Quality Improvement Initiative to Improve Endoscopic Reassessment of Eosinophilic Esophagitis

The eosinophilic esophagitis (EoE) endoscopic reference score (EREFS) is a validated system for description, recognition, and reporting of EoE findings during esophagogastroduodenoscopy (EGD). This scoring system correlates with esophageal eosinophilia and therapeutic responses and has validated diagnostic accuracy with good inter- and intraobserver reliability in pediatric and adult patients. In this study, we aimed to improve physician education on and documentation of EREFS and correlate EREFS scoring with eosinophil density on histology.

Applying the "Plan, Do, Study, Act" methodology for quality improvement between October 2018 and November 2019, we established a baseline rate of EREFS completion by review of the electronic medical record (EMR). Key drivers were identified, and 3 interventions were implemented.

Over 12 months, 542 distinct endoscopies were performed on 410 patients for EoE surveillance. Patients were 68% male with a mean age of 10.9 years (SD 5.7 years), mean EREFS score of 2.14 (SD 1.88), and mean peak eosinophil count 30.9 eos/hpf (SD 37.1 eos/hpf). Baseline EREFS completion rate of 72.7% (90% CI, 67.4-77.4). Following all 3 PDSA cycles, EREFS completion rate significantly improved to greater than desired target of 90% (94.9%; 90% CI, 90.6-97.6; P < 0.001).

Interventions including provider education and the inclusion of EREFS in documentation templates can increase adoption rates of EREFS among providers caring for patients with known EoE.