The Toronto Upper Gastrointestinal Cleaning Score: a prospective validation study

Abstract

Background Assessment of mucosal visualization during esophagogastroduodenoscopy (EGD) can be improved with a standardized scoring system. To address this need, we created the Toronto Upper Gastrointestinal Cleaning Score (TUGCS).

Methods We developed the TUGCS using Delphi methodology, whereby an international group of endoscopy experts iteratively rated their agreement with proposed TUGCS items and anchors on a 5-point Likert scale. After each Delphi round, we analyzed responses and refined the TUGCS using an 80 % agreement threshold for consensus. We used the intraclass correlation coefficient (ICC) to assess inter-rater and test–retest reliability. We assessed internal consistency with Cronbach’s alpha and item-total and inter-item correlations with Pearson’s correlation coefficient. We compared TUGCS ratings with an independent endoscopist’s global rating of mucosal visualization using Spearman’s ρ.

Results We achieved consensus with 14 invited participants after three Delphi rounds. Inter-rater reliability was high at 0.79 (95 %CI 0.64–0.88). Test–retest reliability was excellent at 0.83 (95 %CI 0.77–0.87). Cronbach’s α was 0.81, item-total correlation range was 0.52–0.70, and inter-item correlation range was 0.38–0.74. There was a positive correlation between TUGCS ratings and a global rating of visualization (r = 0.41, P = 0.002). TUGCS ratings for EGDs with global ratings of excellent were significantly higher than those for EGDs with global ratings of fair (P = 0.01).

Conclusion The TUGCS had strong evidence of validity in the clinical setting. The international group of assessors, broad variety of EGD indications, and minimal assessor training improves the potential for dissemination.

• References

• 1 Park WG, Shaheen NJ, Cohen J. et al. Quality indicators for EGD. Gastrointest Endosc 2015; 81: 17-30
• 2 Sajid MS, Rehman S, Chedgy F. et al. Improving the mucosal visualization at gastroscopy: a systematic review and meta-analysis of randomized, controlled trials reporting the role of Simethicone ± N-acetylcysteine. Transl Gastroenterol Hepatol 2018; 3: 29
• 3 Emura F, Rodriguez-Reyes C, Giraldo-Cadavid L. Early gastric cancer: current limitations and what can be done to address them. Am J Gastroenterol 2019; 114: 841-845
• 4 Menon S, Trudgill N. How commonly is upper gastrointestinal cancer missed at endoscopy? A meta-analysis. Endosc Int Open 2014; 2: E46-50
• 5 Pimenta-Melo AR, Monteiro-Soares M, Libânio D. et al. Missing rate for gastric cancer during upper gastrointestinal endoscopy: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2016; 28: 1041-1049
• 6 Beg S, Ragunath K, Wyman A. et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS). Gut 2017; 66: 1886-1899
• 7 Kim GH, Cho YK, Cha JM. et al. Efforts to increase image quality during endoscopy: the role of pronase. World J Gastrointest Endosc 2016; 8: 267-272
• 8 Wu L, Cao Y, Liao C. et al. Systematic review and meta-analysis of randomized controlled trials of simethicone for gastrointestinal endoscopic visibility. Scand J Gastroenterol 2011; 46: 227-235
• 9 Romańczyk M, Ostrowski B, Kozłowska-Petriczko K. et al. Scoring system assessing mucosal visibility of upper gastrointestinal tract: the POLPREP scale. J Gastroenterol Hepatol 2022; 37: 164-168
• 10 Parmar R, Martel M, Rostom A. et al. Validated scales for colon cleansing: a systematic review. Am J Gastroenterol 2016; 111: 197-204
• 11 Rostom A, Jolicoeur E. Validation of a new scale for the assessment of bowel preparation quality. Gastrointest Endosc 2004; 59: 482-486
• 12 Lai EJ, Calderwood AH, Doros G. et al. The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009; 69: 620-625
• 13 Linstone HA, Turoff M. The Delphi method. 1. Aufl. Reading, MA: Addison-Wesley; 1975
• 14 Cook DA, Beckman TJ. Current concepts in validity and reliability for psychometric instruments: theory and application. Am J Med 2006; 119: 166.e7-166.e16
• 15 Khan R, Zheng E, Wani S. et al. Colonoscopy competence assessment tools: a systematic review of validity evidence. Endoscopy 2021; 53: 1235-1245
• 16 Elvas L, Areia M, Brito D. et al. Premedication with simethicone and N-acetylcysteine in improving visibility during upper endoscopy: a double-blind randomized trial. Endoscopy 2017; 49: 139-145
• 17 Monrroy H, Vargas JI, Glasinovic E. et al. Use of N-acetylcysteine plus simethicone to improve mucosal visibility during upper GI endoscopy: a double-blind, randomized controlled trial. Gastrointest Endosc 2018; 87: 986-993
• 18 Fujii T, Iishi H, Tatsuta M. et al. Effectiveness of premedication with pronase for improving visibility during gastroendoscopy: a randomized controlled trial. Gastrointest Endosc 1998; 47: 382-387
• 19 Messick S. Validity of psychological assessment: validation of inferences from persons’ responses and performances as scientific inquiry into score meaning. Am Psychol 1995; 50: 741
• 20 Scaffidi MA, Grover SC, Carnahan H. et al. A prospective comparison of live and video-based assessments of colonoscopy performance. Gastrointest Endosc 2018; 87: 766-775
• 21 Aronchick CA. Bowel preparation scale. Gastrointest Endosc 2004; 60: 1037-1038
• 22 Faul F, Erdfelder E, Lang A-G. et al. G* Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007; 39: 175-191
• 23 Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016; 15: 155-163
• 24 Gao Y, Lin J-S, Zhang H-D. et al. Pilot validation of the Boston Bowel Preparation Scale in China. Dig Endosc 2013; 25: 167-173
• 25 Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979; 86: 420
• 26 Sedgwick P. Pearson’s correlation coefficient. Be Med J 2012; 345: e4483
• 27 Bland JM, Altman DG. Statistics notes: Cronbach’s alpha. Br Med J 1997; 314: 572
• 28 Portney LG, Watkins MP. Foundations of clinical research: applications to practice. Upper Saddle River, NJ: Pearson/Prentice Hall; 2009
• 29 Weir JP. Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. J Strength Cond Res 2005; 19: 231-240
• 30 Gliem JA, Gliem RR. Calculating, interpreting, and reporting Cronbach’s alpha reliability coefficient for Likert-type scales. Midwest Research-to-Practice Conference in Adult, Continuing, and Community Conference; 2003 Oct 8–10. Columbus, Ohio: Ohio State University; 2003
• 31 Streiner DL, Norman GR, Cairney J. Health measurement scales: a practical guide to their development and use. New York, NY: Oxford University Press; 2015
• 32 Davidson KW, Barry MJ, Mangione CM. et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA 2021; 325: 1965-1977
• 33 Kahi CJ, Vemulapalli KC, Johnson CS. et al. Improving measurement of the adenoma detection rate and adenoma per colonoscopy quality metric: the Indiana University experience. Gastrointest Endosc 2014; 79: 448-454
• 34 Januszewicz W, Kaminski MF. Quality indicators in diagnostic upper gastrointestinal endoscopy. Therap Adv Gastroenterol 2020; 13: 1756284820916693