Introduction
Barrett’s esophagus (BE) is a metaplastic condition in which the esophageal squamous
epithelium is replaced by specialized intestinal-like columnar lining [1]
[2]. BE is strongly associated with gastroesophageal reflux disease (GERD) and is a
precursor for the development of esophageal adenocarcinoma (EAC), with an estimated
risk of EAC up to 10-fold higher when compared to the general population [3]
[4]
[5]. While surveillance in BE remains an ongoing topic of debate, recent data suggest
that surveillance endoscopy is associated with improved outcomes of EAC in patients
with BE [6]. Hence, most gastrointestinal societies recommend some form of regular surveillance
in the evaluation and management of BE [7]
[8]
[9]
[10].
The introduction of a standardized classification system (Prague C & M Criteria) and
systematic (four-quadrant) biopsies has improved surveillance. Furthermore, the use
of systematic biopsies has been shown to enhance detection of early neoplastic changes
in patients with BE [11]
[12]. Adherence to these standardized practices and societal recommendations on surveillance
intervals are likely to ensure high-quality patient care and limit unnecessary health-related
expenditures. Nonetheless, prior studies have shown significant variability in clinical
practice in the management of BE among US gastroenterologists [13]
[14]
[15]. The inherent limitations of these survey-based studies include response and reporting
bias that may not accurately reflect actual practice patterns. The aims of this study
were to review real life practice patterns and (1) to evaluate adherence to the standardized
classification (Prague Criteria) and systematic biopsies, (2) to identify predictors
of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic
BE (NDBE).
Materials and methods
Study design and patients
This study was approved with a waiver of informed consent by the institutional review
board (IRB) of the University of Florida. The prospectively maintained electronic
procedure report-generating endoscopic database (ProVation MD; ProVation Medical,
Minneapolis, MN, USA) at the University of Florida (UF Health) was retrospectively
reviewed to search for patients who had undergone evaluation for BE between January
2008 and December 2015. All cases recorded following the release of the 2015 American
College of Gastroenterology (ACG) clinical guideline on the diagnosis and management
of BE were excluded from the analysis [8]. In order to identify all potential BE cases, we searched all upper esophagogastroduodenoscopy
(EGD) using the following terms: “Barrett’s esophagus”, “salmon colored mucosa”, “suspicious
for Barrett’s” within the ProVation software during the study period. Patients were
included if there were endoscopic findings of Barrett’s mucosa (i. e. report describing
“Barrett’s esophagus”, appearance “suspicious for Barrett’s esophagus” and/or “salmon
colored mucosa”) on the procedural report. The electronic medical chart was then reviewed
for each retrieved case to identify the total number of unique patients and confirm
the histopathological diagnosis of BE.
Data collection
Procedural parameters were obtained from the endoscopy operative report in the ProVation
database and/or from the patient’s electronic chart record. These included: esophagogastric
landmarks (i. e. squamocolumnar junction, gastroesophageal junction), the extent of
BE (i. e. Prague Criteria, length of BE, number of tongues and/or islands, visible
lesions), and if and how biopsies (i. e. cold biopsy forceps, endoscopic mucosal resection)
were performed. Patient demographics and histopathology results were retrieved from
the electronic chart review. Demographic data included age, sex, body mass index (BMI),
smoking history, GERD, use of proton-pump inhibitor (PPI) medications, and histopathology
of specimen(s) obtained during the EGD. A dedicated panel of gastroenterology pathologists
evaluated all specimens and the histopathology was classified according to the revised
Vienna classification [16]. Time interval between successive procedures was obtained by reviewing the operative
dates on each EGD report.
Definitions and outcome measures
Adherence to standardized BE classification was based on the use of the Prague Criteria
to describe the extent of BE in the procedural report. Adherence to a standardized
biopsy protocol for BE was determined by the documentation of systematic four-quadrant
biopsies (performed either at every 1 cm or 2 cm interval) on endoscopy (EGD) and
by reviewing the pathology report to confirm that biopsies had been obtained and labeled
as separate specimens every 1 cm or 2 cm along the length of the BE segment.
