Title: Identifying procedure adjusted quality indicators for upper gastrointestinal endoscopy from systematic review and multivariate analysis of cohorts with post endoscopy upper gastrointestinal cancer in the national endoscopy database
Funder: Department of Health and Social Care

Abstract: Research question What procedure adjusted quality indicators for upper gastrointestinal endoscopy can be identified from systematic review and multivariate analysis of cohorts with post endoscopy upper gastrointestinal cancer in the national endoscopy database to reduce unwarranted variation in endoscopy quality? Background People die from oesophageal and gastric cancers being missed and delayed diagnoses. Suboptimal endoscopy quality will be one of the main reasons and it is likely there is unwarranted variation in endoscopy performance. Understanding the variation, finding appropriate quality measures and identifying correctable factors are vital to saving lives from oesophageal and gastric cancer. However, endoscopy lacks the established quality indicators of colonoscopy to enable the improvements in quality seen in national colonoscopy audits. Many people have an endoscopy that does not diagnose cancer but are later found to have oesophageal or gastric cancer &ndash; this is termed post endoscopy upper GI cancer (POUGIC) and occurs in approximately 10% of people with oesophageal or gastric cancer. Aims and objectives Phase 1 - Systematic literature review to identify the evidence-base for potential endoscopy quality measures and for potential confounding factors. Phase 2 - Examine using linked Hospital Episode Statistics and National Cancer Registration and Analysis Service datasets, variation in POUGIC rates between hospitals. Phase 3a - Using the National Endoscopy Database, examine associations with oesophageal and gastric cancer to establish associated patient, procedural, endoscopist and endoscopy unit factors that are potential quality indicators or require adjustment for. Phase 3b- Using the National Endoscopy Database, develop endoscopy quality indicators based on high and low hospital trust POUGIC rates, adjusted for patient, procedural, endoscopist and endoscopy unit factors. Phase 4 - Use Delphi consensus with an expert endoscopist and lay person panel to assess which optimised procedure-adjusted quality indicators are most amenable to improvement through intervention and behavioural changes. Methods Systematic review of investigated quality measures in endoscopy. Examination of POUGIC rates at hospital level using linked cancer and endoscopy datasets with logistic regression analysis to investigate risk factors and generate funnel plots to investigate variation between hospitals. Through logistic regression models in the National Endoscopy Database, examine factors associated with oesophageal or gastric cancer and subsequently high and low POUGIC rates to produce optimised procedure adjusted quality indicators for endoscopy. Delphi consensus to establish which procedure adjusted endoscopy quality indicators are most suited to quality improvement efforts. Timelines for delivery We plan to begin in November 2020 with phases 1 and 2 delivered within a year and phases 3 and 4 in the second year of the project. Anticipated impact and dissemination The project will provide the tools to improve UK endoscopy standards and the care of people with oesophageal and gastric cancer. Through a subsequent randomised trial, we hope to show that regular feedback of procedure adjusted quality indicators to endoscopists and their units can drive improvements and reduce variation in endoscopy quality. The project results will be disseminated through presentation at conferences, published papers and direct feedback to hospitals of POUGIC rates to encourage quality improvement efforts.

Lay abstract: Aims We want to see how accurate endoscopy (flexible telescope examination of the gullet and stomach) is in finding cancer and to find measures of endoscopy performance that help to reduce the risk of missing a cancer. Background 16,800 people in the UK are diagnosed with oesophageal (gullet) or stomach cancer each year. Their outlook is often poor - only 16% of people with oesophageal and 19% with gastric cancer survive 5 years. 10% of people with oesophageal or stomach cancer may have had an endoscopy that did not find their cancer in the three years before their diagnosis. The second highest endoscopy research priority for the British Society of Gastroenterology is &quot;How can we improve the quality of upper gastrointestinal endoscopy?&rdquo;. However, there are no reliable measures of endoscopy quality to help improve cancer diagnosis. Design and methods used Developed with the assistance of the Research Design Service. We will undertake a detailed examination of medical publications on endoscopy quality measures and the evidence behind these. For the first time, using national records of all endoscopies in each hospital and of all people with oesophageal or stomach cancer, we will find out how many people had an endoscopy that did not find their cancer at each hospital, compared with other hospitals and provide this data to hospitals to help them improve. We will look for differences in the endoscopy quality measures in the national endoscopy database records of all endoscopies undertaken within the UK, comparing hospitals with the lowest (best) missed cancer rates with hospitals with the highest (worst) rates. Allowance will be made for factors unrelated to the quality of the endoscopy, to give the quality measures that best predict not missing cancer. An expert medical and lay public panel will review the practicability of these evidence based quality measures as interventions to raise the quality of endoscopy. Patient and public involvement Mimi McCord, chair of Heartburn Cancer UK and co-applicant commented &ldquo;I had not expected patients would be let down and remain undiagnosed for a period of time which is likely to give them a death sentence. It (the project) has my absolute support.&rdquo; 17 of 17 people who have had oesophageal or gastric cancer and their relatives from the charity Upper GI Blues agreed the project was important and that it would make a difference for future cancer patients. They suggested focusing on the issue of sedation during endoscopy as a factor behind cancer not being diagnosed. Dissemination We will share with each hospital how many people with cancer had endoscopies that did not find cancer, in comparison with other hospitals. The results of our research will be presented at conferences and published in medical journals.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: CANCER AND NEOPLASMS