The quality of care in Barrett's esophagus: Endoscopist and pathologist practices

BACKGROUND: The diagnosis of Barrett's esophagus (BE) has important psychol ogical and economic implications. Although accepted standards for endoscopi c biopsy methods and pathological interpretation for BE exist, adherence to these standards as a measure of the quality of care in BE has not been eva luated. Our aim was to assess the quality of care in BE by evaluating the p rocess of care and adherence to accepted standards of practice. METHODS: Explicit process-of-care criteria were developed using a systemati c literature review and expert opinion in four domains of care: the quality of biopsy methods, the adequacy in identifying endoscopic landmarks, endos copist-pathologist communication, and pathological interpretation and repor ting. We reviewed all endoscopy and pathology reports of BE patients at two institutions from 1994-1997. An academic medical center (N = 237) with sta ff endoscopists and an academically affiliated community hospital (N = 100) with private-practice endoscopists were analyzed. RESULTS: Physicians showed the highest adherence to accepted standards of c are in the "adequacy of identifying landmarks" and "endoscopist-pathologist communication" domains, with a greater than or equal to 70% adherence rate in most criteria. Conversely, physicians demonstrated the poorest adherenc e with the "quality of biopsy methods" and "pathologist interpretation and reporting" domains, with adherence rates frequently (60%. Significantly, bi opsies were taken in the presence of visible esophagitis 35% of the time. P erformance on several of the quality indicators varied significantly by the practice setting. CONCLUSIONS: We have identified several opportunities for quality improveme nt efforts. In every domain, there is room for improvement, particularly in the quality of biopsy methods. As initiatives to screen the large populati on of gastroesophageal reflux disease patients for BE may be imminent, the time is now to define the critical process-of-care measures to minimize the risk of overdiagnosis and inadequate endoscopic surveillance. (C) 2001 by Am. Cell. of Gastroenterology.