Background: Eosinophilic Esophagitis (EoE) is a chronic, immune-mediated disease in children that is diagnosed and monitored with serial endoscopic evaluation with the goals of mucosal healing and histologic remission. As such, obtaining biopsies at two or more esophageal levels and scoring macroscopic findings by using the EoE Endoscopic Reference Score (EREFS) is recommended. Nationwide Children’s EoE team has developed multiple quality improvement (QI) initiatives to decrease variability and improve adherence to consensus guidelines. The objectives of this project are to evaluate the completion rates of: (1) repeat endoscopy within 180 days of diagnosis, (2) obtaining biopsies from two esophageal levels, and (3) EREFS documentation.
Methods: Since January 2019, we have performed monthly reviews of our new diagnosis EoE cohort. In May 2022, an EoE Management Pathway was distributed to educate clinicians on repeat endoscopy, 2-level esophageal biopsies, and EREFS documentation recommendations. Interventions to improve QI metrics were also introduced which include pended endoscopy orders, reminders to schedulers, and patient/family education by our nurse coordinator. A statistical process control chart for repeat endoscopy rates from January 2019 – September 2023 was created (QI Macros in Microsoft Excel®). In addition, two-level biopsy collection and EREFS documentation rates from May 2021 – April 2022 (pre-intervention) were compared to those from May 2022 – September 2023 (post-intervention) using Fisher’s exact test (Stata®).
Results: Between January 2019 – September 2023, 671 new EoE patients had initial endoscopy performed by 29 Pediatric GI faculty and 22 Pediatric GI fellows. Our baseline repeat endoscopy rate was 46% and there was a centerline shift up to a mean of 74% completion rate between May 2022-September 2023 (Figure 1). Two-level biopsy rates were increased but not statistically different between pre- and post-intervention groups for initial endoscopy (74% vs 83%, p=0.051). However, on 2^nd endoscopy there was an increase in rates of 2-level biopsies. EREFS documentation rates significantly increased for both initial (48% vs 63%, p=0.007) and 2nd endoscopy cohorts (53% vs 85%, p=<0.001) in the post-intervention groups (Figure 2).
Conclusions: We demonstrated in our single center pediatric practice that standardization of pediatric EoE care is feasible and effective. 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.

Figure 1: Centerline shift for repeat endoscopy rate was noted between May 2022-September 2023.

Figure 2: Comparison of Two-Level Biopsy and EREFS Documentation Rates Pre- and Post-Intervention.

John Grisham

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