Marilyn Hinojosa-Lindsey

Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett's oesophagus

Background The effectiveness of surveillance endoscopy in patients with Barretts oesophagus (BE) for reducing oesophageal adenocarcinoma (EAC)-related mortality in patients with BE is unclear. Methods This is a cohort study of patients with BE diagnosed in the National Veterans Affairs hospitals during 2004–2009 excluding those with conditions that affect overall survival. We identified those diagnosed with EAC after BE diagnosis through 2011 and conducted chart reviews to identify BE surveillance programme, and indication for EAC diagnosis, verify diagnosis, stage, therapy and cause of death. We examined the association between surveillance indication for EAC diagnosis with or without surveillance programme and EAC stage and treatment receipt in logistic regression models, and with time to death or cancer-related death using a Cox proportional hazards regression model. Results Among 29 536 patients with BE, 424 patients developed EAC during a mean follow-up of 5.0 years. A total of 209 (49.3%) patients with EAC were in BE surveillance programme and were diagnosed as a result of surveillance endoscopy. These patients were more likely to be diagnosed at an early stage (stage 0 or 1: 74.7% vs 56.2, p<0.001), survived longer (median 3.2 vs 2.3 years; p<0.001) and have lower cancer-related mortality (34.0% vs 54.0%, p<0.0001) and had a trend to receive oesophagectomy (51.2% vs 42.3%; p=0.07) than 215 patients diagnosed by non-BE surveillance endoscopy (17.2% of whom were BE surveillance failure). BE surveillance endoscopy was associated with a decreased risk of cancer-related death (HR 0.47, 0.35 to 0.64), which was largely explained by the early stage of EAC at the time of diagnosis. Similarly, the adjusted mortality for patients with cancer in a prior surveillance programme for overall death was 0.63 (0.47 to 0.84) compared with patients with cancer not in a surveillance programme. Conclusions Surveillance endoscopy among patients with BE is associated with significantly better EAC outcomes including cancer-related mortality compared with other non-surveillance endoscopy.

