Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
Veterans Affairs Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA.
Dis Esophagus. 2019 Jun 1;32(6). doi: 10.1093/dote/doy133.
Published guidelines for the management of eosinophilic esophagitis (EoE) recommend an initial trial of proton pump inhibitors (PPI), histologic assessment for response to therapy, and tailoring treatments to patient needs and provider resources. Effectiveness studies directly comparing therapies are lacking, leaving a situation ripe for shared decision making. We aimed to assess gastroenterologists' adherence to guidelines and how they respond to EoE patients' preferences regarding management. We administered a web-based survey to practicing US gastroenterologists, assessing knowledge, and practice patterns in the management of EoE, including comfort with alternative treatments to steroids. Ninety-two providers responded, including 55% in private practice. Nearly half (47%) reported spending ≤10 minutes on initial education and counseling and 48% recommended PPI monotherapy prior to other strategies. Of those who did not start with PPI monotherapy, 55% chose topical steroids ± PPI and 26% dietary elimination ± PPI. Despite this, 90% felt comfortable allowing a patient to start dietary elimination instead of steroids, but less comfortable with dilation alone (39%) or no treatment (30%). Upon symptomatic resolution, 72% of academic providers recommended endoscopy with biopsies to demonstrate histologic response to treatment, compared to 27% in private practice. There are substantial variations in adherence to guidelines regarding PPI use and assessing response to therapy. Gastroenterologists prefer topical steroids over other treatment modalities and most spend little time educating and counseling, which may limit informed decision making. Strategies aimed at decreasing these variations in management and promoting shared decision making in EoE are needed.
已发布的嗜酸性食管炎（EoE）管理指南建议初始试用质子泵抑制剂（PPI）、组织学评估治疗反应，并根据患者需求和提供者资源调整治疗方法。缺乏直接比较治疗方法的有效性研究，为共同决策创造了有利条件。我们旨在评估胃肠病学家对指南的遵守情况，以及他们对 EoE 患者管理偏好的反应。我们向美国执业胃肠病学家进行了一项基于网络的调查，评估他们在 EoE 管理方面的知识和实践模式，包括对类固醇替代治疗的舒适度。92 名提供者做出了回应，其中 55%在私人诊所工作。近一半（47%）报告说他们在初始教育和咨询上花费的时间≤10 分钟，并且 48%在其他策略之前建议使用 PPI 单药治疗。在那些没有开始使用 PPI 单药治疗的人中，55%选择局部类固醇±PPI，26%选择饮食排除±PPI。尽管如此，90%的人认为允许患者开始饮食排除而不是使用类固醇是可以接受的，但对单独扩张（39%）或不治疗（30%）的接受程度较低。在症状缓解后，72%的学术提供者建议进行内镜检查和活检，以显示治疗对组织学的反应，而私人诊所的这一比例为 27%。在使用 PPI 和评估治疗反应方面，指南的遵守情况存在很大差异。胃肠病学家更喜欢局部类固醇而不是其他治疗方式，并且大多数人花费很少的时间进行教育和咨询，这可能会限制知情决策。需要制定策略来减少这种管理上的差异，并促进 EoE 中的共同决策。
