Nearly 38% of the upper endoscopies performed in outpatients with gastroesophageal reflux disease and low-risk dyspepsia do not adhere to current best-practice guidelines, according to new research presented at the Society of General Internal Medicine 2015 Annual Meeting in Toronto.
According to the American College of Physicians (ACP), “inappropriate use of endoscopy generates unnecessary costs and exposes patients to harms without improving outcomes.”
“Our study reflects the fact that clinical guidelines do take some time for adoption,” lead investigator Jennifer Cai, MD, a third-year internal medicine resident at Johns Hopkins in Baltimore, toldMedscape Medical News.
In fact, 39.4% of procedures referred by primary care physicians and 33.3% initiated by gastroenterologists did not adhere to the 2012 recommendations of the ACP (P = 0.20).
The most common inappropriate uses were in patients who received an inadequate course of proton pump inhibitors (PPIs) before upper endoscopy and in those who underwent too-frequent surveillance of Barrett’s esophagus.
Inappropriate Testing
The researchers performed a chart review of consecutive outpatients who underwent an esophagogastroduodenoscopy at Massachusetts General Hospital in Boston for evaluation of reflux, dyspepsia, esophagitis, and Barrett’s esophagus.
They identified 550 procedures that took place from September to December 2013, the year after the ACP released its best-practice advice on upper endoscopy for reflux (Ann Intern Med.2012;157:808-816).
Dr Cai and her colleagues defined appropriate indications for upper endoscopy on the basis of the ACP report.
The procedure is appropriate for patients with nondysplastic Barrett’s esophagus who have not undergone surveillance esophagogastroduodenoscopy in the previous 3 years. This is also the advice of the American Gastroenterological Association in their 2012Choosing Wisely recommendation.
It is also appropriate for patients with acute symptoms that have lasted up to 5 years and that persist despite a therapeutic trial of twice-daily PPIs for 4 to 8 weeks; for men older than 50 years with chronic symptoms that have lasted longer than 5 years; for patients with alarm symptoms such as dysphagia, bleeding, anemia, weight loss, and recurrent vomiting; and for patients with severe erosive esophagitis unresolved after 2 months of PPI therapy.
Of the 550 esophagogastroduodenoscopies in the study, 208 (37.8%) did not meet the appropriate-use criteria.
Of these, 63 patients (30.3%) received an inadequate course of PPI therapy before endoscopy; 59 patients (28.4%) underwent surveillance of nondysplastic Barrett’s esophagus more than once in 3 years; 40 patients (19.2%) with chronic reflux symptoms for more than 5 years were women; and 20 patients (9.6%) with chronic reflux symptoms were younger than 50.
Low Risk Cases
Dr Cai explained that the ACP advises against performing routine endoscopic surveillance in women with chronic reflux because the risk for esophageal adenocarcinoma is low in women.
Overall, 49.1% of the procedures for the evaluation of Barrett’s esophagus did not meet the appropriate-use criteria (P = .0005), nor did 47.0% of the procedures for chronic reflux symptoms (P < .0001).
Of the 243 procedures performed for the evaluation of acute symptoms — the most common reason for upper endoscopy referral — 25.5% did not meet appropriate-use criteria (P < .0001).
“If these are current best-evidence guidelines, physicians should be familiar with them, but I think a lot of physicians are not,” said session moderator Gordon Schiff, MD, from Harvard Medical School and Brigham and Women’s Hospital in Boston.
There is a need for better ways to track physician compliance with guidelines for upper endoscopy in the setting of reflux and Barrett’s esophagus, he told Medscape Medical News.
“There should be standardized support to overcome barriers to compliance,” Dr Schiff said. “I’d like to see a clinical-decision support system that would capture the indication for the test and exceptions to the guidelines, as well as have just-in-time checking of the physician’s order.”
In this study, the researchers did not identify extenuating circumstances that would explain nonadherence to the guidelines, which is a limitation, he pointed out.
Dr Cai and Dr Schiff have disclosed no relevant financial relationships.
Society of General Internal Medicine (SGIM) 2015 Annual Meeting: Abstract 2 in session M1. Presented April 25, 2015.