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

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.