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Lewis D, Jimenez L, Mansour MH, Horton S, Wong WWL. A Systematic Review of Cost-Effectiveness Studies on Gastric Cancer Screening. Cancers (Basel) 2024; 16:2353. [PMID: 39001415 PMCID: PMC11240801 DOI: 10.3390/cancers16132353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Gastric cancer (GC) poses notable economic and health burdens in settings where the incidence of disease is prevalent. Some countries have established early screening and treatment programs to address these challenges. The objectives of this systematic review were to summarize the cost-effectiveness of gastric cancer screening presented in the literature and to identify the critical factors that influence the cost-effectiveness of screening. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Economic evaluation studies of gastric cancer screening were reviewed from SCOPUS and PubMed. The Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) was used to assess the quality of reporting presented in the selected articles. Only primary economic evaluation studies addressing the cost-effectiveness, cost-utility, and cost-benefit of gastric cancer screening were selected. Two reviewers scrutinized the selected articles (title, abstract, and full text) to determine suitability for the systematic review based on inclusion and exclusion criteria. Authors' consensus was relied on where disagreements arose. The main outcome measures of concern in the systematic review were cost, effectiveness (as measured by either quality-adjusted life years (QALY) or life-years saved (LYS)), and incremental cost-effectiveness ratio (ICER) of screening versus either no screening or an alternative screening method. Thirty-one studies were selected for the final review. These studies investigated the cost-effectiveness of GC screening based on either primary, secondary, or a combination of primary and secondary interventions. The main primary intervention was Helicobacter pylori (Hp) screening with eradication, while the main secondary intervention was endoscopic screening. Cost-effectiveness was evaluated against no screening or screening using an alternative method in both observational and model-based studies. Screening was mainly cost-effective in Asian countries or their diasporas where the prevalence of GC was high. GC screening was generally not cost-effective among Western countries. GC screening can be cost-effective, but cost-effectiveness is dependent on context-specific factors, including geographical location, the prevalence of GC in the local population, and the screening tool adopted. However, there is benefit in targeting high-risk population groups in Asian countries and their diaspora for GC screening.
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Affiliation(s)
- Diedron Lewis
- School of Pharmacy, University of Waterloo, Waterloo, ON N2G 1C5, Canada
| | - Laura Jimenez
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Manel Haj Mansour
- Department of Haematology and Oncology, Aga Khan University Hospital, Nairobi P.O. Box 30270-00100, Kenya
| | - Susan Horton
- School of Public Health Sciences, University of Waterloo, Waterloo, ON N2L 3G5, Canada
| | - William W L Wong
- School of Pharmacy, University of Waterloo, Waterloo, ON N2G 1C5, Canada
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Stone TC, Ward V, Hogan A, Alexander Ho KM, Wilson A, McBain H, Duku M, Wolfson P, Cheung S, Rosenfeld A, Lovat LB. Using saliva epigenetic data to develop and validate a multivariable predictor of esophageal cancer status. Epigenomics 2024; 16:109-125. [PMID: 38226541 PMCID: PMC10825730 DOI: 10.2217/epi-2023-0248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/04/2024] [Indexed: 01/17/2024] Open
Abstract
Background: Salivary epigenetic biomarkers may detect esophageal cancer. Methods: A total of 256 saliva samples from esophageal adenocarcinoma patients and matched volunteers were analyzed with Illumina EPIC methylation arrays. Three datasets were created, using 64% for discovery, 16% for testing and 20% for validation. Modules of gene-based methylation probes were created using weighted gene coexpression network analysis. Module significance to disease and gene importance to module were determined and a random forest classifier generated using best-scoring gene-related epigenetic probes. A cost-sensitive wrapper algorithm maximized cancer diagnosis. Results: Using age, sex and seven probes, esophageal adenocarcinoma was detected with area under the curve of 0.72 in discovery, 0.73 in testing and 0.75 in validation datasets. Cancer sensitivity was 88% with specificity of 31%. Conclusion: We have demonstrated a potentially clinically viable classifier of esophageal cancer based on saliva methylation.
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Affiliation(s)
- Timothy C Stone
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Vanessa Ward
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Aine Hogan
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Kai Man Alexander Ho
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences (WEISS), University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Ash Wilson
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Hazel McBain
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences (WEISS), University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Margaret Duku
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences (WEISS), University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Paul Wolfson
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Sharon Cheung
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
| | - Avi Rosenfeld
- Department of Computer Science, Jerusalem College of Technology, Havaad Haleumi 21, Givat Mordechai, 91160, Jerusalem, Israel
| | - Laurence B Lovat
- Division of Surgery & Interventional Science, University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences (WEISS), University College London, Charles Bell House, 43-45 Foley Street, London, W1W 7TY, UK
- Department of Gastrointestinal Services, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
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3
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Ceroni L, Lodato F, Tubertini P, Marasco G, Gazzola A, Biselli M, Fabbri C, Buonfiglioli F, Ferrara F, Schiumerini R, Fabbri A, Tassoni A, Descovich C, Mondini S, Tosetti C, Veduti V, De Negri M, Fini A, Guicciardi S, Romanelli M, Navarra GG, Barbara G, Cennamo V. The Gastropack Access System as a Model to Access Gastroenterology Services for Gastroscopy Appropriateness in Patients with Upper Gastrointestinal Symptoms: A Comparison with the Open Access System. J Clin Med 2023; 12:jcm12093343. [PMID: 37176783 PMCID: PMC10178877 DOI: 10.3390/jcm12093343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/16/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Esophagogastroduodenoscopy (EGD) appropriateness in Open-Access System (OAS) is a relevant issue. The Gastropack Access System (GAS) is a new system to access gastroenterological services, based on the partnership between Gastroenterologists and GPs. This study aims to evaluate if GAS is superior to OAS in terms of EGDS appropriateness. Secondarily, we evaluated the diagnostic yield of EGDS according to ASGE guidelines. The GAS was developed in an area of Bologna where General Practitioners (GPs) could decide to directly prescribe EGDS through OAS or referring to GAS, where EGDS can be scheduled after contact between GPs and specialists sharing a patient's clinical information. Between 2016 and 2019, 2179 cases (M:F = 861:1318, median age 61, IQR 47.72) were referred to GAS and 1467 patients (65%) had a prescription for EGDS; conversely, 874 EGDS were prescribed through OAS (M:F = 383:491; median age 58 yrs, IQR 45.68). Indication was appropriate in 92% in GAS (1312/1424) versus 71% in OAS (618/874), p < 0.001. The rate of clinically significant endoscopic findings (CSEF) was significantly higher in GAS (49% vs. 34.8%, p < 0.001). Adherence to ASGE guidelines was not related to CSEF; however, surveillance for pre-malignant conditions was independently related to CSEF. All neoplasm were observed in appropriate EGD. GAS is an innovative method showing extremely high rates of appropriateness. ASGE guidelines confirmed their validity for cancer detection, but their performance for the detection of other conditions needs to be refined.
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Affiliation(s)
- Liza Ceroni
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
| | - Francesca Lodato
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
| | - Paolo Tubertini
- Process Reengineering, AUSL Bologna, 40124 Bologna, Italy
- Enterprise Information Systems for Integrated Care and Research Data Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giovanni Marasco
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40126 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Alessia Gazzola
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
| | - Maurizio Biselli
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40126 Bologna, Italy
| | - Cristiano Fabbri
- Process Reengineering, AUSL Bologna, 40124 Bologna, Italy
- Enterprise Information Systems for Integrated Care and Research Data Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Federica Buonfiglioli
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
| | - Francesco Ferrara
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
| | - Ramona Schiumerini
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
| | - Andrea Fabbri
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40126 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Alessandra Tassoni
- Program for Clinical Governance and Outpatients Care, AUSL Bologna, 40124 Bologna, Italy
| | - Carlo Descovich
- Department of Clinical Governance and Quality, AUSL Bologna, 40124 Bologna, Italy
| | - Sandra Mondini
- Department of Primary Care, Distretto Appennino Bolognese, AUSL Bologna, 40124 Bologna, Italy
| | - Cesare Tosetti
- Department of Primary Care, Distretto Appennino Bolognese, AUSL Bologna, 40124 Bologna, Italy
| | - Valerio Veduti
- Department of Primary Care, Distretto Appennino Bolognese, AUSL Bologna, 40124 Bologna, Italy
| | - Mario De Negri
- Department of Primary Care, Distretto Appennino Bolognese, AUSL Bologna, 40124 Bologna, Italy
| | - Alessandro Fini
- Department of Primary Care, Distretto Appennino Bolognese, AUSL Bologna, 40124 Bologna, Italy
| | - Stefano Guicciardi
- Medical Direction, AUSL Bologna, 40124 Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy
| | | | | | - Giovanni Barbara
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, 40126 Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy
| | - Vincenzo Cennamo
- Department of Gastroenterology and Interventional Endoscopy, AUSL Bologna Bellaria, Maggiore Hospital Bologna, 40133 Bologna, Italy
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4
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The relationship between abnormal tongue features and non-malignant upper gastrointestinal disorders: A hospital-based cross-sectional study. Eur J Integr Med 2021. [DOI: 10.1016/j.eujim.2021.101379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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5
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Endoscopic Evaluation of Radiologic Distal Esophageal Thickening. J Clin Gastroenterol 2021; 55:766-771. [PMID: 32960818 DOI: 10.1097/mcg.0000000000001425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/07/2020] [Indexed: 12/10/2022]
Abstract
GOALS We aim to determine the incidence of esophagogastroduodenoscopies (EGDs) primarily performed for imaging findings of distal esophageal thickening (DET). We also aim to determine if patients with imaging findings of DET have a higher incidence of cancer, and to evaluate the risk factors associated with findings of malignancy. BACKGROUND The growth of diagnostic imaging has led to an increase in incidental findings of DET. This nonspecific finding frequently prompts an EGD for evaluation-many of which demonstrate benign conditions. There may be a misuse of valuable resources. STUDY We performed a retrospective chart review of 1080 EGDs from January 2016 to July 2018 at the Veterans Affairs Medical Center, comparing EGDs for the indication of imaging report of DET with EGDs for other indications. Patient demographics, clinical history, imaging, procedure, and pathology reports were collected. Descriptive analysis and biostatistical analysis with χ2, Fisher exact, Wilcoxon rank sum, and Kruskal-Wallis tests were utilized in analyzing the data. RESULTS Of the 1080 total endoscopies, 8.2% (n=88) were done specifically because of the imaging findings of DET. Those who had EGDs performed because of DET had a higher percentage of abnormal esophageal findings and of cancer. A history of Barrett's esophagus, tobacco use, and having gastrointestinal symptoms were not significant predictors of abnormal findings or of cancer for EGDs done for DET. CONCLUSIONS There may be a role for EGDs performed for radiologic findings of DET. Even those without risk factors for malignancy should have EGDs performed for DET. Radiologists should consider reporting the DET size in order to determine if significant endoscopic findings correlate with wall thickness.
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Manes G, Saibeni S, Pellegrini L, Picascia D, Pace F, Schettino M, Bezzio C, de Nucci G, Hassan C, Repici A. Improvement in appropriateness and diagnostic yield of fast-track endoscopy during the COVID-19 pandemic in Northern Italy. Endoscopy 2021; 53:162-165. [PMID: 32942316 PMCID: PMC7869040 DOI: 10.1055/a-1265-3315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND During the COVID-19 outbreak in Italy, only fast-track endoscopic procedures have been performed; nevertheless, a significant drop in their number has been reported. We evaluated whether the pandemic has impacted the appropriateness and diagnostic yield of fast-track endoscopic procedures compared with those performed in 2019. METHODS This retrospective study involved endoscopy services in Northern Italy. We compared data regarding endoscopic procedures performed in March and April 2020 with those performed during the same period in 2019. RESULTS In 2020, there was a 53.6 % reduction in the number of fast-track endoscopic procedures compared with 2019. Patients undergoing endoscopy in 2020 were younger than in 2019. Both appropriate referral and diagnostic yield increased in 2020 for both upper and lower endoscopy. A higher rate of cancer was diagnosed in 2020 by upper endoscopy (3.6 % vs. 6.6 %; P = 0.04). CONCLUSIONS The high level of inappropriate endoscopy referrals registered in 2019 significantly improved during the COVID-19 outbreak of 2020, with an increase in the diagnostic yield.
