Quality Indicators for Upper GI Endoscopy

Abstract

INTRODUCTION Esophagogastroduodenoscopy (EGD) is a minimally invasive, generally safe, and well-tolerated procedure to diagnose and treat disorders of the esophagus, stomach, and duodenum. The rate of EGDs performed in adults is rising across age groups, with database analyses estimating 7.5 million EGDs performed in adults in the United States in 2019, an increase from 6.1 million EGDs in 2013 (1,2). The expanding list of accepted indications for EGD include evaluation and/or management of dysphagia, odynophagia, gastroesophageal reflux symptoms, upper abdominal symptoms, and gastrointestinal (GI) bleeding; screening, surveillance, and endoscopic management of preneoplastic conditions; and newer treatment modalities in endobariatrics and third-space endoscopy. At the same time, EGD is used without an appropriate indication in 5%–49% of cases, highlighting a clinical challenge and priority area (3). Potential risks of EGD include bleeding, infection, perforation (≤0.30 per 10,000 EGDs performed), emergency department visits and/or hospital admission, and death (0.11 per 10,000 EGDs performed) (2). Delivery of high-quality care in EGD is essential. Generally, a high-quality EGD is one that is clearly indicated, during which relevant diagnoses are established or excluded, any therapy that is provided is appropriate and effective, and harm is minimized to the greatest extent possible (4–6). Quality indicators are a method to assess performance of quality in EGD and can be divided into 3 categories: structural measures, assessing characteristics of the entire healthcare environment (e.g., availability and maintenance of endoscopy equipment at a hospital); process measures, assessing performance during the delivery of care (e.g., proportion of patients who receive endoscopic treatment to ulcers with high-risk stigmata of bleeding); and outcome measures, assessing the results of the care that is provided (e.g., proportion of patients recommended to undergo treatment and assessment for eradication in the case of endoscopically diagnosed Helicobacter pylori infection). By developing quality indicators with performance targets, measuring performance on these benchmarks, and implementing interventions to improve performance, the quality of care delivered at the endoscopist-, practice-, and field-level can be maximized. This document presents quality indicators with performance targets in EGD that, to the greatest extent possible, integrate new data relevant to existing quality indicators and introduces new indicators as appropriate based on interval progress in the field. METHODS This work represents the third iteration of the American Society for Gastrointestinal Endoscopy and American College of Gastroenterology quality indicators document pertaining to EGD. The first version of this document was published by the American Society for Gastrointestinal Endoscopy and American College of Gastroenterology Task Force on Quality in Endoscopy in 2006 (7,8) and was revised in 2015 (5,6). This current revision integrates new data relevant to existing quality indicators and introduces new indicators as appropriate based on interval progress in the field. This document focuses on quality indicators unique to EGD (Table 1). The indicators that are common to all GI endoscopic procedures are presented in detail in a separate article and, for completeness, are also listed in Table 2. These common indicators are addressed herein only insofar as the discussion needs to be modified specifically to relate to EGD. Table 1. - Quality indicators for EGD Quality indicator Performance target (%) Type of measure Level of evidence Preprocedure 1 Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications and the indication is documented >95 Process 1C+ 2 Frequency of EGD performed within 24 hr for patients admitted to or under observation in hospital for upper GI bleeding >80 Process 1C Intraprocedure 3a Frequency of photodocumentation of the esophagus, gastroesophageal junction, gastric cardia/fundus, corpus, incisura, antrum/pylorus, second portion of duodenum, and detected lesions in patients undergoing EGD >90 Process 3 4 Frequency of obtaining a total of 6 biopsy samples (or more) obtained from at least 2 levels (proximal/mid and distal) of the esophagus in the absence of an endoscopically evident etiology for dysphagia in patients reporting dysphagia >90 Process 2B 5 Frequency of endoscopic reference score documentation when eosinophilic esophagitis is suspected or established >95 Process 2C 6a Frequency of Los Angeles classification documentation when erosive esophagitis is present >98 Process 2C 7 Frequency with which the locations of the squamocolumnar junction, gastroesophageal junction, and diaphragmatic hiatus (if there is a hiatal hernia present) are recorded for patients with endoscopically suspected columnar metaplasia in the tubular esophagus >95 Process 1C+ 8a Frequency with which the presence of at least 1 cm of endoscopically evident columnar is documented obtaining biopsy samples to for >95 Process 1C Frequency with which the extent of suspected or is documented the in of suspected or >95 Process 1C+ Frequency with which endoscopy or is used for endoscopy in patients with >90 Process Frequency of biopsy 2 cm the extent of the endoscopically of in patients