Adam Hughston, MD1, Eric A. Lorio, MD2, Grace Hopp, DO, MBA2, Pankaj Aggarwal, MD2, Brenda M. Briones, MD1, Randy Wright, MD2; 1UT Health San Antonio, San Antonio, TX; 2University of Texas Health Science Center, San Antonio, TX
Introduction: Esophagogastroduodenoscopy (EGD) is an important tool for assessing the resolution of high-risk varices, ulcers, and esophagitis. At our institution, the process of scheduling surveillance EGD has proven inconsistent. This quality improvement study is designed to improve rates of short-term follow-up EGD (4-12 weeks) via standardization of the scheduling process, a change we hope will increase early detection rates of high-risk lesions and facilitate rapid management of threatening conditions. Methods: We retrospectively reviewed 191 EGDs from 1/1/19-4/30/19. Collected variables included recommended follow-up timeframe, whether repeat EGD was performed within the recommended period, evidence of a consult being placed, and the presence or absence of a visit being scheduled. Scheduling was then standardized via a newly created form, filled out by fellows/faculty and given directly to scheduling staff. Afterwards, an additional 69 charts were reviewed from 1/1/20-1/31/20, and pre and post-intervention rates were compared using chi squared testing. Results: Of the pre-intervention cases, 103 had follow up EGD recommended within 4-12 weeks. Only 47.6% had an appointment properly scheduled, while 32.0% had an EGD within the recommended timeframe. Of the post-intervention cases, 38 patients had a follow up EGD recommended within a 12 week period. Of these patients, 81.6% had a visit made after initial EGD, demonstrating a dramatic improvement in the overall rate of properly scheduled appointments (p = 0.01) (Fig 1). When controlling for follow-up indication there was significant improvement in scheduled visits for high-risk varices (p= 0.02), ulcers (p= 0.04), and esophagitis (p= 0.028) (Fig 2). Follow-up EGD was actually performed in the recommended period for 42.1% of post-intervention patients (p=0.27), When excluding the 10 patients with cancelations due to COVID 19 (3/25-5/3), this number increases to 57.1%, representing a statistically significant increase in EGDswithin the recommended time period (p= 0.01). Discussion: Clinical expertise plays a large role in identifying high-risk lesions, and the ability to repeat EGDs in a timely manner remains a critical aspect to facilitating excellent patient care. As seen in this project, the standardization of logistic processes can have a dramatic effect on follow-up rates for high-risk lesions. While our data is affected by COVID 19 cancelations, our increase in successful surveillance indicates a positive shift in scheduling effectiveness.
Figure 1: Here we see how both rates of EGD within recommended time frame (A) and rates of appropriately scheduled follow up visits (B) were affected by the standardization of scheduling by a simple form accompanied by practitioner education. It is notable that the previous process of scheduling, whereby it was left to primary teams or the fellow to place a consult, resulted in low rates appointments even being scheduled properly (47.6%).
Figure 2: The breakdown of appointment scheduling rates by indication shows that the failure of these patients to follow up was not limited to a single indication, but rather a process deficiency. Once the process was standardized, dramatic improvements in the rates of scheduled visits and follow ups is seen across each indication.
Figure 3: Variceal bleeding is seen as the most frequent reason for recommended repeat EGD within 12 months. Esophagitis, ulcers, and Barrett’s esophagus remain frequent indications, as these lesions sometimes be a sign of underlying malignancy.
Disclosures: Adam Hughston indicated no relevant financial relationships. Eric Lorio indicated no relevant financial relationships. Grace Hopp indicated no relevant financial relationships. Pankaj Aggarwal indicated no relevant financial relationships. Brenda Briones indicated no relevant financial relationships. Randy Wright indicated no relevant financial relationships.