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• W4210994543 abstract "Esophageal adenocarcinoma (EAC) is a highly fatal disease with an increasing incidence from 0.54 to 3.76 per 100,000 person-years from 1975 to 20161Kolb J.M. Han S. Scott F.I. et al.Early-onset esophageal adenocarcinoma presents with advanced-stage disease but has improved survival compared with older individuals.Gastroenterology. 2020; 159: 2238-2240Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar that has been mirrored by a rise in EAC-related mortality. Because Barrett’s esophagus (BE) is the only known precursor lesion to EAC, early recognition and intervention could potentially reduce the societal burden of EAC by detecting cancers at an earlier stage and improving outcomes. Accordingly, professional gastroenterology society guidelines recommend screening upper endoscopy for at-risk individuals (chronic gastroesophageal reflux disease [GERD] along with the presence of other risk factors such as age >50 years, male sex, White race, smoking, obesity, and family history of BE or EAC).2Shaheen N.J. Falk G.W. Iyer P.G. et al.ACG clinical guideline: diagnosis and management of Barrett’s esophagus.Am J Gastroenterol. 2016; 111: 30-50Crossref PubMed Scopus (983) Google Scholar, 3Spechler S.J. Sharma P. Souza R.F. et al.American Gastroenterological Association technical review on the management of Barrett’s esophagus.Gastroenterology. 2011; 140: e18-e52Abstract Full Text Full Text PDF PubMed Scopus (522) Google Scholar, 4Qumseya B. Sultan S. et al.ASGE Standards of Practice CommitteeASGE guideline on screening and surveillance of Barrett’s esophagus.Gastrointest Endosc. 2019; 90: 335-359Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar, 5Fitzgerald R.C. di Pietro M. Ragunath K. et al.British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus.Gut. 2014; 63: 7-42Crossref PubMed Scopus (852) Google Scholar Notably, most of these are conditional recommendations with weak evidence, and there are no screening guidelines from the US Preventive Services Task Force or other internal medicine societies. Current programs are ineffective because nearly 90% of patients with EAC do not have known BE at the time of cancer diagnosis, and the majority of EACs are found outside of dedicated screening programs.6Tan M.C. Mansour N. White D.L. et al.Systematic review with meta-analysis: prevalence of prior and concurrent Barrett’s oesophagus in oesophageal adenocarcinoma patients.Aliment Pharmacol Ther. 2020; 52: 20-36Crossref PubMed Scopus (17) Google Scholar Screening algorithms largely rely on the diagnosis of GERD, but only 7% to 10% of GERD patients have BE, up to 25% of BE patients are asymptomatic, and 20% to 50% of EAC patients have no prior GERD symptoms.7Lagergren J. Bergström R. Lindgren A. et al.Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma.N Engl J Med. 1999; 340: 825-831Crossref PubMed Scopus (2597) Google Scholar,8Eusebi L.H. Telese A. Cirota G.G. et al.Systematic review with meta-analysis: risk factors for Barrett’s oesophagus in individuals with gastro-oesophageal reflux symptoms.Aliment Pharmacol Ther. 2021; 53: 968-976Crossref PubMed Scopus (4) Google Scholar Not only will patients at risk for BE/EAC be missed if GERD is required for screening, but from a societal and resource standpoint, this approach is not practical, given that GERD is very common. Results from a population-based survey of 78,812 persons in the United States demonstrated that nearly 2 out of 5 patients (44%) had GERD symptoms in the past, and this number is likely to increase with the obesity epidemic.9Delshad S.D. Almario C.V. Chey W.D. et al.Prevalence of gastroesophageal reflux disease and proton pump inhibitor-refractory symptoms.Gastroenterology. 2020; 158: 1250-1261Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Thus, the current paradigm for screening according to GERD and other risk factors needs to be changed. Nguyen et al10Nguyen T.H. Thrift A.P. Rugge M. et al.Prevalence of Barrett’s esophagus and performance of societal screening guidelines in an unreferred primary care population of U.S. veterans.Gastrointest Endosc. 2021; 93: 409-419Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar evaluated the performance characteristics of screening guidelines among 513 veterans evaluated in primary care clinics and demonstrated that published guidelines are suboptimal in predicting BE (sensitivity, 38.6%–43.2%; specificity, 71.