Implementation of guidelines in eosinophilic esophagitis at an academic pediatric practice

Implementation of guidelines in eosinophilic esophagitis at an academic pediatric practice SUMMARY Guidelines for eosinophilic esophagitis (EoE) require high-dose PPI (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. This study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. Retrospective review of new patients treated with HD-PPI after an index EGD showing >15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of >15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. Adherence to guidelines improves with time. Patients are vested in care. Guidelines for eosinophilic esophagitis (EoE) require high-dose proton pump inhibitor (PPI) (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. The primary aim of this study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. This is a retrospective review of new patients treated with HD-PPI after an index EGD showing >15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of >15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. This study shows that adherence to guidelines improves with time suggesting that patients are vested in care. INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic and relapsing disease characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the esophagus.1,2 Symptom presentation varies by age; infants and toddlers often present with feeding dysfunction with or without failure to thrive. Older children usually have abdominal pain, nausea, and/or vomiting, while adolescents most often present with dysphagia.2,3 With increasing prevalence of EoE, there have been several studies and guidelines discussing its diagnosis and treatment options.4–6 Endoscopy has an essential role in EoE management as it is required for diagnosis, through histological examination of biopsies, and to assess treatment response. There are limited biomarkers or symptom scoring tools available that reliably assess histological status in EoE, especially in children.1,7,8 In addition, there is a distinct population of patients who have high-dose proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE), and should be identified prior to formal EoE diagnosis and dedicated therapy.9–11 Current consensus practice guidelines recommend a formal diagnosis of EoE be given only if the patient has persistent symptoms and esophageal eosinophilia after a high-dose PPI (HD-PPI) trial.4 These guidelines underscore the essential role that esophagogastroduodenoscopy (EGD) has in primary evaluation and further management of esophageal eosinophilia and potential for a second EGD with biopsies before a diagnosis of EoE is established. There, however, is controversy over this approach due to the risks that are inherent with undergoing an EGD and that follow-up of asymptomatic patients is not universal for various reasons.7 The primary aim of this study is to explore adherence to current guidelines of HD-PPI trial in evaluation of patients with esophageal eosinophilia in an academic pediatric gastroenterology practice. METHODS This retrospective study included patients with esophageal eosinophilia, defined as ≥15 eosinophils per high power field (hpf), seen at Riley Hospital for Children/Indiana University School of Medicine, Indianapolis IN. Patient records were identified via an IRB-approved electronic database. We included patients over a 3-year period (from January 1, 2011 to December 31, 2013), who were younger than 18 years of age and underwent initial EGD off PPI therapy. We excluded patients with other known causes/past history of eosinophilic inflammation such as gastroesophageal reflux disease, celiac disease, inflammatory bowel disease, hypereosinophilic syndrome, known EoE, or if on HD-PPI therapy at time of index EGD. Clinical data were obtained from patient charts in the electronic medical record and included demographics, clinical history and course, endoscopic findings, and histological results. Longitudinal data including from return clinic visits and endoscopic procedures were recorded. Initial esophageal eosinophilia was defined as ≥15 eosinophils/hpf as was EoE after a HD-PPI trial. PPI-REE was defined as ≤15 eosinophils/hpf. Histologic improvement was defined as 6–14 eosinophils/hpf while resolution was noted if ≤5 eosinophils/hpf. HD-PPI at our center is defined as 1 mg/kg/dose twice daily to adult maximum dose for that particular PPI. This study was approved by the Indiana University Institutional Review Board. RESULTS Patient clinical data A total of 314 cases of eosinophils in esophageal biopsies were identified during the 3-year study period, of whom180 cases met study inclusion/exclusion criteria (Fig. 1). The mean age was 8.7 years (range 1 month to 17 years) 72.2% (n130) were males and 88% Caucasians, 10% African American, 1% Asian, and 1% American Indian. Presenting symptoms are in Figure 2. Endoscopic findings at index EGD included furrows/vertical lines (74.4%), white plaques (32.8%), and thickening/edema (28.9%). Fig. 1 View largeDownload slide Determination of patient population. Fig. 1 View largeDownload slide Determination of patient population. Fig. 2 View largeDownload slide Presenting symptoms of patients with esophageal eosinophilia. Fig. 2 View largeDownload slide Presenting symptoms of patients with esophageal eosinophilia. Initial treatment after index EGD All patients were counseled by their provider, based on individual practices and taking into account family preference, on possible medical or dietary intervention after their first EGD. The different management strategies are in Table 1. Of the 180 patients who showed esophageal eosinophilia on index EGD, 97/180 (53.9%) received a high-dose PPI while the remaining 83/180 (46.2%) were prescribed dietary changes, topical corticosteroids, combination therapy, or no treatment. Table 1 Initial management strategies after index EGD. Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% †A variety of diets were employed. EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor; TCS, topical corticosteroids. View Large Table 1 Initial management strategies after index EGD. Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% †A variety of diets were employed. EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor; TCS, topical corticosteroids. View Large Return visit and second EGD information Of the 180 patients with esophageal eosinophilia, 143 (79.4%) returned for follow-up; 57.3% patients returned at or before 3 months. Symptoms were persistent in 54 (37.8%) of the 143 returning patients. Repeat EGD was performed in 96 of the 143 patients (67.1%) who returned for follow-up. PPI-receiving patients were more likely to undergo a second EGD compared to patients who received other therapies at 82% (n64) versus 49% (n32), respectively with an odds ratio of 3.09. In patients receiving PPI alone initially (97/180 (53.8%), histological improvement rates were 41%, with resolution in 5%. Of the 83/180 (46.2%) patients who received any treatment other than single agent high-dose PPI for initial management, the histological improvement rate was similar at 41%, with resolution in 16%. These PPI response rates are similar to previously reported in adults.12 Management outcomes and PPI prescription trends Additional information on the management strategies after return clinic visit or second EGD is in Table 2. The most common treatments were PPI either alone or in combination with another therapy especially corticosteroids. Table 2 Final management strategies after follow-up (clinic visit OR second EGD). Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor. View Large Table 2 Final management strategies after follow-up (clinic visit OR second EGD). Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor. View Large There was a significant increase over time in prescribing high-dose PPI trial in eligible patients with esophageal eosinophilia at index EGD; the rates improved from 40.0% in 2011 to 69.5% in 2013 showing significance with a p value of 0.0056 (Fig. 3). Fig. 3 View largeDownload slide Patient characteristics regarding treatment and follow-up as shown by years from 2011 to 2013. Fig. 3 View largeDownload slide Patient characteristics regarding treatment and follow-up as shown by years from 2011 to 2013. DISCUSSION In this study to investigate adherence to high-dose PPI trial guidelines after index EGD, we find the adherence to be variable, limited initially with substantial improvement over time. There have been only a few studies investigating the implementation of controversial guidelines in the longitudinal care, diagnosis, and treatment of chronic diseases. One prior study looking into invasive diagnostic procedures such as for nonalcoholic steatohepatitis, reported mature adherence rates of 40–73% with a wide variety of clinical practice patterns.13 The invasive nature of multiple EGDs as well as the unclear role of PPI therapy in EoE could be explanations for the varied practices in respect to initial evaluation of patients with suspected EoE. Several important and intriguing observations result from this study. First, there was a significant increase over time in prescribing high-dose PPI trial in eligible patients with esophageal eosinophilia at index EGD; the rates improved from 40.0% in 2011 to 69.5% in 2013. This improved adherence may be due to the improved dissemination of guidelines and increased familiarity among clinicians. Second, in spite of the possibility of an invasive procedure at follow-up, i.e., repeats EGD, there was a consistent high return-appointment rate among patients with 79.4% averaged over the study period with little variation between years. This indicates that patients and families are highly vested in their care even for a evolving disease and with controversies in management and provides opportunities for future study into motivators for return appointment and ways to even further improve follow-up rate Third, we note the adherence to performing a second EGD improved from 40% in 2011 to 55.8% in 2013. This change was not quite as dramatic as that with adherence to initially prescribing HD-PPI. The reasons for this variations need further definition in a future study including factors such as provider-perceived barriers or patient concerns. These improving yet suboptimal adherences to guidelines underscore need to identify factors to enhance implementation of guidelines. Prior studies have investigated the implementation of guidelines as well as making effective change on clinician's practices. These investigations have high-lighted the need for collaboration and educational interventions involving physicians, nurses, and pharmacists to improve compliance with guidelines by up to 30%.14,15 Other factors aside of increased interdisciplinary collaborations, include modes of dissemination of guidelines as well as institutional, knowledge, and bias barriers that may impact acceptance.15 Multiple and recurring modes of dissemination