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Research Letter | Less Is More

Concordance of Outpatient Esophagogastroduodenoscopy of the Upper Gastrointestinal Tract With Evidence-Based Guidelines FREE

Jennifer X. Cai, MD, MPH1; Emily J. Campbell, MPH2; James M. Richter, MD, MA2
[+] Author Affiliations
1Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
2Division of Gastroenterology, Massachusetts General Hospital, Boston
JAMA Intern Med. 2015;175(9):1563-1564. doi:10.1001/jamainternmed.2015.3533.
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Published online

Esophagogastroduodenoscopy (EGD) is widely used for the management of gastroesophageal reflux disease and low-risk dyspepsia.1 Indications for endoscopy in patients with gastroesophageal reflux disease were recently clarified as guidelines from the American College of Physicians2 to help primary care physicians decide when to refer a patient for EGD. Our study examined procedures that were concordant with the guidelines across types of physicians and indications, the percentage of repeated EGDs within 3 years, and reasons for discordance.

A retrospective review was conducted of all adult outpatient EGDs performed at Massachusetts General Hospital from September 1, 2013, through December 31, 2013, for indications of gastroesophageal reflux disease, dyspepsia, esophagitis, and Barrett esophagus. Institutional review board approval was waived by Massachusetts General Hospital. Exclusion criteria included a history of esophageal malignant neoplasms, a history of Barrett esophagus with dysplasia and/or intramucosal adenocarcinoma, and elective therapeutic EGDs to exclude patients who were at increased risk of esophageal cancer and may have warranted more frequent surveillance. Concordance with the American College of Physicians guidelines was defined as patients with (1) nondysplastic Barrett esophagus without an EGD for surveillance in the past 3 years, (2) acute symptoms (<5 years) that persisted despite 4 to 8 weeks of twice-daily proton-pump-inhibitor therapy, (3) chronic symptoms (>5 years) in men who were older than 50 years, (4) alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting), and (5) severe erosive esophagitis despite 2 months of proton-pump inhibitor therapy.2 Pearson unpaired χ2 tests and 2-sided t tests were used for statistical analysis.

We identified 550 EGDs that were performed in 549 patients (54.8% women; mean age, 54 years). Of the EGDs, 208 (37.8%) were discordant with the evidence-based guidelines. Of the patients, 123 (22.4%) had more than 1 EGD within 3 years. There were no differences in rates of guideline-discordant EGDs by the referring physicians’ specialty or level of training (P = .20 for referring specialty and P = .58 for physician level of training) (Table 1). Barrett esophagus and chronic symptoms had the highest rates of discordance at 49.1% and 47.0%, respectively. The most common reasons that EGDs were discordant with the guidelines included an inappropriate proton-pump inhibitor trial before endoscopy, surveillance for Barrett esophagus within 3 years, and chronic reflux symptoms in women (Table 2).

Table Graphic Jump LocationTable 1.  Frequency of EGD and Guideline Discordance Overall and Stratified by Indication, Referral Specialty, and Level of Referring Physician Training
Table Graphic Jump LocationTable 2.  Reasons That EGDs Were Discordant With Evidence-Based Guidelines

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. Weak evidence that surveillance programs for Barrett esophagus reduce mortality due to esophageal adenocarcinoma and the presence of multiple differing recommendations may contribute to these high rates.35 No statistical difference in discordance rates existed between EGDs that were referred by primary care physicians vs gastroenterologists. Possible explanations include the relatively recent guideline publication and potential selection bias for greater symptom severity among gastroenterologists.6 Limitations included our short study duration and inability to capture patient-driven referrals, insurance data, and additional endoscopies performed at other institutions. A multidisciplinary approach of specialist prereview of open-access referrals, incorporation of appropriate indications in referral orders, and continued education may result in improved concordance with the evidence-based guidelines.

Corresponding Author: James M. Richter, MD, MA, Division of Gastroenterology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (jrichter@mgh.harvard.edu).

Published Online: July 20, 2015. doi:10.1001/jamainternmed.2015.3533.

Author Contributions: Dr Cai and Ms Campbell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Cai, Richter.

Drafting of the manuscript: Cai, Richter.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cai.

Obtained funding: Richter.

Administrative, technical, or material support: Campbell, Richter.

Study supervision: Campbell, Richter.

Conflict of Interest Disclosures: None reported.

Pohl  H, Robertson  D, Welch  HG.  Repeated upper endoscopy in the Medicare population: a retrospective analysis. Ann Intern Med. 2014;160(3):154-160.
PubMed   |  Link to Article
Shaheen  NJ, Weinberg  DS, Denberg  TD, Chou  R, Qaseem  A, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Upper endoscopy for gastroesophageal reflux disease: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.
PubMed   |  Link to Article
Spechler  SJ, Sharma  P, Souza  RF, Inadomi  JM, Shaheen  NJ; American Gastroenterological Association.  American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):1084-1091.
PubMed   |  Link to Article
Hirota  WK, Zuckerman  MJ, Adler  DG,  et al; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy.  ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006;63(4):570-580.
PubMed   |  Link to Article
Wang  KK, Sampliner  RE; Practice Parameters Committee of the American College of Gastroenterology.  Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103(3):788-797.
PubMed   |  Link to Article
Cabana  MD, Rand  CS, Powe  NR,  et al.  Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282(15):1458-1465.
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1.  Frequency of EGD and Guideline Discordance Overall and Stratified by Indication, Referral Specialty, and Level of Referring Physician Training
Table Graphic Jump LocationTable 2.  Reasons That EGDs Were Discordant With Evidence-Based Guidelines

References

Pohl  H, Robertson  D, Welch  HG.  Repeated upper endoscopy in the Medicare population: a retrospective analysis. Ann Intern Med. 2014;160(3):154-160.
PubMed   |  Link to Article
Shaheen  NJ, Weinberg  DS, Denberg  TD, Chou  R, Qaseem  A, Shekelle  P; Clinical Guidelines Committee of the American College of Physicians.  Upper endoscopy for gastroesophageal reflux disease: best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816.
PubMed   |  Link to Article
Spechler  SJ, Sharma  P, Souza  RF, Inadomi  JM, Shaheen  NJ; American Gastroenterological Association.  American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):1084-1091.
PubMed   |  Link to Article
Hirota  WK, Zuckerman  MJ, Adler  DG,  et al; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy.  ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006;63(4):570-580.
PubMed   |  Link to Article
Wang  KK, Sampliner  RE; Practice Parameters Committee of the American College of Gastroenterology.  Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103(3):788-797.
PubMed   |  Link to Article
Cabana  MD, Rand  CS, Powe  NR,  et al.  Why don’t physicians follow clinical practice guidelines? a framework for improvement. JAMA. 1999;282(15):1458-1465.
PubMed   |  Link to Article

Correspondence

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