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Affiliation(s)
- Gianpiero Manes
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Simone Saibeni
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Lucienne Pellegrini
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Desiree Picascia
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Fabio Pace
- Bolognini Hospital, Gastroenterology Unit, Seriate, Italy
| | - Mario Schettino
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Cristina Bezzio
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Germana de Nucci
- ASST Rhodense, Gastroenterology and Endoscopy Unit, Garbagnate Milanese, Milan, Italy,ASST Rhodense, Gastroenterology and Endoscopy Unit, Rho, Milan, Italy
| | - Cesare Hassan
- Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Humanitas University, Department of Biomedical Sciences, Rozzano, Milan, Italy
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7
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Salerno R, Conti CB, De Silvestri A, Campbell Davies SE, Mezzina N, Ardizzone S. The impact of covid-19 pandemic on urgent endoscopy in Italy: a nation-wide multicenter study. Scand J Gastroenterol 2020; 55:870-876. [PMID: 32615891 DOI: 10.1080/00365521.2020.1782466] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: COVID-19 pandemic has seriously affected Italy. Radical changes occurred in the Italian NHS and thus in GI departments, as only urgent endoscopies were guaranteed. The study aimed to report how the demand for urgent endoscopy changed during the COVID-19 pandemic in Italy and to evaluate the appropriateness of urgent referrals in the Endoscopy Unit.Material and methods: Nation-wide, cross-sectional survey study in 54 Italian GI Units. Data were collected regarding urgent endoscopies (EGD, CS, ERCP) in two different time periods: March 2019 and March 2020.Results: Thirty-five (64.8%) GI endoscopy Units responded to the survey. The entity of reduction of overall urgent EGDs and CSs performed in March 2020 versus March 2019 was statistically significant: 541 versus 974 (-80%), p < .001 for EGD and 171 versus 265 (-55%), p < .008, for CS, respectively. No statistically significant reduction of urgent ERCP performed in March 2020 versus March 2019 was found. The increase in overall diagnostic yield for urgent EGD in March 2020 versus March 2019 was 7.3% (CI [0.028-0.117], p = .001). No statistically significant difference in diagnostic yield for CS between 2019 and 2020 was found.Conclusion: The study showed a statistically significant reduction of urgent EGD and CS performed during the SARS-CoV-2 pandemic, in March 2020, compared to March 2019. The diagnostic yield of urgent EGD performed in March 2020 was significantly higher than that of March 2019. No statistically significant difference was found in terms of diagnostic yield of urgent CS between March 2020 and March 2019.
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Affiliation(s)
- Raffaele Salerno
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Annalisa De Silvestri
- Clinic Epidemiology and Biometric, Scientific Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Nicolò Mezzina
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco, Department of Biochemical and Clinical Sciences, University of Milan, Italy
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8
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Zullo A, Manta R, De Francesco V, Fiorini G, Hassan C, Vaira D. Diagnostic yield of upper endoscopy according to appropriateness: A systematic review. Dig Liver Dis 2019; 51:335-339. [PMID: 30583999 DOI: 10.1016/j.dld.2018.11.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/29/2018] [Accepted: 11/24/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIM Despite some official guidelines are available, a substantial rate of inappropriateness for upper gastrointestinal (UGI) endoscopies has been reported. This study aimed to estimate the inappropriate rate of UGI in different countries, also including the diagnostic yield. METHODS A systematic review of studies on UGI endoscopy appropriateness was performed by adopting official guidelines as reference standard. Diagnostic yield of relevant endoscopic findings and cancers was compared between appropriate and inappropriate procedures. The Odd Ratio (OR) values and the Number-Needed-to-Scope (NNS) were calculated. RESULTS Data of 23 studies with a total of 53,392 patients were included. UGI indications were overall inappropriate in 21.7% (95% CI = 21.4-22.1) of the patients. The inappropriateness rate significantly (P < 0.0001) decreased from 35.1% in the earlier studies to 22.1%-23% in the more recent ones. A relevant finding was found in 43.3% of appropriate and in 35.1% of inappropriate endoscopies (P < 0.0001; OR: 1.42, 95% CI = 1.36-1.49; NNS = 12). Prevalence of cancers was also higher in appropriate than in inappropriate UGIs (2.98% vs. 0.09%, P < 0.0001; OR = 3.33; NNS = 48). The prevalence of detected cancers significantly (P < 0.004) increased from 1.38% in the earlier studies to 2.11% in the more recent ones, whilst prevalence of other relevant findings remained similar. CONCLUSIONS Rate of inappropriate UGI endoscopies is still high. Diagnostic yield of appropriate endoscopies is higher than that of inappropriate procedures, including upper GI cancers. Therefore, implementation of guidelines in clinical practice is urged.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy,'Nuovo Regina Margherita' Hospital, Rome, Italy.
