Quality Improvement in Gastroenterology Clinical Practice

Rakhi Kheraj; Sumeet K. Tewani; Gyanprakash Ketwaroo; Daniel A. Leffler


Clin Gastroenterol Hepatol. 2012;10(12):1305-1314. 

In This Article

Gastroesophageal Reflux Disease

The lifetime prevalence of gastroesophageal reflux disease (GERD) in the United States is 20%–40%, making it one of the most common outpatient gastrointestinal complaints. Patients with mild-to-moderate symptoms are unlikely to have complications, and therefore the AGA considers initial empiric trial of lifestyle modification and acid suppression therapy appropriate.[54,55] Most cases of GERD (70%–80%) may be managed with these approaches; evaluation of refractory GERD is beyond the scope of this review. Two major quality issues in the management of GERD include the appropriate timing and use of endoscopic evaluation and mitigation of adverse medication effects.[56]

The ACG and ASGE recommend that at initial presentation, endoscopy should be reserved for patients with alarm symptoms of complicated disease, such as involuntary weight loss, dysphagia, or gastrointestinal bleeding[54,57] (grade C*). Concordantly, the AGA recommends that when an empiric trial of twice-daily proton pump inhibitor (PPI) therapy has failed to provide adequate control of GERD symptoms, patients without alarm symptoms should undergo endoscopy to determine whether they have esophagitis, complications, or Barrett's esophagus (BE) (grade B*). Any visualized area of mucosal irregularity, as well as an area of normal-appearing mucosa, should be analyzed by biopsy to identify BE, eosinophilic esophagitis, or other lesions.[58] The AGA also recommends against the use of routine endoscopy to assess disease progression, because endoscopy has not been shown to decrease outcomes from esophageal cancer detection.[58] Screening those at risk for BE remains controversial and has not been consistently recommended, because it has not been shown to affect the incidence or prognosis of esophageal adenocarcinoma[57,59,60] (grade B*). The AGA and ACG state that screening the general population with GERD is not cost-effective,[59,60] and a large number of patients with BE lack symptoms.[57] The highest yield appears to be in white men older than the age of 50 with long-standing GERD symptoms (more than 10 years), although the effects of screening in this high-risk population have not been established.

Because GERD is a chronic condition, continuous medical therapy is often necessary to control symptoms and prevent complications.[54] However, the cost and side effects of long-term acid suppression, particularly with PPI therapy, should be carefully considered. Recent studies have reported several clinical consequences of chronic potent acid inhibition, including decreased calcium absorption and increased rates of pneumonia and Clostridium difficile–associated colitis.[58,61–67] Few patients are reassessed on a regular basis to determine whether the PPIs are still needed, despite the fact that many patients who are receiving continuous therapy are able to have their dose modified or reduced on the basis of the presence or absence of symptoms.[56] Patients with nonerosive GERD could be candidates for ondemand acid suppressive therapy, whereas those with erosive esophagitis most often require once-daily PPI therapy to reduce the risk of recurrence. The AGA recommends that long-term acid suppression therapy be titrated to the lowest effective dose needed to achieve therapeutic goals (grade A*).[58]

One QI initiative could focus on the appropriate referral of patients with GERD for endoscopic evaluation. (1) Consider review of the panel of patients seen in clinic for GERD to assess validity of recommendations made for or against endoscopy. (2) A mechanism to improve the appropriate rate of referral for endoscopy can be developed, which is based specifically on the presence or absence of alarm symptoms, by using a checklist or reminder system in the medical chart to assess alarm symptoms. (3) A positive result would trigger an automated endoscopy referral or require specific documentation of the medical, patient, or system reason(s) for not referring to endoscopy. (4) Once implemented, it is possible to assess the proportion of GERD patients with and without alarm symptoms who were referred for endoscopy. Imperfections of the endoscopy referral mechanism can then be evaluated for further improvement.

Another QI initiative in GERD could focus on controlling symptoms in patients who receive continuous medical therapy to identify those whose doses or frequencies of therapy might be reduced. The QI initiative would involve the following: (1) reviewing records of patients seen in the last year with GERD who receive continuous PPI therapy to identify the proportion that had a follow-up assessment of their symptoms within those 12 months; (2) developing a mechanism to increase the rate of regular symptom assessment; a system-based alert might be used to inform clinicians that a patient has been on PPI therapy for longer than 1 year, with a reminder to reassess the patient's symptoms and need for continued PPI use at least annually and to record this in the medical record; and (3) reevaluating shortcomings of this PPI reminder system so it can be improved.