"Appropriateness" or "prioritization" for GI endoscopic procedures?

Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams

BACKGROUND

Colonoscopy is frequently performed in industrialised countries. Inappropriate colonoscopies might lead to unnecessary exams, increasing risks and costs.

AIM

To estimate the impact of colonoscopy appropriateness in terms of gain in additional diagnoses and sparing of unnecessary exams.

METHODS

Systematic review including studies reporting the prevalence of relevant findings, colorectal cancer (CRC) and inflammatory bowel disease (IBD) according to colonoscopy appropriateness as defined by the American Society for Gastrointestinal Endoscopy and European Panel on Appropriateness of Gastrointestinal Endoscopy.

RESULTS

Twenty-one studies with 19,822 patients were included. Colonoscopy was appropriate in 15,162 (71%, CI 64%-78%). Appropriateness significantly increased the probability of relevant findings (34% vs. 18%; RR 1.81, CI 1.53-2.14), CRC (7% vs. 2%; RR 3.62, CI 2.44-5.37) and IBD (6% vs. 4%; RR 1.86, CI 1.09-3.19). Appropriateness had sensitivity 88% (CI 85%-91%), 97% (CI 93%-98%) and 89% (CI 80%-94%), and specificity 24% (CI 20%-29%), 22% (CI 18%-26%) and 24% (CI 20%-28%) for relevant findings, CRC and IBD, respectively. On average, performing colonoscopy with appropriate indication would find 15 (CI 10-21) more relevant findings, five (CI 3-9) more CRCs and three (CI 1-9) more diagnoses of IBD per 100 patients, and save 24 (CI 20-29), 22 (CI 18-26) and 24 (CI 20-28) examinations per 100 patients for relevant findings, CRC and IBD, respectively.

CONCLUSIONS

Appropriateness affects the diagnostic yield of colonoscopy for CRC, IBD and relevant findings. Appropriateness criteria are useful, although integrated with clinical evaluation of the patient.

Diagnostic yield of endoscopy in patients with abdominal complaints: incremental value of faecal calprotectin on guidelines of appropriateness

BACKGROUND

European Panel on the Appropriateness of Gastrointestinal Endoscopy (EPAGE) criteria have been developed to increase diagnostic yield, but their predictive value is limited. We investigated the incremental diagnostic value of faecal calprotectin to EPAGE criteria.

METHODS

In a post-hoc analysis of a prospective study, EPAGE criteria were applied to 298 of 575 (51.8%) patients who had undergone esophagogastroduodenoscopy (EGD), colonoscopy or both for abdominal complaints at the Division of Gastroenterology & Hepatology at the University Hospital Basel in Switzerland. Faecal calprotectin was measured in stool samples collected within 24 hours before the investigation using an enzyme-linked immunosorbent assay. Final endoscopic diagnoses were blinded to calprotectin values.

RESULTS

Of 149 EGDs and 224 colonoscopies, 17.6% and 14.7% respectively were judged inappropriate by EPAGE criteria. Appropriate or uncertain indications revealed more endoscopic findings in both EGD (46.3% vs. 23.1%, P = 0.049) and colonoscopy (23.6% vs. 6.1%, P = 0.041) than inappropriate indications. Median calprotectin levels were higher (81.5 μg/g, interquartile range 26-175, vs. 10 μg/g, IQR 10-22, P < 0.001) and testing was more often positive (>50 μg/g) in patients with endoscopic findings, both in EGD (58.2% vs. 33.0%, P = 0.005) and in colonoscopy (57.3% vs. 7.4%, P < 0.001). The use of faecal calprotectin in addition to EPAGE criteria improved the risk reclassification of patients by endoscopic findings. The calculated net reclassification index was 37.8% (P = 0.002) for EGD and 110.9% (P <0.001) for colonoscopy, thus improving diagnostic yield to 56.8% and 70.2%, respectively.

CONCLUSIONS

The use of faecal calprotectin in addition to EPAGE criteria improved diagnostic yield in patients with abdominal complaints.

Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system

BACKGROUND/AIM

Open access endoscopy (OAE) decreases the waiting time for patients and clinical burden to gastroenterologist; however, the appropriateness of referrals for endoscopy and thus the diagnostic yield of these endoscopies has become an important issue. The aim of this study was to determine the appropriateness of upper gastrointestinal (GI) endoscopy requests in an OAE system.

PATIENTS AND METHODS

A retrospective chart review of all consecutive patients who underwent an upper gastroscopy in the year 2008 was performed and was defined as appropriate or inappropriate according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Endoscopic findings were recorded and classified as positive or negative. Referrals were categorized as being from a gastroenterologist, internist, surgeon, primary care physicians or others, and on an inpatient or out-patient basis.

RESULTS

A total of 505 consecutive patients were included. The mean age was 45.3 (standard deviation 18.1), 259 (51%) of them were males. 31% of the referrals were thought to be inappropriate. Referrals from primary care physicians were inappropriate in 47% of patients while only 19.5% of gastroenterologists referrals were considered inappropriate. Nearly, 37.8% of the out-patient referrals were inappropriate compared to only 7.8% for inpatients. Abnormal findings were found in 78.5% and 78% of patients referred by gastroenterologists and surgeons respectively while in those referred by primary care physicians it was (49.7%). Inpatients referred for endoscopy had abnormal findings in (81.7%) while in out-patients it was (66.6%). The most common appropriate indications in order of frequency were "upper abdominal distress that persisted despite an appropriate trial of therapy "(78.9%),''persistent vomiting of unknown cause "(19.2%), upper GI bleeding or unexplained iron deficiency anemia (7.6%). The sensitivity and specificity of the ASGE guidelines in our study population was 70.3% and 35% respectively.

CONCLUSION

A large proportion of patients referred for endoscopy through our open-access endoscopy unit are considered inappropriate, with significant differences among specialties. These results suggest that if proper education of practitioners was implemented, a better utilization would be expected.

How to predict a high rate of inappropriateness for upper endoscopy in an endoscopic centre?

BACKGROUND

Inappropriateness of upper endoscopy (EGD) indication causes decreased diagnostic yield. Our aim of was to identify predictors of appropriateness rate for EGD among endoscopic centres.

METHODS

A post-hoc analysis of two multicentre cross-sectional studies, including 6270 and 8252 patients consecutively referred to EGD in 44 (group A) and 55 (group B) endoscopic Italian centres in 2003 and 2007, respectively, was performed. A multiple forward stepwise regression was applied to group A, and independently validated in group B. A <70% threshold was adopted to define inadequate appropriateness rate clustered by centre.

RESULTS

discrete variability of clustered appropriateness rates among the 44 group A centres was observed (median: 77%; range: 41-97%), and a <70% appropriateness rate was detected in 11 (25%). Independent predictors of centre appropriateness rate were: percentage of patients referred by general practitioners (GP), rate of urgent examinations, prevalence of relevant diseases, and academic status. For group B, sensitivity, specificity and area under receiver operating characteristic curve of the model in detecting centres with a <70% appropriateness rate were 54%, 93% and 0.72, respectively.

CONCLUSIONS

A simple predictive rule, based on rate of patients referred by GPs, rate of urgent examinations, prevalence of relevant diseases and academic status, identified a small subset of centres characterised by a high rate of inappropriateness. These centres may be presumed to obtain the largest benefit from targeted educational programs.

Appropriateness guidelines and predictive rules to select patients for upper endoscopy: a nationwide multicenter study

OBJECTIVES

Selecting patients appropriately for upper endoscopy (EGD) is crucial for efficient use of endoscopy. The objective of this study was to compare different clinical strategies and statistical methods to select patients for EGD, namely appropriateness guidelines, age and/or alarm features, and multivariate and artificial neural network (ANN) models.

METHODS

A nationwide, multicenter, prospective study was undertaken in which consecutive patients referred for EGD during a 1-month period were enrolled. Before EGD, the endoscopist assessed referral appropriateness according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, also collecting clinical and demographic variables. Outcomes of the study were detection of relevant findings and new diagnosis of malignancy at EGD. The accuracy of the following clinical strategies and predictive rules was compared: (i) ASGE appropriateness guidelines (indicated vs. not indicated), (ii) simplified rule (>or=45 years or alarm features vs. <45 years without alarm features), (iii) logistic regression model, and (iv) ANN models.

