Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists

Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists Tony E. Yusuf, MD, Gavin C. Harewood, MD, MSc, Jonathan E. Clain, MD, Michael J. Levy, MD, Kenneth K. Wang, MD, Mark D. Topazian, MD, Elizabeth Rajan, MD Rochester, Minnesota

Background: The level of awareness among non-gastroenterologists of the indications for EUS is unknown. This study assessed knowledge of the indications and the utility of EUS among gastroenterologists and non-gastroenterologists in a large multispecialty academic practice. Methods: A questionnaire was designed that tested knowledge of the indications for EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary system and colorectum. The questionnaire was distributed by electronic mail to gastroenterologists, general internists, non-gastroenterologist subspecialists, and surgeons in a large multispecialty practice. Results: The survey was distributed to 659 attending physicians of whom 227 (34%) replied: gastroenterologists (53%), internists (30%), non-gastroenterologist specialists (33%), and surgeons (28%). Knowledge of appropriate indications was highest among gastroenterologists (84.3%) compared with internists (68.9%), non-gastroenterologist specialists (65.4%), and surgeons (65.3%) (p < 0.0001). Among all non-gastroenterologists, knowledge of indications for hepatopancreatobiliary (mean 66.3% correct responses) and colorectal applications (64.0%) was inferior to knowledge of esophageal (71.5%) and gastroduodenal (83.5%) applications. Conclusions: Internists, non-gastroenterologist specialists, and surgeons in a large multispeciality practice have moderate knowledge of the indications and the utility of EUS. Knowledge was at the lowest level for hepatopancreatobiliary and colorectal applications of EUS for all 3 groups of nongastroenterologists. Future studies should focus on the education of non-gastroenterologists regarding the role of EUS and assess the impact of such education on the appropriateness of EUS referral patterns. (Gastrointest Endosc 2004;60:575-9.)

Since the first descriptions in 1980,1,2 EUS has evolved into an accurate modality for staging GI malignancies and for the evaluation of submucosal lesions and pancreaticobiliary diseases. EUS influences the management of patients with rectal or esophageal cancer.3-5 Moreover, changes in management arising from the use of EUS improve outcomes for patients with either of these malignancies. Patients with these diseases often are cared for by physicians who are not specialists in gastroenterology, including general internists, non-GI medical subspecialists, and general surgeons. Whether these non-gastroenterologists are familiar with the utility of EUS is unclear. The aim of this study was to assess knowledge of the indications for EUS among both gastroenterologists and non-gastroenterologists in a large multiReceived March 2, 2004. For revision May 17, 2004. Accepted June 29, 2004. Current affiliation: Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. Reprint requests: Gavin C. Harewood, MD, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First St. SW, Rochester, MN 55905. Copyright Ó 2004 by the American Society for Gastrointestinal Endoscopy 0016-5107/$30.00 PII: S0016-5107(04)02015-2 VOLUME 60, NO. 4, 2004

specialty academic practice. Characterization of non-gastroenterologist knowledge of EUS will identify areas that require improvement through education. A broader and improved understanding of the indications and utility of EUS may ultimately lead to more appropriate patient referrals for EUS by nongastroenterologists. MATERIALS AND METHODS A survey designed to assess knowledge of EUS was distributed by electronic mail (e-mail) to gastroenterologists (121), internists (259), non-GI medical subspecialists (129), and surgeons (150) who practice at the Mayo Clinic (Rochester, Minn.). All physicians who work in our institution are given an e-mail address. The responses were returned electronically to the principal investigator, and the data were analyzed. A reminder e-mail was sent after 10 weeks to physicians who did not respond to the initial survey. All data were analyzed at 3 weeks after distribution of the second e-mail. If no reply was received after two e-mails, the recipient was considered a non-respondent. Survey instrument A questionnaire was developed that addressed the indications for EUS in 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary, and colorectum (Appendix). To adequately assess these areas, 6 experienced endosonographers (>1000 EUS procedures) each GASTROINTESTINAL ENDOSCOPY

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Table 1. American Society for Gastrointestinal Endoscopy recommended indications for EUS EUS generally is indicated for Staging tumors of the GI tract, pancreas, bile ducts, and mediastinum Evaluating abnormalities of the GI-tract wall or adjacent structures Tissue sampling of lesions within, or adjacent to, the wall of the GI tract Evaluation of abnormalities of the pancreas, including masses, pseudocysts, and chronic pancreatitis Evaluation of abnormalities of the biliary tree Providing endoscopic therapy under US guidance