with undergoing endoscopy >90 Process 1C Frequency with which biopsy samples or endoscopic is obtained from lesions and from the biopsy samples in a with with a on endoscopy >90 Process 3 Frequency with during EGD at least 1 of the stigmata is bleeding, or based >98 Process Frequency of endoscopic treatment delivered to ulcers with or or with >90 Process Frequency of a second treatment delivered (e.g., when is used to treat bleeding or in patients with bleeding ulcers >98 Process Frequency with which of in of of upper GI bleeding is documented >90 Frequency with which gastric biopsy is or endoscopy is to in patients with gastric ulcers >80 Process 2C Frequency of biopsy of the gastric corpus, and in patients with patients at high-risk for gastric or patients with an endoscopic for >90 Process 2C Frequency with which endoscopy and is used in patients with patients at high-risk for gastric or patients with an endoscopic for >90 Process 2C Frequency with which gastric the of a in undergo biopsy or are >80 Process 2C Frequency with which biopsy samples 1 from the are obtained in patients with suspected >98 Process 1C Frequency of endoscopy a of in of Los Angeles or erosive esophagitis >90 Process 2B Frequency of therapy for patients who for and or to these >98 Process 2B 24 Frequency with which endoscopy is recommended 3 biopsy was performed in a to without of >80 Process 2C Frequency of eradication of metaplasia within of endoscopic treatment in patients with and or undergoing endoscopic eradication therapy 1C+ Frequency of therapy or for 3 endoscopic therapy of a bleeding in patients without or to the >95 Process Frequency with which to for Helicobacter pylori are documented in patients with and >95 Process 2C Frequency with which to treat and assess eradication of pylori are documented in patients with endoscopically diagnosed pylori >95 Frequency that the is documented in patients with >90 Process 2C are from to 3 based on the evidence and of a that can be to clinical a that is to be to and 1C+ a that can to in 1C an that when evidence is an in which the on or or 2B a in which be under 2C a in which are to be under 3 a to as data gastric a priority Table 2. - Quality indicators common to all endoscopic procedures with performance targets Quality indicator of Performance target (%) Preprocedure 1. Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications and the indication is documented 1C+ Process >95 2. Frequency with which is obtained and documented 3 Process >98 Frequency with which and are performed and documented 3 Process >98 Frequency with which a that for is documented is 3 Process >98 Frequency with which are for appropriate indications Process >98 Frequency with which management of therapy is and documented the procedure 3 Process >95 Frequency with which a is performed and documented 3 Process >98 Frequency with which endoscopy is performed or by an who is and to that procedure 3 Process >98 Intraprocedure Frequency with which photodocumentation is performed 3 Process >90 Frequency with which during is performed and documented 3 Process >98 Frequency with which procedure and of is documented 3 Process >98 Frequency with which endoscopic is performed and documented 3 Process >98 Frequency with which from the endoscopy to is documented 3 Process >98 Frequency with which are provided 3 Process >98 Frequency with which endoscopic and are to the and appropriate 3 Process >98 Frequency with which a procedure is 3 Process >98 Frequency with which are documented 3 Process >98 Frequency with which Frequency with which data are are from to 3 based on the evidence and of a that can be to clinical a that is to be to and 1C+ a that can to in 1C an that when evidence is an in which on or or 2B a in which be under 2C a in which are to be under 3 a to as data in indicators that clinical are with in and and in clinical in endobariatrics and third-space within the of this quality indicator data indicators of clinical by progress in the in to measure and the to include a of relevant indicators to in quality indicators are divided into 3 and quality indicator is as an outcome or process outcome are generally quality of can be or to measure in clinical of the for of data and/or and or be by cases, process indicators are provided as of high-quality endoscopic The of a process indicator on the evidence that with a relevant and process The in this document to endoscopic the quality of care delivered to patients is by to the in which endoscopy is These structural are in a separate article to quality this the existing quality indicators and to or by based on and of new quality indicators by and, by based on relevant by the a of of of from which was the of the of this The for indicator included a of in and the and reference of relevant for the indicators by with in on the of for indicator was to a used (Table this the of quality indicator was divided across a from a quality indicator that can be to clinical to a quality indicator of absence of evidence on The of for indicator was established by of the Table - of of evidence without can be to clinical with to to 1C+ evidence from can to in 1C when evidence is without on or or 2B with be under 2C are to be under 3 only to as data from from evidence to to the The process included in this document are to a performance measure is a quality The performance