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BEHAVIOURAL FACTORS IN ACHIEVING QUALITY BARRETT’S SURVEILLANCE ENDOSCOPY: A QUALITATIVE INTERVIEW STUDY OF UK ENDOSCOPISTS USING THE THEORETICAL DOMAINS FRAMEWORK

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BEHAVIOURAL FACTORS IN ACHIEVING QUALITY BARRETT’S SURVEILLANCE ENDOSCOPY: A QUALITATIVE INTERVIEW STUDY OF UK ENDOSCOPISTS USING THE THEORETICAL DOMAINS FRAMEWORK

Elizabeth Ratcliffe 1, Maria Horne 2, James Britton 3, Shaheen Hamdy 4, John McLaughlin 5, Yeng Ang 6

Affiliations

1 University of Manchester, Manchester, United Kingdom

2 University of Leeds, Leeds, United Kingdom

3 Salford Royal Hospital, Northern Care Alliance NHS Trust, Salford, United Kingdom

4 Salford Royal Hospital, Salford, United Kingdom

5 University of Manchester Salford Royal Hospital Gastrointestinal Centre, Manchester, United Kingdom

6 Salford Royal NHS Foundation, Salford, United Kingdom

Summary

AI Generated

Qualitative interviews with 22 UK endoscopists identified 21 barriers and facilitators to Barrett's oesophagus surveillance quality, mapped to behavioural interventions targeting training, scheduling, and organisational culture.

Semi-structured interviews achieved thematic saturation at 22 participants (3 consultant surgeons, 9 consultant gastroenterologists, 6 clinical nurse endoscopists, 2 trainee gastroenterologists, 2 trainee surgeons) across UK hospitals between August 2021 and July 2022.
Framework analysis using the Theoretical Domains Framework and COM-B model identified barriers and facilitators across three themes: intrapersonal factors (knowledge and recall of guidelines, technical skills, competing workload, motivation), interpersonal factors (motivated and skilled endoscopy team, pre- and post-certification training, continued professional development), and organisational factors (adequate scheduling for lesion detection, competing procedure burden, equipment availability).
Twenty-one barriers and facilitators were mapped to specific behavioural interventions including local education sessions on guidelines, demonstrations by UGI experts, streamlining surveillance to interested endoscopists on dedicated lists, training focused on tip control and lesion recognition, credentialling similar to bowel cancer screening programmes, key performance indicators such as oesophageal withdrawal times and Seattle protocol completion, and AI-assisted lesion recognition to reduce burden.
The study concludes that while training and education are vital, the real challenge may be achieving an organisational shift from high-turnover to quality-centred Barrett's endoscopy, with clinician behaviour being one aspect of a multifaceted care pathway amenable to improvement.
Study funded by Medtronic Ltd (ref ERP-2019-11987), which had no input to study design or conduct.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Introduction

Barrett’s oesophagus endoscopic surveillance pathways exist to aid detection of early progression at the dysplastic phase. Performance in accordance with guidelines can be mixed, and rates of missed dysplasia are high(1). Barrett’s surveillance endoscopy is a complex skill and requires a broad outlook when considering behaviour change interventions. Behavioural theory can be used to target aspects which influence behaviour which are most likely to affect change when used in implementation studies and has been used in prior studies of colonic polyp detection(2).

Aims & Methods

In this study we aimed to explore using qualitative methodology and behavioural theory, factors which influence endoscopists behaviours to identify barriers and facilitators to the adherence of Barrett’s surveillance endoscopy guidelines which could be utilised in future implementation research to improve practice.
Semi-structured interviews were performed over video conferencing software between August 2021 and July 2022 with purposively sampled clinicians who perform endoscopic Barrett’s surveillance from across the UK who work in a range of hospital types. Framework qualitative analysis was used to identify modifiable factors in line with the Theoretical Domains Framework (TDF) and Capability, Opportunity Motivation - Behaviour (COM-B) model of behaviour change(3,4).

Results

Thematic saturation was achieved at 22 interviews consisting of 3 consultant surgeons, 9 consultant gastroenterologists, 6 clinical (nurse) endoscopists, 2 trainee gastroenterologists and 2 trainee surgeons. Themes were mapped into key themes of intrapersonal, interpersonal and organisational factors.
Key intrapersonal factors included the endoscopists' knowledge of and recall of Barrett's surveillance guidelines, their technical skills required to perform quality Barrett's surveillance, the influence of a competing workload and their motivation to perform Barrett’s surveillance well.
Interpersonal factors included having a motivated endoscopy team who are skilled in assisting endoscopic surveillance and who understand the importance of surveillance, endoscopists' training both pre-certification and post certification and facilitating continued professional development for those in later career years.
Organisational factors included departments allowing adequate scheduling of procedure to allow time for lesion detection, the completing burden of other procedures and waiting lists and availability of equipment e.g. acetic acid.
From these themes, 21 barriers and facilitators were identified and mapped to behavioural interventions for use in future intervention studies - some examples are outlined in Table 1.

