The quality of care in Barrett's esophagus: endoscopist and pathologist practices.

BACKGROUND: The diagnosis of Barrett's esophagus (BE) has important psychological and economic implications. Although accepted standards for endoscopic biopsy methods and pathological interpretation for BE exist, adherence to these standards as a measure of the quality of care in BE has not been evaluated. Our aim was to assess the quality of care in BE by evaluating the process of care and adherence to accepted standards of practice. METHODS: Explicit process-of-care criteria were developed using a systematic literature review and expert opinion in four domains of care: the quality of biopsy methods, the adequacy in identifying endoscopic landmarks, endoscopist-pathologist communication, and pathological interpretation and reporting. We reviewed all endoscopy and pathology reports of BE patients at two institutions from 1994-1997. An academic medical center (N = 237) with staff endoscopists and an academically affiliated community hospital (N = 100) with private-practice endoscopists were analyzed. RESULTS: Physicians showed the highest adherence to accepted standards of care in the "adequacy of identifying landmarks" and "endoscopist-pathologist communication" domains, with a > or =70% adherence rate in most criteria. Conversely, physicians demonstrated the poorest adherence with the "quality of biopsy methods" and "pathologist interpretation and reporting" domains, with adherence rates frequently <60%. Significantly, biopsies were taken in the presence of visible esophagitis 35% of the time. Performance on several of the quality indicators varied significantly by the practice setting. CONCLUSIONS: We have identified several opportunities for quality improvement efforts. In every domain, there is room for improvement, particularly in the quality of biopsy methods. As initiatives to screen the large population of gastroesophageal reflux disease patients for BE may be imminent, the time is now to define the critical process-of-care measures to minimize the risk of overdiagnosis and inadequate endoscopic surveillance.

Is there publication bias in the reporting of cancer risk in Barrett's esophagus?

BACKGROUND & AIMS: The published risk of adenocarcinoma in the setting of Barrett's esophagus (BE) varies. Publication bias, the selective reporting of studies featuring positive or extreme results, may result in overestimation of this cancer risk in the literature. The aim of this study was to assess those publications reporting a cancer risk in BE for evidence of publication bias. METHODS: A MEDLINE search for all published estimates between 1966 and 1998 of cancer risk in BE was performed. All studies reporting a cancer risk expressible in cancers per patient-year of follow-up were retrieved. Bibliographies of these studies were surveyed for additional estimates. All publications that required an initial endoscopy with histologic confirmation of BE and any cancer were included. The relationship of reported cancer risk to size of the study was assessed. Multivariable regression controlling for differences in definition of BE, as well as other study characteristics, was performed. The data were also analyzed by means of a funnel diagram, an epidemiologic method to assess publication bias. RESULTS: Five hundred fifty-four abstracts were reviewed. Twenty-seven publications met the stated criteria for inclusion. There was a strong correlation between cancer risk and the size of the study, with small studies reporting much higher risks of cancer than larger studies. This association persisted when differences in the definition of BE, retrospective vs. prospective nature of the study, surveillance interval, and the effect of cancer detected in the first year were considered. The funnel diagram analysis suggested publication bias. CONCLUSIONS: The cancer risk in BE may be overestimated in the literature due to publication bias.

Hyoscyamine as a pharmacological adjunct in colonoscopy: a randomized, double blinded, placebo-controlled trial.

OBJECTIVE: Investigators have assessed the utility of antispasmodic agents in colonoscopy, with conflicting results. The aim of this study is to determine the effects of premedication with hyoscyamine, an anticholinergic antispasmodic, on outcomes in colonoscopy. METHODS: A total of 165 patients undergoing elective colonoscopy were randomized in a double blinded fashion to one of three arms: intravenous hyoscyamine (0.25 mg), oral hyoscyamine (0.25 mg), or placebo, administered 20-40 min before colonoscopy. Primary outcome measures included insertion time to cecum, patient's assessment of pain, and physician assessment of spasm. Secondary outcome measures included amount of analgesic medications used, total procedure time, amount and type of pathology visualized, and physician assessment of patient's pain. RESULTS: Bivariate analysis showed no difference between the three groups in insertion time (13.8 min, 14.8 min, and 13.8 min for placebo, intravenous hyoscyamine, and oral hyocyamine, respectively), analgesic medication necessary, or any other primary or secondary outcome variable. Multivariate analysis controlling for potential confounders also failed to demonstrate any differences between the groups. Women had higher procedure duration and analgesic requirement, and reported more pain than did men. CONCLUSIONS: This randomized, double blinded, placebo-controlled trial did not demonstrate efficacy of either intravenous or oral hyoscyamine as a premedication for colonoscopy.

A preliminary study of patients' concerns related to GI endoscopy.

OBJECTIVES: In addition to the well known complications of bleeding and perforation, GI endoscopy also can produce discomfort, anxiety, and dissatisfaction. In this pilot study, our objective was to obtain information on the fears and concerns of patients about to undergo endoscopy and to assess the relationship of such worries to patient satisfaction and difficulty with the procedure. METHODS: At our two referral hospitals, 793 unsedated patients (45% men, 55% women, average 58 yr) were interviewed by GI nurses before the intended procedure. Information on procedure-related concerns and difficulty/satisfaction with the procedure was obtained. RESULTS: Sixty percent of our sample reported preprocedure concerns, most often: 1) finding out what is wrong (18%); 2) pain (12%); and 3) finding cancer (4%). New York patients were more concerned than North Carolina patients with finding out what was wrong (23 vs 12%) although patients at both sites were equally concerned about having pain during the procedure (12%); women (16%), younger patients (16%), and those about to have their first procedure (17%) reported more concerns about pain. Regression analysis indicated that women and persons having no or fewer procedures were more likely to report a concern. Having had previous endoscopic procedures predicted greater satisfaction with subsequent endoscopies. Finally, a high level of preprocedure concerns was associated with perceived difficulties related to the procedure. CONCLUSIONS: We believe that, by considering patient demographics, asking about previous experiences with endoscopy, and eliciting special concerns, the nurse or physician can focus patient education in a fashion that may reduce anticipatory anxiety.

Pathophysiology and diagnosis of gastroesophageal reflux disease.

The pathophysiology and diagnosis of gastroesophageal reflux disease (GERD) are discussed. GERD is a clinical syndrome involving the reflux of gastric contents into the esophagus. It is distinguished from the reflux that occurs normally in the general population. A low pressure exerted by the lower esophageal sphincter (LES) and inappropriate spontaneous relaxation of the LES may contribute to the development of GERD. Other possible contributory factors are increased intra-abdominal pressure and impaired esophageal clearance. The amount and concentration of refluxed gastric acid, proteolytic enzymes, and bile acids are among the determinants of the extent of esophageal injury. Heartburn is a specific symptom of GERD. Other symptoms include coughing, wheezing, hoarseness, epigastric pain, and regurgitation. Upper-GI roentgenography, endoscopy, biopsy, 24-hour ambulatory pH monitoring, and esophageal manometry have been used to diagnose and evaluate the disease. The complications of GERD are strictures, hemorrhaging, perforation, aspiration, and Barrett esophagus. The causes of GERD are incompletely understood, but low LES pressure seems important. GERD may lead to serious complications. A broad array of diagnostic approaches is available.