may capture a larger number of clinicians, increase familiarity and promote recall. In summary, this study shows improved provider-adherence over time to high-dose PPI trial in patients with esophageal eosinophilia after index EGD. Majority of patients returned for follow-up and underwent repeat EGD. Future studies should investigate factors that can further improve these benchmarks and accelerate implementation of guidelines, identify provider-perceived barriers, and explore patient motivators. These are important factors to consider in this era of health-care quality and provider performance-matrices while promoting patient engagement. Acknowledgments Cindy Sawyers, RT: Assisted in primary data acquisition. Notes Specific author contributions: Brendan R. Harris: Devised the conception and design of study with the assistance of Dr. Gupta and Dr. Hon. Wrote the study protocol and carried out the data acquisition. Once data was collected, he worked with Dr. Gupta and Dr. Hon in the data analysis and interpretation. Wrote the first draft of the manuscript and with the aid and revisions of Dr. Gupta and Dr. Hon was able to provide a final copy. Provided final approval and agrees to be accountable; Sandeep K. Gupta: Provided significant contribution through discussions in the conception and design of study. Contributed to the protocol design and IRB approval process. Collaborated with Dr. Harris to analyze data and interpret. Provided multiple revisions in the production of the manuscript. Provided final approval and agrees to be accountable; Emily Hon: Provided significant contribution in the design of the study. Once data were collected, she was able to discuss analysis and interpretation as well as plans for final presentation. Once manuscript draft was written, provided feedback and revision. Provided final approval and agrees to be accountable. References 1 Bohm M E , Gupta S K , Wo J M . Most children with eosinophilic esophagitis have a favorable outcome as young adults . Dis Esophagus 2017 ; 30 : 1 – 6 ( Epub ahead of print ) Google Scholar PubMed 2 Teoh T , Chan E S , Avinashi V , Ko H H , Goldman R D . Diagnosis and management of eosinophilic esophagitis in children . Can Fam Physician 2015 ; 61 : 687 – 90 Google Scholar PubMed 3 Rodrigues M , D’Amico M F , Patino F R , Barbieri D , Damiao A O , Sipahi A M . Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis . J Pediatr (Rio J) 2013 ; 89 : 197 – 203 . Google Scholar CrossRef Search ADS PubMed 4 Furuta G T , Liacouras C A , Collins M H et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment . Gastroenterology 2007 ; 133 : 1342 – 63 . Google Scholar CrossRef Search ADS PubMed 5 Muir A B , Merves J , Liacouras C A . Role of endoscopy in diagnosis and management of pediatric eosinophilic esophagitis . Gastrointest Endosc Clin N Am 2016 ; 26 : 187 – 200 . Google Scholar CrossRef Search ADS PubMed 6 Dellon E S , Gonsalves N , Hirano I et al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE) . Am J Gastroenterol 2013 ; 108 : 679 – 92 . Google Scholar CrossRef Search ADS PubMed 7 Papadopoulou A , Amil Dias J . Eosinophilic esophagitis: an emerging disease in childhood—review of diagnostic and management strategies . Front Pediatr 2014 ; 129 : 1 – 8 . 8 Lucendo A J , Molina-Infante J . Limitation of symptoms as predictors of remission in eosinophilic esophagitis: the need to go beyond endoscopy and histology . Gastroenterology 2016 : 150 : 547 – 9 . Google Scholar CrossRef Search ADS PubMed 9 Asher W A , Dellon E S . Eosinophilic esophagitis and proton pump inhibitors: controversies and implications for clinical practice . Gastroenterol Hepatol 2014 ; 10 : 427 – 32 10 Gutierrez-Junquera C , Fernández-Fernández S , Cilleruelo M L et al. High prevalence of response to proton-pump inhibitor treatment in children with esophageal eosinophilia . J Pediatr Gastroenterol Nutr 2016 ; 62 : 704 – 10 . Google Scholar CrossRef Search ADS PubMed 11 Syed A A , Andrews C N , Shaffer E , Urbanski S J , Beck P , Storr M . The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: a population-based study . Aliment Pharmacol Ther 2012 ; 36 : 950 – 8 . Google Scholar CrossRef Search ADS PubMed 12 Lucendo A J , Arias A . Diagnostic and therapeutic management of eosinophilic oesophagitis in children and adults: results from a Spanish registry of clinical practice . Dig Liver Dis 2013 ; 45 : 562 – 8 . Google Scholar CrossRef Search ADS PubMed 13 Rinella M E , Lominadze Z , Loomba R et al. Practice patterns in NAFLD and NASH: real life differs from published guidelines . Therap Adv Gastroenterol 2016 , 9 : 4 – 12 . Google Scholar CrossRef Search ADS PubMed 14 Tartaglia K M , Campbell J , Shaniuk P , McClead R E . A quality project to improve compliance with AAP guidelines for inpatient management of neonatal hyperbilirubinemia . Hosp Pediatr 2013 ; 3 : 251 – 7 . Google Scholar CrossRef Search ADS PubMed 15 Vander Schaaf E B , Seashore C J , Randolph G D . Translating clinical guidelines into practice: challenges and opportunities in a dynamic health care environment . NC Med J 2015 ; 76 : 230 – 4 . Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Diseases of the Esophagus Oxford University Press

Implementation of guidelines in eosinophilic esophagitis at an academic pediatric practice

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The International Society for Diseases of the Esophagus
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Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus 2018.