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy, 'Generale' Hospital, Perugia, Italy
| | - Vincenzo De Francesco
- Section of Gastroenterology, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Giulia Fiorini
- Internal Medicine and Gastroenterology, Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
| | - Cesare Hassan
- Gastroenterology and Digestive Endoscopy,'Nuovo Regina Margherita' Hospital, Rome, Italy
| | - Dino Vaira
- Internal Medicine and Gastroenterology, Department of Surgical and Medical Sciences, University of Bologna, Bologna, Italy
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9
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de Jong JJ, Lantinga MA, Drenth JPH. Prevention of overuse: A view on upper gastrointestinal endoscopy. World J Gastroenterol 2019; 25:178-189. [PMID: 30670908 PMCID: PMC6337020 DOI: 10.3748/wjg.v25.i2.178] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 12/06/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed Helicobacter pylori test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.
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Affiliation(s)
- Judith J de Jong
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
| | - Marten A Lantinga
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
| | - Joost PH Drenth
- Department of Gastroenterology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
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10
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Guerra MAR, Rossetti M, Zhang Z, Zhou X, Whang EC, Venick RS, Marcus EA, McDiarmid SV, Farmer DG, Reed EF, Wozniak LJ. Characterization of T cell immunophenotypes in intestinal transplantation: A pilot study. Transpl Immunol 2018; 51:50-57. [PMID: 30243797 DOI: 10.1016/j.trim.2018.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 09/11/2018] [Accepted: 09/16/2018] [Indexed: 01/08/2023]
Abstract
Immunophenotyping of peripheral blood mononuclear cells has been shown to be a useful, non-invasive method of predicting acute cellular rejection (ACR) following intestinal transplantation (ITx). Our objectives were to characterize differences in the T cell immunophenotype of ITx recipients in peripheral blood samples (1) collected late versus early after ITx and (1) associated with episodes of ACR and infectious enteritis. An IRB-approved, cross-sectional study of ITx recipients was performed. Peripheral blood samples were collected during normal visits and episodes of allograft dysfunction. A total of 38 patients were included in the analysis: 31 ITx recipients (87% liver-inclusive allografts) and 7 intestinal failure control patients. Of the ITx patients, 26 patients were pediatric patients (<21 years). A total of 70 samples were analyzed from ITx recipients, including 51 during normal visits and 19 during episodes of allograft dysfunction (median of 2 samples per patient; range of 1-6 samples per patient). In the late (n = 32) versus early post-ITx (n = 19) normal samples, there was a significantly higher percentage of central memory CD4 T cells (p = .001). In the ACR (n = 5) versus infectious enteritis (n = 14) samples, there was a higher percentage of CD8 T cells expressing HLA-DR (p = .002), CD57 (p < .001), and KLRG1 (p < .001) and a higher percentage of CD4 T cells expressing CD57 (p = .03). Additional studies are needed with larger cohorts to validate these changes in the T cell immunophenotype. Further elucidating T cell immunophenotypes in ITx will lead to a better understanding of immune mechanisms of allograft dysfunction, identification of potential biomarkers in ITx, and optimized selection of immunosuppressive therapies.
