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Yang J, Yan JS, Xiong CX, Zhang XM, Shen L, Zhi JL, Ma SY, Dong HX, Yang YS. Development and validation of a scoring system to predict esophagogastroduodenoscopy necessity. J Dig Dis 2023; 24:671-680. [PMID: 37971314 DOI: 10.1111/1751-2980.13241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/10/2023] [Accepted: 11/14/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE This study aimed to develop and validate a scoring system for predicting the need for esophagogastroduodenoscopy (EGD) in clinical practice to enhance accuracy and reduce misapplications. METHODS From February 2021 to April 2022, outpatients scheduled for EGD at the Department of Gastroenterology in our hospital were recruited. Patients completed the system evaluation by providing clinical symptoms, relevant medical history, and endoscopic findings. Patients were randomly divided into the training and validation cohorts (at 2:1 ratio). The optimal algorithm was selected from five alternatives including a parallel test. Six physicians participated in a human-computer comparative validation. Sensitivity and negative likelihood ratio (-LR) were used as the primary indicators. RESULTS Altogether 865 patients were enrolled, with 578 in the training cohort and 287 in the validation cohort. The scoring system comprised 21 variables, including age, 13 typical clinical symptoms, and seven medical history variables. The parallel test was selected as the final algorithm. Positive EGD findings were reported in 54.5% of the training cohort and 62.7% of the validation cohort. The scoring system demonstrated a sensitivity of 79.0% in the training cohort and 83.9% in the validation cohort, with -LR being 0.627 and 0.615, respectively. Compared to physicians, the scoring system exhibited higher sensitivity (84.0% vs 68.7%, P = 0.02) and a lower -LR (1.11 vs 2.41, P = 0.439). CONCLUSIONS We developed a scoring system to predict the necessity of EGD using a parallel test algorithm, which was user-friendly and effective, as evidenced by single-center validation.
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Affiliation(s)
- Jing Yang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | | | - Cen Xi Xiong
- School of Medicine, Nankai University, Tianjin, China
| | - Xiao Mei Zhang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Lei Shen
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun Li Zhi
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Shu Yun Ma
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hong Xia Dong
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yun Sheng Yang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
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Tursi A, Palieri AP, Lattarulo V, Elefante A, Gigliobianco A, Spinazzola D, Elisei W, Papa A. How we can improve the appropriateness of ambulatory gastrointestinal endoscopy: the lesson of the COVID-19 outbreak. Eur J Gastroenterol Hepatol 2023; 35:1149-1153. [PMID: 37665614 DOI: 10.1097/meg.0000000000002626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) outbreak has significantly modified hospital and outpatient activities. AIMS To assess the pandemic's impact on the appropriateness of outpatient gastrointestinal (G.I.) endoscopy in a southern Italy Region. METHODS Between 1 January 2019 and 31 December 2022, we compared the number, the type of activities, and the appropriateness of the G.I. endoscopy procedures in the four territorial gastroenterology and digestive endoscopy services of the Apulia region. RESULTS In 2019, 11 173 outpatient procedures were provided, which dropped by about 44% (P < 0.05) during 2020. The endoscopic activity was slightly reduced during 2020 (-18.77%), while every other activity dropped significantly. During 2021-2022, the overall activities slightly increased but remained below the number of activities provided before the pandemic (P < 0.05). However, the endoscopic activity increased by +6.86% from 2019 to 2022, mainly due to more colonoscopies. During the 4 years analysed, the overall appropriateness rate of the endoscopic examinations increased during 2020 (2019: 67%; 2020: 81%) while dropping again in the following years (2021: 75%; 2022; 69%). CONCLUSION The appropriateness of the G.I. endoscopic procedures in the territorial gastroenterology services in the Apulia Region has improved during the acute phase of the COVID-19 pandemic, dropping again in the following years. Overall, the appropriateness of endoscopic procedures remains suboptimal; thus, educational activities are needed to improve the appropriateness rate to optimise the limited resources.
