Introduction

According to Chicago Classification version 4.0 a diagnosis of absent contractility and esophagogastric junction outflow obstruction (EGJOO) during high-resolution manometry (HRM), are both considered inconclusive diagnoses of achalasia, thus requiring presence of relevant symptoms such as dysphagia, and additional supportive tests, including timed barium esophagram (TBE) or functional lumen imaging probe (FLIP), in order to confirm the presence of achalasia and treat accordingly.

Aims & Methods

Aim: To evaluate the clinical utility of TBE and FLIP to further confirm diagnosis of achalasia in patients with inconclusive diagnosis of achalasia per HRM.
Methods: We conducted a retrospective study in patients referred for evaluation of dysphagia from December 2021 until December 2022 . Patients completed an upper gastrointestinal endoscopy and HRM per Chicago classification v.4.0. Those patients with an inconclusive diagnosis of achalasia during HRM, either absent contractility or EGJOO, followed by additional assessment with TBE and/or FLIP were included. Patients with anatomic lesions of the esophagus (i.e Schatzki ring, esophageal diverticula), esophageal surgery and chest radiotherapy were excluded.

Results

A total of 101 consecutive patients were referred for evaluation and 29 patients were included for analysis. Median age was 71 (p=0.58) and 65.51% of the patients were female (p=0.1). Of the 29 patients who had an HRM diagnosis of inconclusive achalasia, 55.17 % had absent contractility and 44.82% were diagnosed with EGJOO. After completing a TBE, 28.68 % of those patients had an abnormal result (delayed TBE). There was a significant correlation between an inconclusive diagnosis of achalasia per HRM and delayed TBE (OR 3.83 95 % CI [1.36-10.79], p=0.001). Furthermore, diagnosis of EGJOO was significantly correlated with esophageal stasis and delayed TBE (p=0.025). Additionally, we found a significant correlation between inconclusive diagnosis of achalasia and confirmation of achalasia with FLIP in one patient (p=0.0008). All patients were referred for achalasia-treatments.

Conclusion

Patients classified as inconclusive diagnosis of achalasia during HRM benefit from additional supportive testing with TBE to confirm the presence of achalasia, therefore, provide treatment.

Introduction

In the southwest Netherlands, hospitals collaborate to provide high quality, uniform care for inflammatory bowel disease (IBD). To achieve this, a care pathway (CP) was implemented for treating IBD with biologics and small molecules (1). The CP consists of protocols addressing different stages in IBD treatment, such as initiation and switching of therapy, frequency and type of follow-up. This study assessed the adherence to the CP and identified barriers and facilitators to its implementation.

Aims & Methods

A mixed-methods study was conducted. Quantitative data was used to evaluate the adherence to different protocols of the CP and was collected retrospectively from electronic health records (EHRs) from December 2020 until March 2023. Surveys and semi-structured interviews were used to identify barriers and facilitators, using the Extended Normalisation Theory. Surveys were sent to all healthcare providers and interviews were conducted with gastroenterologists, IBD-nurses, healthcare assistants, and IT-personnel.

Results

A total of 299 patients were included. Adherence to the CP regarding the documentation of travel plans and vaccination status improved after implementing the CP (15% pre-implementation vs. 33% post-implementation), as well as written communication with general practitioners (31% vs. 83%) and body weight registration (12% vs. 50%). Among patients switching medication, 25% had a repeated screening for HIV, tuberculosis, and hepatitis B and C documented if prior tests were over a year old. Post-implementation, scheduling outpatient visits were more closely aligned with CP recommendations across CP protocols (57% vs. 100%), as did blood test ordering (10% vs. 44%). Disease activity scoring with validated questionnaires remained low (7% vs. 21%).  Adherence to registering medication adherence, current smoking status, and side effects during annual outpatient visits remained low (18% vs. 40%).
Of 85 surveys, 42 were completed, and 11 interviews were conducted. Facilitators were improving collaboration between healthcare providers and the potential to standardise care. Barriers included the complexity of the use in EHRs, difficulty for healthcare providers to change their current routine, and the heterogeneity of IBD.

Conclusion

A CP for the treatment of IBD with biologics and small molecules has been implemented to improve IBD care, however, adherence appears to be challenging, partially contributed to the difficulty healthcare providers experience in changing their behaviour. The gradual improvement indicates that increased familiarity with the CP may enhance adoption. Discrepancies between performed and documented tasks in EHRs may also contribute to lower adherence rates, which could be improved by audit and feedback sessions.

References

1. van Linschoten R, van Leeuwen N, Nieboer D, Birnie E, Scherpenzeel M, Verweij KE, et al. Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period. (2044-6055 (Electronic))

Disclosure

Drs. Visser received speaker fees from Lilly outside the submitted work. Prof. Dr. van der Woude reports grants from Pfizer and Janssen and personal fees from AbbVie and Celltrion outside the submitted work. Dr. van Noord reports personal fees from Janssen, Takeda, and Falk outside the submitted work. Dr. West reports personal fees from AbbVie, Janssen, and Pfizer outside the submitted work.