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Abstract

SUMMARY Guidelines for eosinophilic esophagitis (EoE) require high-dose PPI (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. This study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. Retrospective review of new patients treated with HD-PPI after an index EGD showing >15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of >15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. Adherence to guidelines improves with time. Patients are vested in care. Guidelines for eosinophilic esophagitis (EoE) require high-dose proton pump inhibitor (PPI) (HD-PPI) trial to evaluate for PPI-responsive esophageal eosinophilia (PPI-REE) prior to EoE diagnosis and dedicated therapy. This involves a second esophagogastroduodenoscopy (EGD) to assess for PPI-REE. The primary aim of this study is to evaluate adherence to current guidelines in evaluation of PPI-REE and EoE. This is a retrospective review of new patients treated with HD-PPI after an index EGD showing >15 eos/hpf in esophageal biopsies. One hundred and eighty patients had an index EGD with esophageal eosinophilia of >15 eos/hpf. Of these, 97/180 (53.8%) received HD-PPI; remaining 83/180 were prescribed other interventions without a HD-PPI trial. Of the 180 patients, 143 (79.4%) patients returned for follow-up and of whom 96/143 (67.1%) underwent repeat EGD. This study shows that adherence to guidelines improves with time suggesting that patients are vested in care. INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic and relapsing disease characterized by symptoms of esophageal dysfunction and eosinophilic infiltration of the esophagus.1,2 Symptom presentation varies by age; infants and toddlers often present with feeding dysfunction with or without failure to thrive. Older children usually have abdominal pain, nausea, and/or vomiting, while adolescents most often present with dysphagia.2,3 With increasing prevalence of EoE, there have been several studies and guidelines discussing its diagnosis and treatment options.4–6 Endoscopy has an essential role in EoE management as it is required for diagnosis, through histological examination of biopsies, and to assess treatment response. There are limited biomarkers or symptom scoring tools available that reliably assess histological status in EoE, especially in children.1,7,8 In addition, there is a distinct population of patients who have high-dose proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE), and should be identified prior to formal EoE diagnosis and dedicated therapy.9–11 Current consensus practice guidelines recommend a formal diagnosis of EoE be given only if the patient has persistent symptoms and esophageal eosinophilia after a high-dose PPI (HD-PPI) trial.4 These guidelines underscore the essential role that esophagogastroduodenoscopy (EGD) has in primary evaluation and further management of esophageal eosinophilia and potential for a second EGD with biopsies before a diagnosis of EoE is established. There, however, is controversy over this approach due to the risks that are inherent with undergoing an EGD and that follow-up of asymptomatic patients is not universal for various reasons.7 The primary aim of this study is to explore adherence to current guidelines of HD-PPI trial in evaluation of patients with esophageal eosinophilia in an academic pediatric gastroenterology practice. METHODS This retrospective study included patients with esophageal eosinophilia, defined as ≥15 eosinophils per high power field (hpf), seen at Riley Hospital for Children/Indiana University School of Medicine, Indianapolis IN. Patient records were identified via an IRB-approved electronic database. We included patients over a 3-year period (from January 1, 2011 to December 31, 2013), who were younger than 18 years of age and underwent initial EGD off PPI therapy. We excluded patients with other known causes/past history of eosinophilic inflammation such as gastroesophageal reflux disease, celiac disease, inflammatory bowel disease, hypereosinophilic syndrome, known EoE, or if on HD-PPI therapy at time of index EGD. Clinical data were obtained from patient charts in the electronic medical record and included demographics, clinical history and course, endoscopic findings, and histological results. Longitudinal data including from return clinic visits and endoscopic procedures