Endoscopy use for GERD may not align with guidelines

Last Updated: 2015-07-23

By Shannon Aymes

NEW YORK (Reuters) - A substantial amount of esophagogastroduodenoscopy (EGD) for evaluation of reflux and related disorders may not align with evidence-based guidelines, according to a new study.

Dr. James Richter and colleagues at the Massachusetts General Hospital in Boston sought to examine whether use of EGD aligned with current guidelines from the American College of Physicians (ACP).

As reported in a research letter online July 20 in JAMA, they reviewed all adult outpatient EGD done for Barrett's esophagus, gastroesophageal reflux disease (GERD), esophagitis, and dyspepsia at Massachusetts General Hospital over four months in 2013.

Patients with a history of esophageal malignancy, intramucosal adenocarcinoma, elective therapeutic EGD, and dysplasia with Barrett's esophagus were excluded.

According to the ACP, appropriate indications for EGD include persistent acute symptoms after four to eight weeks of proton pump inhibitors (PPIs), more than five years of symptoms in men older than 50, two months of PPIs with severe erosive esophagitis, nondysplastic Barrett's esophagus with the last EGD more than three years prior, and "alarm symptoms" such as anemia, bleeding, weight loss, dysphagia, and vomiting.

The full guidelines are here: http://bit.ly/1CXGTNK.

Out of 550 EGDs, 208 (37.8%) were discordant from the guidelines - most often due to inappropriate PPI trials (30.3%), too-early follow-up for Barrett's esophagus (28.4%), and chronic reflux symptoms in women (19.2%).

Indications with the highest rate of discordance were Barrett's esophagus (49.1%) and chronic symptoms (47%). Discordance between referrals from trainees vs staff and primary care vs gastroenterologist was not significant.

The investigators say their findings might be explained by "the relatively recent guideline publication (2012) and potential selection bias for greater symptom severity among gastroenterologists."

In an editor's note, Dr. Joseph Ross of Yale School of Medicine, New Haven, Connecticut, wrote, "This article is a reminder of what we need to do to improve. Guidelines and recommendations are not enough. Practices need to change at the point of care. More steps need to be taken, including checklists before procedures, to review appropriate indications for use, substantive discussion with patients to obtain informed consent to comprehensively review expected benefits, risks, and costs as well as treatment alternatives; and better physician reimbursement policies are needed to provide sufficient financial support for these discussions between patients and their physicians."

Dr. Richter did not respond to a request for comment.

SOURCE: http://bit.ly/1MqjHuv and http://bit.ly/1IoGgz3

JAMA 2015.