Endoscopy in Barrett's oesophagus: adherence to standards and neoplasia detection in the community practice versus hospital setting

J Intern Med. 2008 Oct;264(4):370-8. doi: 10.1111/j.1365-2796.2008.01977.x. Epub 2008 May 15.

Abstract

Objective: Potential process differences between hospital and community-based endoscopy for Barrett's oesophagus have not been examined. We aimed at comparing adherence to guidelines and neoplasia detection rates in medical centres (MC) and community practices (CP).

Design: Retrospective analysis.

Setting: All histologically confirmed Barrett cases seen over a 3-year period in six MC and 19 CP covering a third of all upper gastrointestinal endoscopies (n = 126,000) performed annually in Berlin, Germany.

Main outcome measure: Rate of relevant neoplasia (high-grade intraepithelial neoplasia or more) in both settings in relation to adherence to standards.

Results: Of 1317 Barrett cases, 66% were seen in CP. CP patients had a shorter mean Barrett length (2.6 cm vs. 3.8 cm; P < 0.001) with fewer biopsies taken during an examination (2.5 vs. 4.1 for Barrett length <or=2 cm; P < 0.001). CPs also provided fewer complete esophagogastroduodenoscopy documentation (25.1% vs. 57.8%, P < 0.001). Neoplasias were found more commonly in MCs compared to CPs (9.2% vs. 0.8%; P < 0.001). However, on exclusion of all referred patients with known neoplasia (65%) or those examined for other reasons (27.5%), the detection rate at MCs decreased to 1.3%, not different from the one seen at CPs (0.8%, P = 0.43). Only 13% were found during surveillance, but 57% were diagnosed at an early stage.

Conclusions: Referral bias and not better adherence to guidelines could explain the higher neoplasia prevalence in Barrett's oesophagus at hospital centres. Despite a generally poor adherence to guidelines, most neoplasias found were at an early and potentially curable stage.

Publication types

  • Comparative Study

MeSH terms

  • Adenocarcinoma / pathology
  • Age Factors
  • Aged
  • Barrett Esophagus / diagnosis*
  • Berlin
  • Carcinoma in Situ / pathology
  • Community Health Services / standards
  • Esophageal Neoplasms / diagnosis*
  • Esophagoscopy / methods
  • Esophagoscopy / standards*
  • Family Practice / standards
  • Female
  • Guideline Adherence / standards*
  • Hospitals
  • Humans
  • Logistic Models
  • Male
  • Middle Aged
  • Precancerous Conditions / diagnosis
  • Retrospective Studies