Adherence to Biopsy and Follow-Up Guidelines in a Population-Based Cohort of Children With Eosinophilic Esophagitis Q4 Amber McClain, * Molly O’Gorman, * Carlos Barbagelata, * Raza Patel, * Amy Lowichik, ‡ Kathryn Peterson, § Stephen Guthery, * and Jacob Robson* *Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Utah, Salt Lake City, Utah; ‡ Division of Pediatric Pathology, Department of Pathology, University of Utah, Salt Lake City, Utah; and § Division of Gastroenterology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah E osinophilic esophagitis (EoE) is a chronic, immune- mediated condition that is becoming more widely recognized in children. Recent EoE practice guidelines pro- vide clear recommendations on adequate biopsy sampling at diagnostic endoscopy and necessity of close follow-up endoscopy with biopsy to ensure mucosal healing with therapy. 1 Despite these recommendations, adherence to biopsy guidelines, time to first follow-up endoscopy, and overall surveillance endoscopy rates have not been robustly studied. Using a population-based cohort of chil- dren diagnosed with EoE in Utah, we assessed adherence to guidelines across multiple provider types, including ac- ademic pediatric gastroenterologists (PGIs), private prac- tice PGIs, and adult-trained providers performing endoscopy in children. Methods We analyzed a recently defined cohort of 1060 Utah children diagnosed with EoE over a 5-year span. 2 All patients were diagnosed with EoE based on (1) esoph- ageal symptoms, (2) an esophageal biopsy with >14 eosinophils per high-power field and no significant eosinophilia in other gastrointestinal biopsies, and (3) no systemic illness or infection to account for esophageal eosinophilia. 1 We assessed patient age, endoscopy, and histopathology findings at diagnosis, as well as follow-up endoscopy rates (subclassified by EoE activity at follow- up). We defined adequate EoE biopsy assessment as 2 or more biopsies at 2 or more esophageal levels. Children had at least 18 months of follow-up from their EoE diagnosis. As timing for close follow-up endoscopy is not specified in most EoE consensus guidelines, we defined this as repeat endoscopy with biopsy within 6 months of diagnosis and presumed treatment initiation. Results Children diagnosed with EoE by an academic-focused PGI were younger and had higher peak esophageal eosinophil counts than were those diagnosed by adult- trained endoscopists (Table 1). Adult-trained endo- scopists diagnosing EoE in children rarely adhered to biopsy sampling guidelines. Less than half of children newly diagnosed with EoE had a surveillance biopsy during the follow-up window and only 20.7% (n ¼ 220) had a close follow-up biopsy. The majority of children that did return for a repeat biopsy had active disease, regardless of follow-up timing; however, those that had close follow-up had 1.58 times the odds (95% confidence interval, 1.08–2.31; P ¼ .018) of being in histologic remission compared with those who returned late for surveillance. Discussion Utah is a unique area for pediatric EoE study, with a high disease incidence and the vast majority of pediatric endoscopy and biopsy data housed in an integrated electronic medical record via Intermountain Healthcare. Across this large pediatric EoE cohort, we found notable differences in children diagnosed with EoE across pro- vider types. We also showed that PGIs frequently ob- tained an adequate number of biopsy samples during EoE diagnostic endoscopy—a notable difference from prior reports. 3 EoE is a patchy disease that can be missed with inadequate number and distribution of biopsies. Therefore, education of all providers performing endos- copy in children with concern for EoE will be key to ensure those with EoE are not missed. We also showed that EoE activity surveillance, via endoscopic biopsy, was lacking across all diagnosing provider types. EoE treatment is targeted towards improving the child’s symptoms; however, a notable subset of children have continued EoE activity despite feeling better on therapy. 4 While treating to symptom © 2019 by the AGA Institute 1542-3565/$36.00 https://doi.org/10.1016/j.cgh.2019.08.060 Clinical Gastroenterology and Hepatology 2019;-:-–- SSU 5.6.0 DTD  YJCGH56733_proof  4 October 2019  7:19 pm  ce OB 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116