Table 1: Outlining examples of barriers and facilitators to performing quality Barrett's surveillance mapped to the Theoretical domains framework(TDF).

Barriers	Facilitators	TDF Domains	COM-B domains	Action	Level	Behaviour change wheel Intervention function
- Knowledge and recall of Barrett’s surveillance guidelines	- Barrett’s surveillance performed by those with an interest in the condition - Motivation to perform Barrett’s surveillance well to find early lesions	Knowledge Memory Skills Goals and intentions Motivation Social and professional role	Capability Reflective motivation Psychological capability Social opportunity	- Local education sessions on guidelines - Demonstrations of good practice by local experts/UGI lead - Streamline Barrett’s surveillance procedures to those with an interest in UGI disease on dedicated endoscopy lists -Departments engage in Barrett’s related research	Intrapersonal Interpersonal Organisational	Training and education Restrictions Enablement Modelling Persuasion
- Technical skills required to perform quality Barrett’s surveillance	- Increasing frequency of performing Barrett’s surveillance improves skills	Skills Knowledge	Physical capability Automatic motivation	-Training in Barrett’s surveillance should include focus on tip control and lesion recognition in UGI endoscopy -Improve access to UGI specialist trainers -Credentialling in Barrett’s surveillance like Bowel cancer screening	Interpersonal	Training and education Modelling
- Lack of standardisation of Barrett’s audit and credentialling	- Guidelines providing a framework for behaviour and reassurance of quality of care being provided	Motivation Behaviour regulation Reinforcement	Reflective motivation Automatic motivation Psychological capability	-Continue to maintain regular updates on Barrett’s surveillance guidelines to support endoscopists’ behaviour -Key performance indicators e.g. oesophageal withdrawal times, completion of Seattle protocol -Audit Barrett’s practice, dysplasia detection and post endoscopy cancers	Interpersonal Organisational	Education Incentivisation Restrictions Coercion
- Negative emotion regarding completion of Barrett’s surveillance endoscopy - Workload burden for endoscopists		Emotions Behaviour regulation Environmental context	Reflective motivation Automatic motivation Psychological capability Physical capability	-Reduce the burdensome aspects of surveillance – e.g. AI-assisted lesion recognition -Adequate scheduled time for procedures - Dedicated Barrett's endoscopy lists ring-fenced away from other tasks -Wider issues of workload in the health service	Intrapersonal Organisational	Enablement Incentivisation Environmental restructuring Restrictions

Conclusion

The findings of this study provide potential targets for intervention studies which may improve Barrett’s surveillance practice through facilitating behaviour change. Intra and interpersonal factors such as training and education are vital, but the real challenge may be the organisational shift from high turnover to a quality-centred approach for Barrett’s endoscopy. As a complex care intervention, clinician behaviour is one aspect in a multifaceted care pathway which can be improved.

References

1) van Putten M, Johnston BT, Murray LJ, et al. ‘Missed’ oesophageal adenocarcinoma and high-grade dysplasia in Barrett’s oesophagus patients: A large population-based study. United Eur Gastroenterol J. Published online 2018. doi:10.1177/2050640617737466
2) Atkins L, Hunkeler EM, Jensen CD, et al. Factors influencing variation in physician adenoma detection rates: A theory-based approach for performance improvement. Gastrointest Endosc. Published online 2016. doi:10.1016/j.gie.2015.08.075
3) Michie S. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005;14(1):26-33. doi:10.1136/qshc.2004.011155
4) Michie S, Atkins L, West R. The Behaviour Change Wheel: A Guide to Designing interventions$Susan Michie; Lou Atkins; Robert West. Silverback Publishing; 2014

Disclosure

Funding for this study was obtained from Medtronic Ltd ref number ERP-2019-11987. Medtronic Ltd had no input to the study design or undertaking of the study itself.

Event

UEG Week Vienna 2024

Topics

Endoscopy Histopathology Oesophagus

Submission format

Abstract

Session

Barrett's oesophagus: Treatment and surveillance

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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THE IMPLEMENTATION OF A NEW TYPE OF MERGING ANALYSIS REVEALS THE DYNAMIC INTERACTIONS BETWEEN BACTERIA AND FUNGI IN THE LOWER GASTROINTESTINAL TRACT

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