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Adherence to clinical guidelines for Barrett's esophagus
Dag Holmberg1, Eivind Ness-Jensen1,2,3, Fredrik Mattsson1
1Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.
Scandinavian Journal of Gastroenterology
|July 18, 2019
Summary
Adherence to clinical guidelines for Barrett's esophagus with dysplasia is poor, especially for low-grade dysplasia (LGD). This study highlights the need for improved implementation of surveillance and treatment recommendations in clinical practice.
Area of Science:
- Gastroenterology
- Oncology
- Clinical Practice Guidelines
Background:
- Clinical guidelines recommend regular endoscopy surveillance or endoscopic therapy for Barrett's esophagus (BE) with low-grade dysplasia (LGD) and high-grade dysplasia (HGD).
- The actual adherence to these evidence-based guidelines in routine clinical practice remains largely unassessed.
- This study investigates the real-world application of management recommendations for dysplastic BE in Sweden.
Purpose of the Study:
- To evaluate adherence to clinical guidelines for patients diagnosed with Barrett's esophagus with LGD or HGD.
- To identify potential risk factors associated with deviations from recommended surveillance and treatment protocols.
- To assess the frequency of follow-up endoscopy, endoscopic therapy, and esophagectomy in this patient cohort.
Main Methods:
- A nationwide Swedish cohort study included 211 patients with histologically confirmed LGD or HGD in BE from 50 centers (2006-2013).
- Patient data were collected and followed up using nationwide registers.
- Multivariable logistic regression analysis was employed to identify risk factors for guideline deviation, calculating adjusted odds ratios (OR) with 95% confidence intervals (95%CI).
Main Results:
- Overall guideline adherence was low, with 60% of patients experiencing deviations, primarily due to under-surveillance (86% of deviations).
- Deviations were significantly higher in patients with LGD (69%) compared to HGD (39%).
- Key risk factors for deviation included LGD versus HGD (OR 3.4), longer Barrett's segment length (≥3 cm vs. <3 cm, OR 2.0), and treatment at gastroenterology versus surgery departments (OR 2.3).
Conclusions:
- Adherence to established clinical guidelines for managing dysplastic Barrett's esophagus is suboptimal, particularly for patients with LGD.
- Significant deviations from recommended surveillance protocols were observed, indicating a gap between guidelines and clinical practice.
- Targeted interventions and enhanced implementation strategies are crucial to improve guideline adherence and optimize patient management for dysplastic BE.