Consensus on Upper Gastrointestinal Endoscopy Key Performance Indicators to Reduce Post Endoscopy Upper Gastrointestinal Cancer

Background: Upper gastrointestinal (UGI) endoscopy lacks established key performance indicators. Up to three‐fold variation in post endoscopy upper gastrointestinal cancer rates has been observed among endoscopy providers in England, highlighting the need for standardisation of UGI endoscopy practices. Objective: We aimed to achieve consensus on evidence‐based key performance indicators to reduce post endoscopy upper gastrointestinal cancer. Methods: Modified nominal group technique was employed in two consensus workshops, with representation from clinicians, patients and relatives, moderated by James Lind Alliance facilitators. Potential indicators were identified from the umbrella systematic review, English provider post endoscopy upper gastrointestinal cancer rates, and differences in endoscopy practices from the National Endoscopy Database between providers with the highest (worst) and lowest (best) post endoscopy upper gastrointestinal cancer rates. KPIs were categorised as provider or endoscopist/procedure related and ranked as of major or minor importance. Minimum standards were proposed where possible. Results: Participants included 14 clinicians (gastroenterologists and UGI surgeons), 3 nurse endoscopists, 2 UGI cancer nurse specialists, 14 patients, their relatives and representatives from patient support groups and four observers. Endoscopy provider related major key performance indicators and proposed standards included monitoring post endoscopy upper gastrointestinal cancer rates (minimum standard ≤ 7%); less intense endoscopy lists (maximum 10 ‘points’ per list [one point is equivalent to 15 min]); endoscopy provider accreditation (all providers); and premalignant condition surveillance on dedicated lists by endoscopists with adequate training (> 90% surveillance endoscopies). Endoscopist/procedure related major key performance indicators included: examination time ≥ 7 min; training in early UGI neoplasia recognition (all endoscopists); mucosal view quality recorded and cleansing agents used if not excellent (> 90% endoscopies); intravenous sedation offered to all appropriate patients; recommended number of biopsies from cancer associated or premalignant lesions (> 90% endoscopy where such lesions identified); and endoscopists' annual UGI endoscopy volume > 100 (all endoscopists). Conclusion: This study offers a consensus on the key performance indicators and minimum standards that should be used to improve UGI endoscopy quality and reduce post endoscopy upper gastrointestinal cancer

Calibrating a large computer experiment simulating radiative shock hydrodynamics

We consider adapting a canonical computer model calibration apparatus, involving coupled Gaussian process (GP) emulators, to a computer experiment simulating radiative shock hydrodynamics that is orders of magnitude larger than what can typically be accommodated. The conventional approach calls for thousands of large matrix inverses to evaluate the likelihood in an MCMC scheme. Our approach replaces that costly ideal with a thrifty take on essential ingredients, synergizing three modern ideas in emulation, calibration and optimization: local approximate GP regression, modularization, and mesh adaptive direct search. The new methodology is motivated both by necessity - considering our particular application - and by recent trends in the supercomputer simulation literature. A synthetic data application allows us to explore the merits of several variations in a controlled environment and, together with results on our motivating real-data experiment, lead to noteworthy insights into the dynamics of radiative shocks as well as the limitations of the calibration enterprise generally.Comment: Published at http://dx.doi.org/10.1214/15-AOAS850 in the Annals of Applied Statistics (http://www.imstat.org/aoas/) by the Institute of Mathematical Statistics (http://www.imstat.org

Case-mix-adjusted mean number of polyps per 100 procedures : a new candidate gold standard colonoscopy key performance indicator

Objective: Adenoma detection rate (ADR) has been criticised as a colonoscopy key performance indicator (KPI), for excluding serrated polyps, requiring histological data and fostering a ‘one-and-done’ attitude. We hypothesised that a case-mix-adjusted mean number of polyps (aMNP) would address these criticisms and provide a better measure of colonoscopy quality. We aimed to develop an aMNP using the National Endoscopy Database (NED) and assess its relationship with quality metrics. Methods: We extracted colonoscopy data from NED for 1 January 2019–4 April 2019. Multiple negative binomial regression was undertaken to estimate effects of patient variables on MNP and generate aMNP. Associations between aMNP and polyp detection rate (PDR), proximal polypectomy rate (PPR), postcolonoscopy colorectal cancer (PCCRC) rate and Joint Advisory Group for GI endoscopy (JAG) Global Rating Scale (GRS) were explored. Results: 92 892 colonoscopies were analysed. Patient age, sex and procedure indication were significantly associated with MNP and used to create aMNP. At endoscopist level, aMNP strongly correlated with PDR (Spearman rho=0.834,

Colonoscopic cancer detection rate: a new performance measure – is it FIT for purpose?

