Quality indicators in Barrett's endoscopy: Best is yet to come

Abstract

There is growing interest in establishing quality indicators (QIs) for endoscopic screening and surveillance in Barrett's esophagus (BE). QIs are objective, measurable, and evidence‐based metrics that are applicable in a health‐care setting to monitor a process and identify key performance indicators (KPIs) to achieve defined goals. In the Barrett's endoscopy setting, QIs can offer a standardized approach to monitor and maintain high‐quality endoscopy for BE screening and surveillance that will allow measuring performance of an endoscopist as an individual, a group, or a facility. Since BE is an endoscopically identifiable premalignant condition with histological corroboration, adherence to QIs is paramount for the early and accurate detection of dysplasia and neoplasia. It is the holy grail for BE screening and surveillance. Although several suggested QIs for Barrett's endoscopy exist, issues remain in determining the most appropriate ones. These issues include inconsistent use of terminology, unclear definitions, and a scarcity of studies linking these QIs with relevant patient outcomes, making it difficult for clinicians to understand the concept and clinical importance. Hence, there is an urgent need to determine what should constitute appropriate QIs for Barrett's endoscopy, clearly define items used in the QIs, and identify ways to measure these KPIs. Ultimately, well‐defined and validated QIs will contribute to clinically effective, safe, timely, and patient‐focused care. In this review, we summarize recent literature and discuss four proposed QIs: (i) neoplasia detection rate; (ii) postendoscopy Barrett's neoplasia; (iii) Barrett's inspection time; and (iv) adherence to the Seattle biopsy protocol.

INTRODUCTION

Barrett's esophagus (BE) is a premalignant condition that arises from the partial replacement of the normal squamous epithelium of the esophagus with the columnar epithelium containing goblet cells, typically caused by long‐term acid reflux. BE progresses through the stages of low‐ and high‐grade dysplasia (LGD and HGD) before becoming esophageal adenocarcinoma (EAC), an aggressive cancer with a poor prognosis (5‐year survival rate of <25%). ¹ , ² BE length is classified as long segment (≥3 cm) or short segment (<3 cm) measured from the gastro‐esophageal junction. Patients with BE are advised to undergo long‐term endoscopic surveillance based on length and dysplasia grade to reduce the risk of developing EAC. ³ Over the last four decades, the incidence of EAC has rapidly increased fivefold in developed countries, implying that the incidence of BE may have also increased substantially because almost all cases of EAC arise from BE. ⁴ , ⁵ Currently, it is not possible to predict who will develop EAC arising from BE.

The fundamental purpose of endoscopic screening and surveillance for BE is to detect dysplastic and neoplastic changes as early and accurately as possible. A recent systematic review that included 11 studies with 59,795 patients by Desai et al. ⁶ has shown that more than 90% of HGD/EAC were detected either at or within 6 months after the index endoscopy. Therefore, high‐quality Barrett's endoscopy is crucial, especially for the first examination, as it enables early and accurate detection of HGD/EAC. This, in turn, will enable minimally invasive endoscopic treatment, thus avoiding a major surgery or missing the opportunity to treat EAC with a curative intent. As such, there is growing interest in establishing quality indicators (QIs) in endoscopic screening and surveillance for BE to improve the detection rate of HGD and EAC, thereby optimizing patient outcomes and health‐care practices. In colonoscopy settings, QIs for surveillance and screening of colorectal polyps have been extensively studied and validated, demonstrating their effectiveness in reducing the incidence and mortality from colorectal cancer (CRC).

By contrast, several QIs for Barrett's endoscopy are suggested, but none have reached a consensus yet. This is due to the scarcity of studies investigating QIs relevant to patient outcomes. In this review, we aimed to summarize recently published articles by outlining the suggested QIs and discussing the challenges they pose. We also deliberated on key priority topics for future research.

