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Overuse or underuse of endoscopy? The optimal indications
Perspectives
REFERENCES 1. Johnson TD, Berenson MM, Buchi KN. Restoration of normal esophageal mucosa after argon laser photoablation and omeprazole treatment of esophageal columnar epithelium [abstract]. elin Res 1991;39:93A. 2. Berenson MM, Johnson TD, Markowitz NR, Buchi KN, Samowitz WS. Restoration of squamous mucosa after ablation of Barrett's esophageal epithelium. Gastroenterology 1993;104:1686-91. 3. Sampliner RE, Hixson LJ, Fennerty MB, Garewal HS. Regression of Barrett's esophagus by laser ablation in an anacid environment. Dig Dis Sci 1993;38:365-8. 4. Salo JA, Salminen JT, Kiviluoto TA, Nemlander AT, Ramo OJ, Farkkila MA, et al. Treatment of Barrett's esophagus by endoscopic ablation and antireflux surgery. Ann Surg 1998;227:40-4. 5. Luman W, Lessels AM, Palmer KR. Failure of Nd-YAG photocoagulation therapy as treatment for Barrett's oesophagus: a pilot study. Eur J Gastroenterol Hepatol1996;8:627-30. 6. Sampliner RE, Fennerty MB, Garewal HS. Reversal of Barrett's esophagus with acid suppression and multipolar electrocoagulation: preliminary results. Gastrointest Endosc 1996;44:532-5. 7. Overholt BF, Panjehpour M. Photodynamic therapy for Barrett's esophagus: clinical update. Am J Gastroenterol 1996;91:1719-23. 8. Barr H, Shepherd NA, Dix A, Roberts DJH, Tan we, Krasner N. Eradication of high-grade dysplasia in columnar lined oesophagus by photodynamic therapy with endogenously generated protoporphyrin IX. Lancet 1996;348:584-5. 9. Gossner L, Stolte M, Sroka R, Rick K, May A, Hahn EG, et al. Photodynamic ablation of high-grade dysplasia and early cancer in Barrett's esophagus by means of 5-aminolevulinic acid. Gastroenterology 1998;114:448-55. 10. Dumoulin FL, TeIjung B, Neubrand M, Scheurlen e, Fischer HP, Sauerbruch T. Treatment of Barrett's esophagus by endoscopic argon plasma coagulation. Endoscopy 1997;29:751-3. 11. Brandt W, Kauvar DR. Laser induced transient regression of Barrett's epithelium. Gastrointest Endosc 1992;38:619-22. 12. Brandt LJ, Kauvar DR. Repeat laser therapy of recurrent Barrett's epithelium: success with anacidity [Letterl. Gastrointest Endosc 1995;41:267. 13. Fink MA, Martin eJ, Ewing HP, Thompson ME, Machet D, Rode J. Reversal of experimental Barrett's esophagus by endoscopic laser ablation and reduction of acid reflux [abstractl. Gastroenterology 1992; 102:A924. 14. Gillen P, Keeling P, Byrne P, West AB, Hennessy TP. Experim~ntal columnar metaplasia in the canine esophagus. Br J SUl~ 1988;75:113-5. 15. Sharma P, Morales TG, Bhattacharyya A, Garewal HS, Sampliner RE. Squamous islands in Barrett's esophagus: what lies underneath? Am J GastroenteroI1998;93:332-5. 16. Sampli~er RE, Steinbronn K, Garewal HS, Riddell RH. Squamous mucosa overlying columnar epithelium in Barrett's esophagus in the absence of anti-reflux surgery. Am J Gastroenterol 1988;83:510-2.
