Introduction

Post endoscopy upper gastrointestinal cancer (PEUGIC) is an important key performance indicator of endoscopy quality. PEUGIC rates vary more than threefold between endoscopy providers in England.

Aims & Methods

We examined differences in endoscopy practices between providers with the highest and lowest PEUGIC rates to identify factors which can potentially be addressed to improve endoscopy quality in England. PEUGIC rates were calculated for all endoscopy providers in England using the National Cancer Registration and Analysis Service and Hospital Episode Statistics databases. Endoscopy providers were categorised into quartiles based on their PEUGIC rates and those in the highest and lowest quartiles were included in this study. Data for all diagnostic UGI endoscopies performed in these providers between January 2019 and February 2020 were extracted from the National Endoscopy Database (NED). Multivariable regression analysis was performed to identify endoscopy practices associated with low PEUGIC rate providers, after adjusting for patient characteristics and indications.

Results

330,851 endoscopies performed at 60 endoscopy providers were included. UGI cancers were diagnosed on 0.9% (n=3,071) of endoscopies. PEUGIC rates ranged from 5.1% to 7.6% in the low PEUGIC rate providers and 9.3% to 13.0% among high PEUGIC rate providers. Low PEUGIC rate providers were associated with: training lists (Odds Ratio 2.31 (95% CI 2.26-2.36)); more high risk endoscopy indications (alarm features or patients ≥55 years of age) (1.08 (1.06-1.1)); intravenous sedation use (1.24 (1.22-1.26)); endoscopists with an average UGI endoscopy annual volume of 101-200 (1.10 (1.07-1.12)), compared with <100; and endoscopy lists with 7 to 9 points per list (1.23 (1.21-1.25)). Compared with Midazolam alone, use of combined sedation (Midazolam and Fentanyl) was also more common among low PEUGIC rate providers (1.17 (1.15-1.19)). Endoscopies at low PEUGIC rate providers were less likely to be performed by endoscopists not on specialist, nursing or trainee registers (0.88 (0.85-0.90) and biopsies (other than Helicobacter testing) were less common (0.83 (0.81-0.84).

Conclusion

In the National Endoscopy Database, formal training, more high-risk endoscopy indications, endoscopist annual endoscopy volume, intravenous sedation, less biopsies and lower intensity endoscopy lists were associated with low PEUGIC rate providers. These findings can guide endoscopy quality improvement efforts and hopefully reduce PEUGIC rate in future.

Introduction

The development and validation of non-invasive fibrosis tests have transformed clinical practice in hepatology in recent years. Metabolic-associated fatty liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is currently the most prevalent liver disease.
In this study, our aim was to evaluate the utility of non-invasive tests in the diagnosis and staging of fibrosis in type 2 diabetic (T2D) patients with hepatic steatosis.

Aims & Methods

This was a prospective cross-sectional study that included 122 T2D patients over a 10-month period. Hepatic steatosis was confirmed by abdominal ultrasound or a FLI score >=60. We used non-invasive tests including the serum marker FIB-4, transient elastography FibroScan®, and the combined Agile -3 score.
Interpretation of the scores was as follows:
For FIB-4, < 1.3 indicated a low risk of advanced fibrosis, 1.3–2.67 indicated an intermediate risk of advanced fibrosis, and > 2.67 indicated a high risk of advanced fibrosis. For FibroScan, minimal or absent fibrosis (F0-F1) was defined by a LSM value <8 kPa, moderate hepatic fibrosis (≥F2) by a LSM value between 8-9.6 kPa, and advanced fibrosis by a hepatic elasticity LSM >9.6 kPa. For the Agile -3 score, a value < 0.451 excluded advanced fibrosis (F3) and a value >= 0.679 confirmed advanced fibrosis (F3).

Results

The average age was approximately 60 years with a female predominance. The FIB-4 score ranged from 0.311 to 4.01, with an average of 1.0881. 73.77% of patients had a FIB-4 indicating no fibrosis. 2.45% had advanced fibrosis, and 23.77% were in an indeterminate FIB-4 score range. The FIB-4 score had a positive predictive value (PPV) of 42.86% and a negative predictive value (NPV) of 77.23% for detecting significant fibrosis. Regarding advanced hepatic fibrosis, FIB-4 had a PPV of 45.45% and an NPV of 75.67%. Hepatic elasticity ranged from 1.5 to 75 kPa with an average of 6.62 kPa. 82.78% had no fibrosis, 8.19% had significant fibrosis, and 9.01% had advanced fibrosis. To reduce the grey zone, we calculated the AGILE-3 score, which was observed in a range from 0.03 to 1. It reduced the grey zone by up to 40%. Among the 10 patients in the grey zone on FibroScan, 3 were reclassified to fibrosis F3 by the AGILE-3 score, 4 remained in the grey zone, and 3 were reclassified to absent or minimal fibrosis.

Conclusion

The implementation of approaches using non-invasive tests is generally a promising strategy in the management of MASLD in primary care, providing clinically effective and cost-effective pathways to identify patients at risk of advanced fibrosis and streamline referrals to secondary care, subsequently benefiting from accurate risk assessments without the need for liver biopsies. Our study suggests the sequential use of non-invasive tests, starting with FIB-4 which, according to our study, has an NPV of over 75% to rule out advanced or significant fibrosis, followed by sequential use of FibroScan and Agile 3+ score to better reduce the grey zone, , hence limiting the need for liver biopsy.

References

Sanyal AJ, Foucquier J, Younossi ZM, Harrison SA, Newsome PN, Chan WK, et al. Enhanced diagnosis of advanced fibrosis and cirrhosis in individuals with NAFLD using FibroScan-based Agile scores. Journal of Hepatology. 1 févr 2023;78(2):247‑59.
Ma X, Zhu Y, Yeo YH, Fan Z, Xu X, Rui F, et al. The impact of an increased Fibrosis-4 index and the severity of hepatic steatosis on mortality in individuals living with diabetes. Hepatol Int [Internet]. 22 janv 2024 [cité 21 avr 2024]; Disponible sur: https://doi.org/10.1007/s12072-023-10625-7