Open access endoscopy

Open access gastroscopy--3 year experience of a new service

We have audited the first 3 yr of a new open access gastroscopy service in the Royal Victoria Hospital, Belfast to assess service demands, patient demography and diagnostic trends. Over 3 yr there were 1872 referrals (800 from fundholding general practitioners), 8.8 per cent were non attenders and 5.4 per cent cancelled appointments. Endoscopic diagnostic categories showed no significant change over the 3 yr, 39 per cent non ulcer dyspepsia, 35 per cent gastro-oesophageal reflux disease (GORD), 17 per cent peptic ulcer disease (PUD), 6 per cent GORD and PUD, 1 per cent gastric erosions and 0.8 per cent carcinoma.

Open access gastroscopy: second survey of current practice in the United Kingdom

In June 1990 a survey of members of the endoscopy section of the British Society of Gastroenterology showed that 47% of respondents were offering some form of open access gastroscopy (OAG). Only 10% offered true (non-censored) OAG. The survey was repeated in June 1994. The overall provision of OAG had risen to 74%, most of whom were offering true OAG. Censored OAG is still widely practised and characterised by referral letters to a consultant in contrast with the use of referral forms (p < 0.001). Referral forms are being increasingly used and are an effective way of capturing important data such as the patients' symptoms (100%), previous treatment (87%), non-steroidal anti-inflammatory drug or aspirin use (78%), suspected diagnosis (74%), and other medical conditions (72%). Forms were used to establish clinical responsibility with the general practitioner in 64% of units. Standardised referral and reporting forms were used by 27% of respondents. A perceived inability to cope with the expected workload was still the most commonly cited reason for not being able to offer OAG. Although 20% of units with a single handed endoscopist were able to offer OAG, this compared with 68% of units with two or more endoscopists (p < 0.001). Only three units indicated that an OAG service had had to be withdrawn, but a further 12 consultants (nine units) were now offering an age restricted service because of excessive workload. Two thirds of the respondents not offering OAG were hoping to do so in the near future. True OAG has increased from 10% to 41% in four years.

Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison

OBJECTIVE

Under the Pharmaceutical Benefits Scheme, the use of H2-receptor antagonists (H2A) in the treatment of dyspepsia and heartburn is only subsidised when there is a proven diagnosis of ulcer. This study compared the costs of this Australian practice with a simulation of British practice, which allows unrestricted prescribing of subsidised H2A.

DESIGN

Patients with heartburn and/or dyspepsia were prospectively randomised to either a "British" group treated freely at the discretion of their general practitioner without necessarily being investigated or an "Australian" group where use of H2A was allowed only after gastroscopy or a barium meal had demonstrated a peptic ulcer or ulcerative oesophagitis. The patients were followed up for six months and all direct and indirect costs were recorded.

SETTING

Forty-nine Sydney general practitioners recruited primary care patients for the study.

PATIENTS

Any patient with heartburn or dyspepsia was considered for recruitment; 139 patients entered the study and 137 completed it.

MAIN OUTCOME MEASURES

The outcome measures were the costs of general practitioner consultations, specialist consultations, radiology and gastroscopy, other tests, H2A, other medications, personal costs, and total cost per patient.

RESULTS

The cumulative total cost per patient at the end of the study was equivalent in the "Australian" ($392) and "British" ($406) groups. A higher initial cost per patient of H2A in the "British" group was offset by a rapid decrease in the proportion that continued to use H2A and by the cost of specialist consultations and investigations in the "Australian" group.

CONCLUSION

Over a six-month period the cost of early investigation of heartburn and dyspepsia was equivalent to the cost of a therapeutic trial of H2A.

Do young patients with dyspepsia need investigation?