Introduction: Gastrointestinal symptoms correlate poorly with cancer diagnosis. A Faecal Immunochemical Test (FIT) result of ≥10μg has high sensitivity and negative predictive value for colorectal cancer (CRC) detection. A FIT-based diagnostic pathway may lead to more effective resource utilisation. We aimed to use National Endoscopy Database (NED) data to create a new colonoscopy performance measure, cancer detection rate (CDR) to assess the appropriate identification of target populations for colonoscopy; then to use CDR to assess the impact of implementing a FIT-based referral pathway locally. Methods: NED data was analysed to compare local diagnostic colonoscopic CDR in 2019 (pre�pathway revision) and 2021 (post-pathway revision), benchmarked against overall national CDR for the same timeframes. Results: 1,123,624 NED diagnostic colonoscopies were analysed. Locally, there was a significant increase in CDR between 2019 and 2021, from 3.01%[2.45–3.47%] to 4.32%[3.69–4.95%],p=0.003. The CDR increase was due to both a 10% increase in the number of colorectal cancers detected and a 25% reduction in the number of diagnostic colonoscopies performed. Nationally, there was a smaller, but significant, increase in CDR from 2.02%[1.99 – 2.07%] to 2.33%[2.29 – 2.37%],p<0.001. The rate of increase in CDR% between 2019 and 2021 was significantly different locally compared to nationally. Conclusion: Our study indicates that the introduction of a robustly-vetted FIT-based algorithm to determine whether diagnostic colonoscopy is required, is effective in increasing the colonoscopic CDR. Moreover, CDR appears to be a meaningful performance metric that can be automatically calculated through NED, enabling monitoring of the quality of referral and vetting pathways

The National Endoscopy Database (NED) automated performance reports to improve quality outcomes trial (APRIQOT) randomized controlled trial design

© 2020 The Authors. Published by Thieme Open. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: https://www.thieme-connect.de/products/ejournals/html/10.1055/a-1261-3151Background and study aims Colonoscopists with low polyp detection have higher post colonoscopy colorectal cancer incidence and mortality rates. The United Kingdom’s National Endoscopy Database (NED) automatically captures patient level data in real time and provides endoscopy key performance indicators (KPI) at a national, endoscopy center, and individual level. Using an electronic behavior change intervention, the primary objective of this study is to assess if automated feedback of endoscopist and endoscopy center-level optimal procedure-adjusted detection KPI (opadKPI) improves polyp detection performance. Methods This multicenter, prospective, cluster-randomized controlled trial is randomizing NHS endoscopy centres to either intervention or control. The intervention is targeted at independent colonoscopists and each center’s endoscopy lead. The intervention reports are evidence-based from endoscopist qualitative interviews and informed by psychological theories of behavior. NED automatically creates monthly reports providing an opadKPI, using mean number of polyps, and an action plan. The primary outcome is opadKPI comparing endoscopists in intervention and control centers at 9 months. Secondary outcomes include other KPI and proximal detection measures at 9 and 12 months. A nested histological validation study will correlate opadKPI to adenoma detection rate at the center level. A cost-effectiveness and budget impact analysis will be undertaken. Conclusion If the intervention is efficacious and cost-effective, we will showcase the potential of this learning health system, which can be implemented at local and national levels to improve colonoscopy quality, and demonstrate that an automated system that collects, analyses, and disseminates real-time clinical data can deliver evidence- and theory-informed feedback.Published versio

Excess years of life lost to COVID-19 and other causes of death by sex, neighbourhood deprivation, and region in England and Wales during 2020: A registry-based study

BackgroundDeaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups.Methods and findingsWe used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording.ConclusionsIn this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL

Comparative efficacy and safety of endoscopic modalities for colorectal cancer screening in inflammatory bowel disease: A systematic review and network meta-analysis

Background Long-standing Inflammatory bowel disease (IBD) increases the risk of colonic neoplasia, necessitating effective screening strategies. This network meta-analysis (NMA) compared the efficacy and safety between different endoscopic modalities in the high-definition (HD) era. Methods We searched CENTRAL, ClinicalTrials.gov, Embase, MEDLINE, and WHO for randomised controlled trials (RCTs) comparing endoscopic modalities for screening colonoscopy in IBD patients up to February 2024. The primary outcome was detection of any dysplastic lesion per patient. The certainty of the evidence was GRADE assessed. Results A total of 26 RCTs involving 4,159 participants were included, comparing 6 endoscopic modalities: HD white light endoscopy (HD-WLE), HD virtual chromoendoscopy (HD-VCE), HD dye-based chromoendoscopy (HD-DCE), HD-WLE with segmental re-inspection (SR), auto-fluorescence imaging (AFI), and full-spectrum endoscopy (FUSE). HD-DCE may have a small benefit in detecting dysplasia over HD-WLE (low certainty, small magnitude, RR 1.42, 95% CI: 1.02-1.98). FUSE may be no different to HD-WLE (low certainty, RR 3.24, 95% CI: 0.66-15.87). The other modalities were assessed as very low certainty (HD-WLE with SR: RR 1.35, 95% CI: 0.66-2.77; AFI: RR 1.18, 95% CI: 0.55-2.57; HD-VCE: RR 0.99, 95% CI: 0.69-1.43). Sensitivity analyses supported these findings. Limited data on serious adverse events precluded meta-analysis; 2 serious events were reported among 2164 patients (very low certainty). Conclusions HD-DCE is the only modality for IBD surveillance with evidence (low-certainty) demonstrating potential to detect more dysplastic lesions compared to HD-WLE. There was no evidence to support any of the other modalities as an alternative due to very low-certainty evidence