targets based on published by the absence of when the to a quality indicator a as to during the performance target was as only in the quality indicator be is to that the included quality indicators and performance targets the standard of or and is a to any of the quality indicators in this document as the quality indicators are and to as a for quality for and in of quality the a of indicators based on clinical and evidence that performance in clinical and of of the of procedures to an with and the of that quality on priority indicators and progress to include indicators is that are recommended at or The at the of first the and of the endoscopy and at the of of (or of the in Preprocedure quality indicators common to all endoscopic procedures are in a separate article and appropriate and management of and and (Table 1. Frequency with which endoscopy is performed for an indication that is included in a published standard list of appropriate indications and the indication is of 1C+ Performance Type of Process Table 4 indications for EGD evaluation and/or management of upper as as a list of indications for which EGD is generally an appropriate indication be a procedure is performed for a the for the procedure be in the endoscopy is when the or the therapy provided improve and the clearly any that when EGD is for appropriate relevant diagnoses are 2. Frequency of EGD performed within 24 for patients admitted to or under observation in the hospital for upper GI bleeding of 1C Performance Type of Process Table - for upper GI endoscopy EGD is generally for and/or abdominal symptoms, which an appropriate of therapy abdominal with or (e.g., and or in patients or or reflux which are or appropriate therapy of for or reflux in absence of erosive reflux for esophagus of in which the presence of upper GI patients with a of or GI bleeding for or therapy for and with of the and and of or or GI bleeding patients with or bleeding and for when the clinical an upper GI or when is of or is patients with suspected to document or treat assess of bleeding lesions as and (e.g., or or of of of lesions of or endoscopic or endoscopic of lesions (e.g., with or by of (e.g., endoscopic treatment of (e.g., therapy for metaplasia of lesions (e.g., endoscopic therapy evaluation of of (e.g., evaluation of and during of (e.g., of of or in or EGD be for in patients with esophagus, gastric of in eosinophilic esophagitis or eosinophilic GI of and for esophagus in patients with erosive esophagitis EGD is generally for that are in include endoscopic to are to of when the results management of or hiatal hernia that to therapy when are or to therapy or EGD is generally for of as esophagitis or gastric or during of there is a in EGD is recommended to be performed within 24 of for patients admitted or under observation with This patients who are for a score and/or be from the emergency The to EGD within 24 from the by of and a and in for in that endoscopy within 1 of is with a of with a possible of and a of bleeding, there was an in high-risk patients Society of score of to with or endoscopy EGD within a with EGD and EGD in a of patients with endoscopy within 6 of to be as a of EGD in within 6 with within of in high-risk patients with score with in or bleeding The from the of or of the when is the is This all of the endoscopy and for and of the Intraprocedure quality indicators to all endoscopic procedures are in a separate article and during and and (Table The quality indicators in EGD photodocumentation and indicators to biopsy for dysphagia, documentation of Los Angeles classification in erosive and for esophagus evaluation and management of ulcers and for gastric evaluation and management of gastric and evaluation for Frequency of photodocumentation of the esophagus, gastroesophageal gastric cardia/fundus, corpus, incisura, antrum/pylorus, second portion of the duodenum, and detected lesions in patients undergoing EGD of 3 Performance Type of Process EGD is generally with the to the esophagus at the upper a of the gastric and to the second portion of the (if based on of the second portion of the is as of the to a to the there is evidence to the of photodocumentation in is that this is a for and a endoscopic and as a reference in and lesions for endoscopic is a quality indicator in and in is recommended in EGD by the Society of Gastrointestinal Endoscopy as as the Endoscopy in EGD photodocumentation of the and is recommended to a esophagus, of the of the gastric cardia/fundus, of the gastric antrum/pylorus, of the gastric incisura, and second portion of the 1). The is as of the gastric or of the the with the with a of gastric to of the to quality a increase in the rate of photodocumentation by a Frequency of obtaining a total of 6 biopsy samples (or more) from at least 2 levels (proximal/mid and distal) of the esophagus in the absence of an endoscopically evident etiology for dysphagia in patients reporting of 2B Performance Type of Process for photodocumentation during gastroesophageal gastric second portion of duodenum. of for at of esophagitis an by eosinophilic of the is rising in The current standard for is the presence of per on biopsy in evaluation and management of of the and in and is from the to esophagus that to a of reflux esophagitis as the of biopsy samples be by biopsy in a of only of obtaining biopsy samples from 2 levels