The index EGD was defined as the first endoscopy procedure performed for a given patient
in which endoscopic findings of BE were documented. Index EGDs were defined as being
performed in an academic (UF Health) or community (all procedures performed at non-academic
community centers) setting. The EGDs following the index EGD, performed in patients
with NDBE, were labeled as confirmatory EGD (1st EGD following index EGD) or surveillance
EGD (EGD following confirmatory EGD), respectively. Since the published societal guidelines
during the study period permitted a confirmatory EGD to establish BE diagnosis, the
time period between the index EGD and the confirmatory EGD was not used to assess
the adherence to suggested surveillance recommendations. An appropriate surveillance
interval for patients with NDBE was defined as a surveillance EGD performed within
6 months (either prior to or after) of the 3- to 5-year window following the confirmatory
EGD. This was based on the available 2008 – 2012 ACG, American Gastroenterology Association
(AGA) and American Society of Gastrointestinal Endoscopy (ASGE) guidelines corresponding
to our study period [7]
[10]
[17].
Different variables (patient, procedural, and endoscopists’ characteristics) were
evaluated to identify predictors of practice patterns (use of Prague Criteria; use
of a standardized biopsy protocol). Practitioners were identified as BE therapeutic
endoscopists if they performed esophageal endoscopic mucosal resection (EMR) and/or
ablative techniques (i. e. radiofrequency ablation, cryoablation) for the management
of BE. Time in practice was measured by years of experience as board-certified gastroenterologists
(from the time of completion of a 3-year gastroenterology fellowship to the beginning
of the study period in 2011). An endoscopist was considered junior faculty if they
had < 5 years of experience before the beginning of the study period (2011).
Patient follow-up
All patients were followed from the date of the index EGD to the date of the last
EGD available in our electronic medical record through 31 December 2015.
Statistical analysis
Descriptive statistics for continuous variables were summarized using means and standard
deviations whereas categorical variables were summarized using proportions. Two-sample
Student’s t test was used to test the difference in means between two continuous variables whereas
Pearson’s Chi-squared test of independence was used to test for associations between
two categorical variables. The difference in proportions was assessed using z test large-sample statistics. Univariate logistic regression was used to estimate
unadjusted associations of main predictors of interest with the response variables.
Multiple (multivariable) logistic regression models were fitted to model the associations
of the responses with the predictors while adjusting for demographic factors and other
covariates in the model. The level of significance was set at 5 % throughout the analysis.
Stata Statistical Software: Release 14 was used for analysis (StataCorp LLC, College
Station, TX, USA).
Results
Study population
A total of 727 patients treated between June 2008 and December 2015 were identified
on our initial search in the ProVation endoscopy database. Three-hundred and thirty
patients were excluded from the analysis as their index EGD was not available. Of
the remaining 397 subjects, 311 had their index EGD at UF Health (academic setting)
whereas 86 had their index EGD performed in the community setting before their referral
into our system.
Endoscopist characteristics
Data on endoscopists’ characteristics were available for procedures performed at the
University of Florida during the study period. In all, 41 individual endoscopists
were identified based on operative reports. Eight (20 %) of them were BE therapeutic
endoscopists. Overall, the mean years in practice was 8 ± 7 years (range; 1 to 25 years).
This was not significantly different between endoscopists who treated BE (mean 8.6 ± 7 years,
range; 1 to 22 years) and those who did not (mean 7.7 ± 7.1 years, range; 1 to 25 years)
(P = 0.73). Fifteen (37 %) of the endoscopists had ≥ 10 years in practice whereas 20
(49 %) were identified as junior faculty (< 5 years of experience).
Baseline characteristics
The baseline characteristics of patients who underwent index EGD are summarized in
[Table 1]. Patients with index EGD performed in the community were predominantly male (86 %
vs. 61.4 %; P < 0.001) and older (mean age 64 ± 10.7 years vs. mean age 58.8 ± 12.9; P < 0.001) when compared to their counterparts who had their index EGD at an academic
center. There were no statistically significant differences in smoking history or
GERD symptoms between the two groups. Long-segment BE (40.7 % vs. 27.3 %; P = 0.04) and use of a proton-pump inhibitor (72.1 % vs. 64.3 %; P < 0.001) were also more commonly reported in patients with index EGD performed in
the community setting.