RESULTS

A total of 8,252 patients were enrolled in 57 centers. Overall, 3,803 (46%) relevant findings and 132 (1.6%) new malignancies were detected. Sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the simplified rule were similar to that of the ASGE guidelines for both relevant findings (82%/26%/0.55 vs. 88%/27%/0.52) and cancer (97%/22%/0.58 vs. 98%/20%/0.58). Both logistic regression and ANN models seemed to be substantially more accurate in predicting new cases of malignancy, with an AUC of 0.82 and 0.87, respectively.

CONCLUSIONS

A simple predictive rule based on age and alarm features is similarly effective to the more complex ASGE guidelines in selecting patients for EGD. Regression and ANN models may be useful in identifying a relatively small subgroup of patients at higher risk of cancer.

Appropriateness of the indication for upper endoscopy: a meta-analysis

BACKGROUND

Application of appropriate indications for upper endoscopy (EGD) should conserve limited endoscopic resources. To perform a systematic review and meta-analysis to assess the efficacy of American Society for Gastrointestinal Endoscopy and European Panel on the Appropriateness of Gastrointestinal Endoscopy guidelines in selecting patients referred for an upper endoscopy relative to the detection of gastro-oesophageal cancer.

METHODS

Studies comparing the appropriateness of EGD indication according to American Society for Gastrointestinal Endoscopy or European Panel on the Appropriateness of Gastrointestinal Endoscopy guidelines and the detection of relevant endoscopic findings and cancer were identified by searching the Medline (1982 to September 2008). Pre-defined outputs of the meta-analysis were sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-).

RESULTS

We included eight cohort studies comprising 13,856 patients; 10,643 EGD indications were categorized as appropriate, and 3010 (22%) as inappropriate. For relevant findings, the adjusted sensitivity, specificity, LR+, and LR- were 85% (95% CI, 84-86%), 28% (95% CI, 27-29%), 1.18 (95% CI, 1.1-1.3) and 0.6 (95% CI, 0.5-0.7), respectively. For cancer detection, the adjusted sensitivity, specificity, LR+, and LR- were 97% (95% CI, 94-98%), 22% (95% CI, 22-23%), 1.2 (95% CI, 1.1-1.4), and 0.2 (95% CI, 0.05-0.9), respectively.

CONCLUSIONS

For inappropriate EGD, the very low likelihood of cancer argues against endoscopic referral, whereas the low specificity substantially reduces the predictive value of an appropriate indication for both cancer and relevant endoscopic findings.

Cost-effectiveness of upper gastrointestinal endoscopy according to the appropriateness of the indication

OBJECTIVE

Application of appropriate indications for upper endoscopy (EGD) should conserve limited endoscopic resources. The cost-effectiveness of current guidelines for the detection of gastro-oesophageal cancer is unknown. The aim of this study was to assess the clinical and economic impact of ASGE and EPAGE guidelines in selecting patients referred for upper endoscopy relative to the detection of gastro-oesophageal cancer.

MATERIAL AND METHODS

A decision analysis model was constructed to compare a strategy of not referring patients for EGD (with either an appropriate or inappropriate indication) with a policy of carrying out the requested EGD. Cancer prevalence in appropriate and inappropriate EGDs was estimated using a systematic review of the literature. Costs of EGD and cancer care were estimated from Medicare reimbursement data.

RESULTS

The number of appropriate and inappropriate EGDs required to detect one case of cancer was 41 and 753, respectively, and to prevent one gastro-oesophageal cancer-related death the numbers were 571 and 11,111, respectively. The incremental cost-effectiveness ratios of appropriate and inappropriate EGDs as compared to a policy of not referring patients for endoscopy were $16,577 and $301,203, respectively, per life-year gained.

CONCLUSIONS

For inappropriate EGD, the very low likelihood of cancer and the relatively high costs associated with this procedure argue against endoscopic referral.