The effectiveness of partnerships with commercial actors to improve food environments: a systematic review

Partnerships with commercial actors have been proposed as a policy approach to create healthier food environments. We conducted a systematic review to assess their effectiveness for improving food environments and population health at state, national, or international levels. We searched in 14 databases and two websites for real-world evaluations published between 2010 and 2020. Study quality was appraised using a modified Newcastle–Ottawa Scale. Data were synthesized narratively by outcome (human, food environment, policy content, and implementation progress), considering their effect direction. Seventeen studies reporting on seven PPPs in four countries were included. Most studies (n = 14) involved food reformulation, especially salt reduction. Three focused on specific settings (the eating out-of- home sector, schools, and convenience stores). There was mixed evidence that partnerships make people buy fewer calories or more school meals (n = 3 studies) or reduce product sodium content (n = 6). Some positive effects were described in one uncontrolled study each for decreasing trans-fatty acid intake and for making healthier options more available in school cafeterias, but these studies had important limitations. Five document analyses highlighted shortcomings in the partnerships, including their limited scope, failure to add value to ongoing actions, varying participation levels, and lack of implementation, monitoring, and reporting. Alternative policy approaches should be considered. This systematic review is registered on PROSPERO as CRD42020170963

Risk stratification of Barrett's oesophagus using a non-endoscopic sampling method coupled with a biomarker panel: a cohort study.

BACKGROUND: Barrett's oesophagus predisposes to adenocarcinoma. However, most patients with Barrett's oesophagus will not progress and endoscopic surveillance is invasive, expensive, and fraught by issues of sampling bias and the subjective assessment of dysplasia. We investigated whether a non-endoscopic device, the Cytosponge, could be coupled with clinical and molecular biomarkers to identify a group of patients with low risk of progression suitable for non-endoscopic follow-up. METHODS: In this multicentre cohort study (BEST2), patients with Barrett's oesophagus underwent the Cytosponge test before their surveillance endoscopy. We collected clinical and demographic data and tested Cytosponge samples for a molecular biomarker panel including three protein biomarkers (P53, c-Myc, and Aurora kinase A), two methylation markers (MYOD1 and RUNX3), glandular atypia, and TP53 mutation status. We used a multivariable logistic regression model to compute the conditional probability of dysplasia status. We selected a simple model with high classification accuracy and applied it to an independent validation cohort. The BEST2 study is registered with ISRCTN, number 12730505. FINDINGS: The discovery cohort consisted of 468 patients with Barrett's oesophagus and intestinal metaplasia. Of these, 376 had no dysplasia and 22 had high-grade dysplasia or intramucosal adenocarcinoma. In the discovery cohort, a model with high classification accuracy consisted of glandular atypia, P53 abnormality, and Aurora kinase A positivity, and the interaction of age, waist-to-hip ratio, and length of the Barrett's oesophagus segment. 162 (35%) of 468 of patients fell into the low-risk category and the probability of being a true non-dysplastic patient was 100% (99% CI 96-100) and the probability of having high-grade dysplasia or intramucosal adenocarcinoma was 0% (0-4). 238 (51%) of participants were classified as of moderate risk; the probability of having high-grade dysplasia was 14% (9-21). 58 (12%) of participants were classified as high-risk; the probability of having non-dysplastic endoscopic biopsies was 13% (5-27), whereas the probability of having high-grade dysplasia or intramucosal adenocarcinoma was 87% (73-95). In the validation cohort (65 patients), 51 were non-dysplastic and 14 had high-grade dysplasia. In this cohort, 25 (38%) of 65 patients were classified as being low-risk, and the probability of being non-dysplastic was 96·0% (99% CI 73·80-99·99). The moderate-risk group comprised 27 non-dysplastic and eight high-grade dysplasia cases, whereas the high-risk group (8% of the cohort) had no non-dysplastic cases and five patients with high-grade dysplasia. INTERPRETATION: A combination of biomarker assays from a single Cytosponge sample can be used to determine a group of patients at low risk of progression, for whom endoscopy could be avoided. This strategy could help to avoid overdiagnosis and overtreatment in patients with Barrett's oesophagus. FUNDING: Cancer Research UK.The BEST2 study was funded by Cancer Research UKThis is the author accepted manuscript. The final version is available from Elsevier via https://doi.org/10.1016/S2468-1253(16)30118-