Table 1
Baseline characteristics of all patients (n = 397) who underwent index EGD during
the study period and subdivided into academic (n = 311) and community (n = 86) setting.
|
Characteristics
|
Overall (n = 397)
|
Academic setting (n = 311)
|
Community setting (n = 86)
|
P value[1]
|
|
Age, mean ± SD, years
|
60.1 ± 12.5
|
58.8 ± 12.9
|
64 ± 10.7
|
0.0007
|
|
Male gender, n (%)
|
264 (66.5)
|
193 (61.4)
|
74 (86.0)
|
0.0001
|
|
BMI, mean ± SD
|
28.5 ± 5.7
|
28.5 ± 5.9
|
28.5 ± 4.3
|
0.68
|
|
Smoking history
|
|
|
|
0.87
|
|
|
65 (16.4)
|
52 (16.7)
|
13 (15.1)
|
|
|
|
177 (44.6)
|
129 (41.5)
|
48 (55.8)
|
|
|
|
136 (34.2)
|
114 (36.7)
|
22 (25.6)
|
|
|
|
19 (4.8)
|
16 (5.1)
|
3 (3.5)
|
|
|
History of GERD at time of index EGD
|
|
|
|
0.27
|
|
|
324 (81.6)
|
250 (80.4)
|
74 (86.0)
|
|
|
|
73 (18.4)
|
61 (19.6)
|
12 (14.0)
|
|
|
History of PPI use at time of index EGD
|
|
|
|
0.0001
|
|
|
262 (66.0)
|
200 (64.3)
|
62 (72.1)
|
|
|
|
33 (8.3)
|
25 (8.0)
|
8 (9.3)
|
|
|
Classification of BE
|
|
|
|
0.036
|
|
|
175 (44.1)
|
146 (47.0)
|
29 (33.7)
|
|
|
|
120 (30.2)
|
85 (27.3)
|
35 (40.7)
|
|
|
|
102 (25.7)
|
80 (25.7)
|
22 (25.6)
|
|
GERD = gastroesophageal reflux; EGD = esophagogastroduodenoscopy; BMI = body mass
index; PPI = proton-pump inhibitor; BE = Barrett’s esophagus. Short-segment BE was
defined as < 3 cm of BE mucosa.
1
P value of comparisons of variables between the two cohorts (academic vs. community
setting).
Biopsies were performed in 273 (87.8 %) and 80 (93 %) patients during their index
EGD in the
academic and community setting, respectively (P = 0.24). Histopathological results from
these biopsies are shown in [Table 2]. In aggregate, dysplastic BE (low grade and/or high grade) and EAC were more commonly
encountered on index EGD in the community setting.
Table 2
Histopathology results of biopsies obtained from all patients who underwent index
EGD.
|
Histopathology
|
Academic setting (n = 273)
|
Community setting (n = 80)
|
P value
|
|
Non-dysplastic BE, n
|
146
|
14
|
< 0.001
|
|
Indefinite for dysplasia, n
|
8
|
8
|
0.01
|
|
Low grade dysplasia, n
|
21
|
21
|
< 0.001
|
|
High grade dysplasia, n
|
33
|
36
|
< 0.001
|
|
EAC, n
|
13
|
12
|
0.002
|
|
Other[1], n
|
62
|
6
|
0.003
|
EAC, esophageal adenocarcinoma.
1 Other = normal squamous epithelium, esophagitis.
Adherence to Prague Criteria for BE classification and the use of systematic four-quadrant
biopsies
In aggregate, the Prague classification system for the endoscopic characterization
of BE was only
used in 27.5 % (109/397) of the procedures. Prague Criteria were more often utilized
by
endoscopists in the academic (32.4 %) vs. the community (9.3 %) setting (odds ratio
4.81; 95 %
confidence interval: 2.34 – 10.33, P < 0.001). Systematic four-quadrant biopsies were
performed in less than a quarter of cases when biopsies were obtained and this did
not vary
based on practice setting ([Table 3]).