were recorded. Initial esophageal eosinophilia was defined as ≥15 eosinophils/hpf as was EoE after a HD-PPI trial. PPI-REE was defined as ≤15 eosinophils/hpf. Histologic improvement was defined as 6–14 eosinophils/hpf while resolution was noted if ≤5 eosinophils/hpf. HD-PPI at our center is defined as 1 mg/kg/dose twice daily to adult maximum dose for that particular PPI. This study was approved by the Indiana University Institutional Review Board. RESULTS Patient clinical data A total of 314 cases of eosinophils in esophageal biopsies were identified during the 3-year study period, of whom180 cases met study inclusion/exclusion criteria (Fig. 1). The mean age was 8.7 years (range 1 month to 17 years) 72.2% (n130) were males and 88% Caucasians, 10% African American, 1% Asian, and 1% American Indian. Presenting symptoms are in Figure 2. Endoscopic findings at index EGD included furrows/vertical lines (74.4%), white plaques (32.8%), and thickening/edema (28.9%). Fig. 1 View largeDownload slide Determination of patient population. Fig. 1 View largeDownload slide Determination of patient population. Fig. 2 View largeDownload slide Presenting symptoms of patients with esophageal eosinophilia. Fig. 2 View largeDownload slide Presenting symptoms of patients with esophageal eosinophilia. Initial treatment after index EGD All patients were counseled by their provider, based on individual practices and taking into account family preference, on possible medical or dietary intervention after their first EGD. The different management strategies are in Table 1. Of the 180 patients who showed esophageal eosinophilia on index EGD, 97/180 (53.9%) received a high-dose PPI while the remaining 83/180 (46.2%) were prescribed dietary changes, topical corticosteroids, combination therapy, or no treatment. Table 1 Initial management strategies after index EGD. Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% †A variety of diets were employed. EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor; TCS, topical corticosteroids. View Large Table 1 Initial management strategies after index EGD. Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% Initial management strategies after index EGD Management strategies Number of patients Percentage Single agent therapy PPI 97 53.89% TCS 38 21.11% Prednisone 1 0.56% Diet† 12 6.67% None 7 3.89% Combination therapy PPI/TCS 17 9.44% PPI/steroids 1 0.56% PPI/diet 2 1.11% PPI/TCS/diet 1 0.56% TCS/diet 4 2.22% Total 180 100.00% †A variety of diets were employed. EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor; TCS, topical corticosteroids. View Large Return visit and second EGD information Of the 180 patients with esophageal eosinophilia, 143 (79.4%) returned for follow-up; 57.3% patients returned at or before 3 months. Symptoms were persistent in 54 (37.8%) of the 143 returning patients. Repeat EGD was performed in 96 of the 143 patients (67.1%) who returned for follow-up. PPI-receiving patients were more likely to undergo a second EGD compared to patients who received other therapies at 82% (n64) versus 49% (n32), respectively with an odds ratio of 3.09. In patients receiving PPI alone initially (97/180 (53.8%), histological improvement rates were 41%, with resolution in 5%. Of the 83/180 (46.2%) patients who received any treatment other than single agent high-dose PPI for initial management, the histological improvement rate was similar at 41%, with resolution in 16%. These PPI response rates are similar to previously reported in adults.12 Management outcomes and PPI prescription trends Additional information on the management strategies after return clinic visit or second EGD is in Table 2. The most common treatments were PPI either alone or in combination with another therapy especially corticosteroids. Table 2 Final management strategies after follow-up (clinic visit OR second EGD). Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor. View Large Table 2 Final management strategies after follow-up (clinic visit OR second EGD). Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% Final management strategies after follow-up (clinic visit OR second EGD) Management strategies Number of patients Percentage Single agent therapy PPI 40 27.97% Flovent 30 20.98% Budesonide 7 4.90% Diet 18 12.59% None 10 6.99% Combination therapy PPI/flovent 9 6.29% PPI/budesonide 6 4.20% PPI/diet 8 5.59% PPI/flovent/diet 2 1.40% Flovent/diet 4 2.80% Budesonide/diet 3 2.10% Unknown 4 2.80% Enrolled in a study 2 1.40% Total 143 100.00% EGD, esophagogastroduodenoscopy; PPI, proton pump inhibitor. View Large There was a significant increase over time in prescribing high-dose PPI trial in eligible patients with esophageal eosinophilia at index EGD; the rates improved from 40.0% in 2011 to 69.5% in 2013 showing significance with a p value of 0.0056 (Fig. 3). Fig. 3 View largeDownload slide Patient characteristics regarding treatment and follow-up as shown by years from 2011 to 2013. Fig. 3 View largeDownload slide Patient characteristics regarding treatment and follow-up as shown by years from 2011 to 2013. DISCUSSION In this study to investigate adherence to high-dose PPI trial guidelines after index EGD, we find the adherence to be variable, limited initially with substantial improvement over time. There have been only a few studies investigating the implementation of controversial guidelines in the longitudinal care, diagnosis, and treatment of chronic diseases. One prior study looking into invasive diagnostic procedures such as for nonalcoholic steatohepatitis, reported mature adherence rates of 40–73% with a wide variety of clinical practice patterns.13 The invasive nature of multiple EGDs as well as the unclear role of PPI therapy in EoE could be explanations for the varied practices in respect to initial evaluation of patients with suspected EoE. Several important and intriguing observations result from this study. First, there was a significant increase over time in prescribing high-dose PPI trial in eligible patients with esophageal eosinophilia at index EGD; the rates improved from 40.0% in 2011 to 69.5% in 2013. This improved adherence may be due to the improved dissemination of guidelines and increased familiarity among clinicians. Second, in spite of the possibility of an invasive procedure at follow-up, i.e., repeats EGD, there was a consistent high return-appointment rate among patients with 79.4% averaged over the study period with little variation between years. This indicates that patients and families are highly vested in their care even for a evolving disease and with controversies in management and provides opportunities for future study into motivators for return appointment and ways to even further improve follow-up rate Third, we note the adherence to performing a second EGD improved from 40% in 2011 to 55.8% in 2013. This change was not quite as dramatic as that with adherence to initially prescribing HD-PPI. The reasons for this variations need further definition in a future study including factors such as provider-perceived barriers or patient concerns. These improving yet suboptimal adherences to guidelines underscore need to identify factors to enhance implementation of guidelines. Prior studies have investigated the implementation of guidelines as well as making effective change on clinician's practices. These investigations have high-lighted the need for collaboration and educational interventions involving physicians, nurses, and pharmacists to improve compliance with guidelines by up to 30%.14,15 Other factors aside of increased interdisciplinary collaborations, include modes of dissemination of guidelines as well as institutional, knowledge, and bias barriers that may impact acceptance.15 Multiple and recurring modes of dissemination may capture a larger number of clinicians, increase familiarity and promote recall. In summary, this study shows improved provider-adherence over time to high-dose PPI trial in patients with esophageal eosinophilia after index EGD. Majority of patients returned for follow-up and underwent repeat EGD. Future studies should investigate factors that can further improve these benchmarks and accelerate implementation of guidelines, identify provider-perceived barriers, and explore patient motivators. These are important factors to consider in this era of health-care quality and provider performance-matrices while promoting patient engagement. Acknowledgments Cindy Sawyers, RT: Assisted in primary data acquisition. Notes Specific author contributions: Brendan R. Harris: Devised the conception and design of study with the assistance of Dr. Gupta and Dr. Hon. Wrote the study protocol and carried out the data acquisition. Once data was collected, he worked with Dr. Gupta and Dr. Hon in the data analysis and