Usefulness of prioritization systems during the resumption of gastrointestinal endoscopy activity during the COVID-19 pandemic

During the coronavirus disease 2019 (COVID-19) first pandemic wave, gastrointestinal endoscopy activity dropped considerably and was limited to urgent or preferential endoscopy in most countries [1]. After the outbreak, a progressive resumption of health system activity was recommended. We aimed to assess the usefulness of endoscopic prioritization to detect significant lesions (Table 1 s, see online-only Supplementary material) and advanced neoplasia (adenoma ≥ 10 mm, high grade dysplasia, or cancer anywhere).

Table 1 Diagnostic performance of significant lesions and advanced neoplasia using the different criteria.

	NICE-AEG	ESGE	SEED-AEG
Significant lesions
AUC (95 %CI)	0.56 (0.52–0.59)	0.58 (0.55–0.62)	0.63 (0.59–0.66)
Sensitivity, n/N % (95 %CI)	161/247 65.2 % (59.1 %–70.9 %)	150/247 60.7 % (54.5 %–66.6 %)	173/247 70 % (64.1 %–75.4 %)
Specificity, n/N % (95 %CI)	276/594 46.5 % (42.5 %–50.5 %)	333/594 56.1 % (52.0–60.0 %)	327/594 55.1 % (51.0 %–59.0 %)
PPV, n/N % (95 %CI)	161/479 33.6 % (29.5 %–38.0 %)	150/411 36.5 % (32.0 %–41.3 %)	173/440 39.3 % (35.1 %–44.2 %)
NPV, n/N % (95 %CI)	276/362 76.2 % (71.6 %–80.4 %)	333/430 77.4 % (73.3 %–81.2 %)	327/401 81.5 % (77.4 %–85.1 %)
Advanced neoplasia
AUC (95 % CI)	0.62 (0.58–0.66)	0.65 (0.61–0.70)	0.63 (0.59–0.68)
Sensitivity, n/N % (95 %CI)	90/116 77.6 % (69.1 %–84.3 %)	87/116 75 % (66.4 %–82.0 %)	87/116 75 % (66.4 %–82.0 %)
Specificity, n/N % (95 %CI)	336/725 46.3 % (42.7 %–50.0 %)	401/725 55.3 % (51.7 %–58.9 %)	372/725 51.3 % (47.7 %–54.9 %)
PPV, n/N % (95 %CI)	90/479 18.8 % (15.5 %–22.5 %)	87/411 21.2 % (17.5 %–25.4 %)	87/440 19.8 % (16.3 %–23.8 %)
NPV, n/N % (95 %CI)	336/362 92.9 % (89.7 %–95.1 %)	401/430 93.3 % (90.5 %–95.3 %)	372/401 92.8 % (89.8 %–95.0 %)

NICE, National Institute Health and Care Excellence; AEG, Asociación Española de Gastroenterología; ESGE, European Society of Gastrointestinal Endoscopy; SEED, Sociedad Española de Endoscopia Digestiva; AUC, area under the curve; CI, confidence interval; PPV, positive predictive value; NPV, negative predictive value.

Patients who underwent elective endoscopy in a tertiary referral center (Hospital Universitario de Canarias, Spain) between 20 April and 14 June 2020 were included. The chief of the endoscopy unit re-evaluated the endoscopic agenda. He reviewed all the new endoscopy requests and re-evaluated the already scheduled examinations. Priority was prospectively assigned following the National Institute Health and Care Excellence criteria and the Asociación Española de Gastroenterología (NICE-AEG-Semfyc) criteria (Table 2 s) [2]. The indications with high priority were scheduled first, and the remaining slots were completed with non-high priority examinations. The indications were adapted to the European Society of Gastrointestinal Endoscopy (ESGE) (Table 3 s) and the Sociedad Española de Endoscopia Digestiva/AEG (SEED-AEG) (Table 4 s) prioritization criteria [3] [4].

The protocol was approved by the Local Ethics Committee of Hospital Universitario de Canarias (CHUC_2020_50). For the statistical analysis, continuous variables are expressed as means and standard deviations, and categorical variables as frequencies and percentages. Simple logistic regression analysis was carried out as appropriate. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver operating characteristic (ROC) curve (AUC) were calculated for each criterion. The DeLong method was used to compare ROC curves [5].

A total of 1222 outpatients were included in the study (Fig. 1 s). Overall, the percentage of high priority indications was significantly higher following the NICE-AEG-Semfyc criteria (n = 721; 59.0 %) than the ESGE criteria (n = 580; 47.5 %; P < 0.001) or the SEED-AEG criteria (n = 653; 53.4 %; P < 0.001). A total of 841 outpatients had a valid endoscopic examination (Fig. 1 s). Significant lesions were found in 247 diagnostic examinations (29.4 %), advanced neoplasia in 116 (13.8 %), and cancer in 23 (2.7 %).

Regardless of the priority criteria used, the detection rate of significant lesions was significantly higher in high priority examinations than in low priority examinations (Table 5 s). The highest detection rates were for advanced neoplasia and cancer (Table 6 s). We found that the performance of the SEED-AEG criteria for significant lesions was higher than with the NICE-AEG-Semfyc (0.63 vs. 0.56; P < 0.001) and ESGE criteria (0.63 vs. 0.58; P = 0.003) ([Table 1]). The performance of the ESGE criteria was higher than those of the NICE-AEG-Semfyc (0.58 vs. 0.56; P = 0.03). Regarding advanced neoplasia, the performance of the ESGE criteria was higher than with the NICE-AEG criteria (0.65 vs. 0.62; P = 0.001) ([Table 1]). Other comparisons did not show any statistically significant differences. The NPV for significant lesions ranged from 76.2 % to 81.5 % (false negatives of 18.5 %–23.8 %) and from 92.8 % to 93.3 % for advanced neoplasia. The PPV ranged from 34 % to 39 % for significant lesions (false positives of 61 %–66 %) and from 19 % to 21 % for advanced neoplasia.

In conclusion, the current criteria do not optimally stratify the examinations owing to the high rate of missed significant lesions and high number of unnecessary examinations.

Funding

Instituto de Salud Carlos III
Fondo Europeo de Desarrollo Regional (FEDER) http://dx.doi.org/10.13039/501100004587

Publication History

Article published online:
26 April 2021

• References

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