Table 3
Adherence to the use of Prague Criteria for BE classification and systematic four-quadrant
biopsies during index EGD.
|
Overall
|
Academic setting
|
Community setting
|
OR (95 %CI)[1]
|
P value[1]
|
|
Adherence to Prague Criteria, n (%)
|
109/397 (27.5)
|
101/311 (32.4)
|
8/86 (9.3)
|
4.81 (2.34 – 10.33)
|
< 0.001
|
|
Adherence to systematic biopsies, n (%)
|
85/353 (24.1)
|
68 (24.9)
|
17 (21.2)
|
1.14 (0.63 – 2.06)
|
0.77
|
OR = odds ratio; CI = confidence interval.
1 OR and P value of comparison between the two cohorts (academic vs. community).
Predictors for practice patterns
Univariate and multiple logistic regression analyses were performed to identify independent
factors associated with adherence to the use of Prague Criteria and systematic biopsies
during index EGD performed at an academic setting. The variables included were: age,
gender, BMI, GERD symptoms (yes vs. no), PPI use (yes vs. no), cigarette smoking (yes
vs. no), length of BE (short vs. long), background in BE therapeutics (yes vs. no),
trainee involvement (yes vs. no), and endoscopist’s time in practice (years).
Patient characteristics, including older age, male gender, length of BE, GERD symptoms,
cigarette smoking, and PPI use, did not have an impact on the adherence to Prague
Criteria or the use of systematic biopsies during index EGD for BE on multivariable
analysis ([Table 4] and [Table 5]). Trainee involvement during the procedures also did not affect practice patterns.
With each year of additional experience, endoscopists were more likely to use the
Prague Criteria (OR 1.07; 95 %CI:1.02 – 1.12; P < 0.01) and less likely to perform systematic four-quadrant biopsies (OR: 0.91; 95 %CI:
0.85 – 0.97; P = 0.001). Endoscopists who performed endoscopic therapy for BE and those having at
least 10 years of experience were more likely to adhere to the use of the Prague Criteria.
Conversely, time in practice was inversely associated with the likelihood of performing
systematic biopsies for BE ([Table 4] and [Table 5]).
A multivariable analysis was performed to evaluate the impact of practice setting
(academic vs. community) for adherence to the use of the Prague Criteria or systematic
biopsies in our entire cohort. Overall, endoscopists in the academic setting were
more likely to use the Prague Criteria than their community counterparts (OR 6.9,
95 %CI: 2.87 – 16.7; P < 0.01), yet, there was no statistically significant difference in the likelihood
of performing systematic biopsies between the two groups (OR 0.80, 95 %CI: 0.39 – 1.74;
P = 0.58).
Surveillance intervals for non-dysplastic BE
Of the 311 patients with an index EGD at UF Health, 146 patients were diagnosed with
NDBE ([Fig. 1]). A total of 38 patients did not undergo repeat EGD whereas 78 patients (53.4 %)
had a confirmatory EGD and a subsequent surveillance EGD at a median of 20.5 months
(range: 3 – 85 months). Thirty-two of 78 patients (41 %) had either remission of BE
(n = 21) or dysplastic progression based on histopathology (n = 11). Fourteen patients
were lost to follow-up. Of the remaining 28 patients with NDBE, surveillance EGD was
performed at a median of 27 months (range: 10 – 62 months) with most of these (15/28;
53.6 %; [Fig. 1]) being performed prior to the recommended interval of 3 to 5 years (range 1 – 29 months).
Fig. 1 Flow diagram of surveillance intervals in patients with NDBE.
Discussion
The implementation and adherence to quality indicators and surveillance guidelines
in the evaluation and management of BE is of utmost importance to ensure high-quality
and cost-effective care for patients. Nonetheless, previous studies have shown significant
variability in the treatment of BE in clinical practice [13]
[14]
[15]. In this single-center retrospective study, adherence to the use of both a standardized
BE classification system (Prague Criteria) and systematic four-quadrant biopsies (Seattle
protocol) during endoscopic examination of BE was low. These practice patterns were
affected by the level of experience of practitioners and whether they performed endoscopic
therapy for BE. Furthermore, this study suggests that many patients with NDBE still
undergo surveillance endoscopy at more frequent time intervals than what is recommended
by published gastroenterology societal guidelines.