Indications for EUS: gastroenterologists vs. non-gastroenterologists

Table 2. Average score per specialty Organ system

GI

IM

Non-GI

Surgery

Esophagus (5 questions) Gastroduodenum (6 questions) Hepatopancreatobiliary (9 questions) Colorectum (5 questions) Total (25 questions)

81% 92%

68% 84%

69% 81%

68% 77%

84%

63%

58%

60%

80% 84.3%

62% 68.9%

56% 65.4%

58% 65.3%

GI, Gastroenterologists; IM, internists; non-GI, non-gastroenterologists.

square test. A p value <0.05 was considered statistically significant. generated a list of the most important appropriate and most commonly encountered inappropriate indications for EUS. At our institution, an open-access scheduling mechanism is used, which allows non-gastroenterologists to schedule an EUS procedure. By using the lists generated by the endosonographers, a multi-item questionnaire was developed that incorporated appropriate and inappropriate indications. Elements taken from American Society for Gastrointestinal Endoscopy (ASGE) guidelines on recommended indications for EUS (Table 1) also were incorporated into the questionnaire. The revised version then was distributed to the 6 endosonographers. Based on their feedback, the survey was modified and ultimately included a total of 27 questions (Appendix). The first two questions in the survey addressed medical specialty of the physician and prior patient referral for EUS. The organ-specific section comprised 25 questions, which assessed diseases of esophagus (5 questions), gastroduodenum (6), hepatopancreatobiliary tract (9) and colorectum (5). Failure to answer a question was considered an incorrect response for the purposes of analysis. The study was approved by our institutional review board. All endosonographers were in agreement as to the correct response to each question. Care was taken to incorporate elements from each item on the list of ASGErecommended indications for EUS (Table 1) as follows: Indication 1 (tumor staging): addressed by questions 1 (esophagus); 1,3 (gastroduodenum); and 1 (colorectum). Indication 2 (assessing wall abnormalities): addressed by questions 2 (gastroduodenum) and 2 (colorectum). Indication 3 (tissue sampling): addressed by questions 5 (gastroduodenum) and 9 (hepatopancreatobiliary). Indication 4 (evaluating pancreas abnormalities): addressed in questions 2, 4, 6 (hepatopancreatobiliary). Indication 5 (evaluating biliary tree abnormalities): addressed by question 8 (hepatopancreatobiliary). Indication 6 (EUS-guided therapy): addressed in question 7 (hepatopancreatobiliary). Statistical analysis A summary of the mean overall score and mean organspecific category score for each physician group was constructed. The proportion of correct responses recorded by various physician groups was compared by using a chi576

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RESULTS The survey was distributed to 659 attending physicians: 121 practiced gastroenterology, 259 general internal medicine, 129 other medical subspecialties, and 150 surgery. Of these, 203 responded to the initial questionnaire and a further 24 responded to the reminder e-mail. The responses provided by the 227 respondents (34.4%) comprised the data for analysis. Response rates varied by specialty, with a higher rate for gastroenterologists (53%) compared with internists (30%), non-GI medical subspecialists (33%), and surgeons (28%). Among all respondents, 156 (69%) had referred patients for an EUS procedure; a larger proportion of gastroenterologists had referred patients for EUS (98%) compared with internists (49%), non-GI specialists (67%), and surgeons (62%). Survey performance according to physician group The mean total score for gastroenterologists was higher (84.3%) compared with that for internists (68.9%), non-GI specialists (65.4%), and surgeons (65.3%) (p < 0.0001) (Table 2). When performance of the various physician groups according to organspecific categories (esophagus, gastroduodenum, hepatopancreatobiliary system, and colorectum) was compared, gastroenterologists scored highest in all 4 categories (Fig. 1). Scores among non-gastroenterologists were not significantly different for the different organ system categories. With respect to applications of EUS in the colorectum, internists (62%) fared slightly better than non-GI subspecialists (56%) (p = 0.04). Survey performance according to organ-specific category Among all non-gastroenterologists, knowledge of the role of EUS in the hepatopancreatobiliary system VOLUME 60, NO. 4, 2004

