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Lessons From a Quality Improvement Project to Standardize the Process of Gastric Biopsy Culture for Helicobacter
Silvana Bonilla1, Athos Bousvaros1, Jeff Cardini2
1From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA.
Insights
A quality improvement project successfully increased the use of gastric biopsy cultures for diagnosing Helicobacter pylori (H pylori) infection in children. Educational initiatives improved culture positivity rates, aiding in more effective treatment selection.
Area of Science:
- Pediatric Gastroenterology
- Infectious Diseases
- Clinical Microbiology
Background:
- Adherence to pediatric clinical practice guidelines for diagnosing Helicobacter pylori (H pylori) infection is inconsistent.
- Utilizing gastric biopsy culture for initial H pylori diagnosis faces implementation challenges, impacting successful primary culture rates.
Purpose of the Study:
- To enhance the successful primary culture rate for Helicobacter pylori (H pylori) diagnosis in pediatric patients.
- To evaluate the impact of a quality improvement (QI) initiative on gastric biopsy culture utilization and positivity.
Main Methods:
- A quality improvement (QI) project was implemented, involving educational interventions for gastroenterologists, endoscopy, and laboratory personnel.
- Gastric biopsy culture frequency and culture positivity rates were compared before (Feb-Oct 2019) and after (Nov 2019-Jul 2020) the QI intervention.
- International Classification of Diseases codes 041.86 (9th rev) and B96.81 (10th rev) were used to identify relevant patient cohorts.
Main Results:
- Gastric biopsy acquisition frequency significantly increased from 39% pre-intervention to 67% post-intervention (P = 0.004).
- The percentage of culture positivity in patients with positive histology rose from 21% to 45% post-intervention, although not statistically significant (P = 0.39).
Conclusions:
- Educational initiatives and interdisciplinary collaboration effectively increased the use of gastric biopsy cultures for H pylori diagnosis.
- Improved surveillance of local antimicrobial resistance patterns is crucial for optimizing primary treatment strategies in pediatric H pylori infections.
Abstract:
Despite expert recommendations, clinician's adherence to pediatric societal clinical practice guidelines is variable, particularly with respect to the use of gastric biopsy culture in the initial diagnosis of Helicobacter pylori infection. In addition, the implementation of routine use of gastric biopsy culture has been challenging with several factors affecting the rate of successful primary H pylori culture.
Methods:
We conducted a quality improvement (QI) project with the aims of increasing the rate of successful primary culture. The QI project involved educational efforts among our gastroenterologists, endoscopy suite personnel, and laboratory personnel. We compared the frequency of gastric biopsy culture sent in patients with international classification of diseases 9th revision code 041.86, and 10th revision codes B96.81 evaluated by pediatric gastroenterologists at Boston Children's Hospital during the 9 months before the QI intervention (February 1, 2019 to October 31, 2019) and 9 months after the QI intervention (November 1 2019 to July 31 2020). We also compared the rate of culture growth in patients with positive histology (culture positivity), and antimicrobial susceptibilities before and after November 1, 2019.
Results:
We observed an increased frequency of gastric biopsy acquisition by any gastroenterologist, obtained in 39% (28 of 71) preintervention patients compared with 67% (36 of 54) intervention patients (P = 0.004). There was an increase in the percentage of culture positivity across study periods from 21% (3 of 14) preintervention to 45% (5 of 11) postintervention (P = 0.39; 95% confidence interval, 0.64-7.00).
Conclusion:
Educational initiatives and collaborative work with staff physicians, endoscopy personnel, and hospital laboratory appear to be effective tools to increase usage of gastric biopsy culture as a diagnostic tool for H pylori infection and to increase culture positivity. Improving the surveillance of local resistance rates will improve the selection of the most effective primary treatment in specific geographic areas.
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