As a precursor to esophageal adenocarcinoma (EAC), Barrett esophagus (BE) is a crucial diagnosis for gastroenterologists to make during upper endoscopy (EGD). There has been building momentum for more formal guidelines enforcing stricter detection guidelines similar to those governing adenoma detection rate (ADR) during colonoscopy for colorectal cancer screening. This type of quality indicator (QI) has become increasingly popular in medicine in a push for an emphasis on quality-based outcomes that at times have been tied to reimbursement strategies. For example, ADR has been considered a high value metric based on its correlation with significant clinical outcomes such as its inverse correlation with interval colon cancer development and death.1-3

A recent systematic review and meta-analysis were performed by Parasa et al4 with an aim to determine the “neoplasia detection rate” (NDR). NDR was defined as the prevalence of high-grade dysplasia (HGD) and EAC associated with BE during a patient’s index EGD. This study included a total of 10,632 patients and found a pooled prevalence of 7% for HGD/EAC (95% CI, 4%-10%, P <.001). Pooled prevalence of individual dysplastic findings included 10% LGD (95% CI, 7%-15%), 3% HGD (95% CI, 2%-5%), and 3% EAC (95% CI 2%-5%). The overall pooled dysplasia rate was 20% (95% CI, 15%-27%). NDR was higher in studies performed in the United States (11%; 95% CI, 7%-16%) compared with studies performed outside the United States (5%; 95% CI, 3%-9%). Based on these findings, the authors recommended 4% as the proposed threshold for NDR on a patient’s index EGD for BE screening in average-risk patients.

A group of authors recently reviewed this meta-analysis and offered some additional thoughts on QIs in BE.5 The Parasi et al study was limited by significant heterogeneity, which needs to be taken into account when reviewing the results and recommendations. In addition, most patients were from tertiary care centers, which could limit how generalizable the findings are to more community-based practices. The study also did not detail the type of sampling technique used while screening for BE. The 4% threshold recommended by the study authors requires many additional studies in the future in order to validate this proposal.

One way to track a metric such as NDR would be routine inclusion of BE screening findings in the GI Quality Improvement Consortium (GIQuIC) database. GIQuIC is a joint venture of the American College of Gastroenterology and American Society for Gastroenterology Endoscopy (ASGE) to which gastroenterologists routinely report their endoscopic findings; however, only approximately one-third of gastroenterologists in the United States are currently using this registry.6 Therefore, the validation of NDR as well as collection of additional information to aid in developing other potential QIs will be challenging based solely on GIQuIC. Real-time capture of this type of information can at times become tedious and time consuming for many busy gastroenterologists with limited time. In addition to developing a formal QI for BE, the adherence to such a measure along with strategies to improve those gastroenterologists with suboptimal performance needs to be further evaluated.


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It is important to note that recent guidelines published by the ASGE in 2019 state that there is insufficient evidence on the effectiveness for screening for BE.7 The guidelines recommend that if screening for BE is performed, it is done in at-risk patients. “At-risk” patients include those with a family history of BE or EAC or patients with gastroesophageal reflux disease with at least 1 other risk factor (age greater than 50 years, obesity/central adiposity, history of smoking, or male sex). This type of proposed “at-risk” patient population varies differently than for colonoscopy, in which all “average”-risk patients undergo colonoscopy and not just “at-risk” or higher-than-average-risk patients. This needs to be taken into consideration when developing QIs in BE and how they will be implemented in clinical practice.

Outside of the determination of a specific QI for BE, it is important to note whether insurances would consider covering EGDs for BE screening in “average”-risk patients without symptoms. It is well known that patients with BE can be asymptomatic, however, how this is documented and interpreted by insurance companies could limit the uptake of screening protocols based on potential out-of-pocket costs for patients.

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One additional point to consider that was briefly described in the Jones and Wani5 article is the cumulative time it takes to collect and document these types of data. Recently, a study published by Overhage and McCallie8 found that among 155,000 US physicians, an average of 16 minutes 14 seconds was spent per patient encounter using the electronic health record. In addition, 11% of this time was spent after office hours. This type of time commitment needs to be factored into future BE screening research because it can substantially affect a physician’s schedule and patient time spent with physicians.

Moving forward, developing optimal QIs for BE will continue to be a popular area of research. In addition to the development of NDR, it will be interesting to see if there is an increased emphasis on other QIs for BE such as “withdrawal time” during an EGD for BE evaluation, similar to same metric used in colonoscopy for colorectal cancer screening and surveillance.

References

  1. Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-1803.
  2. Corely DA, Jenson CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370(14):1298-1306.
  3. Kaminski MF, Wieszczy P, Rupinski M, et al. Increased adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017;153(1):98-105.
  4. Parasa S, Desai M, Vittal A, et al. Estimating neoplasia detection rate (NDR) in patients with Barrett’s oesophagus based on index endoscopy: a systematic review and meta-analysis. Gut. 2019;68:2122-2128.
  5. Jones B, Wani S. Catching up to the colon: time for an adenoma detection rate equivalent in Barrett’s esophagus? Gastroenterology. 2019;S0016-5085(19)41594-1.
  6. Pochapin MB. 2017 Emily Couric Memorial Lecture: colorectal cancer: polyps, prevention, and progress. Am J Gastroenterol. 2018;113(12):1772-1777.
  7. Qumseya B, Sultan S, Bain P, et al; ASGE Standards of Practice Committee. ASGE guideline on screening and surveillance of Barrett’s esophagus. Gastrointest Endosc. 2019;90(3):335-359.e2.
  8. Overhage JM, McCallie D Jr. Physician time spent using the electronic health record during outpatient encounters: a descriptive study [published online January 14, 2020]. Ann Intern Med. doi: 10.7326/M18-3684