Accurate measurement and description of the extent of BE are clinically relevant given
its implications on management strategies and the risk of developing EAC [18]
[19]. Measurement of BE using the Prague Criteria, which account for both circumferential
and maximal length of the segment, has been shown to have a high inter-observer agreement
among endoscopists [11] and has been advocated by experts as the preferred classification system for BE
[20]. Even though the Prague Criteria have been studied and validated in multiple settings
and their use endorsed by societal guidelines [7]
[8]
[9]
[17]
[21], these criteria were only used in 27.4 % of all index EGDs in this study. The adherence
to the Prague Criteria for measuring the extent of BE was significantly lower in community-based
practitioners when compared to the academic setting (9.3 % vs. 32.4 %; P < 0.001). The available data from survey-based studies on the use of the Prague Criteria
has varied widely, with rates ranging from 19 % to 67 % [14]
[15]
[21]. Potential shortcomings of those studies include both recall and reporting bias.
Hence, our study may potentially provide a more accurate estimate of the actual adherence
rate to the use of Prague Criteria for BE in clinical practice.
The use of a systematic biopsy protocol (four-quadrant biopsies every 1 or 2 cm) remains
an important component in the detection of intestinal metaplasia and/or dysplasia,
and is advocated as a quality indicator in the management of BE [20]. When compared to non-systematic surveillance biopsies, a systematic four-quadrant
biopsy approach has been associated with an almost 13-fold increase in the detection
of dysplasia [12]. Yet, adherence to biopsy guidelines for BE surveillance is low and has been estimated
to range between 30 % and 50 % [22]
[23]. In our study, overall adherence to a systematic biopsy protocol was 24.1 % and
this did not vary significantly based on practice setting (academic vs. community
setting). Surveillance systematic biopsies may be perceived as time-consuming and
labor intensive, which can be potential deterrents for adherence. Having said this,
it is important to highlight that systematic biopsies are not devoid of sampling error
and alternative/adjunct methods to improve detection of dysplasia are actively being
studied [22]
[24]
[25].
Our study identified the number of years the endoscopists had spent in practice and
whether they performed endoscopic BE therapy as predictors of practice patterns. On
logistic regression analysis, endoscopists who treated BE (i. e. EMR and/or ablation)
were found to be more likely to use the Prague Criteria when compared to those who
did not perform therapeutic interventions for BE (OR 3.16, 95 %CI: 1.47 – 6.82; P < 0.01). Similarly, increasing time in practice was positively associated with the
use of Prague Criteria. Endoscopists with at least 10 years in practice were approximately
threefold more likely to use the Prague Criteria when compared to gastroenterologists
in their first year of practice. We speculate that endoscopists with increasing experience
and those who treat BE may be more aware of the Prague Criteria and the importance
of recording landmarks during BE evaluation for prognostic and therapeutic reasons.
Conversely, our study demonstrated that a longer time in practice was inversely associated
with the use of a systematic four-quadrant biopsy protocol.
These findings are congruent with those reported by Falk et al. who showed that gastroenterologists
in practice for less than 10 years obtained biopsies at 1 cm intervals more frequently
than those in practice for more than 10 years (36 % vs. 25 %; P = 0.03) [13]. The reason for this discrepancy remains uncertain. With the ongoing emphasis on
restraining costs in healthcare delivery and improvement in diagnostic performance,
several non-invasive imaging techniques for BE are being evaluated as adjuncts or
alternatives to tissue sampling [26]. Whether the reduction in the use of systematic biopsies based on time in practice
reflects the evolving landscape in BE and perhaps the incorporation of advanced endoscopic
imaging and targeted biopsies remains to be determined.
Surveillance endoscopy in BE patients has not conclusively been shown to provide a
survival advantage in patients with BE but there is evidence supporting its association
with improved outcomes for EAC [6]. Hence, current societal guidelines recommend performing surveillance endoscopy
in patients with NDBE every 3 – 5 years [7]
[8]. In our study, more than half of the patients (55.6 %) underwent surveillance within
29 months from their confirmatory EGD, instead of the guideline recommended interval.