interpretation. Wrote the first draft of the manuscript and with the aid and revisions of Dr. Gupta and Dr. Hon was able to provide a final copy. Provided final approval and agrees to be accountable; Sandeep K. Gupta: Provided significant contribution through discussions in the conception and design of study. Contributed to the protocol design and IRB approval process. Collaborated with Dr. Harris to analyze data and interpret. Provided multiple revisions in the production of the manuscript. Provided final approval and agrees to be accountable; Emily Hon: Provided significant contribution in the design of the study. Once data were collected, she was able to discuss analysis and interpretation as well as plans for final presentation. Once manuscript draft was written, provided feedback and revision. Provided final approval and agrees to be accountable. References 1 Bohm M E , Gupta S K , Wo J M . Most children with eosinophilic esophagitis have a favorable outcome as young adults . Dis Esophagus 2017 ; 30 : 1 – 6 ( Epub ahead of print ) Google Scholar PubMed 2 Teoh T , Chan E S , Avinashi V , Ko H H , Goldman R D . Diagnosis and management of eosinophilic esophagitis in children . Can Fam Physician 2015 ; 61 : 687 – 90 Google Scholar PubMed 3 Rodrigues M , D’Amico M F , Patino F R , Barbieri D , Damiao A O , Sipahi A M . Clinical manifestations, treatment, and outcomes of children and adolescents with eosinophilic esophagitis . J Pediatr (Rio J) 2013 ; 89 : 197 – 203 . Google Scholar CrossRef Search ADS PubMed 4 Furuta G T , Liacouras C A , Collins M H et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment . Gastroenterology 2007 ; 133 : 1342 – 63 . Google Scholar CrossRef Search ADS PubMed 5 Muir A B , Merves J , Liacouras C A . Role of endoscopy in diagnosis and management of pediatric eosinophilic esophagitis . Gastrointest Endosc Clin N Am 2016 ; 26 : 187 – 200 . Google Scholar CrossRef Search ADS PubMed 6 Dellon E S , Gonsalves N , Hirano I et al. ACG clinical guideline: evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE) . Am J Gastroenterol 2013 ; 108 : 679 – 92 . Google Scholar CrossRef Search ADS PubMed 7 Papadopoulou A , Amil Dias J . Eosinophilic esophagitis: an emerging disease in childhood—review of diagnostic and management strategies . Front Pediatr 2014 ; 129 : 1 – 8 . 8 Lucendo A J , Molina-Infante J . Limitation of symptoms as predictors of remission in eosinophilic esophagitis: the need to go beyond endoscopy and histology . Gastroenterology 2016 : 150 : 547 – 9 . Google Scholar CrossRef Search ADS PubMed 9 Asher W A , Dellon E S . Eosinophilic esophagitis and proton pump inhibitors: controversies and implications for clinical practice . Gastroenterol Hepatol 2014 ; 10 : 427 – 32 10 Gutierrez-Junquera C , Fernández-Fernández S , Cilleruelo M L et al. High prevalence of response to proton-pump inhibitor treatment in children with esophageal eosinophilia . J Pediatr Gastroenterol Nutr 2016 ; 62 : 704 – 10 . Google Scholar CrossRef Search ADS PubMed 11 Syed A A , Andrews C N , Shaffer E , Urbanski S J , Beck P , Storr M . The rising incidence of eosinophilic oesophagitis is associated with increasing biopsy rates: a population-based study . Aliment Pharmacol Ther 2012 ; 36 : 950 – 8 . Google Scholar CrossRef Search ADS PubMed 12 Lucendo A J , Arias A . Diagnostic and therapeutic management of eosinophilic oesophagitis in children and adults: results from a Spanish registry of clinical practice . Dig Liver Dis 2013 ; 45 : 562 – 8 . Google Scholar CrossRef Search ADS PubMed 13 Rinella M E , Lominadze Z , Loomba R et al. Practice patterns in NAFLD and NASH: real life differs from published guidelines . Therap Adv Gastroenterol 2016 , 9 : 4 – 12 . Google Scholar CrossRef Search ADS PubMed 14 Tartaglia K M , Campbell J , Shaniuk P , McClead R E . A quality project to improve compliance with AAP guidelines for inpatient management of neonatal hyperbilirubinemia . Hosp Pediatr 2013 ; 3 : 251 – 7 . Google Scholar CrossRef Search ADS PubMed 15 Vander Schaaf E B , Seashore C J , Randolph G D . Translating clinical guidelines into practice: challenges and opportunities in a dynamic health care environment . NC Med J 2015 ; 76 : 230 – 4 . Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Journal

Diseases of the EsophagusOxford University Press

Published: May 10, 2018

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