GUTS UK – the national charity for the digestive system – has recently set up an endoscopy priority setting partnership (PSP) in collaboration with Crohn’s & Colitis UK and the British Society of Gastroenterology (BSG). This endoscopy PSP brought together patients, carers and healthcare professionals to identify unanswered questions and agree on shared priorities, guiding researchers and funding bodies towards areas that could make the biggest difference to care pathways. For the team at BIOHIT, these priorities reflect what we routinely hear as we meet gastroenterology teams across the country. Establishing a set direction is an important step for the specialty, and we hope it will lead to sector-wide transformation.
What priorities did the report identify?
Over 665 people took part in an open answer survey, together submitting 332 different questions, which were then summarised into 19 unique questions, evidence-checked to ensure that there was not already a clear answer in the research. The final 19 questions were ranked by a panel of 12 patients and carers and 11 healthcare professionals, creating a list of top ten key priorities, and nine further research questions. Many of the questions related specifically to the process of administering an endoscopy, while others dealt with concerns around patient experience, the pathways surrounding endoscopy, or emerging topics such as artificial intelligence and sustainability. Interestingly, many of the challenges identified can already be addressed, at least in part, through pathway redesign and improved triage before patients reach endoscopy. In this blog, we explore some of the areas where these changes could make a difference.
Ensuring endoscopy is used appropriately
Priority 7: Is there value in undergoing endoscopy for people with minor symptoms, including impact on patient outcomes and demand on services?
This question represents a major issue in healthcare. Only a small minority of patients with minor symptoms will have serious underlying disease while, for the vast majority, the symptoms are not indicative of anything sinister. This is particularly relevant for gastrointestinal diseases, where relatively minor symptoms – such as dyspepsia, reflux, epigastric pain and heartburn – can be caused by anything ranging from lifestyle choices to gastroesophageal reflux to atrophic gastritis and gastric cancer. As these symptoms are very common in the general population, it makes it challenging for primary care clinicians to decide who to refer for endoscopic investigation when no red flag signs are present.
Referring all patients for an endoscopy would reduce instances of serious underlying disease being missed, but would also create huge workloads for already overstretched endoscopy departments. It would also result in very high costs for the NHS, and is clearly unsustainable. On the other hand, waiting for symptoms to progress further means many patients will be diagnosed later, increasing the complexity and cost of treatment, as well as worsening outcomes. The key question therefore is how can clinical teams determine which patients with relatively minor symptoms require endoscopy, and which can be managed safely in primary care.
Triage tests that can be performed at the point of care could hold the key to safely prioritising these patients. A good example of this is approach is the GastroPanel® Quick Test, a simple serological test that can be performed at the point of care or in the laboratory to identify biomarkers associated with atrophic gastritis. The test examines levels of pepsinogen I and II, gastrin-17 and H. pylori antibodies. When these biomarkers are considered together, they can aid clinicians in deciding which patients are likely to benefit from endoscopic investigation. This test has a high negative predictive value, helping to identify patients who are unlikely to benefit from endoscopy, meaning they can avoid an invasive procedure altogether. At the same time, this would ease pressure on endoscopy teams and help to make sure those who really do need further investigation are seen sooner.
The future of endoscopy is much more than leveling up the procedure. It needs to ensure that the pathway leading to endoscopy delivers the right patients at the right time for the right outcome.
Graham Johnson, BIOHIT Managing Director
Pain, trauma and complications
Priority 1: What are the best ways to reduce patients’ anxiety or distress both before and during endoscopy?
Priority 6: What are the best ways to reduce the risk of complications from endoscopy?
Unsurprisingly, several of the research priorities are related to the pain, trauma and potential complications of endoscopy. Many patients find the endoscopy experience extremely distressing, particularly if pain relief and sedation are not offered. Serious complications from endoscopy are rare, but can lead to lengthy hospital admissions and, in cases such as oesophageal perforation, have relatively high mortality rates.
Although risk of complications of endoscopy cannot be removed entirely, it can be reduced considerably by reducing the number of procedures associated with cases of low-disease risk. Reducing the number of endoscopies through smarter and more efficient diagnostic pathways using triage tests is an ideal way to address these issues. Point-of-care testing (POCT) in primary care can significantly reduce feelings of worry or anxiety in patients assessed to be low risk, as they receive results immediately. At the same time, reducing the overall endoscopy burden by diverting low-risk patients down other pathways will reduce the total number of complications.
Improving endoscopy for patients with comorbidities
Priority 8: What are the best ways to prepare for endoscopy of the upper digestive tract, especially for people whose health condition may affect how well this works?
There are several health conditions that make endoscopy more challenging. For instance, achalasia – a rare condition where the muscles of the oesophagus are weakened – increases the risk of regurgitation or aspiration during endoscopy. Unfortunately, there is no way to completely avoid endoscopies for patients at higher risk of complications if the procedure is necessary for diagnosis. However, this is another situation where a triage test could help to avoid unnecessary procedures. Using a triage test with a high negative predictive value could help to reduce the number of high risk, low yield endoscopy procedures, ensuring that patients only with potentially serious underlying conditions undergo an invasive confirmatory procedure.
An open conversation about the future of endoscopy
Addressing the research priorities identified by the PSP does not mean having to redesign endoscopy services from scratch. Existing diagnostic tools, such as triage testing, already offer ways to improve some parts of the pathway. Endoscopy will remain an essential diagnostic procedure, but better triage could help to ensure capacity is focused on patients who are most likely to benefit from it. This is about driving pathway efficiency and clinical prioritisation.
Introducing appropriate testing earlier in the pathway will allow healthcare teams to prioritise endoscopy referrals for those who need them, while identifying lower risk patients who do not require invasive investigation. However, the benefits extend far beyond capacity, and address many of the major concerns expressed by patients and carers. Fewer unnecessary procedures means less anxiety and discomfort for patients, fewer opportunities for complications, and more time for endoscopy teams to focus on the patients that need their expertise most.
The PSP has provided a valuable picture of what patients, carers and healthcare professionals want future endoscopy services to look like. The next step is to explore how research, pathway redesign and technologies such as POCT can work together to turn these priorities into meaningful improvements in patient care.
Learn more about how GastroPanel can help to transform pathways