of the esophagus of the of biopsy samples the of with biopsy samples a of was for a total of for a total of for a total of and for a total of 6 biopsy samples be from at least 2 the and/or esophagus in to the esophagus for a total of at least 6 biopsy Frequency of endoscopic reference score documentation when is suspected or of 2C Performance Type of Process endoscopic of include as of and and as and in endoscopic treatment of endoscopic assessment of can The is a for that the of of or and or 1). The and the score with and with treatment and is used as a and outcome measure of endoscopic is used to patients as or and in patients with established and in with suspected the score be documented in the endoscopic Frequency of classification documentation when erosive esophagitis is present of 2C Performance Type of Process in the esophagus can a of from to erosive of is with a of in the esophagus and an for The classification is the used and for erosive esophagitis esophagitis is for a of gastroesophageal reflux be from and can be in of the or esophagitis is of and reflux to a of and esophagitis on reflux and with is with the on reflux and a proportion of patients with or esophagitis to on endoscopy with patients with or documentation of classification when erosive esophagitis is on and Frequency with which the locations of the squamocolumnar and diaphragmatic hiatus (if a hiatal hernia is present) are recorded for patients with endoscopically suspected columnar metaplasia in the tubular of 1C+ Performance Type of Process Los Angeles classification for erosive Los is to document the locations of the and diaphragmatic in columnar metaplasia is suspected in the tubular The is the of the and columnar and is in the The is the the tubular esophagus and the stomach, by the extent of the gastric The of the and endoscopically in of columnar The of the diaphragmatic hiatus is by the or the of the a the diaphragmatic hiatus be at the of the be at the of the in the of a hiatal documentation of these for and management for of in the extent and of the and in biopsy and treatment documentation of the and the esophagus and stomach, as reflux hiatal and of which management of the and diaphragmatic hiatus time, of and interventions the locations of these and of clinical healthcare for of and in Frequency with which the presence of at least 1 cm of endoscopically evident columnar is documented obtaining biopsy samples to for of 1C Performance Type of Process at least 1 cm of endoscopically evident columnar is 1 of the to diagnose a with of metaplasia from the by the presence of columnar cm to the in of undergoing upper with the of to or is for with a or measuring a patients undergoing surveillance, for a of of patients with an or biopsy samples in with an evidence of in of in a of patients with of the a of to or a of patients with an and with or the on an or columnar cm is These data that the of in with an is in the of is to documentation of at least 1 cm of endoscopically evident columnar for to into This and and the quality of for patients and the healthcare Frequency with which the extent of suspected or is documented the in of suspected or of 1C+ Performance Type of Process from the and classification to a to the endoscopic of This classification the to the and the to the of the in The classification for and extent of and as established the of this classification in and The classification also reporting of extent in and clinical This for of and and to The classification a common for healthcare and of The documentation of extent the for and of patients time, in the evaluation of and to Frequency with which endoscopy with or is used for endoscopy in patients with of Performance Type of Process of the to lesions or by endoscopic therapy to or treat in is in and in of the the to or is with a of lesions or 1 of as a during these or can be in a proportion of patients and to improve to improve of the the with to the the with to of the which in into the as and are also These to the of the and or the same with These can be with the of a on the and are to the with time, of to for of these and with Performance for the of these Society for Gastrointestinal Endoscopy and of and and that and the of these of the of in with presented in 2 with biopsy the with biopsy a and that of or the of and by with biopsy with the of with with for the of obtaining biopsy Frequency of biopsy 2 cm the extent of the endoscopically of in patients with undergoing endoscopy. of 1C Performance Type of Process endoscopic in patients with the biopsy 2 cm in without and 1 cm in with to undergo with biopsy samples at in a separate to of lesions patients with biopsy 2 cm from the of columnar can be with a of 4 biopsy samples The of a biopsy to improve with biopsy and the of with the on the of with this the of by and was for the of and of by as and that and with with or This and also and patients with was also with of at an was that the for and this with the to be from a database with to be only which with was with of as the of performance of by was also a of This is the of with a of and of Frequency with which biopsy or endoscopic is obtained from lesions and from the biopsy in a with with a on endoscopy. of 3 Performance Type of Process for endoscopic in include of the the with the of which and of the classification of endoscopic lesions of reporting