Given the low risk of progression to EAC in patients with NDBE [1]
[2]
[27], surveillance at an interval shorter than 3 – 5 years is not a cost-effective approach
[28]. The costs associated with more frequent procedures should not be overlooked, especially
considering the ever-changing legislative measures underscoring the need to reduce
healthcare associated expenditures. Current research focusing on identifying potential
factors associated with a higher risk for progression in patients with NDBE and non-invasive
surveillance methods may assist in the effort of limiting unnecessary frequent endoscopies
[29]
[30]
[31].
This study has several strengths. Unlike prior studies that have used surveys to assess
patterns of practice in the management of BE, our study reviewed all endoscopic reports
within the study period (2011 – 2015) to estimate adherence rates to the use of Prague
Criteria and systematic biopsies for BE. Hence, our results may be more reflective
of actual clinical practice patterns as survey-based responses can be limited by recall
bias and be skewed toward adherence to guidelines. Furthermore, in addition to evaluating
adherence to suggested quality indicators for BE, we also performed a logistic regression
analysis which helped us identify predictors of practice patterns, specifically operator
characteristics.
We also acknowledge the limitations of this study. This is a single tertiary-care
academic experience and may not apply to other healthcare settings. The relatively
small number of patients, particularly in the community cohort, may have precluded
the detection of other meaningful differences in outcomes. Given the observational
and retrospective nature of this study, unobserved confounding factors may have influenced
our outcome measures. These may have included important variables, such as the use
of chromoendoscopy and the duration of the examination during BE evaluation. Furthermore,
the baseline characteristics of the two cohorts (patients with index EGD at an academic
vs. community setting) were different. Patients who had index EGD in the community
setting were older, predominantly male, had a higher proportion with long-segment
BE and more advanced histopathology when compared to patients with an index EGD at
the academic center. These differences were somewhat expected as the community-based
cohort likely represented the more complicated patients who required referral to our
system for further management. Hence, it comes as no surprise that the proportion
of patients with non-dysplastic BE from the community was artificially low; as most
of these uncomplicated patients were likely followed in the community and not referred
to our center and thereby included in the study. Therefore, direct comparisons in
outcomes between the two cohorts (academic vs. community-based) are limited and should
be interpreted with caution. Lastly, factors that could have influenced surveillance
intervals, including patients’ willingness and availability, endoscopy unit scheduling
and the role of the referring physician, were not accounted for in the analysis.
In summary, adherence to quality indicators (use of Prague Criteria and systematic
biopsies) for the management of BE is low in clinical practice. Endoscopists who perform
therapeutic BE interventions are more likely to use the Prague Criteria. Likewise,
longer time in practice (years of experience) was positively associated with adherence
to Prague Criteria but a lower likelihood of performing systematic biopsies in the
evaluation of BE. A significant proportion of patients with NDBE still undergo surveillance
sooner than the guideline recommended intervals. Future efforts are needed to promote
adherence to quality indicators and published surveillance guidelines in order to
reduce variability in practice and thereby promote high-quality, cost-effective care.
Table 4
Factors associated with adherence to the use of Prague Criteria for BE evaluation.
|
Clinical variable
|
Prague Criteria
|
|
Univariate analysis
|
Multivariable analysis
|
|
OR (95 %CI)
|
P value
|
OR (95 %CI)
|
P value
|
|
Age
|
1.02 (0.99 – 1.04)
|
0.06
|
1.00 (0.98 – 1.04)
|
0.53
|
|
BMI
|
1.00 (0.95 – 1.04)
|
0.84
|
0.98 (0.93 – 1.04)
|
0.60
|
|
Sex (male)
|
2.34 (1.38 – 3.94)
|
0.001
|
2.07 (0.99 – 4.31)
|
0.05
|
|
GERD
|
1.31 (0.71 – 2.43)
|
0.40
|
0.64 (0.17 – 2.40)
|
0.51
|
|
PPI use
|
1.48 (0.90 – 2.47)
|
0.13
|
1.29 (0.49 – 3.39)
|
0.61
|
|
Smoking history
|
|
|
1.53 (0.77 – 3.00)
|
0.22
|
2.16 (0.81 – 5.80)
|
0.17
|
|
|
0.97 (0.57 – 1.70)
|
0.91
|
0.82 (0.37 – 1.81)
|
0.62
|
|
Short segment BE
|
1.28 (1.09 – 2.84)
|
0.02
|
|
|
Long segment BE
|
0.78 (0.44 – 1.37)
|
0.40
|
0.61 (0.27 – 1.34)
|
0.22
|
|
1 experience year[1]
|
1.06 (1.02 – 1.11)
|
0.001
|
1.07 (1.02 – 1.12)
|
< 0.01
|
|
BE therapeutics[2]
|
3.82 (2.31 – 6.33)
|
< 0.001
|
3.16 (1.47 – 6.82)
|
< 0.01
|
|
Attending only[3]
|
0.70 (0.43 – 1.14)
|
0.157
|
0.77 (0.36 – 1.64)
|
0.50
|
|
Total years[4]
|
|
|
0.94 (0.47 – 1.88)
|
0.866
|
0.93 (0.44 – 1.95)
|
0.85
|
|
|
2.16 (1.09 – 4.26)
|
0.03
|
3.25 (1.52 – 6.96)
|
0.002
|
|
|
2.54 (1.22 – 5.31)
|
0.01
|
2.84 (1.27 – 6.36)
|
0.01
|
1 Odds of adherence to Prague Criteria or systematic biopsies with each additional
year of clinical experience.