Choosing Wisely and the Perceived Drivers of Endoscopy Use

Choosing Wisely is a campaign led by the American Board of Internal Medicine (ABIM) Foundation in collaboration with specialty medical societies including the American Gastroenterological Association (AGA)1. Choosing Wisely seeks to reduce several categories of overutilization of health care services (e.g., overtreatment, and failures in care coordination and execution of care processes)2. Choosing Wisely is based on principles of Parsimonious Medicine: an appeal to professionalism and physicians’ “good, sound judgment” to identify and apply clinical evidence 3. Parsimonious medicine suggests that appropriate utilization occurs when physician judgment and best evidence are applied within the context of individual patient’s needs3. Choosing Wisely addresses both physicians and patients through the publication of lists of “Five Things Physicians and Patients Should Question” for each specialty. The Choosing Wisely items identified by the AGA highlight potential overutilization of 1) pharmacologic treatments for gastroesophageal reflux disease, 2) screening colonoscopy in average risk individuals, 3) surveillance colonoscopy in individuals with low-risk polyps, 4) surveillance esophagogastroduodenoscopy (EGD) in individuals with Barrett’s Esophagus (BE), and 5) computed tomography (CT) in individuals with functional abdominal pain.1 The success of Choosing Wisely will depend on how patients and physicians weight the importance of best evidence against other factors that shape decisions at the clinical encounter. As part of a patient-centered, comparative effectiveness study of screening and surveillance esophagogastroduodenoscopy (EGD), we conducted qualitative interviews to explore patient and physician perceptions of one of the AGA Choosing Wisely items.4 Analysis of these interviews identified factors perceived to influence under and over utilization of surveillance EGD for Barrett’s Esophagus in the context of AGA clinical practice guidelines. We conducted in-depth qualitative interviews with 20 patients with BE who use the Veterans Administration (VA) system and 14 gastroenterologists from three practice settings: tax-supported public, private academic, and VA settings. We concluded sampling for each subgroup at the point of thematic saturation5. Interview content was informed by models of decision-making6. Interviews with patients elicited information about their experiences, perceptions, and attitudes regarding BE and surveillance EGD. Interviews with physicians elicited perceptions of practice guidelines and decision making regarding surveillance EGD in patients with BE. All interviews were recorded, transcribed, and analyzed for content.5 Of our sample of 20 patients with BE, the mean age of participants was 62.9±7.3 years; all male; and 10 had BE without dysplasia and 9 had BE with low-grade dysplasia. All of the 14 gastroenterologists interviewed were experienced endoscopists, 36% were female, 50% practiced in private settings full or part time; and had a median of 14 (range 1–36) years post-fellowship experience. Table 1 describes quotes from patients and gastroenterologists that frame the drivers of utilization of EGD for patients with BE as part of guideline-based cancer surveillance. Figure 1 depicts these 9 themes as drivers of utilization for surveillance EGD. Figure 1 Table 1 Drivers of Utilization Among Patients and Gastroenterologists Our interviews identified drivers of over and under utilization of EGD within the context of BE surveillance. Patients and physicians endorsed many factors (Figure 1) that drive utilization of EGD, other than the quality of evidence, that may not be influenced by appeals for professionalism or quality of evidence. These factors include, access and payments for healthcare (for patients), financial incentives and medical-legal considerations (for physicians). The results of our study specifically explore one of the Choosing Wisely items co-sponsored by AGA: follow-up surveillance examination should not be performed in less than three years as per published guidelines for BE patients without dysplasia1. However, current practice is not indicative of adherence to this item; for example, a recent three-site study (including one VA facility) found EGD overutilization was common among BE patients and insurance-related incentives were the primary driver of utilization6. The emphasis that Choosing Wisely places on Parsimonious Medicine is unlikely to mitigate the many drivers of overtreatment given some of the current evidence and structural issues related to heathcare delivery in a largely fee-for-service system. High quality evidence is critical because it anchors definitions of appropriate utilization (as illustrated in Figure 1). However, three of the five Choosing Wisely items from the AGA directly address overutilization of endoscopy (colonoscopy and EGD) where evidence guiding the optimal time interval between repeat studies is modest at best, yet there are multiple perceived factors driving overutilization. Moreover, systematic changes affecting incentive structures and medico-legal concerns are needed to encourage and enable the types of shared decisions that are consistent with best evidence. Without incentives to counteract the factors favoring overutilization, Choosing Wisely will struggle to meaningfully impact clinical decision making.

Practice patterns of surveillance endoscopy in a Veterans Affairs database of 29,504 patients with Barrett's esophagus

BACKGROUND Practice guidelines recommend surveillance endoscopy every 2 to 3 years among patients with Barretts esophagus (BE) to detect early neoplastic lesions. Although surveys report that >95% of gastroenterologists recommend or practice BE surveillance, the extent and patterns of surveillance in clinical practice are unknown. OBJECTIVE To identify the extent and determinants of endoscopic surveillance among BE patients. DESIGN Retrospective cohort study. SETTING A total of 121 Veterans Affairs facilities nationwide. PATIENTS Veteran patients with BE diagnosed from 2003 to 2009, with follow-up through September 30, 2010. INTERVENTION Not an interventional study. MAIN OUTCOME MEASUREMENTS The proportions of patients with BE who received any EGD after the index BE EGD date. In the subgroup of patients with at least 6 years of follow-up, we also calculated proportions for regular (EGD during both 3-year intervals), irregular (EGD in only 1 interval), and no surveillance. We examined differences in demographics and clinical and facility factors among these groups in unadjusted and adjusted analyses. RESULTS We identified 29,504 patients with BE; 97% were men, 83% white, and their mean age was 61.8 years. During a 3.8-year median follow-up period, 45.4% of patients with BE received at least one EGD. Among the subgroup of 4499 patients with BE who had at least 6 years of follow-up, 23.0% had regular surveillance, and 26.7% had irregular surveillance. There was considerable facility-level variation in percentages with surveillance EGD across the 112 facilities and by geographic region of these facilities. Demographic and clinical factors did not explain these variations. Patients with at least one EGD were significantly more likely to be white; to be aged <65 years, with a low level of comorbidity; to have GERD, obesity, dysphagia, or esophageal strictures; to have more outpatient visits; and to be seen in smaller hospitals (<87 beds) than those without any EGD. LIMITATIONS There might be misclassification of BE and surveillance EGD. Lack of pathology data on dysplasia, which dictates surveillance intervals. CONCLUSION Endoscopic surveillance for BE is considerably less commonly practiced in Veterans Affairs facilities than is self-reported by physicians. Although several clinical factors are associated with variations in surveillance, facility-level factors play a large role. The comparative effectiveness of the different practice-based surveillance patterns needs to be examined.

