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Researchers find upper GI endoscopy substantially overused according to current guidelines
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Over a third of esophagogastroduodenoscopies were found to be in conflict with the American College of Physicians evidence-based guidelines in a recent study.
“To our knowledge, this study is the first to demonstrate substantial use of EGD in patients with gastroesophageal reflux disease and related disorders to be discordant with the current guidelines,” the researchers wrote.
Aiming to evaluate guideline concordance of EGD procedures, researchers performed a retrospective review of 549 adults (54.8% women; mean age, 54 years) who underwent a total of 550 outpatient EGDs at Massachusetts General Hospital from September through December 2013. Indications for EGD included GERD, dyspepsia, esophagitis and Barrett’s esophagus. Patients with increased risk for esophageal cancer (history of esophageal malignant neoplasms, Barrett’s esophagus with dysplasia and/or intramucosal adenocarcinoma, and elective therapeutic EGDs) were excluded.
EGDs were considered to be in agreement with guidelines if patients had nondysplastic Barrett’s esophagus and no surveillance EGD for 3 years; if patients had persistent acute symptoms not responding to 4 to 8 weeks of proton pump inhibitors twice a day; if male patients aged older than 50 years had chronic symptoms; if patients had alarm symptoms; or if patients had severe erosive esophagitis that did not respond to PPIs for 2 months.
They found 37.8% of all EGDs were in conflict with guidelines. Overall, 22.4% of patients underwent more than one EGD within 3 years. No significant differences in guideline-adherence were observed between referring primary care physicians and gastroenterologists, or between trainees or attending staff.
Indications with the highest rates of guideline-discordant EGDs were Barrett’s esophagus (49.1%) and chronic symptoms (47%), and the most common reasons for conflict with guidelines included inappropriate PPI trial before endoscopy (30.3%), surveillance for Barrett’s esophagus within 3 years (28.4%), and chronic reflux symptoms in female patients (19.2%).
“Weak evidence that surveillance programs for Barrett[’s] esophagus reduce morality due to esophageal adenocarcinoma and the presence of multiple differing recommendations may contribute to these high rates,” the researchers wrote. “A multidisciplinary approach of specialist pre-review of open-access referrals, incorporation of appropriate indications in referral orders, and continued education may result in improved concordance with the evidence-based guidelines,” they concluded.
“This article is a reminder of what we need to do to improve,” Joseph S. Ross, MD, MHS, from Yale School of Medicine, wrote in an editor’s note. “As patients and physicians grow increasingly aware of the need to promote evidence-based high-value health care, we need to develop the tools to make this care a reality in practice.” – by Adam Leitenberger
Disclosure: The researchers and Ross report no relevant financial disclosures.
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