DEFINING AND MEASURING QUALITY

Today, upper gastrointestinal (UGI) endoscopy is a common and safe procedure used to survey, diagnose, and treat various diseases in the esophagus, stomach, and duodenum, leading to its increasing global usage. Each year, it is estimated that approximately 6.1 and 1.2 million UGI endoscopies are performed in the United States and the UK, respectively. ⁷ , ⁸ Considering this frequency, several organizations and professional societies in gastroenterology suggested that QIs for UGI endoscopy should be developed, enabling the evaluation of endoscopist performance and patient outcomes. ⁹

However, the term QI is not always straightforward for clinicians, since similar terms, including quality control, quality assurance, quality metrics, quality improvement, quality measure, and quality management, are often used with similar definitions. The interpretation of the term “quality” can also vary among individuals, especially when determining what constitutes “high quality.” This term has been used in business and can be defined as a measure of conformance to customer expectations or requirements when purchasing products or receiving services. ¹⁰ In other words, it can be reflected as a performance indicator on the provider side. While everyone agrees on the importance of quality, the most challenging question is what, when, and how to measure quality.

Desai and Sharma described “quality” in Barrett's endoscopy as the “degree of goodness of endoscopy.” ¹¹ They suggested three pivotal facets that are essentially quality measurements: (i) meticulous examination; (ii) appropriate and effective sampling; and (iii) recommending appropriate surveillance intervals. These quality measures can be linked to several QIs (Table 1). Since the primary expectation of patients with BE is to undergo Barrett's surveillance as a safety net against EAC, QIs should be associated with reducing mortality from EAC by detecting and treating dysplasia and early neoplasia. These QIs will then attest to the goodness of Barrett's endoscopy performed by all endoscopists. Here, we discuss four QIs to measure “the degree of goodness” in Barrett's endoscopy: (i) neoplasia detection rate (NDR), (ii) postendoscopy Barrett's neoplasia (PEBN), (iii) Barrett's inspection time, and (iv) adherence to the Seattle biopsy protocol. The QIs listed above were chosen because they are measurable, reviewable over a period of time, and indicative of patient outcomes.

Table 1.

Quality measures and quality indicators in Barrett's endoscopy

Quality measure	Quality indicator
Meticulous examination	Use of HD +/− magnification endoscopy Use of mucosal cleansing agents (e.g. simethicone, pronase, N acetyl cysteine) Prague classification and recording anatomical landmarks Use of advanced imaging techniques Image capture and photo documentation NDR PEBN Inspection time
Biopsy sampling	Adherence to Seattle protocol
Recommended surveillance intervals	Adherence to Societal guidelines

HD, high definition; NDR, neoplasia detection rate; PEBN, postendoscopy Barrett's neoplasia.

NEOPLASIA DETECTION RATE (NDR)

Neoplasia detection rate is one of the most emphasized QIs for Barrett's endoscopy. The definition of NDR is the percentage of patients with BE who were histologically confirmed to have HGD or EAC within BE at index endoscopy. A higher NDR indicates a higher rate of detecting neoplasia during surveillance, which is desirable, as it allows for timely intervention and improved patient outcomes. Recent reported NDRs have ranged from 4.9% to 7.0%. ⁶ , ¹² , ¹³ , ¹⁴ This measurement was developed akin to the concept of the adenoma detection rate (ADR) in colonoscopy, which reflects the quality and effectiveness of the examination. ADR is a percentage of colonoscopic examinations where polyps (adenomas) were detected in comprehensive examinations. It is now an established QI, with previous studies confirming that a higher ADR is associated with a reduced risk of postcolonoscopy colorectal cancer (PCCRC) and mortality. While ADR has gained universal consensus, NDR has not gained much attention.

Issues with NDR as a QI

A possible reason for nonconsensus could be that the calculation of the NDR is unclear, preventing the recognition of its clinical importance. There are several publications on NDR, but most of them state only the numerator, not the denominator. As above, NDR can be computed by dividing the number of BE patients with histologically confirmed HGD or EAC detected at index endoscopy (numerator) by the total number of patients with histologically confirmed BE (including nondysplasia, LGD, HGD, and EAC) identified at index endoscopy (denominator). The term, “index endoscopy” is used to define the endoscopy procedure when BE was first diagnosed.

While the published NDRs vary as mentioned above, Dhaliwal et al. ¹⁴ specifically outlined the NDR by pathological grade in their large US population‐based retrospective cohort study of 1066 patients with historically confirmed BE over the last 28 years. It was approximately 3.1% (95% confidence interval [CI] 2–4%) in patients with HGD and 1.8% in those with EAC. ¹⁴ These recent reviews, however, showed considerably high heterogeneity (I ² ≥96% for all reviews) among included studies, suggesting that the studies were clinically and methodologically different from each other. ¹⁵ These differences may be caused by study design, definition, the volume of endoscopic examination at each site, and/or the absence of experienced endoscopists with a particular interest in BE. The authors of these studies have acknowledged these points, and the results should be interpreted cautiously.

Unlike ADR, which has shown a valid inverse association between ADR and CRC mortality, NDR is not straightforward to determine such an association with EAC mortality. The vast majority of patients with BE do not die of EAC. On the other hand, over 80% of patients presenting with symptomatic EAC have never been diagnosed with BE. ¹⁶ It is well known that up to 40% of patients with BE do not have troubling reflux symptoms and would never come to the attention of doctors or have an endoscopy to diagnose BE and undergo regular surveillance. ¹⁷ Several studies have shown that patients with BE are likely to have EAC at the index endoscopy rather than during subsequent surveillance. Unless all or most patients with BE are identified and undergo screening endoscopy, it is unlikely that there will be reduction in the EAC incidence and mortality. Currently, not all patients with BE are identified and undergo surveillance, leading to an imprecise denominator with a perhaps overestimation of NDR. Essentially, the denominator for NDR has to be precisely determined. A simple, noninvasive, and cost‐effective screening program for BE is crucial to address this problem.

Despite these limitations, NDR and the development of Barrett's neoplastic lesions may have an inverse relationship. In a systematic review that analyzed 10 studies of 27,894 patients, Hamade et al. ¹³ showed that for every 1% increase in the NDR, there was a 3.5% reduction in Barrett's neoplastic lesion identified in the postfollow‐up endoscopy. This study has been the only one to currently demonstrate the inverse relationship, but this finding has not yet been supported by other studies.

Future studies

Future studies should focus on how we could improve the certainty of NDR given the current limitations. A few studies have reported that the NDR for general endoscopists could be significantly greater in those who received focused training in Barrett's endoscopy compared to those who did not. ¹⁸ , ¹⁹ , ²⁰ The impact of an effective standardized training program in Barrett's endoscopy needs further exploration. Robust studies investigating the association between NDR and EAC mortality using a large linked or prospectively collected dataset will make the NDR a more reliable QI.

POSTENDOSCOPY BARRETT'S NEOPLASIA (PEBN) RATE

Postendoscopy Barrett's neoplasia is another recently suggested QI based on a similar concept as PCCRC. The PEBN rate can be calculated by dividing the number of patients with EAC found within a certain period after a negative index UGI endoscopy (numerator) over the number of patients with BE who were identified with EAC subsequently up to 3 years (denominator). Some studies referred to the PEBN as the “missed rate” when EAC or HGD was found on subsequent endoscopy after index endoscopy that histologically showed no evidence of dysplasia or neoplasia. ¹⁴ , ²¹ , ²²

Issues with PEBN as a QI

An issue with PEBN is that it uses an inconsistent definition in terms of the “postendoscopy periods” after index endoscopy (Table 2). The latest American Gastroenterological Association clinical practice update states that this period should be within the first 6 months after an index endoscopy with negative histology results. ²³ However, an aforementioned review by Hamade et al. ¹³ and another systematic review that analyzed 52 studies of 145,726 patients by Sawas et al. ²⁴ used the longer postendoscopy period of 1 year. Moreover, in a recent large population‐based retrospective cohort study that included 50,817 patients, Vajravelu et al. ²⁵ defined this period as between 30 and 365 days after index endoscopy that had negative histology results for EAC. In contrast, Desai et al. ⁶ considered the PEBN to be the cases of BE neoplasia found within 7–36 months after index endoscopy in which no EAC was detected histologically according to the PCCRC concept.

Table 2.

Postendoscopy Barrett’ neoplasia (PEBN) rate and its definition among the recent studies

Author (year)	Definition	PEBN rate (%) (95% CI)	Difference to the AGA guidelines
AGA	Barrett's neoplasia was detected within the first 6 months after an index endoscopy with histological results of no EAC	NA	NA
Visrodia et al. (2016) 22	EAC detected within 1 year after an index endoscopy with negative histology results for EAC	25.3 (16.4–36.8)	Different time period
	EAC detected within 1 year after an index endoscopy with nondysplastic BE	23.9 (13.5–35.4)	Different cohort
Hamade et al. (2021) 13	HGD/EAC detected on a repeated endoscopy within 1 year after an index endoscopy with negative histology results for EAC/ HGD	19.6 (10.1–34.7)	Different inclusion criteria and time period
Desai et al. (2022) 6	EAC arising from BE detected at an index endoscopy (a) or within the first 6 months thereafter after a negative index endoscopy (b) (prevalent)	(a) 4.5 (2.2–8.9) (b) 0.3 (0.1–0.7)	Different time period
	EAC arising from BE detected between 7 and 36 months after a negative index endoscopy (interval)	0.52 (0.46–0.58)	Different time period
Sawas et al. (2022) 24	EAC detected within 1 year after an index endoscopy with negative histology results for EAC	21 (13–31)	Different time period
	EAC/HGD detected within 1 year after an index endoscopy with negative histology results for EAC/HGD	26 (19–34)	Different inclusion criteria and time period
	EAC detected within 1 year after an index endoscopy with nondysplastic BE	17 (11–23)	Different cohort
Vajravelu et al. (2022) 25	EAC detected within 30–365 days after an index endoscopy with negative histology results for EAC	21 (13–31)	Different time period

AGA, American Gastroenterological Association; BE, Barrett's esophagus; CI, confidence interval; EAC, esophageal adenocarcinoma; HGD, high‐grade dysplasia; NA, not applicable.

The different periods used in these studies confuses the definition of this QI and makes it harder to directly compare the PEBN rates. Desai et al. ⁶ argued that many repeat‐endoscopies performed within 6 months of the previous endoscopy were often associated with findings of the previous endoscopy. Indeed, patients with BE often present with coexistent esophagitis, peptic ulcer disease, gastrointestinal bleeding, and/or other conditions like anticoagulation, wherein detailed esophageal examination and biopsy sampling might have been suboptimal. In such conditions, UGI endoscopy is usually repeated within 6 months to optimize and adequately examine the Barrett's segment. Desai et al. ⁶ also insisted that a dysplasia or neoplasia found during this period is not an oversight, and should still be considered a finding of the same period as at index endoscopy. Hence, the “postendoscopy” period could be 6 months after index endoscopy in which there was no histology report of diagnosing dysplasia or neoplasia. ⁶

In addition to the different timeframe of the postendoscopy, the numerator for calculating the PEBN differs across studies. For example, Desai et al. ⁶ included those who developed EAC, while Hamade et al. ¹³ included those with HGD as well as EAC. Sawas et al. ²⁴ calculated the PEBN in two ways: postendoscopy EAC and postendoscopy EAC/HGD. The overall rates for these outcomes were 21% (95% CI 13–31%) based on the data from 32 studies and 26% (95% CI 19–34%) from 42 studies, respectively. ²⁴ When specifically focusing on the nondysplastic BE cohort, the postendoscopy EAC rate was 17% (95% CI 11–23%) from eight studies and the rate of postendoscopy EAC/HGD was 14% (95% CI 8–19%) from 10 studies. ²⁴

Although it is difficult to set the baseline PEBN rate due to the different definitions in use, the study by Sawas et al. ²⁴ importantly found a significant inverse relationship between PEBN rate and EAC incidence by meta‐regression analysis. While providing new insights, this study also showed substantial heterogeneity among included studies (I ² ≥86.5% for 32 studies of postendoscopy EAC and I ² ≥93.4% for 42 studies of postendoscopy EAC/HGD). ²⁴

Future studies

Different inclusion criteria, periods, terminology, and definitions of PEBN across the studies precludes direct comparison between studies, let alone the PEBN rates. Accordingly, an accurate evaluation of this QI will be difficult to draw a conclusion and merely cause confusion. Further studies and consensus should focus on determining the appropriate time period of postendoscopy and analyzing the association between the PEBN rate and mortality from EAC.

BARRETT'S INSPECTION TIME

Inspection time is the time spent inspecting the Barrett's segment. Similar to colonoscopy withdrawal time, spending sufficient time to inspect the Barrett's segment is critical for increasing the detectability of dysplasia and neoplasia. This QI may indicate how thoroughly and carefully the endoscopic examination was performed by an endoscopist, suggesting it may become a predictor of the NDR.

Issues with inspection time as a QI

To date, two studies have reported the association of the detectability of BE dysplasia and neoplasia with the inspection time. Gupta et al. ²⁶ investigated the association between inspection time and the detection rate of HGD/EAC by post‐hoc analysis of data from a multicenter clinical trial of 122 patients. This study showed that patients who had a longer inspection time were associated with increased detectability of HGD/EAC (P = 0.001). ²⁶ This association remained significant even after excluding the cases with endoscopically evident suspicious lesions. Specifically, the proportion of patients diagnosed with HGD/EAC in the whole cohort increased significantly with a longer inspection time (≤2 min, 15%; 3–4 min, 32.3%; 5–6 min, 46.4%; ≥7 min, 69.2%; P = 0.001). ²⁶ Furthermore, a longer inspection time yielded a better identification of suspicious lesions (≤2 min, 30%; 3–4 min, 35.5%; 5–6 min, 82.1%; ≥7 min, 84.6%; P < 0.001). ²⁶ These findings suggested that a longer inspection time for BE may result in improved detection of lesions. Based on these results, in 2016 the UGI working group of the European Society of Gastrointestinal Endoscopy Quality Improvement Initiative recommended that the inspection time for Barrett's endoscopy should be at least 1 min per cm of Barrett's segment. ²⁷ This guideline recommended that the proportion of Barrett's surveillance endoscopies that spent more than 1 min per 1 cm of Barrett's segment among all Barrett's surveillance endoscopies should be greater than 90% as a target. ²⁷ Recently, another study by Vithayathil et al. ²⁸ investigated inspection time by a prospective cross‐over randomized controlled trial of 142 patients with BE segment of ≥C2 and/or ≥M3 without known visible dysplastic lesions. The results from the post‐hoc data analysis revealed a median inspection time of ~14.0 min for a BE length of 2–5 cm, 17.0 min for 6–10 cm, and 22.0 min for 11 cm, with a median of 16.5 min for an average length of 5.6 cm. ²⁸ The study found that the duration of the total endoscopy significantly increased by 0.9 min for each cm increase in BE length (P < 0.001). ²⁸ Further, a longer procedural time was associated with an increased likelihood of dysplasia diagnosis in quadratic biopsies and in patients with BE length >6 cm also in targeted biopsy. ²⁸

Both the studies were post‐hoc analyses of an imaging study in BE. The evidence is still limited on the recommended inspection time. Further, a uniform definition of inspection time needs to be determined, as the two studies above differed in the way the Barrett's inspection time was calculated. While one study used the total endoscopy time from the insertion to extubation, ²⁸ the other measured precisely the start and end of the Barrett's segment inspection ²⁷ (Table 3).

Table 3.

Recent studies with the definition and recommendation of Barrett's inspection time

Author (year)	Definition	Recommendation	Difference to the ESGE UGI guidelines
Gupta et al. (2012) 26	The time from the start of the BE segment inspection to the completion of the segment inspection	An inspection time of 1 min per cm of BE segment resulted in increased detection of BE neoplasia	Different definition
Bisschops et al. (2016) 27	The time from the start of the BE segment inspection to the completion of the segment inspection	At least 1 additional min per cm of BE segment	NA
Vithayathil et al. (2023) 28	The time from the endoscope insertion to extubating from a patient	Increased endoscopy time by 0.9 min for an additional 1 cm of BE length	Different definition

BE, Barrett's esophagus; ESGE, European Society of Gastrointestinal Endoscopy; NA, not applicable; UGI, upper gastrointestinal.