The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus.

OBJECTIVES:The increasing incidence of esophageal adenocarcinoma (EA) in the United States may have leveled off in recent years. The risk of EA among patients with Barrett’s esophagus (BE) seems to be decreasing in several European cohorts, but these estimates are unknown in the United States. We aimed to determine the risk of developing EA in a national cohort of BE patients in the US Veterans Health Administration and to account for the use of endoscopic ablation and esophagectomy.METHODS:This was a retrospective cohort study from a total of 121 facilities in the Veterans Health Administration. Veteran patients with BE diagnosed between 1 October 2003 and 30 September 2009 were included and followed until esophageal cancer diagnosis, death or 30 September 2011. All EA diagnoses were verified in detailed structured reviews of medical records.RESULTS:We identified 29,536 patients with BE who met our eligibility criteria. Most were men (96.9%) and White (83.2%), with a mean age of 61.8 years. During 144,949 person-years of follow-up, 466 patients developed EA, yielding an incidence rate of 3.21 per 1,000 person-years (95% confidence interval (CI) 2.94–3.52). Excluding those who developed EA within 1 year of their index BE date lowered the incidence rate to 1.75 per 1,000 person-years. However, including additional patients who underwent endoscopic ablation or esophagectomy for HGD or EA increased the incidence rate to 4.79 (95% CI 4.44–5.16).CONCLUSIONS:The incidence of EA in a US national cohort of mostly male veterans may be lower than previous estimates. Almost half of the EA cases were diagnosed within 1 year of their BE index date.

Patient-centered, comparative effectiveness of esophageal cancer screening: protocol for a comparative effectiveness research study to inform guidelines for evidence-based approach to screening and surveillance endoscopy

BackgroundThe comparative effectiveness (CE) of endoscopic screening (versus no screening) for Barrett’s esophagus (BE) in patients with GERD symptoms, or among different endoscopic surveillance strategies in patients with BE, for the early detection of esophageal adenocarcinoma (EA) is unknown. Furthermore, it is unclear if patients or providers have or will adopt any of these strategies (screening only, screening and surveillance, vs. none), irrespective of their effectiveness. Endoscopic screening and surveillance is expensive and can be risky. Therefore, it is imperative to establish the CE and acceptability about the risks and outcomes related to these practices to better inform expert recommendations and provider-patient decisions.Methods/ResultsWe propose a mixed methods study which will involve: (1) an analysis of secondary databases (VA and VA-Medicare linked datasets for 2004–09) to examine CE of endoscopic screening and surveillance in an observational study cohort (an estimated 680,000 patients with GERD; 25,000–30,000 with BE; and 3,000 with EA); (2) a structured electronic medical record (EMR) review on a national sample of patients using VA EMRs to verify all EA cases, identify cancer stage, cancer-targeted therapy, and validate the screening and surveillance endoscopy; and (3) qualitative in depth interviews with patients and providers to elicit preferences, norms, and behaviors to explain clinical contexts of these findings and address gaps arising from the CE study.ConclusionThis study will compare clinical strategies for detecting and monitoring BE, a pre-cancerous lesion. Additionally, by eliciting acceptability of these strategies for patients and providers, we will be able to propose effective and feasible strategies that are likely to be implemented in routine use. Findings will inform recommendations for clinical practice guidelines. Our innovative approach is consistent with the methodological standards of patient-centered outcomes research, and our findings will offer a significant contribution to the literature on cancer surveillance.Trial RegistrationNot applicable