During 1986, 1386 patients with simple dyspepsia were referred by general practitioners for endoscopy (686) or double-contrast barium meal examination (700) at Leicester General Hospital. 618 (45%) were under the age of 45 years. Abnormal findings were more common in older than younger dyspeptic patients (58% vs 40% at endoscopy, 69% vs 25% by barium meal). Malignant disorders were diagnosed in 5% at endoscopy and 3% at barium meal, but in no patient under 45 years old. The incidence of malignant disorders at endoscopy was analysed for the 6 years 1980-86. Of 707 cases identified, only 13 (1.8%) occurred in patients under 45 years old; all 13 had symptoms suggesting pathology more serious than simple dyspepsia. It can be concluded that young patients with simple dyspepsia are overinvestigated. A majority can be treated safely with antacids and/or histamine receptor type 2 antagonists.

Open access colonoscopy for suspected colonic neoplasia

An open access endoscopy service for direct referral of patients suspected to have colonic neoplasia has been analysed. In the first year of the service 137 patients were referred by 52 general practitioners. The most common reason for referral was rectal bleeding (58%). Colonoscopy was done without outpatient consultation or barium enema examination in 130 patients: there were no complications. The diagnostic yield was 57%: 34 patients (25%) had neoplasia (cancer 14, adenoma 20), which was higher than the yield of neoplasia in patients referred for open access double contrast barium enema during the same period. Only nine patients (7%) needed further investigation because colonoscopy was incomplete and 21 (16%) were treated by polypectomy at the diagnostic colonoscopy.

Open access fibresigmoidoscopy: a comparative audit of efficacy

A total of 541 open access referrals for fibresigmoidoscopy over five years were compared with 495 hospital initiated procedures during the same period. The number of open access fibresigmoidoscopies doubled during the five years but diagnostic yield remained unchanged at about 40% and was similar to that of the hospital initiated procedures. Colorectal carcinoma was seen in 64 open access patients compared with 47 hospital referred patients, the proportion of Dukes's type A lesions being similar (34%) in both groups. Polyps, colitis, and diverticular disease were equally common in open access and hospital referred patients. Fibresigmoidoscopy failed to detect disease in only 12 patients (1.2%) and the procedure was unsatisfactory in only 54. Referral was considered justified in 475 (88%) open access patients, and only 54 (17%) patients with normal appearances at endoscopy required further investigations. Diagnostic yields were low (19%; 30/156 cases) in open access patients under 40 and in patients with abdominal pain, constipation, or abdominal pain with constipation (0-17%). Most of these young patients presumably suffer from the irritable bowel syndrome and do not justify fibresigmoidoscopy. In contrast, there was a high diagnostic yield (90-100%) in patients of all ages referred for diarrhoea and rectal bleeding, altered blood from the rectum, and rectal bleeding associated with abdominal pain. Open access fibresigmoidoscopy is an effective service that should be freely available to general practitioners.

Clinical aspects of pseudodysphagia

Pseudodysphagia is the description of the sensation of a feeling of a lump in the throat--commonly known as the globus symptom. A prospective analysis of 145 consecutive patients with this symptom seen by an Otolaryngologist has provided confirmation that a high proportion of these patients have a treatable basis for their complaints and that most can be successfully managed without time-consuming and expensive investigations--provided clinical evaluation includes thorough visualisation of the oropharynx and supraglottis. The explanation for the symptomatology in patients who suffer from reflux oesophagitis is probably referred pain from the region of the lower oesophageal sphincter rather than spasm of the upper sphincter. The expression globus hystericus is outdated and should be discarded, and we recommended describing the symptoms as primary globus pharyngeus when there is no evident cause and secondary globus pharyngeus when the aetiology is detectable.

Use of an open-access gastroscopy service by a general practice: findings and subsequent specialist referral rate

An analysis of 102 open-access gastroscopy requests from one general practice over 38 months showed that the detection rate of abnormalities was 58%. Even though no predetermined investigation criteria were used these results compare favourably with gastroscopy findings generally and are superior to the detection rate of lesions using barium meals. Only 12% of the patients who underwent gastroscopy required subsequent referral to a consultant. This represents a major benefit, hitherto undocumented, of an open-access gastroscopy service. Considerations of accuracy, safety and cost effectiveness coupled with the availability of efficacious drugs appear to favour the case for open-access gastroscopy for general practitioners.