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Affiliation(s)
- Marjorie-Anne R Guerra
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, UCLA, United States.
| | | | - Zhenyu Zhang
- Biostatistics, Fielding School of Public Health, UCLA, United States
| | - Xinkai Zhou
- Medicine,Statistics Core, David Geffen School of Medicine, UCLA, United States
| | - Emily C Whang
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, UCLA, United States
| | - Robert S Venick
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, UCLA, United States; Liver and Pancreas Transplantation, David Geffen School of Medicine, UCLA, United States
| | - Elizabeth A Marcus
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, UCLA, United States; VA Greater Los Angeles Health Care System, United States
| | - Suzanne V McDiarmid
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, UCLA, United States; Liver and Pancreas Transplantation, David Geffen School of Medicine, UCLA, United States
| | - Douglas G Farmer
- Liver and Pancreas Transplantation, David Geffen School of Medicine, UCLA, United States
| | | | - Laura J Wozniak
- Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine, UCLA, United States
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11
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Areia M, Carvalho R, Cadime AT, Rocha Gonçalves F, Dinis-Ribeiro M. Screening for gastric cancer and surveillance of premalignant lesions: a systematic review of cost-effectiveness studies. Helicobacter 2013; 18:325-37. [PMID: 23566268 DOI: 10.1111/hel.12050] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cost-effectiveness studies are highly dependent on the models, settings, and variables used and should be based on systematic reviews. We systematically reviewed cost-effectiveness studies that address screening for gastric cancer and/or surveillance of precancerous conditions and lesions. MATERIALS AND METHODS A systematic review of cost-effectiveness studies was performed by conducting a sensitive search in seven databases (PubMed, Scopus, Web of Science, Current Contents Connect, Centre for Reviews and Dissemination, Academic Search Complete, and CINAHL Plus), independently evaluated by two investigators. Articles were evaluated for type of study, perspective, model, intervention, incremental cost-effectiveness ratio, clinical or cost variables, and quality, according to published guidelines. RESULTS From 2395 abstracts, 23 articles were included: 19 concerning population screening and 4 on following up premalignant lesions. Studies on Helicobacter pylori screening concluded that serology was cost-effective, depending on cancer incidence and endoscopy cost (incremental cost-effectiveness ratio: 6264-25,881), and eradication after endoscopic resection was also cost-effective (dominant) based on one study. Studies on imaging screening concluded that endoscopy was more cost-effective than no screening (incremental cost-effectiveness ratio: 3376-26,836). Articles on follow-up of premalignant lesions reported conflicting results (incremental cost-effectiveness ratio: 1868-72,519 for intestinal metaplasia; 18,600-39,800 for dysplasia). Quality assessment revealed a unanimous lack of a detailed systematic review and fulfillment of a median number of 23 items (20-26) of 35 possible ones. CONCLUSIONS The available evidence shows that Helicobacter pylori serology or endoscopic population screening is cost-effective, while endoscopic surveillance of premalignant gastric lesions presents conflicting results. Better implementation of published guidelines and accomplishment of systematic detailed reviews are needed.
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Affiliation(s)
- Miguel Areia
- CINTESIS - Center for Research in Health Technologies and Information Systems, Faculty of Medicine, Porto University, Porto, Portugal.
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12
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Zhou HJ, Li SC, Naidoo N, Zhu F, Yeoh KG. Empirical evidence of the continuing improvement in cost efficiency of an endoscopic surveillance programme for gastric cancer in Singapore from 2004 to 2010. BMC Health Serv Res 2013; 13:139. [PMID: 23587354 PMCID: PMC3637081 DOI: 10.1186/1472-6963-13-139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 04/05/2013] [Indexed: 12/16/2022] Open
Abstract
Background Endoscopic surveillance has been proven effective in prolonging the survival of gastric cancer (GC) patients. However, there is limited evidence on the cost efficiency of delivering this intervention, especially on a national level in spite of cost efficiency being a major determinant of the actual cost-effectiveness of a cancer prevention programme. The Singapore Gastric Cancer Epidemiology Clinical and Genetic Programme (GCEP) is a demonstration project offering scheduled endoscopy to the Chinese population aged 50 years or older in Singapore. By assessing the cost efficiency of the GCEP, this study aimed to provide empirical evidence on the cost structure and mechanisms underlying cost generation in conducting GC surveillance, thus informing resource allocation and programme budgeting for the Singapore government. Methods From a societal perspective, we reported on the direct cost (resource consumption) of conducting endoscopic surveillance through the GCEP network. We retrospectively collected individual-level data of 216 subjects recruited at the National University Hospital, Singapore from 01/04/2004 to 31/10/2010. The Overall Cost, Clinical Cost, GCEP Cost and Personal Cost incurred in serving one subject was computed and discounted as 2004 US dollar (US$) per capita for every year. The Generalized Estimation Equation (GEE) was used to model the data. Results All cost indices continuously declined over the 6.5-year costing period. For the total sample, Overall Cost, Clinical Cost, GCEP Cost and Personal Cost declined by 42.3%, 54.1%, 30% and 25.7% respectively. This downward trend existed for age and gender subgroups and the high risk group only with cost reductions varying between 3.5% and 58.4%. The GEE models confirmed statistical significance of the downward trend and of its association with risk profile, where the moderate risk group had cost indices at most 77% of the high risk group. Conclusions Our study offered empirical evidence of improved cost efficiency of a surveillance programme for GC in the early phase of programme implementation. Mechanisms such as economies of scale and self-learning were found to be involved in the cost reduction. Our findings highlighted the importance of assessing the cost efficiency and offered valuable insights for future programme budgeting and policy making.
