GERD Endoscopy Screening 'Best Practices' Offered

Joe Barber Jr, PhD

December 03, 2012

Physicians commonly overuse upper endoscopy on low-risk patients with gastroesophageal reflux disease (GERD), leading to higher healthcare costs without improving patient outcomes, according to guidelines published by the American College of Physicians in the December issue of the Annals of Internal Medicine.

"GERD is among the most common conditions encountered in primary care practice," write Nicholas J. Shaheen, MD, MPH, director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine in Chapel Hill, North Carolina, and colleagues, and can significantly impact quality of life. "Upper endoscopy is widely available and routinely done for diagnosis and management of GERD and its complications. However, the indications for this procedure are incompletely defined."

The authors note that a number of guidelines have been published with conflicting recommendations. "The 3 major U.S. gastroenterologic professional societies have all released guideline documents with differing recommendations, which may confuse clinicians about the most appropriate course," they write.

To help primary care physicians make "high-value, cost-conscious decisions about referral of patients for upper endoscopy," the Clinical Guidelines Committee, composed of general interests, gastroenterologists, and clinical epidemiologists, reviewed the literature and offer their best practice advice.

"[F]ormulation of these guidelines was hampered by the generally poor quality of data about the use of endoscopic screening and surveillance programs," the authors explain. Therefore, "[t]his document is not based on a formal systematic review, but instead seeks to provide practical advice based on the best available evidence."

Dr. Shaheen and colleagues identified "fear of medicolegal liability," financial incentives, and patient and primary caregiver expectations as common reasons for the overuse of upper endoscopy. In reviewing the available data, they identified 3 clinical scenarios in which the use of upper endoscopy is medically and economically valuable.

Alarm Symptoms

First, the authors recommended upper endoscopy for both men and women with heartburn and GERD "alarm symptoms" (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting). The authors note that in this setting, upper endoscopy is valuable because it can identify clinically necessary information such as stomach or esophageal cancer, bleeding lesions in the foregut, or stenosis of the esophagus or pylorus.

Second, the authors recommended upper endoscopy for men and women with GERD symptoms that persist after 4 to 8 weeks of proton pump inhibitor (PPI) therapy, men and women with severe erosive esophagitis after 2 months of PPI therapy to assess healing and rule out Barrett's esophagus, and men and women with a history of esophageal stricture who have recurrent dysphagia symptoms. The authors mentioned the utility of upper endoscopy in these populations, as patients with severe erosive esophagitis often have incomplete healing and the strictures commonly recur.

In the third guideline, the authors recommended upper endoscopy for men older than 50 years with chronic GERD symptoms and additional risk factors such as nocturnal reflux, tobacco use, elevated body mass index, and hiatal hernia to detect esophageal adenocarcinoma and Barrett's esophagus and as a surveillance evaluation for men and women with a history of Barrett's esophagus. The authors indicate that surveillance examinations should occur at intervals of 3 to 5 years for patients without dysplasia.

They conclude that although endoscopy has improved the diagnosis and management of gastrointestinal illness, its use should be carefully limited. "Data suggest that upper endoscopy in the setting of GERD symptoms is useful only in a few, well-circumscribed situations, as previously reviewed," the authors write. "Avoidance of repetitive, low-yield endoscopy that has little effect on clinical management or health outcomes will improve patient care and reduce costs."

In a related commentary, John I. Allen, MD, MBA, from the University of Minnesota School of Medicine in Bloomington and vice president of the American Gastroenterological Association, agreed that physicians must use resources in a manner that improves patient outcomes while limiting healthcare costs. "The importance of this guidance is underscored by the cumulative financial and clinical burden of endoscopy in 2012," Dr. Allen writes. "Primary care physicians must decide how best to manage patients in a manner that provides an excellent experience but balances attention to the improvement of population health and one that uses resources efficiently."

Joel H. Rubenstein, MD, from the Veterans Affairs Center for Clinical Management Research and University of Michigan Medical School in Ann Arbor, indicated that some questions remain unanswered by the guidelines. "The best practice advice recommends that screening endoscopy 'may be indicated in men older than 50 years with additional risk factors' such as long-standing GERD symptoms, nocturnal reflux symptoms, obesity, or tobacco use, but we do not know which combinations of these factors and to what degree should trigger a screening exam," Dr. Rubenstein told Medscape Medical News by email. Further research is needed in this area.

Development of these guidelines was paid for via the operating budget of the American College of Physicians. Dr. Shaheen is a paid consultant with AstraZeneca and Takeda Pharmaceuticals and has submitted grants to the American Society for Gastrointestinal Endoscopy, Takeda Pharmaceuticals, BARRX Medical, and CSA Medical; he has also been supported by the National Cancer Institute. One coauthor is a paid consultant with ECRI; is employed by the Department of Veterans Affairs; has submitted grants to the Agency for Healthcare Research and Quality, the Department of Veterans Affairs, the Centers for Medicare & Medicaid Services, the National Institute of Nursing Research at the National Institutes of Health, and Office of the National Coordinator for Health Information Technology; and has received royalties from Up to Date. Dr. Allen serves on the boards of the American Gastroenterological Association and Allina Health and is employed by Minnesota Gastroenterology PA. The other authors and Dr. Rubenstein have disclosed no relevant financial relationships.

Ann Intern Med. 2012;157:808-816. Full text