652 GASTROINTESTINAL ENDOSCOPY
PERSPECTIVES Overuse or underuse of endoscopy? The optimal indications The quality and costs of health care depend on the appropriate indications for medical procedures. Although upper gastrointestinal endoscopy is safe and effective, the increasing number of patients referred for this procedure leads to high cost and in some countries an overload on endoscopic resources. Health care insurers, public and private, look for a reduction in the number of upper gastrointestinal endoscopic examinations and a reduction in coding. Patients and endoscopists fear that restricted use might lead to a decrease in the quality of health care provided to the general population of western Europe. In two articles a Swiss group showed in the same population the two possibilities of an inadequate referral system. Froehlich et al.1,2 reported the results of a prospective study that involved 8135 patients visiting primary care practices and a university outpatient clinic in Switzerland. Identification of the use of endoscopy was based on criteria developed by the Swiss experts. For overuse the investigators considered 611 patients with gastrointestinal symptoms, more than 75% of whom had dyspepsia. Sixty-three of these patients were referred for endoscopic examination. According to the criteria, 25 (40%) of the endoscopies were rated appropriate, 7 (11%) were considered equivocal, and 31 (49%) were considered inappropriate. That led to overuse of upper gastrointestinal endoscopy for 5.1% of all patients with gastrointestinal symptoms. The most common cause of overuse was dyspepsia without a previous trial of a symptomatic treatment. Underuse was identified for 72 (11.8%) of the 611 patients. Peptic symptoms resistant to proper treatment and unevaluated dysphagia were the two most prominent clinical situations leading to underuse of upper gastrointestinal endoscopy. The rate of underuse was higher for patients older than 65 years and in primary care practices (13.6%). The underuse rate decreased during the 3-month follow-up period to 4.7% because for most patients a spontaneous clinical remission, medical treatment, or secondary endoscopy performed because of a referral led to modification of the experts' criteria.
VOLUME 48, NO.6, 1998
Perspectives
It is surprising to find underuse of endoscopic examinations in a country that has open access endoscopy without limits by managed care plans, a limited supply, or long waiting lists. From the clinical point of view, underuse among patients older than 65 years or in the case of dysphagia should spur better postgraduate training for practitioners in primary care centers. On the other hand, dyspepsia was the main cause of overuse, reflecting controversy about the conditions for which dyspepsia is an indication for upper gastrointestinal endoscopy, especially for patients younger than 45 years. For all these reasons, the Swiss group has decided to extend its work to a European panel to issue guidelines for better indications for upper gastrointestinal endoscopy. This group might emphasize the clinical conditions for optimal use of upper gastrointestinal endoscopy. From an economical point of view, it should be emphasized that overuse of endoscopy is expensive. However, in the long term many patients with dyspepsia treated with H2 blockers or proton pump inhibitor will undergo endoscopic examination for recurrent symptoms. There are many conflicting data on the financial benefit to he~lth care systems of the systematic eradication of Helicobacter pylori. If treatment is prescribed, it is important to give clear guidelines to the family practitioner about the clinical condition and for how long medical treatment can be given without a correct diagnosis. Taking into account clinical and financial considerations, we should not forget our primary purpose. As physicians we treat not statistical groups but individual patients. Patient satisfaction with a correct normal or' benign endoscopic diagnosis is a very important criterion. Satisfied patients take fewer useless and costly drugs, have fewer days away from work because of psychologic distress, and do not have repeated referrals from primary care physicians. In individual cases, epidemiologic factors are important to consider. Although the prevalence of gastric cancer is slowly decreasing in Europe, the number of cardial and low esophageal cancers (Barrett's esophagus) has been increasing markedly in the last decade. Underu~e or overuse is a long-term debate. As physicians we have to improve the quality of indications for and the accuracy and reliability of our endoscopip examinations. As shown by the Swiss group, the total number of endoscopic examinations was corrected (overuse equaled underuse), but the patients referred or not referred were not correctly selected. It is the duty of the gastroenterology community to define and teach the optimal use of upper gastrointestinal endoscopy. JEAN-FRANQOIS REV, MD Saint-Laurent du Var, France
VOLUME 48, NO.6, 1998
REFERENCES 1. Froehlich F, Pache I, Burnand B, Vader JP, Fried M, Kosecoff J, et al. Underutilisation of upper gastrointestinal endoscopy. Gastroenterology 1997;112:690-7. 2. Froehlich F, Burnand B, Pache I, Vader JP, Fried M, Schneider C, et al. Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care. Gastrointest Endosc 1997;45:13-9.