Cost effectiveness of colonoscopy, based on the appropriateness of an indication

BACKGROUND & AIMS

Determination of the appropriateness of an indication for colonoscopy has been advanced as a means to help rationalize the use of endoscopic resources. However, the efficacy and cost effectiveness of the current guidelines used to select patients for colonoscopy are largely unknown. The goal of this study was to assess the clinical and economic impact of American Society for Gastrointestinal Endoscopy and the European Panel on the appropriateness of Gastrointestinal Endoscopy appropriateness guidelines in selecting patients who are referred for colonoscopy, in relation to colorectal cancer (CRC) detection.

METHODS

A decision-analysis model was constructed to compare colonoscopy strategies for "appropriate" indications with those for which colonoscopy is deemed "inappropriate" or "generally not indicated." A 50% cancer upstaging was modeled to simulate cancer progression for patients not referred for colonoscopy. CRC prevalence was estimated using a pooled data analysis based on a systematic review of the literature. Costs of colonoscopy and cancer care were estimated from Medicare reimbursement data. The number of colonoscopies needed to detect one case of cancer and to prevent one cancer-related death and incremental cost-effectiveness ratios (ICER), according to appropriateness categories, were computed in a simulated population of patients that were 60 years of age and referred for colonoscopy.

RESULTS

The numbers of appropriate and inappropriate colonoscopies that needed to be performed to detect one patient with cancer were 18 and 93, respectively. Similarly, 115 and 617 colonoscopies would be needed, respectively, to prevent one CRC-related death. The ICER for appropriate and inappropriate colonoscopies, compared with a policy of not referring patients to colonoscopy, was $6154 and $31,807 per life-year gained, respectively. In a sensitivity analysis, only a reduction from the baseline value of 1.1% to 0.2% was associated with an ICER for inappropriate colonoscopy higher than $150,000.

CONCLUSIONS

Current guidelines regarding the appropriateness of colonoscopy are relatively inefficient in excluding a clinically meaningful CRC risk for patients in whom colonoscopy is generally not indicated, raising serious concerns about their applicability to clinical practice.

Education improves colonoscopy appropriateness

BACKGROUND

Appropriateness in GI endoscopy is critical to face the rising amount of demands. Education of physicians has been advocated to reduce the level of inappropriateness.

OBJECTIVE

Our purpose was to assess the effectiveness of an educational program in determining a reduction of inappropriate colonoscopies in an open access system.

DESIGN

Prospective study.

SETTING

A single endoscopy unit in Italy.

PATIENTS

A total of 495 consecutive outpatients referred to our endoscopy unit by family physicians for diagnostic colonoscopy before the educational course and 522 after its completion, for a total of 1017 patients.

MAIN OUTCOME MEASUREMENTS

Inappropriate colonoscopy reduction rates, cost savings, and reduction of waiting lists were evaluated.

RESULTS

With regard to inappropriate colonoscopies, the post-course group rate of inappropriateness was significantly lower than that of the pre-course group (P < or = .001). The economic savings for 1 year was estimated to be euro19,000. The reduction of the waiting list was about 15% of the original value.

CONCLUSIONS

Education has a high incidence in reducing inappropriate colonoscopies in an open-access system determining reduction of costs and waiting lists.

The appropriateness of colonoscopy: a multi-center, international, observational study

OBJECTIVE

To examine the appropriateness and necessity of colonoscopy across Europe.

DESIGN

Prospective observational study.

SETTING

A total of 21 gastrointestinal centers from 11 countries.

PARTICIPANTS

Consecutive patients referred for colonoscopy at each center.

INTERVENTION

Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy.

MAIN OUTCOME MEASURE

Appropriateness of colonoscopy.

RESULTS

A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45-54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia [OR: 30.84, 95% CI: 19.79-48.06] or change in bowel habits [OR: 3.69, 95% CI: 2.74-4.96] were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain [OR: 0.64, 95% CI: 0.49-0.83] or chronic diarrhea [OR: 0.54, 95% CI: 0.40-0.75] were less likely to have an appropriate or necessary indication.

CONCLUSIONS

This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptoms.