Table 2.

Appropriate pre-endoscopy QIs after round 2 voting with the median score, MAD-M, BIOMED analysis, p value, IPRAS analysis and the performance threshold

Pre-endoscopy QIs	Median score	MAD-M	BIOMED analysis	P value	IPRAS analysis	Performance threshold, median % (range)
BET should be performed in high-volume centres within a local cancer network to meet efficacy and safety standards.	9	0.2	No disagreement	1	No disagreement	100 (90–100)
Aspirational performance target: 100% (range: 90–100). Evidence summary: Endoscopic training should start with knowledge acquisition, followed by resection and ablation in animal models, before training in human subjects. Endoscopist proficiency increases with the number of treatment sessions performed.8 Adherence to BE surveillance biopsy protocol in non-tertiary centres is poor, resulting in reduced dysplasia detection rate. Adherence to this protocol is further reduced with an increasing length of BE segment. Advanced imaging with HD-WLE and NBI has been shown to improve the detection rate of early neoplasia in patients with BE. The majority of gastroenterologists from academic centres use high definition white light endoscopy (HD-WLE) to classify BE as per guidelines and perform significantly more EET procedures per month, in comparison with those in district general hospitals. These factors favour the referral of patients with BE neoplasia to dedicated high-volume centres. In addition, data from the UK RFA registry have shown that increasing experience in performing EET is associated with significantly improved CR-D and CR-IM rates, less number of rescue EMRs and faster protocol completion. At the start of the registry and at a time when only less than 20 patients were enrolled, the documented CR-D and CR-IM after completing EET were 79.8% and 71.3%, respectively; however, with increasing experience (ie, once >40 patients enrolled), the study was able to show significantly better CR-D (91%) and CR-IM (83.9%) (p<005).9 These data support improvement in experience and outcomes with increase in the number of procedures performed. The expert panel has therefore suggested that endoscopic therapy should be performed in high-volume referral centres to optimise outcomes. Hospitals performing >40 EET cases per year may therefore be suitable centres for performing BE endoscopic eradication therapy.
Patients considered for BET should be discussed in an oesophagogastric MDT.	9	0.3	No disagreement	1	No disagreement	93 (85–100)
Aspirational performance target: 93% (range: 85–100). Evidence summary: The National Institute for Health and Care Excellence (August 2010) guidelines on ablative therapy for the treatment of BE recommends to discuss the MDT’s views on the range of appropriate treatments with the patient. It also recommends giving patients verbal and written information about their diagnosis, available treatments, patient support groups and the uncertainty of the long-term outcomes of ablative therapies.10 In addition the BSG recommends that the treatment of patients with BE neoplasia should be discussed in a dedicated GI specialist MDT taking into account patient comorbidities, nutritional status, patient preferences and staging.2 Patients should be provided with information on all treatment options and offered verbal and written information on support groups available to them,2 including clinical nurse specialists. Despite little evidence, the expert panel advocates an MDT approach (consisting of an expert BE pathologist) for these patients in order to safeguard against incorrect use of BET in patients with more advanced disease and to ensure that the case management provided is directed to best patient interest.

BE, Barrett’s oesophagus; BET, Barrett’s endotherapy; BSG, British Society of Gastroenterology; CR-D, complete remission of dysplasia; CR-IM, complete remission of intestinal metaplasia; EET, endoscopic eradication therapy; EMR, endoscopic mucosal resection; GI, gastrointestinal; IPRAS, interpercentile range adjusted for symmetry; MAD-M, mean absolute deviation from the median; MDT, multidisciplinary team; NBI, narrow band imaging; QI, quality indicator; RFA, radiofrequency ablation.