Open access endoscopy in Britain: a service in evolution The clinical impact of diagnostic endoscopy
The introduction of flexible digestive endoscopy in the late 1960s revolutionized the practice of gastroenterology. By the early 1970s the internal surfaces of the esophagus, stomach, duodenum, and colon could be seen directly and biopsies could be performed with safety to provide an accurate and immediate diagnosis of most organic gastrointestinal diseases. Of greater importance numerically was that it also became possible to exclude organic disease reliably because of the demonstration of normal anatomic and histologic features. Endoscopy at first was limited to patients whose clinical features gave a strong indication that an organic pathologic condition was present. Experience has shown, however, that gastrointestinal symptoms often are misleading. The identification of new diseases, the discovery of premalignant lesions, and the development of more sophisticated histologic techniques changed gastrointestinal practice and made endoscopy the first-line diagnostic modality in the care of most patients with symptoms reasonably attributable to the gastrointestinal tract. Indeed, failure to undertake endoscopy in the care of such patients today may lead to litigation initiated by patients subsequently found to have organic pathologic conditions. The change in gastroenterologic practice from a contemplative, inductive exercise based on a carefully taken clinical history and physical examination to a proactive look-first-and-ask-questionsafterward approach has caused fundamental changes in the training of gastroenterologists and the way in which they practice their specialty. The endoscopy explosion
The frequency of gastrointestinal symptoms within the general population, the increasing reliance of physicians on endoscopy, and the appreciation by the general public that endoscopic examination is essential to exclude organic disease have led to a demand for endoscopy that in some countries has caused a strain on the financial provision of health care. Pressures such as these have encouraged the emergence of professional endoscopists who undertake GASTROINTESTINAL ENDOSCOPY 653
REFERENCES 1. Johnson TD, Berenson MM, Buchi KN. Restoration of normal esophageal mucosa after argon laser photoablation and omeprazole treatment of esophageal columnar epithelium [abstract]. elin Res 1991;39:93A. 2. Berenson MM, Johnson TD, Markowitz NR, Buchi KN, Samowitz WS. Restoration of squamous mucosa after ablation of Barrett's esophageal epithelium. Gastroenterology 1993;104:1686-91. 3. Sampliner RE, Hixson LJ, Fennerty MB, Garewal HS. Regression of Barrett's esophagus by laser ablation in an anacid environment. Dig Dis Sci 1993;38:365-8. 4. Salo JA, Salminen JT, Kiviluoto TA, Nemlander AT, Ramo OJ, Farkkila MA, et al. Treatment of Barrett's esophagus by endoscopic ablation and antireflux surgery. Ann Surg 1998;227:40-4. 5. Luman W, Lessels AM, Palmer KR. Failure of Nd-YAG photocoagulation therapy as treatment for Barrett's oesophagus: a pilot study. Eur J Gastroenterol Hepatol1996;8:627-30. 6. Sampliner RE, Fennerty MB, Garewal HS. Reversal of Barrett's esophagus with acid suppression and multipolar electrocoagulation: preliminary results. Gastrointest Endosc 1996;44:532-5. 7. Overholt BF, Panjehpour M. Photodynamic therapy for Barrett's esophagus: clinical update. Am J Gastroenterol 1996;91:1719-23. 8. Barr H, Shepherd NA, Dix A, Roberts DJH, Tan we, Krasner N. Eradication of high-grade dysplasia in columnar lined oesophagus by photodynamic therapy with endogenously generated protoporphyrin IX. Lancet 1996;348:584-5. 