Accurate and timely diagnosis of Eosinophilic Esophagitis improves over time in Europe. An analysis of the EoE CONNECT Registry

Abstract

Background: Poor adherence to clinical practice guidelines for eosinophilic esophagitis (EoE) has been described and the diagnostic delay of the disease continues to be unacceptable in many settings.

Objective: To analyze the impact of improved knowledge provided by the successive international clinical practice guidelines on reducing diagnostic delay and improving the diagnostic process for European patients with EoE.

Methods: Cross-sectional analysis of the EoE CONNECT registry based on clinical practice. Time periods defined by the publication dates of four major sets of guidelines over 10 years were considered. Patients were grouped per time period according to date of symptom onset.

Results: Data from 1,132 patients was analyzed and median (IQR) diagnostic delay in the whole series was 2.1 (0.7-6.2) years. This gradually decreased over time with subsequent release of new guidelines (p < 0.001), from 12.7 years up to 2007 to 0.7 years after 2017. The proportion of patients with stricturing of mixed phenotypes at the point of EoE diagnosis also decreased over time (41.3% vs. 16%; p < 0.001), as did EREFS scores. The fibrotic sub-score decreased from a median (IQR) of 2 (1-2) to 0 (0-1) when patients whose symptoms started up to 2007 and after 2017 were compared (p < 0.001). In parallel, symptoms measured with the Dysphagia Symptoms Score reduced significantly when patients with symptoms starting before 2007 and after 2012 were compared. A reduction in the number of endoscopies patients underwent before the one that achieved an EoE diagnosis, and the use of allergy testing as part of the diagnostic workout of EoE, also reduced significantly over time (p = 0.010 and p < 0.001, respectively).

Conclusion: The diagnostic work-up of EoE patients improved substantially over time at the European sites contributing to EoE CONNECT, with a dramatic reduction in diagnostic delay.

Keywords: Diagnostic delay; Endoscopy; Eosinophilic esophagitis; Gastrointestinal; Guideline Adherence; Practice Guidelines as Topic; Registries.

FIGURE 1

Box plot for diagnostic delay (time span from symptom onset to reaching an EoE diagnosis) (a) and proportion of patients exhibiting different EoE phenotypes (b), in patient groups defined according to the year of symptom onset. Differences in diagnostic delay according to patient phenotypes were also found (c). *p < 0.05, **p < 0.01, ***p < 0.001.

FIGURE 2

Box plots for EREFS (edema, rings, exudates, furrows and strictures) score calculated at diagnostic endoscopy (a) and for DSS (dysphagia symptom score) at EoE diagnosis (b), in patients classified according to the year of symptom onset. *p < 0.05, **p < 0.01, ***p < 0.001.

FIGURE 3

Histogram showing the percentage of patients with between 1 to 5 endoscopies prior to the one which lead to an EoE diagnosis, and classified according to the year of symptom onset (in 2007 or before and in 2008 or later) (a). Box plot for number of allergy tests per patient after EoE diagnosis, for patients classified in four groups according to the year of EoE diagnosis (b). ***p < 0.001.

FIGURE 4

Box plot for diagnostic delay (time span from symptom onset to reaching an EoE diagnosis) among patients recruited in Spain compared to non‐Spanish patients. *p < 0.05, **p < 0.01, ***p < 0.001.