to the the undergo at that time, is recommended that samples from these be in separate biopsy with a of the (e.g., biopsy at cm from the and at the 3 or at cm from the at the 6 to and treatment as by the This of biopsy samples cm in a of in biopsy samples and for the with reporting of by biopsy in biopsy this endoscopically lesions or is to of can be by biopsy or endoscopic endoscopic is biopsy samples from these lesions be and to the to biopsy The on and of of endoscopic The of biopsy in is in the a reporting the of or in patients undergoing first biopsy samples in patients these and these of all and the of biopsy in with biopsy in of patients in the and of patients in the be that this was with patients with and and these be of the that with and without in a with a biopsy rate of in the with in the Frequency with which during EGD at least 1 of the stigmata is bleeding, or based of Performance Type of Process during an EGD be the classification to and high-risk stigmata for bleeding The classification is as based a of bleeding endoscopic for bleeding presence of bleeding at the endoscopy or was a for bleeding ulcers with a or are at a for bleeding and endoscopic therapy of data from an with in bleeding that bleeding endoscopic for for for and for ulcers that the classification of bleeding ulcers a on bleeding and the for endoscopic therapy and the classification be used in procedure Frequency of endoscopic treatment delivered to ulcers with or or with of Performance Type of Process therapy is recommended for ulcers with and of in bleeding for endoscopic therapy with endoscopic therapy in patients with bleeding and and bleeding into 1 data that bleeding endoscopic is in ulcers with the of which a bleeding rate American College of Gastroenterology on the management of a for the for endoscopic therapy in ulcers with of a of data for endoscopic therapy with data include and of that therapy with a or was with a of bleeding with endoscopic therapy a of 3 as a was to endoscopic therapy for bleeding for the of is as of with therapy in to be to in 2 in bleeding for treatment with quality evidence include with and an of patients with high-risk bleeding when with the of that be a for with standard an of patients with high-risk of standard endoscopic treatment therapy or with or without was with a of bleeding of patients with with of bleeding, of standard therapy of at least 2 or with a was with rate of clinical and rate of bleeding with endoscopic treatment for high-risk stigmata be an of patients admitted across with only of patients with high-risk stigmata endoscopic Frequency of a second treatment delivered (e.g., when is used to treat bleeding or in patients with bleeding of Performance Type of Process only be used as of a therapy with endoscopic when high-risk a of 4 as the was in bleeding with standard as and a of 7 with a second was in bleeding with a of 3 that the of and therapy was with bleeding with therapy to to of 2 the of an with and a in of bleeding a that the of therapy with bleeding with The of that can be used to only be used in with a second treatment to a of Frequency with which of in of of is documented of Performance Type of The with which in patients undergoing endoscopy for is documented was a process measure in the iteration of this with the of The American College of Gastroenterology clinical on the management of bleeding on the outcome of bleeding and and for documentation of or targets for be obtaining in of bleeding is an to during the endoscopy is with bleeding, and hospital data of during EGD. a of standard treatment therapy or with in patients with the of was in of the and in the standard a of standard therapy in the rate was in the and in the standard of and include of bleeding of endoscopic therapy of of and as of and are to the treatment for bleeding, in of and The current quality indicator focuses on documentation of the of of be as a quality in and characteristics to a for Frequency with which gastric biopsy is or endoscopy is to in patients with gastric of 2C Performance Type of Process of gastric ulcers are endoscopic are to biopsy of gastric ulcers at the endoscopy or at the endoscopy is in or The of biopsy to is be of the when the gastric is bleeding or high-risk stigmata for bleeding, biopsy can be to a endoscopy. biopsy samples be there are in which the of gastric is (e.g., a with ulcers in the of Frequency of biopsy of the gastric corpus, and in patients with patients at for gastric or patients with an endoscopic for of 2C Performance Type of Process with a biopsy is for 3 of patients with or gastric who indications for at for gastric or for with a of gastric or from and patients with an endoscopic for The is the standard for gastric biopsy in patients with suspected or The biopsy 1 to 2 biopsy samples from of 5 and incisura, and and At 2 separate be 1 for the and and 1 for the The of endoscopy (e.g., in these of patients biopsy within the of the biopsy of be in a separate gastric biopsy for indications for gastric biopsy gastric high-quality gastric for patients with or suspected who biopsy the include pylori of and gastric and extent of is to the and incisura, also the The to the proportion of (or in biopsy samples in incisura, The and extent and presence of or are the for the of endoscopy. The of biopsy

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