%–75.1%). The 2011 American Gastroenterological Association guidelines, which do not mandate the presence of GERD symptoms to screen for BE, had a sensitivity of 100% and specificity of 0.2%.10Nguyen T.H. Thrift A.P. Rugge M. et al.Prevalence of Barrett’s esophagus and performance of societal screening guidelines in an unreferred primary care population of U.S. veterans.Gastrointest Endosc. 2021; 93: 409-419Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Ongoing efforts to incorporate risk prediction models that go beyond the presence of GERD symptoms will help better target individuals who would benefit most from screening.11Rubenstein J.H. McConnell D. Waljee A.K. et al.Validation and comparison of tools for selecting individuals to screen for Barrett’s esophagus and early neoplasia.Gastroenterology. 2020; 158: 2082-2092Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar There are also more nuanced limitations to screening in the clinical setting and a lack of studies characterizing practice patterns among gastroenterologists (GIs) and primary care providers (PCPs). Prior data demonstrate significant heterogeneity among GIs regarding BE screening practices,12Menezes A. Tierney A. Yang Y.X. et al.Adherence to the 2011 American Gastroenterological Association medical position statement for the diagnosis and management of Barrett’s esophagus.Dis Esophagus. 2015; 28: 538-546Crossref PubMed Scopus (21) Google Scholar but overall, there are minimal data to explain if BE screening is inadequate because of providers failing to recognize at-risk patients and refer them for endoscopy, patients failing to heed their physicians’ recommendation, system-level factors preventing patients from completing screening endoscopy, or a combination of these. Additionally, PCPs often serve at the front line in managing reflux symptoms and assessing candidacy for BE and EAC screening, but their attitudes and barriers to screening are not known. A detailed understanding of provider practice patterns, predictors of behavior, and key barriers to effective screening are essential to develop and implement interventions to improve BE screening and ultimately make population-level improvements in EAC outcomes. We conducted the Study of Compliance, Practice Patterns, and Barriers Regarding Established National Screening Programs for Barrett’s Esophagus (SCREEN-BE), a Web-based survey study to define GI and PCP knowledge, attitudes, and barriers to BE screening and to evaluate how these relate to their application of screening guidelines in clinical practice. This was performed at 4 tertiary care referral and 2 affiliated safety-net health systems in the United States (NCT04408105) (Supplementary Figure 1). Surveys were developed using a theoretical model of physician behavior based on social cognitive theory13Bandura A. Health promotion by social cognitive means.Health Educ Behav. 2004; 31: 143-164Crossref PubMed Scopus (4130) Google Scholar and the theory of reasoned action, and questions were adapted from earlier validated cancer screening-based surveys.14Singal A.G. Tiro J.A. Murphy C.C. et al.Patient-reported barriers are associated with receipt of hepatocellular carcinoma surveillance in a multicenter cohort of patients with cirrhosis.Clin Gastroenterol Hepatol. 2021; 19: 987-995Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar To assess knowledge of BE screening, we designed 9 clinical vignettes and categorized provider responses as concordant or discordant with published guidelines2Shaheen N.J. Falk G.W. Iyer P.G. et al.ACG clinical guideline: diagnosis and management of Barrett’s esophagus.Am J Gastroenterol. 2016; 111: 30-50Crossref PubMed Scopus (983) Google Scholar,4Qumseya B. Sultan S. et al.ASGE Standards of Practice CommitteeASGE guideline on screening and surveillance of Barrett’s esophagus.Gastrointest Endosc. 2019; 90: 335-359Abstract Full Text Full Text PDF PubMed Scopus (155) Google Scholar (the criterion standard for construct validity for this study) (Supplementary Figure 2). To evaluate responses to 9 clinical vignettes, 1 point was assigned for each guideline-concordant recommendation (score range, 0–9). GIs were given a point for a guideline concordant recommendation to perform screening endoscopy and PCPs for ordering screening endoscopy or referring to a GI to discuss screening (see Supplementary Methods). The multicenter administration of rigorously developed surveys with multiple domains of physician behavior across different health care systems with geographic, socioeconomic, and cultural diversity adds to the generalizability of results and enhances validity. We obtained a GI and PCP response rate of 74.5% (120/161) and 