[Compliance with terminology standards in reflux, ulcers, and gastritis: A study of 881 consecutive upper gastrointestinal endoscopy reports]

Abstract

Background: The German version of the Minimal Standard Terminology document for endoscopy was discussed in 1997 and 1998, and finally published at the end of 1999 as one of the German Gastroenterology Society guidelines. The diagnoses and descriptive terms included in this standard terminology are based on the consensus views of a large number of German endoscopists (20 endoscopists based in Munich and 20 elsewhere in Germany). The aim of the present study was to investigate how much spontaneous compliance there is with the descriptive terms included in the standard terminology - both among the members of the consensus discussions, and among colleagues not involved in this project.

Methods: A total of 881 endoscopy reports with the diagnoses of reflux, ulcer, and gastritis were collected from 11 centers (2 hospitals and 9 private offices, with a total of 26 examiners) over a one-month period. Nine of the 26 examiners were actively involved in the terminology consensus discussion. The rate of occurrence of the descriptive terms contained in the standard terminology was assessed for the diagnoses listed above.

Results: Compliance with the descriptive terms was high (> 90 %) only for basic parameters such as the Savary classification of reflux and the area in which gastroduodenal ulcers were located. Other important parameters, such as the extent (length) of Barrett's esophagus, ulcer size, and circumferential location, were reported in only three-quarters of cases or less. The descriptions of gastritis were inconsistent. There was no difference in the degree of compliance either between endoscopists using free dictation and those using computerized text blocks, or between members of the terminology group and those not involved in preparing the terminology.

Conclusions: Adherence to standard terminology and its descriptive parameters is poor even among specialized gastroenterologists who have been involved in terminology consensus discussions. Compliance needs to be improved by providing suitable software programs with automatic reporting functions.