9. Gossner L, Stolte M, Sroka R, Rick K, May A, Hahn EG, et al. Photodynamic ablation of high-grade dysplasia and early cancer in Barrett's esophagus by means of 5-aminolevulinic acid. Gastroenterology 1998;114:448-55. 10. Dumoulin FL, TeIjung B, Neubrand M, Scheurlen e, Fischer HP, Sauerbruch T. Treatment of Barrett's esophagus by endoscopic argon plasma coagulation. Endoscopy 1997;29:751-3. 11. Brandt W, Kauvar DR. Laser induced transient regression of Barrett's epithelium. Gastrointest Endosc 1992;38:619-22. 12. Brandt LJ, Kauvar DR. Repeat laser therapy of recurrent Barrett's epithelium: success with anacidity [Letterl. Gastrointest Endosc 1995;41:267. 13. Fink MA, Martin eJ, Ewing HP, Thompson ME, Machet D, Rode J. Reversal of experimental Barrett's esophagus by endoscopic laser ablation and reduction of acid reflux [abstractl. Gastroenterology 1992; 102:A924. 14. Gillen P, Keeling P, Byrne P, West AB, Hennessy TP. Experim~ntal columnar metaplasia in the canine esophagus. Br J SUl~ 1988;75:113-5. 15. Sharma P, Morales TG, Bhattacharyya A, Garewal HS, Sampliner RE. Squamous islands in Barrett's esophagus: what lies underneath? Am J GastroenteroI1998;93:332-5. 16. Sampli~er RE, Steinbronn K, Garewal HS, Riddell RH. Squamous mucosa overlying columnar epithelium in Barrett's esophagus in the absence of anti-reflux surgery. Am J Gastroenterol 1988;83:510-2.
652 GASTROINTESTINAL ENDOSCOPY
PERSPECTIVES Overuse or underuse of endoscopy? The optimal indications The quality and costs of health care depend on the appropriate indications for medical procedures. Although upper gastrointestinal endoscopy is safe and effective, the increasing number of patients referred for this procedure leads to high cost and in some countries an overload on endoscopic resources. Health care insurers, public and private, look for a reduction in the number of upper gastrointestinal endoscopic examinations and a reduction in coding. Patients and endoscopists fear that restricted use might lead to a decrease in the quality of health care provided to the general population of western Europe. In two articles a Swiss group showed in the same population the two possibilities of an inadequate referral system. Froehlich et al.1,2 reported the results of a prospective study that involved 8135 patients visiting primary care practices and a university outpatient clinic in Switzerland. Identification of the use of endoscopy was based on criteria developed by the Swiss experts. For overuse the investigators considered 611 patients with gastrointestinal symptoms, more than 75% of whom had dyspepsia. Sixty-three of these patients were referred for endoscopic examination. According to the criteria, 25 (40%) of the endoscopies were rated appropriate, 7 (11%) were considered equivocal, and 31 (49%) were considered inappropriate. That led to overuse of upper gastrointestinal endoscopy for 5.1% of all patients with gastrointestinal symptoms. The most common cause of overuse was dyspepsia without a previous trial of a symptomatic treatment. Underuse was identified for 72 (11.8%) of the 611 patients. Peptic symptoms resistant to proper treatment and unevaluated dysphagia were the two most prominent clinical situations leading to underuse of upper gastrointestinal endoscopy. The rate of underuse was higher for patients older than 65 years and in primary care practices (13.6%). The underuse rate decreased during the 3-month follow-up period to 4.7% because for most patients a spontaneous clinical remission, medical treatment, or secondary endoscopy performed because of a referral led to modification of the experts' criteria.
VOLUME 48, NO.6, 1998
Perspectives
It is surprising to find underuse of endoscopic examinations in a country that has open access endoscopy without limits by managed care plans, a limited supply, or long waiting lists. From the clinical point of view, underuse among patients older than 65 years or in the case of dysphagia should spur better postgraduate training for practitioners in primary care centers. On the other hand, dyspepsia was the main cause of overuse, reflecting controversy about the conditions for which dyspepsia is an indication for upper gastrointestinal endoscopy, especially for patients younger than 45 years. For all these reasons, the Swiss group has decided to extend its work to a European panel to issue guidelines for better indications for upper gastrointestinal endoscopy. This group might emphasize the clinical conditions for optimal use of upper gastrointestinal endoscopy. From an economical point of view, it should be emphasized that overuse of endoscopy is expensive. However, in the long term many patients with dyspepsia treated with H2 blockers or proton pump inhibitor will undergo endoscopic examination for recurrent symptoms. There are many conflicting data on the financial benefit to he~lth care systems of the systematic eradication of Helicobacter pylori. If treatment is prescribed, it is important to give clear guidelines to the family practitioner about the clinical condition and for how long medical treatment can be given without a correct diagnosis. Taking into account clinical and financial considerations, we should not forget our primary purpose. As physicians we treat not statistical groups but individual patients. Patient satisfaction with a correct normal or' benign endoscopic diagnosis is a very important criterion. Satisfied patients take fewer useless and costly drugs, have fewer days away from work because of psychologic distress, and do not have repeated referrals from primary care physicians. In individual cases, epidemiologic factors are important to consider. Although the prevalence of gastric cancer is slowly decreasing in Europe, the number of cardial and low esophageal cancers (Barrett's esophagus) has been increasing markedly in the last decade. Underu~e or overuse is a long-term debate. As physicians we have to improve the quality of indications for and the accuracy and reliability of our endoscopip examinations. As shown by the Swiss group, the total number of endoscopic examinations was corrected (overuse equaled underuse), but the patients referred or not referred were not correctly selected. It is the duty of the gastroenterology community to define and teach the optimal use of upper gastrointestinal endoscopy. JEAN-FRANQOIS REV, MD Saint-Laurent du Var, France
VOLUME 48, NO.6, 1998
REFERENCES 1. Froehlich F, Pache I, Burnand B, Vader JP, Fried M, Kosecoff J, et al. Underutilisation of upper gastrointestinal endoscopy. Gastroenterology 1997;112:690-7. 2. Froehlich F, Burnand B, Pache I, Vader JP, Fried M, Schneider C, et al. Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care. Gastrointest Endosc 1997;45:13-9.
Open access endoscopy in Britain: a service in evolution The clinical impact of diagnostic endoscopy
The introduction of flexible digestive endoscopy in the late 1960s revolutionized the practice of gastroenterology. By the early 1970s the internal surfaces of the esophagus, stomach, duodenum, and colon could be seen directly and biopsies could be performed with safety to provide an accurate and immediate diagnosis of most organic gastrointestinal diseases. Of greater importance numerically was that it also became possible to exclude organic disease reliably because of the demonstration of normal anatomic and histologic features. Endoscopy at first was limited to patients whose clinical features gave a strong indication that an organic pathologic condition was present. Experience has shown, however, that gastrointestinal symptoms often are misleading. The identification of new diseases, the discovery of premalignant lesions, and the development of more sophisticated histologic techniques changed gastrointestinal practice and made endoscopy the first-line diagnostic modality in the care of most patients with symptoms reasonably attributable to the gastrointestinal tract. Indeed, failure to undertake endoscopy in the care of such patients today may lead to litigation initiated by patients subsequently found to have organic pathologic conditions. The change in gastroenterologic practice from a contemplative, inductive exercise based on a carefully taken clinical history and physical examination to a proactive look-first-and-ask-questionsafterward approach has caused fundamental changes in the training of gastroenterologists and the way in which they practice their specialty. The endoscopy explosion
The frequency of gastrointestinal symptoms within the general population, the increasing reliance of physicians on endoscopy, and the appreciation by the general public that endoscopic examination is essential to exclude organic disease have led to a demand for endoscopy that in some countries has caused a strain on the financial provision of health care. Pressures such as these have encouraged the emergence of professional endoscopists who undertake GASTROINTESTINAL ENDOSCOPY 653