Future studies

These studies suggested that, on average, one additional minute per 1 cm of BE segment is essential to increase the detectability of dysplasia and neoplasia. This QI needs further confirmation in multicenter randomized control trials with a standardized definition performed by endoscopists of varying experience to confirm its validity and reproducibility.

ADHERENCE TO SEATTLE BIOPSY PROTOCOL

Most international clinical guidelines have recommended the Seattle protocol as the standard endoscopic biopsy sampling technique for BE. ²⁹ , ³⁰ This protocol involves systematic 4‐quadrant biopsies every 1–2 cm of the entire length of the BE, starting at the gastro‐esophageal junction. This is also called the random biopsy, although from a purist point of view this is not entirely random, rather a systematic biopsy in the absence of a visible abnormality to target. Since biopsy techniques could affect the accuracy of the diagnosis, grading of dysplasia, and staging of neoplastic lesions, its quality is crucial to minimize sampling error.

A Scottish retrospective cohort study showed higher detection rates of LGD and HGD with compliance to the Seattle protocol compared to noncompliance (18.9% vs. 1.6% for LGD, P < 0.001; 2.8% vs. 0% for HGD, P = 0.03). ³¹ In an 8‐year prospective cohort study of 340 patients, the Seattle protocol identified significantly more cases of dysplasia, particularly LGD, compared to targeted biopsy with image‐enhanced endoscopy (IEE). ³² Another recent retrospective comparative study of the sampling technique in the UK involving 222 patients demonstrated that systematic 4‐quadrant biopsy detected 73% of LGD, HGD, and early EAC cases, while targeted biopsy with IEE detected only 27% (P < 0.001). ³³ These studies have suggested that, currently, there is no substitute to this suggested QI to benchmark biopsy sampling techniques in Barrett's endoscopy. Although IEE increases the potential to detect dysplasia and neoplasia, still there is no evidence to discontinue the Seattle protocol in routine clinical practice.

Issues with adherence to Seattle biopsy protocol as a QI

Although the Seattle protocol recommended systematic biopsy sampling for BE, there is an issue of low adherence to this protocol. Wani et al. ³⁴ reported that ~20% of endoscopies did not adhere to the Seattle protocol based on retrospective data from 53,541 patients with past or present BE who underwent UGI endoscopy in the United States. This study found that the longer the Barrett's segment, the less likely it was to adhere to the Seattle protocol, with an increase of 31% of nonadherence for every 1 cm of the segment (odds ratio 0.69, 95% CI 0.67–0.71). ³⁴ A systematic review and meta‐analysis, including 56 studies, by Roumans et al. ³⁵ presented that only 49% of endoscopies adhered to the Seattle biopsy protocol recommended by the US clinical guidelines. Another recent prospective study in the UK investigating adherence rate to the Seattle protocol recommended by the UK guidelines compared endoscopists who specialized in BE with those who did not. ³⁶ They reported that the adherence rate of the Seattle protocol is significantly higher in those with a particular interest in BE than in those without (72% vs. 42%, P < 0.0001). ³⁶ This adherence rate (72%) was also higher than that from the previously reported surveillance data (50%) (P < 0.0001). ³⁶

Among Asian endoscopists, targeted biopsies with IEE are often preferred, while systematic 4‐quadrant biopsies are less practiced, with only 30% adherence among those specializing in BE. ³⁷ This preference might be due to the emphasis on IEE and the challenges of obtaining multiple biopsies from short segment BE (SSBE) frequently observed in Asia. ³⁸ However, targeted biopsies alone may not effectively detect LGD, even with the use of IEE.

