European patients with eosinophilic esophagitis (EoE) had an improved diagnosis process and a faster diagnosis as new clinical practice guidelines were published over time, according to the results of a recent study.
Study results published in the United European Gastroenterology Journal showed significant improvements over time in eosinophilic esophagitis (EoE) management and significant reductions in diagnostic delay for European patients with EoE.
International clinical practice guidelines, consensus documents, and technical reviews published since 2007 have provided more information about EoE. Researchers aimed to investigate whether better knowledge of EoE has resulted in a reduction of diagnostic delay and improvement in the diagnostic process for patients with EoE in Europe.
This study involved a cross-sectional analysis of the EoE CONNECT registry. The EoE connect is a large, collaborative database that prospectively and retrospectively collects demographic and clinical patient characteristics and diagnostic and therapy outcomes for patients with EoE in Europe. Researchers collected patients’ sex, birth date, date of symptom onset, and date of EoE diagnosis. Using patients’ EREFS (edema, rings, exudates, structuring or mixed) scores, researchers analyzed the endoscopic features present at diagnosis. The Straumann’s Dysphagia Symptoms Score (DSS) evaluated patients’ symptoms.
Researchers divided patients into different groups for analysis depending on the publication dates of the major international clinical practice guidelines. Patients were assigned to their group based on the date of symptom onset. Because the first guidelines were published in 2007, the groups were up to 2007, 2008-2011, 2012-2013, 2014-2017, and after 2017. Data was collected from the registry on January 11, 2022. The study included 1132 patients with 865 (76.5%) being male. The mean age at diagnosis was 33.3 years old.
For variables with a normal distribution, mean and standard deviation was used. For variables with a non-normal distribution median and interquartile ranges (IQR) were used.
Diagnostic delay was defined as the time from first symptom onset to definitive EoE diagnosis. Median (IQR) diagnostic delay was 2.1 years. As new guidelines were released, diagnostic delay gradually decreased. Median diagnostic delay for patients with symptom onset before 2007 was 12.7 years and this significantly reduced to 0.7 years (8 months) after the last guidelines published in 2017.
For 1062 patients in the study, researchers investigated a possible impact of early EoE diagnosis on a shorter progression of esophageal fibrosis and EoE phenotype at the time of diagnosis. At diagnosis, 133 patients had a stricturing EoE phenotype, 147 patients had a mixed EoE phenotype, and 782 patients had an inflammatory EoE phenotype.
Over time, there was a significant decrease in the proportion of patients with stricturing and mixed EoE phenotypes present at the time of diagnosis. For patients with symptom onset before 2007, 41.3% had stricturing or mixed EoE phenotypes at the time of diagnosis. After 2017, only 16% had stricturing or mixed EoE phenotypes at the time of diagnosis.
EREFS scores also decreased over time. In comparing patients whose symptoms appeared before 2007 and those with symptom onset after 2017, the median (IQR) fibrotic EREFS sub-score decreased from 2 to 0.
The DSS examined EoE symptom severity. Patients with symptom onset in 2012 or later had significantly reduced DSS than patients with symptom onset before 2007.
Researchers also analyzed the number of previous upper endoscopies before the one that lead to an EoE diagnosis. For 92 patients in the study, the mean (SD) number of endoscopies before diagnosis was higher among patients with esophageal symptoms before 2007 than among patients with esophageal symptoms after 2008.
Recent guidelines discourage allergy tests as a part of EoE diagnosis as results are not able to improve EoE for most patients. For 297 patients in the study, use of allergy tests to manage EoE significantly reduced over time. The mean number of allergy tests performed decreased between patients diagnosed up to 2011 and those diagnosed after the next release of guidelines.
Limitations of this study include not considering other factors besides publication of the main international clinical practice guidelines that may have led to improvement in EoE care. Researchers also did not assess changes in therapy or monitoring patient responses. In addition, study results are applicable to EoE CONNECT centers. Study results may not be applicable to other settings with less awareness and expertise in EoE.
“In conclusion, substantial improvement over time in EoE management, in European centers, has been demonstrated in this EoE CONNECT analysis. This is reflected in a reduction in diagnostic delay, endoscopic severity and symptom scores at diagnosis; less usage of endoscopies to obtain the diagnosis; and a decreased in allergy testing after diagnosis,” the researchers concluded.
Navarro P, Laserna-Mendieta EJ, Casabona S, et al. Accurate and timely diagnosis of eosinophilic esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry. United European Gastroenterol J. 2022;10(5):507-517. doi: 10.1002/ueg2.12240