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Affiliation(s)
- Hui Jun Zhou
- Saw Swee Hock School of Public Health, National University of Singapore, MD3, 16 Medical Drive, Singapore, Singapore
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13
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Abadir A, Streutker C, Brezden-Masley C, Grin A, Kim YI. Intestinal metaplasia and the risk of gastric cancer in an immigrant asian population. CLINICAL MEDICINE INSIGHTS. GASTROENTEROLOGY 2012; 5:43-50. [PMID: 24833933 PMCID: PMC3987763 DOI: 10.4137/cgast.s10070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The development of intestinal metaplasia (IM) has been purported to be a critical step in the pathogenesis of gastric cancer. However, the natural history of IM in migrant human populations has not been well elucidated. The purpose of this study was to determine the risk of gastric cancer posed by IM in Asian immigrants undergoing gastric cancer screening. A retrospective review of Asian immigrants found to have IM during screening was conducted over an 18-month period. In total, 222 patients were found to have IM. Altogether, 24% had a history of smoking, 48% had a family history of gastric cancer, and 52% had a history of Helicobacter pylori (H. pylori) infection with a 96% eradication rate. Patients with stable IM (SIM) were then compared with those who developed high risk pathology (HRP), specifically dysplasia and/or adenocarcinoma. Thirty-five patients (16%) were included in the HRP group, 31 with dysplasia (14%) and 4 with adenocarcinoma (2%). Of those with dysplasia, 55% demonstrated regression to IM over the course of follow-up. Patients in the SIM group were more likely to be female (60% vs. 31%, P = 0.002) and more likely to have had a normal biopsy during follow-up (32% vs. 9%, P = 0.005). Odds ratios for IM stability were 3.3 (95% CI 1.5-7.0) and 5.0 (95% CI 1.5-17.1) for female gender and presence of a normal biopsy, respectively. Intestinal metaplasia in immigrant Asian populations is predominantly a stable histologic finding associated with a low rate of persistent dysplasia and adenocarcinoma.
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Affiliation(s)
- Amir Abadir
- Division of Gastroenterology, Department of Medicine, University of Toronto
| | - Catherine Streutker
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto
| | | | - Andrea Grin
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto
| | - Young-In Kim
- Division of Gastroenterology, Department of Medicine, University of Toronto. ; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
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14
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Buri L, Hassan C, Bersani G, Anti M, Bianco MA, Cipolletta L, Di Giulio E, Di Matteo G, Familiari L, Ficano L, Loriga P, Morini S, Pietropaolo V, Zambelli A, Grossi E, Intraligi M, Buscema M. Appropriateness guidelines and predictive rules to select patients for upper endoscopy: a nationwide multicenter study. Am J Gastroenterol 2010; 105:1327-37. [PMID: 20029414 DOI: 10.1038/ajg.2009.675] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Luigi Buri
- Gastroenterology and Digestive Endoscopy Unit, Cattinara Hospital, Trieste, Italy
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15
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Porro GB. This month in the Scandinavian Journal of Gastroenterology. Scand J Gastroenterol 2009; 44:388-9. [PMID: 19308853 DOI: 10.1080/00365520902799242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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