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Endoscopist biopsy rate as a quality indicator for outpatient gastroscopy: a multicenter cohort study with validation

  • Wladyslaw Januszewicz
    Correspondence
    Reprint requests: Wladyslaw Januszewicz, MD, MRC Cancer Unit, University of Cambridge, Cambridge CB2 0XZ, United Kingdom.
    Affiliations
    Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland

    Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland

    MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
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  • Paulina Wieszczy
    Affiliations
    Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland

    Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
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  • Andrzej Bialek
    Affiliations
    Department of Gastroenterology, Pomeranian Medical University, Szczecin, Poland
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  • Katarzyna Karpinska
    Affiliations
    Department of Pathomorphology, Pomeranian Medical University, Szczecin, Poland
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  • Jakub Szlak
    Affiliations
    Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
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  • Jakub Szymonik
    Affiliations
    Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
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  • Maciej Rupinski
    Affiliations
    Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland

    Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland
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  • Andrzej Mroz
    Affiliations
    Department of Pathomorphology, Medical Centre for Postgraduate Education, Warsaw, Poland

    Department of Pathology and Laboratory Medicine, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
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  • Jaroslaw Regula
    Affiliations
    Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland

    Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland
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  • Michal F. Kaminski
    Affiliations
    Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland

    Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland

    Department of Cancer Prevention, The Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland

    Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Published:January 16, 2019DOI:https://doi.org/10.1016/j.gie.2019.01.008

      Background and Aims

      The diagnosis of gastric premalignant conditions (GPCs) relies on endoscopy with mucosal sampling. We hypothesized that the endoscopist biopsy rate (EBR) might constitute a quality indicator for EGD, and we have analyzed its association with GPC detection and the rate of missed gastric cancers (GCs).

      Methods

      We analyzed EGD databases from 2 high-volume outpatient units. EBR values, defined as the proportion of EGDs with ≥1 biopsy to all examinations were calculated for each endoscopist in Unit A (derivation cohort) and divided by the quartile values into 4 groups. Detection of GPC was calculated for each group and compared using multivariate clustered logistic regression models. Unit B database was used for validation. All patients were followed in the Cancer Registry for missed GCs diagnosed between 1 month and 3 years after EGDs with negative results.

      Results

      Sixteen endoscopists in Unit A performed 17,490 EGDs of which 15,340 (87.7%) were analyzed. EBR quartile values were 22.4% to 36.7% (low EBR), 36.8% to 43.7% (moderate), 43.8% to 51.6% (high), and 51.7% and 65.8% (very-high); median value 43.8%. The odds ratios for the moderate, high, and very-high EBR groups of detecting GPC were 1.6 (95% confidence interval [CI], 1.3-1.9), 2.0 (95% CI, 1.7-2.4), and 2.5 (95% CI, 2.1-2.9), respectively, compared with the low EBR group (P < .001). This association was confirmed with the same thresholds in the validation cohort. Endoscopists with higher EBR (≥43.8%) had a lower risk of missed cancer compared with those in the lower EBR group (odds ratio, 0.44; 95% CI, 0.20-1.00; P = .049).

      Conclusions

      The EBR parameter is highly variable among endoscopists and is associated with efficacy in GPC detection and the rate of missed GCs.

      Graphical abstract

      Abbreviations:

      BE (Barrett’s esophagus), CI (confidence interval), DA (duodenal adenoma), EBR (endoscopist biopsy rate), GC (gastric cancer), GD (gastric dysplasia), GPC (gastric precancerous condition), OR (odds ratio), SIN (squamous intraepithelial neoplasm), UGI (upper gastrointestinal)
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      Linked Article

      • Endoscopic biopsies in diagnostic outpatient gastroscopy: more is not always better!
        Gastrointestinal EndoscopyVol. 90Issue 3
        • Preview
          We have read with great interest the study by Januszewicz et al1 describing the concept of endoscopist biopsy rate (EBR) as a potential quality indicator for routine diagnostic outpatient EGD. The authors found a significant variability in EBR among 26 endoscopists and an association between higher EBR, a higher detection of gastric precancerous conditions, and a lower risk of missed gastric cancers.1
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        • PDF
      • Routine gastric biopsies: Should we be doing more?
        Gastrointestinal EndoscopyVol. 89Issue 6
        • Preview
          Although extensive research has been focused on the role of quality metrics in the performance of colonoscopy, relatively less attention has been given to the performance of upper endoscopy. The American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy has published quality indicators for upper endoscopy; however, most measures were process related, and the lack of recognized outcome measures was described.1 There are currently no metrics for the detection of gastric premalignant conditions (GPCs) or gastric cancers (GCs).
        • Full-Text
        • PDF