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and in the colorectum was consistently inferior compared with the esophagus and gastroduodenum (Table 2). For each physician group, the ranking of EUS knowledge with respect to the 4 anatomical areas was the same: the gastroduodenum was always highest (mean 83.5% correct), followed by esophagus (71.5%), hepatopancreatobiliary system (66.3%), and colorectum (64.0%), which was always lowest. DISCUSSION EUS is now the investigative modality of choice for tumor staging of certain GI cancers and for evaluation of submucosal masses.5-28 In addition to these well-established indications, new applications are emerging for EUS.29 Moreover, the range of applications is no longer limited to the GI system; studies have highlighted the utility of EUS for staging nonsmall-cell lung cancer.9 EUS also has progressed from a purely imaging modality to one that can provide a tissue diagnosis (EUS-guided FNA) and can deliver therapy (interventional EUS).30-34 Thus, EUS has impacted patient care by improving diagnostic accuracy and cost-effectiveness.35-38 Heretofore, EUS mainly was limited to academic centers, but availability is now broadening. As utilization increases, adequate knowledge of EUS among nongastroenterologists assumes greater importance. The present study is the first to attempt to characterize the knowledge base of both gastroenterologists and non-gastroenterologists regarding the indications for EUS. The present study has several noteworthy findings. As expected, gastroenterologists had a better knowledge of EUS than non-gastroenterologists. However, gastroenterologists responded incorrectly to 15% of the questions, whereas wrong answers were given to a third of the questions by non-gastroenterologists. That most respondents had referred patients for EUS underscores the importance of enhancing EUS knowledge among non-gastroenterologists. Moreover, the findings indicate that the application of EUS to the hepatopancreatobiliary system and colorectum are least understood. Although this result could also reflect differences in the relative difficulty of survey questions between sections, it highlights a need for educational programs that increase knowledge of EUS applications in these organ systems. Future studies should be aimed at devising methods for the education of non-gastroenterologists, with a primary focus on the role of EUS in the hepatopancreatobiliary system and the colorectum. Such studies also should assess the impact of education on the appropriateness with regard to EUS referral patterns. VOLUME 60, NO. 4, 2004

Figure 1. Survey performance according to physician specialty. GI, Gastroenterologists; IM, Internists; non-GI, non-gastroenterologists; Esoph, esophagus; G’duod, gastroduodenum; HPB, hepatopancreatobiliary system.

E-mail was used to distribute the survey. The effectiveness of e-mail compared with standard mail and telephone contact for assessing patient satisfaction with endoscopy was previously demonstrated by us.39 E-mail is virtually free, the only cost being that of the e-mail account. It takes roughly 15 seconds to send each message. Undeliverable messages usually are returned as such within minutes. Repeated messages, clarification requests, and reminders are similarly cost efficient and time efficient. Recipients can quickly and easily complete the survey at a convenient time and return it with a single keystroke. E-mail also maximizes the efficiency of data collection; data can be directly entered into a database, saving time, money, and effort, and thereby avoiding error-prone data transfer. The present study has several limitations. It was conducted at a single tertiary referral institution, which limits the generalizability of the findings. The low response rate (34%) introduces a further element of selection bias. The knowledge level of participants may have been overestimated by the fact that responders were likely to have some knowledge of the application of EUS, as opposed to those who opted not to respond (response bias). These limitations preclude extrapolation of the results to communitybased internists and surgeons. Large-scale studies of a community-based non-gastroenterologists would be needed to establish the external validity of the questionnaire and to obtain results that would be broadly representative. Data were not obtained regarding the level of seniority of responding physicians; these would have been informative as to the relation between physician experience and knowledge of EUS. Lastly, the survey instrument used in the present study was not externally validated; it was GASTROINTESTINAL ENDOSCOPY

