Minimal Standard Terminology for Digestive Endoscopy: Results of Prospective Testing and Validation in the GASTER Project

Background and Study Aims: Standardization of the endoscopic report is a key issue for future research in the field of digestive endoscopy. The Minimal Standard Terminology (MST) has been proposed by the European Society for Gastrointestinal Endoscopy (ESGE) as a structured language for production of computerized endoscopic reports. The aim of this study was to validate version 1.0 of this terminology prospectively, by collecting cases in a multicenter, multilingual trial.

Methods: Endoscopic cases (esophagogastroduodenoscopy [EGD], colonoscopy, endoscopic retrograde cholangiopancreatography [ERCP]) were prospectively collected in nine university hospitals in Europe, using the same software. Reports were produced in the local language, but the software allowed comparison of reports between languages, and global analysis of the database. Outcome measures were the adequacy of terms proposed in the MST to describe “reasons for performing an endoscopy”, “findings”, and “endoscopic diagnoses”, frequency of use and content of free-text fields, and types of lesions described.

Results: A total of 6232 reports were analyzed, including 3447 gastroscopies, 1743 colonoscopies, and 1042 ERCPs. Overall, terms originally contained in the MST were adequate to describe fully 91.0 % of all examinations where “reasons for endoscopy” were described, 99.5 % of examinations where “findings” were described, 95.8 % of all examinations containing descriptions of “endoscopic diagnosis”, 98.9 % of examinations containing descriptions of “additional diagnostic procedures”, and 94.8 % of examinations containing descriptions of “additional therapeutic procedures”. Free-text fields were only used in the other cases (less than 5 % of cases in average).

Conclusions: The MST appeared adequate to cover a large part of routine endoscopy reports, and could thus be used as a tool for standardization of endoscopic reports in clinical practice. The latter could be significantly improved by the use of a structured and standardized terminology for the production of endoscopic reports.

References

• 1 Delvaux M. Image management: the viewpoint of the clinician.  Gastroenterologist. 1996;  4 3-5
• 2 Crespi M, Delvaux M, Schapiro M, et al. Working party report by the Committee for Minimal Standards of Terminology and Documentation in Digestive Endoscopy of the European Society of Gastrointestinal Endoscopy. Minimal standard terminology for a computerized endoscopic database.  Am J Gastroenterol. 1996;  91 191-216
• 3 Maratka Z. Terminology, definitions and diagnostic criteria in digestive endoscopy. 4th edition.  Bad Homburg; Normed Verlag, 1994
• 4 Crespi M, Delvaux M, Schapiro M, et al. Minimal standards for a computerized endoscopic database.  Am J Gastroenterol. 1994;  89 153
• 5 National Electrical Manufacturer's Association. Digital Imaging and Communications in Medicine (DICOM), NEMA PS3, Supplement 15: Visible light image for endoscopy, microscopy, and photography.  Rosslyn, Virginia; National Electrical Manufacturers Association, 1997
• 6 Gonvers J J, Burnand B, Froehlich F, et al. Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open access endoscopy unit.  Endoscopy. 1996;  28 661-666
• 7 Froehlich F, Pache I, Burnand B, et al. Performance of panel-based criteria to evaluate the appropriateness of colonoscopy: a prospective study.  Gastrointest Endosc. 1998;  48 128-136
• 8 Aldridge M C, Sim A JW. Colonoscopy findings in symptomatic patients without X-ray evidence of colonic neoplasms.  Lancet. 1986;  ii 833-834
• 9 Misiewicz J J, Tytgat G NJ, Goodwin S, et al. The Sydney System: a new classification of gastritis.  In: Working party reports of the Ninth World Congress of Gastroenterology.  Melbourne; Blackwell Scientific, 1990: 1-10
• 10 National Electrical Manufacturer's Association. Digital Imaging and Communications in Medicine (DICOM) NEMA PS 3 Suppl. 23: Structured reporting.  Rosslyn, Virginia; National Electrical Manufacturers Association, 1997