Risk of Upper Gastrointestinal Cancers in Patients With Gastroesophageal Reflux Disease After a Negative Screening Endoscopy

BACKGROUND & AIMS Practice guidelines recommend a 1-time screening endoscopy for patients with gastroesophageal reflux disease (GERD) who are at high risk for Barretts esophagus or malignancy. However, little is known about the risk of cancer in patients with negative findings from screening endoscopies. METHODS We conducted a retrospective cohort study using data from 121 Veterans Health Administration facilities nationwide to determine the incidence rate of esophageal adenocarcinoma (EA) separately, as well as any upper gastrointestinal cancers, in patients with an initial negative screening endoscopy (esophagogastroduodenoscopy [EGD]). We included veteran patients with GERD diagnosed between 2004 and 2009 who had a negative screening EGD within 1 year of diagnosis. We estimated the incidence rate of EA, and any upper gastrointestinal cancer, in patients with GERD who had a negative screening EGD. We examined differences in demographic, clinical, and facility factors among patients with and without cancer. RESULTS We identified 68,610 patients with GERD and a negative screening EGD (mean age, 55.5 y; 90% men; 67.5% white). During a mean follow-up period of 3.2 years, 10 patients developed EA and 29 patients developed any upper gastrointestinal malignancies, including EA. The incidence of subsequent EA in this group was 4.6/100,000 patient-years of follow-up evaluation, whereas the incidence of any upper gastrointestinal cancers was 13.2/100,000 patient-years of follow-up evaluation. Patients with a subsequent cancer were significantly older and had higher comorbidity scores than patients without cancer. Other clinical and facility factors did not differ significantly between these 2 groups. CONCLUSIONS The risk of cancer is low, over a mean 3-year period, for patients with GERD who had a negative screening endoscopy. These findings justify recommendations for a 1-time screening endoscopy for patients with GERD.

Clinical and psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy.

BackgroundMany patients with Barrett’s esophagus do not adhere to guideline-recommended endoscopic surveillance. Among patient factors related to cancer prevention behaviors, patients’ stated behavioral intention is a strong predictor of behavior performance. Little is known about the patient factors associated with having a strong behavioral intention to pursue surveillance endoscopy. This study explores the association of clinical and psychosocial variables and behavioral intention to pursue surveillance endoscopy among patients with Barrett’s Esophagus and no or low-grade dysplasia.MethodsPotential subjects were screened using electronic medical records of a regional Veterans Affairs Medical Center and a pathologically confirmed Barrett’s esophagus registry. Eligible participants were recruited by a mailer or phone call and completed a questionnaire to measure six distinct psychosocial factors, their behavioral intention to undergo surveillance endoscopy, and various demographic and clinical variables. Univariate and multivariate linear regression identified the relation of behavioral intention with each of six psychosocial variables.ResultsOne-hundred and one subjects consented and returned surveys. The analytical sample for this study consists of the 94% of surveys with complete responses to the behavior intention items. Three of the six psychosocial domains were statistically significant predictors of intention in both univariate and adjusted univariate analysis (salience/coherence β = 0.59, 95% CI = 0.45-0.76, P <0.01; self-efficacy β = 0.30, 95% CI = 0.10-0.51, P <0.01; and social influence β = 0.20, 95% CI = 0.08-0.33, P <0.01). In a multivariate analysis only salience/coherence (β = 0.65, 95% CI = 0.42-0.88, P <0.01) remained statistically significant predictor of intention.ConclusionThis study established the validity of a scale to measure psychosocial variables associated with behavioral intentions to undergo surveillance endoscopy. Results demonstrate the importance of assessing self-efficacy, social influences, and bottom-line belief in the value of surveillance endoscopy when evaluating a patient’s likelihood of completing surveillance endoscopy.