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based upon the opinions of a panel of expert endosonographers as to the indications for EUS. This study represents a preliminary assessment of EUS knowledge levels among non-gastroenterologists. The findings suggest that further education of non-gastroenterologists (internists, non-GI subspecialists, and surgeons) is required, particularly with respect to EUS of the hepatopancreatobiliary system and the colorectum. Future studies should focus on methods for devising educational programs for nongastroenterologists regarding the role of EUS and should assess the impact of such programs on the appropriateness of patient referrals for EUS. REFERENCES 1. DiMagno EP, Buxton JL, Regan PT, Hattery RR, Wilson DA, Suarez JR, et al. Ultrasonic endoscope. Lancet 1980;I:629-31. 2. Strohm WD, Phillip J, Hagenmuller F, Classen M. Ultrasonic tomography by means of an ultrasonic fiberendoscope. Endoscopy 1980;12:241-4. 3. Harewood GC, Wiersema MJ, Nelson H, Maccarty RL, Olson JE, Clain JE, et al. A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer. Gastroenterology 2002;123:24-32. 4. Vazquez-Sequeiros E, Wiersema MJ, Clain JE, Norton ID, Levy MJ, Romero Y, et al. Impact of lymph node staging on therapy of esophageal carcinoma [see comment]. Gastroenterology 2003;125:1626-35. 5. Chang KJ, Nguyen P, Erickson RA, Durbin TE, Katz KD. The clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of pancreatic carcinoma. Gastrointest Endosc 1997;45:387-93. 6. Rodriguez J, Kasberg C, Nipper M, Schoolar J, Riggs MW, Dyck WP. CT-guided needle biopsy of the pancreas: a retrospective analysis of diagnostic accuracy. Am J Gastroenterol 1992;87:1610-3. 7. Giovannini M, Seitz JF, Monges G, Perrier H, Rabbia I. Fineneedle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients. Endoscopy 1995;27:171-7. 8. Benassai G, Mastrorilli M, Mosella F, Mosella G. Significance of lymph node metastases in the surgical management of pancreatic head carcinoma. J Exp Clin Cancer Res 1999;18:23-8. 9. Gress FG, Savides TJ, Sandler A, Kesler K, Conces D, Cummings O, et al. Endoscopic ultrasonography, fine-needle aspiration biopsy guided by endoscopic ultrasonography, and computed tomography in the preoperative staging of nonsmall-cell lung cancer: a comparison study. Ann Intern Med 1997;127:604-12. 10. Wiersema MJ, Vilmann P, Giovannini M, Chang KJ, Wiersema LM. Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology 1997;112:1087-95. 11. Catalano MF, Alcocer E, Chak A, Nguyen CC, Raijman I, Geenen JE, et al. Evaluation of metastatic celiac axis lymph nodes in patients with esophageal carcinoma: accuracy of EUS. Gastrointest Endosc 1999;50:352-6. 12. Williams DB, Sahai AV, Aabakken L, Penman ID, van Velse A, Webb J, et al. Endoscopic ultrasound guided fine needle aspiration biopsy: a large single centre experience. Gut 1999;44:720-6. 13. Saitoh N, Okui K, Sarashina H, Suzuki M, Arai T, Nunomura M. Evaluation of echographic diagnosis of rectal

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APPENDIX EUS Survey (correct answers are provided in bold print): 1. What is your specialty? ___General internal medicine ___Gastroenterology ___Non-gastroenterology medical subspecialty ___Surgery 2. Have you ever scheduled a patient for Endoscopic Ultrasound (EUS)? ___yes 3. Which of the following are appropriate indications for EUS? ESOPHAGUS: d Local staging of an operable esophageal cancer: ___yes ___no d Evaluation of metastatic esophageal cancer: ___yes ___no d Screening of Barrett’s esophagus: ___yes ___no d Evaluation of achalasia: ___yes ___no d Staging of lung cancer: ___yes ___no GASTRODUODENUM: d Local staging of gastric cancer: ___yes ___no d Evaluation of a submucosal mass: ___yes ___no d Evaluation of dyspepsia: ___yes ___no d Local staging of gastric lymphoma: ___yes ___no d Sampling of suspicious perigastric lymph nodes: ___yes ___no d Assessment of duodenal ulcer: ___yes ___no HEPATO-PANCREATO-BILIARY: d Local staging of ampullary cancer: ___yes ___no d Local staging of pancreatic cancer: ___yes ___no d Evaluation of weight loss: ___yes ___no d Evaluation of pancreatic cysts: ___yes ___no d Evaluation of abdominal pain: ___yes ___no d Assessment of chronic pancreatitis: ___yes ___no d Treatment of abdominal pain secondary to pancreatic cancer: ___yes ___no d Evaluation of suspected choledocholithiasis: ___yes ___no d Sampling of liver metastasis: ___yes (in left hepatic lobe only) ___no COLORECTUM: d Local staging of rectal cancer: ___yes ___no d Evaluation of fecal incontinence: ___yes ___no d Evaluation of constipation: ___yes ___no d Assessment of adenomatous rectal polyp: ___yes ___no d Local staging of colon cancer: ___yes ___no

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___no

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