Standardization of Care Can Improve Outcomes for Children with Eosinophilic Esophagitis

A standardized pediatric care program implemented at Nationwide Children’s Hospital, in Columbus, OH, showed that procedural standardization and clinician education can improve diagnosis of EoE and monitoring of disease activity, leading to better outcomes for children with EoE. John Grisham, MD, discussed the implementation of the quality improvement program and its impact during a clinical symposium at Digestive Disease Week 2024.

EoE is diagnosed by performing upper endoscopy with at least one esophageal biopsy. Serial upper endoscopic procedures with esophageal biopsies are performed periodically after the initiation of therapies to assess for mucosal healing and histologic remission. Current guidelines recommend obtaining biopsy specimens at two or more esophageal levels and scoring macroscopic findings by using the EoE Endoscopic Reference Score (EREFS). Specialists in the management of pediatric EoE at Nationwide Children’s Hospital developed multiple quality improvement initiatives to increase adherence to the guidelines and decrease procedural variability. Grisham and colleagues then conducted a study to evaluate the completion rates of repeat endoscopy within 180 days of diagnosis, the rates of biopsies obtained from two esophageal levels, and EREFS documentation after the implementation of the new workflow.

The records of children who were newly diagnosed with EoE at the hospital beginning in January 2019 were reviewed every month. Between January 2019 and September 2023, nearly 700 patients with newly-diagnosed EoE had initial endoscopy performed by 29 pediatric gastroenterology faculty members and 22 pediatric gastroenterology fellows. In May 2022, an EoE Management Pathway was implemented at the hospital, with the aim to educate clinicians about repeat endoscopy, two-level esophageal biopsies, and EREFS documentation recommendations. Quality improvement interventions also addressed pended endoscopy orders, sending reminders to schedulers, and education of patients and families by nurse coordinators.

The analysis showed that the rate of repeat endoscopy increased from 46% in the pre-intervention period (from May 2021 to April 2022) to a mean completion rate of 74% in the post-intervention period (from May 2022 to September 2023). Two-level biopsy rates also increased, but were not statistically different between pre- and post-intervention groups when looking at the initial endoscopic procedures. However, a significant increase in the rates of two-level biopsies was observed on second endoscopy. EREFS documentation rates also increased for both initial and second endoscopy cohorts in the post-intervention period.

“We demonstrated in our single center pediatric practice that standardization of pediatric EoE care is feasible and effective,” the author said. ”The introduction of our EoE Management Pathway and new workflow were associated with a significant increase in rates of repeat endoscopy within 180 days of diagnosis and EREFS documentation across 51 pediatric providers. In a disease where objective information can help guide clinical decisions, standardization of care is the first step. Ultimately, we hope this standardization across our practice will help improve mucosal remission rates and pediatric EoE outcomes.”