Blog | Friday, January 31, 2014

QD: News Every Day--Upper endoscopy may not be used where it's most needed

Upper endoscopy may be underused in patients at high risk for Barrett’s esophagus and certain cancers, and overused for symptomatic reflux, a study suggests.

As a result, overuse of esophagogastroduodenoscopy (EGD) procedures for uncomplicated gastroesophageal reflux disease (GERD) may crowd out detection of esophageal, gastric or duodenal cancers (E/GC), the study concluded.

Researchers conducted a retrospective cohort study using data from the VA. Patients were included if they had ICD-9 codes from 2004 through 2009 for uncomplicated GERD without signs of anemia, decompensated liver disease, gastrointestinal tract [GI] bleeding, celiac disease, any metastatic cancer or any chemotherapy.

Results appeared in a research letter published online first Jan. 27 at JAMA Internal Medicine.

Of nearly a half-million patients with newly diagnosed, uncomplicated GERD, 7.3% had an EGD within a year and 15.4% had an EGD. The yield was 10.1% for Barrett’s esophagus and 0.81% for E/GC.

Males 50 years or older with GERD were less likely to receive an EGD. But, these patients were more likely to be diagnosed as having Barrett’s esophagus or E/GC than women or those younger than 50.

Other factors led to more likelihood of receiving an EGD, including chest pain, dyspepsia, and use of drugs that inhibit gastric acid; the number of VA visits, GI clinic visits or having a rural residence; and receiving care at a facility that conducted a comparatively high number of EDG procedures. However, there was either no association or a decreased likelihood for detecting Barrett’s esophagus and E/GC.

The results suggest potential underutilization of EGD among high-risk patients and overutilization in low-risk patients. “Given the high Barrett’s esophagus and/or E/GC prevalence (11%) at the time of EGD, this mismatch between high-risk groups and likelihood of receiving EGD may contribute to missed opportunities for conducting effective screening EGD,” the authors wrote.

Instead, EGD is likely to be performed to address symptomatic GERD or other unclear complaints more often than screening for Barrett’s esophagus and cancer, even though the value of such a procedure for those symptoms is unknown. “The volume of EGD performed in this low-risk population may crowd out availability for screening and surveillance EGD in higher-risk patients,” the authors noted.