2 Endoscopists trained in the endoscopic therapy of BE (i. e. endoscopic mucosal resection
and/or ablative techniques).
3 Procedures done without trainee (gastroenterology fellow) participation.
4 Categorical years set against 0.0 – 4.9 years as a reference frame.
Table 5
Factors associated with adherence to the use of systematic four-quadrant biopsies
for BE evaluation.
|
Clinical variable
|
Systematic biopsies
|
|
Univariate analysis
|
Multivariable analysis
|
|
OR (95 %CI)
|
P value
|
OR (95 %CI)
|
P value
|
|
Age
|
1.02 (0.99 – 1.05)
|
0.06
|
1.01 (0.97 – 1.05)
|
0.42
|
|
BMI
|
0.96 (0.90 – 1.03)
|
0.23
|
0.96 (0.89 – 1.05)
|
0.40
|
|
Sex (male)
|
1.32 (0.73 – 2.40)
|
0.35
|
1.18 (0.46 – 3.01)
|
0.73
|
|
GERD
|
1.74 (0.78 – 3.89)
|
0.18
|
1.75 (0.34 – 8.96)
|
0.50
|
|
PPI use
|
1.25 (0.68 – 2.28)
|
0.72
|
0.45 (0.15 – 1.33)
|
0.15
|
|
Smoking history
|
|
|
1.98 (0.86 – 4.60)
|
0.11
|
1.59 (0.45 – 5.65)
|
0.47
|
|
|
1.91 (0.97 – 3.8)
|
0.06
|
1.29 (0.46 – 3.63)
|
0.63
|
|
Short segment BE
|
0.22 (0.18 – 0.82)
|
0.01
|
|
|
|
Long segment BE
|
4.54 (2.37 – 8.7)
|
0.001
|
2.36 (0.96 – 5.88)
|
0.06
|
|
1 experience year[1]
|
0.91 (0.87 – 0.94)
|
0.001
|
0.91 (0.85 – 0.97)
|
0.001
|
|
BE therapeutics[2]
|
1.40 (0.78 – 2.50)
|
0.26
|
1.11 (0.43 – 2.88)
|
0.83
|
|
Attending only[3]
|
1.40 (0.77 – 2.56)
|
0.27
|
1.41 (0.54 – 3.63)
|
0.48
|
|
Total years[4]
|
|
|
0.93 (0.47 – 1.84)
|
0.84
|
0.74 (0.33 – 1.66)
|
0.47
|
|
|
0.32 (0.13 – 0.77)
|
0.01
|
0.35 (0.13 – 0.95)
|
0.04
|
|
|
0.28 (0.10 – 0.80)
|
0.02
|
0.29 (0.10 – 0.91)
|
0.03
|
1 Odds of adherence to Prague Criteria or systematic biopsies with each additional
year of clinical experience.
2 Endoscopists trained in the endoscopic therapy of BE (i. e. endoscopic mucosal resection
and/or ablative techniques).
3 Procedures done without trainee (gastroenterology fellow) participation.
4 Categorical years set against 0.0 – 4.9 years as a reference frame.