A systematic review and meta‐analysis on targeted biopsy guided by IEE for dysplasia detection in BE reported a relatively low sensitivity of 0.60 (95% CI 0.11–1.00) and a high specificity of 0.98 (95% CI 0.95–1.00) for LGD detection. ³⁹ However, for HGD detection the results showed both a high sensitivity of 0.83 (95% CI 0.73–0.93) and specificity of 0.99 (95% CI 0.99–1.00). ³⁹ These results indicated that reliance on targeted biopsy alone may miss dysplasia in some patients, especially those with LGD. Dysplasia in BE are often subtle and patchy, making it difficult to spot endoscopically. ⁴⁰ Even for endoscopists who specialize in BE, only 50% of cases were detected by targeted biopsy. ³¹ If patients with LGD in SSBE go undetected, their next surveillance endoscopy would be scheduled after 3–5 years, potentially resulting in progression from LGD to HGD/EAC. Current clinical guidelines from the United States, Europe, Australia, and the UK, therefore, recommended treating patients with LGD to mitigate the risk of this progression. ³⁰ , ⁴¹ , ⁴² , ⁴³ Adhering to systematic 4‐quadrant biopsies along with targeted biopsies will improve the detection of dysplasia, including LGD, enabling timely intervention, appropriate management, and improved patient outcomes.

Future studies

The use of the standardized Seattle biopsy protocol is an essential benchmark to assess endoscopist performance. At present, the adherence to guidelines is suboptimal, especially in nontertiary centers and non‐Barrett's specialist endoscopists. Further research should prioritize the development of education tools and interventions that promote adherence to the Seattle biopsy protocol by all endoscopists.

OTHER ASPECTS

While our review primarily addressed four specific QIs directly related to endoscopy, it is important to note that there are other aspects, including risk stratification that requires further discussion. Risk stratification is an essential component when addressing the effectiveness of an intervention. In the case of BE, its purpose is to identify individuals at a higher risk of developing EAC by categorizing them based on specific characteristics or factors associated with neoplasia progression. This categorization facilitates clinical decision‐making, treatment planning, and resource optimization. On the other hand, QIs are measures used to assess the quality of health‐care delivery and outcomes by examining the processes, structures, and outcomes of health‐care services to determine the level of quality provided. Therefore, risk stratification itself may not be considered a QI of Barrett’ endoscopy at the moment due to the absence of a direct association with mortality. Nevertheless, risk stratification helps endoscopists to identify high‐risk patients who may require additional interventions, closer monitoring, or tailored treatment plans, thereby indirectly impacting QIs. Incorporating risk stratification as a QI can be considered if adherence to risk stratification by endoscopists leads to increased detection of dysplasia/neoplasia and ultimately reduces mortality from EAC.

CONCLUSION

In this review we discussed four recently proposed QIs to measure the quality of Barrett's endoscopy (Table 4). We identified the current limitations and challenges that need overcoming. QIs for Barrett's endoscopy must have clear definitions, and validated and standardized methods to measure them. QIs related to patient outcomes will enable identification of key performance indicators that will benchmark individual endoscopists and endoscopy unit performance. More studies are needed to validate the existing QIs and perhaps identify newer ones. As such, this is the end of the beginning, and the best is yet to come.

Table 4.

Summary of quality indicators (QIs) discussed in this review

QI	Current issues	Future prioritized research areas
NDR	Unclear calculation and imprecise denominator	Benchmarking NDR for general endoscopists An association between NDR and EAC mortality
PEBN	Inconsistent definition of “postendoscopy period”	Determination of appropriate time period of postendoscopy Association between PEBN rate and EAC mortality
Inspection time	Inconsistent definition	Randomized control trials with standardized definition
Biopsy protocol	Low adherence to Seattle biopsy protocol	Education tools that promote adherence to the Seattle biopsy protocol

EAC, esophageal adenocarcinoma; NDR, neoplasia detection rate; PEBN, postendoscopy Barrett's neoplasia.

CONFLICT OF INTEREST

Author K.R. is an Associate Editor of Digestive Endoscopy. The other author declares no conflict of interest for this article.

FUNDING INFORMATION

None.