilizers as patients who had more than 5 years between their 2nd and 3rd endoscopies; and never-surveilled as patients who never received a 2nd endoscopy. The primary outcomes were effects of patient factors, year, and referring providers on appropriateness of surveillance intervals. RESULTS We identified 477 patients with NDBE. Only 15.9% had appropriate surveillance; 37.9% were over-utilizers 15.7% were under-utilizers and 30.4% were never surveilled. Patients were less likely to be over-surveilled if their primary care physician referred them for their 3rd endoscopy instead of a gastroenterologist (adjusted odds ratio, 0.51; 95% CI, 0.27-0.95). Male patients or those with an increased number of comorbidities were more likely to be under-surveilled or never-surveilled, whereas patients with long BE segment were more likely to be over-surveilled. CONCLUSIONS In a retrospective analysis of data from a registry of patients with BE, we found that less than 16% receive appropriate surveillance for NDBE. A primary care provider in the same health system as the endoscopy clinic reduced risk of over-surveillance. This could reflect better coordination of care between specialists and primary care providers.
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Affiliation(s)
- Anna Tavakkoli
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan.
| | - Henry D Appelman
- Department of Pathology, University of Michigan, Ann Arbor, Michigan
| | - David G Beer
- Department of Thoracic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Chaitra Madiyal
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Maryam Khodadost
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Division of Gastroenterology, Veterans Affairs Hospital, Ann Arbor, Michigan
| | - Kimberly Nofz
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Division of Gastroenterology, Veterans Affairs Hospital, Ann Arbor, Michigan
| | - Val Metko
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Division of Gastroenterology, Veterans Affairs Hospital, Ann Arbor, Michigan
| | - Grace Elta
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Thomas Wang
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan
| | - Joel H Rubenstein
- Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
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