University of South Florida, Morsani College of Medicine Tampa, FL
Samuel O. Slone, MD1, Joel Richter, MD, MACG1, Ambuj Kumar, MD2, Vic Velanovich, MD1, John Jacobs, MD2; 1University of South Florida, Morsani College of Medicine, Tampa, FL; 2University of South Florida, Tampa, FL
Introduction: The Eckardt score and Achalasia-specific quality-of-life questionnaire (ASQ) are used to assess symptom severity before and after treatment for achalasia. However, a head to head performance comparison of these tools has not been performed. The goals were to 1) compare the overall accuracy of Eckardt with the ASQ for assessing improvement post-treatment, 2) evaluate score change after pneumatic dilatation (PD) vs surgical myotomy, and 3) asses the correlation between Eckardt and ASQ to determine post-treatment improvement. Methods: Achalasia patients who underwent PD, Heller myotomy (HM), or POEM between 2011-2018 were eligible. Both instruments were administered. To assess post-treatment success or failure, the reference standard was applied to all patients. The reference standard was a review of all follow-up office notes by the gastroenterologist or surgeon assessing symptom improvement and available results from esophageal testing including timed barium swallow, high resolution manometry, and endoscopy. Investigators applying the reference standards were blinded to the results of the index tests (i.e. Eckardt and ASQ). The predictive ability of ASQ and Eckardt in identifying treatment successes and failures was determined using receiver operating characteristics analysis and summarized as Area Under the Curve (AUC). Results: 106 patients (54 men) met inclusion criteria with 39 PD, 51 HM, and 16 POEM. The average length of follow-up from most recent procedure was 42.4 ±17 months. A review of records and esophageal testing showed 13 failures (12%; PD 2, HM 9, POEM 2). AUC for Eckardt was 0.96 [95% CI 0.87-0.99] and ASQ 0.97 [95% CI 0.92-0.99]. The Eckardt, cutoff ≥4, and ASQ, cutoff ≥15, were 94% and 87% accurate, respectively (Figure). For PD patients, the accuracy of the Eckardt with cutoff ≥4 was 100% versus 95% for ASQ with cutoff ≥15. For surgical patients, the accuracy of the Eckardt with cutoff ≥4 was 91% versus 85% for ASQ with cutoff ≥15 (Table). The correlation coefficient between the two tools is 0.85. Discussion: 1) Eckardt and ASQ are both valid and reliable tools to assess symptom severity in achalasia patients; 2) The Eckardt, cutoff ≥4, and ASQ, cutoff ≥15, offered the highest accuracy in determining treatment failure vs success; 3) Repeat physiologic testing may be reserved for treatment failures with either instrument; patients classified as treatment successes may be spared routine physiologic testing in the long term.
Proportions of patients correctly identified as treatment success or failures and accuracy with either Eckardt score or ASQ questionnaire. A) All treatment types B) Pneumatic Dilatation C) Surgery
Sensitivity, specificity, accuracy, number needed to diagnose and misdiagnose associated with a cutoff >/= 2-5 for the Eckardt and >/= 13-17 for the ASQ questionnaire. A lower number needed to diagnose is associated with better performance of the test and a higher number needed to misdiagnose is associated with a better performance of the test. For the likelihood to be diagnosed or misdiagnosed, a smaller number means better performance for the test
Disclosures: Samuel Slone indicated no relevant financial relationships. Joel Richter indicated no relevant financial relationships. Ambuj Kumar indicated no relevant financial relationships. Vic Velanovich indicated no relevant financial relationships. John Jacobs indicated no relevant financial relationships.