49.2% (195/396), respectively (Supplementary Table 1). Most respondents were physicians (91.5%), with a wide distribution of numbers of years in practice. The majority (76.3% GI, 92.0% PCP) reported seeing 2 or more patients with reflux per week. Despite the high volume of patients, the majority of GI and PCP clinics did not have a mechanism to remind providers when patients were eligible for BE screening; most believed this should be incorporated into the electronic health record. Although more than 70% of GIs and PCPs believe that BE screening is effective for early EAC detection, few believed it reduced all-cause mortality (22.6% and 21.9%, respectively), and PCPs in particular expressed concerns regarding cost effectiveness (Table 1). Most providers agreed that more data evaluating the screening benefits (GI, 74.8%; PCP, 65.7%) and harms (GI, 67.0%; PCP, 59.0%) are needed, including data from randomized controlled trials for BE screening (GI, 90.4%; PCP, 80.3%). This perspective is not particularly surprising, given the lack of randomized controlled trials demonstrating the effectiveness or mortality reduction from BE screening. Prior survey data indicate that 85% of GIs believe the evidence for BE screening is inadequate; only 48% think it is cost-effective to screen; and many perform screening despite concerns about effectiveness, most commonly because of medicolegal liability.15Lin O.S. Mannava S. Hwang K.L. et al.Reasons for current practices in managing Barrett’s esophagus.Dis Esophagus. 2002; 15: 39-45Crossref PubMed Scopus (15) Google Scholar Support for screening is largely derived from retrospective cohort studies showing better outcomes among BE/EAC patients who received screening endoscopy. Furthermore, BE screening with endoscopy and alternative methods appears to be cost effective in high-risk groups; however, this may depend on the potential mortality benefit afforded by treating dysplastic BE.16Ladabaum U. How I do it: does this cost-effectiveness analysis convince me about screening for Barrett’s esophagus?.Gastrointest Endosc. 2019; 89: 723-725Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,17Heberle C.R. Omidvari A.H. Ali A. et al.Cost effectiveness of screening patients with gastroesophageal reflux disease for Barrett’s esophagus with a minimally invasive cell sampling device.Clin Gastroenterol Hepatol. 2017; 15: 1397-1404Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Although recent data from a randomized controlled trial indicates the benefit of a noninvasive screening method in the primary care setting to detect BE compared to usual care,18Fitzgerald R.C. di Pietro M. O’Donovan M. et al.Cytosponge-trefoil factor 3 versus usual care to identify Barrett’s oesophagus in a primary care setting: a multicentre, pragmatic, randomised controlled trial.Lancet. 2020; 396: 333-344Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar studies comparing screening to no screening may never show a reduction in mortality at the population level given the relatively low incidence of EAC and low number of cancers arising from BE. This remains a challenge in widespread adoption of BE screening, especially considering our results showing that 90% of GIs and 80% of PCPs desire strong data from a randomized controlled trial to affect their decision making.Table 1Gastroenterology and Primary Care Provider Attitudes Related to BE ScreeningProvider attitudesGI, n (%)PCP, n (%)P value(n = 120)(n = 195)BE screening with upper endoscopy is effective for early esophageal cancer detectionaThere were 21 missing..02 Strongly agree or agree83 (72.2)127 (70.9) Neither agree nor disagree20 (17.4)46 (25.7) Strongly disagree or disagree,12 (10.4)6 (3.4)BE screening with upper endoscopy reduces all-cause mortalitybThere were 22 missing.<.01 Strongly agree or agree26 (22.6)39 (21.9) Neither agree nor disagree36 (31.3)109 (60.7) Strongly disagree or disagree53 (46.1)31 (17.4)BE screening with upper endoscopy is cost-effective for at-risk individualsaThere were 21 missing.<.01 Strongly agree or agree64 (55.7)68 (38.0) Neither agree nor disagree34 (29.6)92 (51.4) Strongly disagree or disagree17 (14.8)19 (10.6)Not performing Barrett’s esophagus screening poses malpractice liabilityaThere were 21 missing.<.01 Strongly agree or agree47 (40.9)46 (25.7) Neither agree nor disagree45 (39.1)103 (57.5) Strongly disagree or disagree23 (20.00)30 (16.8)Primary care providers should not order BE screening based on lack of recommendation from the US Preventive Services Task ForceaThere were 21 missing.<.01 Strongly agree or agree20 (17.4)51 (28.5) Neither agree nor disagree44 (38.3)92 (51.4) Strongly disagree or disagree51 (44.3)36 (20.1)Better data on the benefits of BE screening are neededbThere were 22 missing.<.01 Strongly agree or agree86 (74.8)117 (65.7) Neither agree nor disagree14 (12.2)56 (31.5) Strongly disagree or disagree15 (13.0)5 (2.8)Better data on the harms of BE screening are neededbThere were 22 missing.<.01 Strongly agree or agree77 (67.0)105 (59.0) Neither agree nor disagree20 (17.4)66 (37.1) Strongly disagree or disagree18 (15.7)7 (3.9)A randomized trial on BE screening would impact my decision to refer patients for screeningbThere were 22 missing..03 Strongly agree or agree104 (90.4)143 (80.3) Do not agree or strongly agree11 (9.6)35 (19.7)BE screening with upper endoscopy has equally strong supporting data as colon cancer screening with colonoscopybThere were 22 missing.<.01 Strongly agree or agree7 (6.1)8 (4.5) Neither agree nor disagree24 (20.9)77 (43.3) Strongly disagree or disagree84 (73.0)93 (52.2)BE, Barrett’s esophagus; GI, gastroenterologist; PCP, primary care provider.a There were 21 missing.b There were 22 missing. Open table in a new tab BE, Barrett’s esophagus; GI, gastroenterologist; PCP, primary care provider. Whereas half (54.2%) of GI providers order at least 1 upper endoscopy for BE screening per month, only 17.4% of PCPs reported ordering BE screening, and 29.7% reported referring patients to a GI to discuss BE screening per month. More than two thirds of GIs but only 31.8% of PCPs discuss the benefits and harms of BE screening in detail with patients with chronic GERD. These results highlighting provider practice patterns are consistent with epidemiologic data showing that only 10% of individuals with GERD undergo upper endoscopy within the first year of diagnosis.19Kramer J.R. Shakhatreh M.H. Naik A.D. et al.Use and yield of endoscopy in patients with uncomplicated gastroesophageal reflux disorder.JAMA Intern Med. 2014; 174: 462-465Crossref PubMed Scopus (13) Google Scholar GI providers were more consistently able to identify BE risk factors that would prompt screening compared to PCPs, who tend to overlook key risk factors and are less likely to recommend screening when appropriate (Supplementary Table 2). This failure to recognize the demographic and clinical factors that warrant consideration for BE screening may be a modifiable target to improve the early detection of EAC. When GIs were asked about the relevance of the US Preventative Services Task Force not having a recommendation on BE screening, 80% believed that this would not prevent GIs from ordering BE screening, and 44.3% of GIs believed that this would not prevent PCPs from ordering BE screening. PCPs appear to value data on benefits and risks of BE screening over direct endorsement from the US Preventative Services Task Force to conduct screening. Unlike most other cancers, where a negative examination result should be followed by additional screening at a future date, BE screening is recommended as a one-time test that does not require repeated screening. Although 18.0% of GIs would not recommend BE screening at all, most GIs (65.8%) appropriately would not recommend repeat screening after a negative endoscopy result for BE. The rest did recommended repeat screening after a negative examination result at either 3, 5, or 10 years (4.2%, 10.0%, and 1.7%, respectively). Approximately 32.0% of PCPs do not recommend screening at all, 31.8% of PCPs would not recommend repeat screening after a negative upper endoscopy result, and the rest recommend repeat screening at 1, 3, 5, or 10 years (2.1%, 16.4%, 14.9%, and 2.6%, respectively). Notably, only two thirds of GIs and one third of PCPs in this study appreciate current recommendations for one-time BE screening. Although screening for BE is grossly underused, these results highlight the potential for overuse or unnecessary repeated examinations and the need for education and clarification of this point in future guidelines. Whereas GIs reported minimal barriers to performing BE screening, PCPs identified several barriers at the provider and system levels (Figure 1A and Supplementary Table 3). Only 15.8% of GIs have difficulty knowing who should undergo upper endoscopy for BE screening, whereas 58.2% of PCPs note difficulty. Similarly, 75.8% of GIs reported that they know the current BE screening guidelines, compared to only 15.5% of PCPs. Neither group believed that patients would have difficulty understanding information about BE or would be hesitant to undergo endoscopy. Most GI providers (62.8%) and PCPs (75.9%) reported they would be interested to learn more about BE screening. In contrast to GIs, PCPs identified multiple barriers at the provider and system levels that hinder their ability to screen appropriately for BE. PCPs report a lack of knowledge related to screening guidelines and have difficulty identifying which patients to screen, despite seeing many patients with GERD. One potential contributing factor is that the published literature on BE risk factors and screening has been largely confined to GI journals and professional circles. Additionally, efforts to dissuade PCPs from referring patients to endoscopy before a trial of acid-suppressive medication or to limit the use of proton pump inhibitors may cause confusion among PCPs about diagnostic vs screening examinations. In a previous questionnaire of >1,000 PCPs attending industry-sponsored conferences on GERD, 87% of respondents agreed that patients with GERD for ≥5 years should have screening endoscopy for BE; however, 50% were unable to order the procedure through open access endoscopy and needed consultation with a GI provider.20Chey W.D. Inadomi J.M. Booher A.M. et al.Primary-care physicians’ perceptions and practices on the management of GERD: results of a national survey.Am J Gastroenterol. 2005; 100: 1237-1242Crossref PubMed Scopus (56) Google Scholar More PCPs than GIs identified competing clinical issues and time limitations that prevented them from addressing screening for BE (44.3% vs 12.5% and 32.8% vs 7.5%, respectively). These barriers are consistent across other cancer screenings, including colorectal cancer and hepatocellular carcinoma.21Simmons O.L. Feng Y. Parikh N.D. et al.Primary care provider practice patterns and barriers to hepatocellular carcinoma surveillance.Clin Gastroenterol Hepatol. 2019; 17: 766-773Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Several types of interventions, such as provider training or best practice alerts in the electronic health record may be effective in improving cancer screening quality in the primary care setting.22Hamel C. Ahmadzai N. Beck A. et al.Screening for esophageal adenocarcinoma and precancerous conditions (dysplasia and Barrett’s esophagus) in patients with chronic gastroesophageal reflux disease with or without other risk factors: two systematic reviews and one overview of reviews to inform a guideline of the Canadian Task Force on Preventive Health Care (CTFPHC).Syst Rev. 2020; 9: 20PubMed Google Scholar Leveraging new technologies within the electronic health record for population health management may prove effective. Our results highlight the need for more robust educational and advocacy efforts on the part of GIs as well as improved partnership with our colleagues because PCPs are at the front line for screening. When presented with clinical scenarios, GI providers were more likely to provide guideline-concordant screening recommendations than PCPs (mean composite score, 7.0 ± 1.3 vs 5.7 ± 1.1; P < .01) (Figure 1B). For the 4 vignettes where screening was not indicated, PCPs were more likely to recommended screening (47.2%) compared to GIs (35.1%; P < .001). Similarly, in the 5 vignettes where screening was indicated, PCPs did not recommend screening 31.8% of the time compared to 14.0% among GIs (P < .001). These results suggest a clear need for education and dissemination of current societal guidelines among primary care audiences. Granular data from the SCREEN-BE study identified multiple knowledge gaps and barriers to appropriate BE screening, mainly in the primary care setting. These potential modifiable targets are ripe for future studies that focus on the following:•intervention trials using decision-support algorithms along with integrated reminder systems to incorporate BE screening during PCP visits and improve the adherence and effectiveness of BE screening.•qualitative research to understand the opinions of key stakeholders (patients and caregivers, GIs, PCPs, pathologists, public health experts) and create screening algorithms that consider resources, cost, and feasibility.•education and dissemination of screening guidelines among PCPs, given their lack of knowledge and nonadherence to GI society guidelines" @default.
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• W4210994543 title "Understanding Compliance, Practice Patterns, and Barriers Among Gastroenterologists and Primary Care Providers Is Crucial for Developing Strategies to Improve Screening for Barrett’s Esophagus" @default.
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