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Affiliation(s)
- Antonio Tursi
- Territorial Gastroenterology Service, ASL BAT, Andria (BT)
- Department of Medical and Surgical Sciences, School of Medicine, Catholic University, Rome
| | | | - Vincenzo Lattarulo
- Territorial Digestive Endoscopy Service, Gioia del Colle Territorial Hospital, ASL BA, Gioia del Colle (BA)
| | - Antonio Elefante
- Territorial Digestive Endoscopy Service, Mesagne Territorial Hospital, ASL BR, Mesagne (BR)
| | | | | | - Walter Elisei
- Division of Gastroenterology, 'S. Camillo' Hospital, Rome
| | - Alfredo Papa
- Department of Medical and Surgical Sciences, School of Medicine, Catholic University, Rome
- Center for Diagnosis and Treatment of Digestive Diseases, CEMAD, Fondazione Policlinico Universitario 'A. Gemelli', IRCCS, Rome, Italy
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Yu X, Deng H, Xiong Z, Gong P, Ye M, Liu T, Long X, Tian L. A scale to measure the worry level in Gastrointestinal Endoscopy with sedation: Development, reliability, and validity. Int J Clin Health Psychol 2023; 23:100410. [PMID: 37701761 PMCID: PMC10493257 DOI: 10.1016/j.ijchp.2023.100410] [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: 03/15/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
Objective This study aims to develop a scale to measure the worry level of patients who will undergo gastrointestinal (GI) endoscopy with deep sedation, and to provide scientific references to alleviate their worries. Method Based on literature review, panel discussion, patient interview and expert consultation, we developed the first version of the scale. After two pre-investigations, the formal version of the scale was formed, and the reliability and validity were tested on 1389 respondents. Reliability was assessed by Cronbach's alpha. Construct validity was tested by confirmatory factor analysis (CFA) and the Spearman correlations analysis. Results The scale was composed of four dimensions: financial and time costs, sedation, examination, and psychology. It has 15 items. Reliability and validity were acceptable. The Cronbach's alpha of the whole scale was 0.959 and all the factor loadings were > 0.50. The Spearman correlations of the inter-dimensions ranged from 0.614 to 0.836, and the correlation coefficients between the dimensions and the total score were 0.795 to 0.957. The correlation coefficient between the total scale score and the APAIS was 0.833. Conclusions This scale has good validity and reliability, which is useful for physicians and medical institutions to take appropriate measures to reduce patients' worries.
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Affiliation(s)
- Xiaoyu Yu
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Haijun Deng
- School of Mathematics and Statistics, Guizhou University of Finance and Economics in Guizhou, China
| | - Ziyi Xiong
- Central South University in Changsha, China
| | - Pan Gong
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Mingmei Ye
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Tao Liu
- Central South University in Changsha, China
| | - Xiuyan Long
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
| | - Li Tian
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Changsha, Hunan 410013, China
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Odeghe EA, Owoseni OO, Chukwudike ES, Adeniyi OF, Adigun BE, Oyeleke GK, Oluyemi AO, Lesi OA. Appropriateness and diagnostic yield of open access gastroscopy in two tertiary centers in South-western Nigeria. Afr Health Sci 2023; 23:386-392. [PMID: 38223609 PMCID: PMC10782350 DOI: 10.4314/ahs.v23i2.44] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Background There is need for the appropriate use of gastroscopy. Objective To determine the appropriateness of upper gastrointestinal endoscopy, and its association with significant endoscopy findings in our environment. Methods This was a prospective study of subjects who underwent gastroscopy at two centers in south-western Nigeria between August 2020 and August 2021. Indications were classified as either appropriate or inappropriate according to the ASGE guidelines, gastroscopic findings as either significant or not significant, patients as either elderly (≥ 60 years) or not, inpatients or outpatients, and referrals as either gastroenterologist referral, or not. Results There were 227 subjects, 131 (57.7%) females, mean age 45 ± 13.7 years. Fifteen percent were elderly, 65.6% were gastroenterologist referrals, 14.1% were inpatients, while 45.8% had co-morbidities. Endoscopy was appropriately indicated in 81.9%, and significant endoscopy findings were detected in 95.6%. Appropriateness was not associated with significant endoscopy findings. The sensitivity, specificity and AUROC of the ASGE guidelines were 10%, 82%, and 0.46 respectively. Conclusion According to our study, most procedures are appropriately indicated. However, appropriateness did not determine endoscopy yield. Larger studies are needed to determine the utility of the ASGE guidelines in our environment.
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Affiliation(s)
- Emuobor A Odeghe
- Medicine department, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | | | | | | | | | - Ganiyat K Oyeleke
- Medicine department, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
| | | | - Olufunmilayo A Lesi
- Medicine department, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria
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Sajid IM, Frost K, Paul AK. 'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2022; 27:141-148. [PMID: 34099498 DOI: 10.1136/bmjebm-2020-111629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 12/21/2022]
Abstract
Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
| | - Ash K Paul
- NHS South West London Health and Care Partnership STP, London, UK
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Galloro G, Musella M, Siciliano S, Berardi G, Vitiello A, Velotti N, Rizzello F, Gionchetti P, Calabrese C. New endoscopic capsule vs upper gastrointestinal endoscopy in preoperative work-up of obese candidate for bariatric surgery: Relevance of a pilot study in the COVID-19 era. Endosc Int Open 2022; 10:E183-E191. [PMID: 35178336 PMCID: PMC8847058 DOI: 10.1055/a-1723-3109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022] Open
Abstract
Background and study aims Obesity represents a major health concern; bariatric surgery is the most effective treatment reducing and maintaining weight loss. The role of a routine esophagogastroduodenoscopy (EGD) prior bariatric surgery is still debated. Moreover, in this scenario of COVID-19 pandemic, EGD is even more questionable due to the procedural risk of viral transmission. A new model of video-endoscopic capsule (VEC) recently has been introduced as a good alternative to the EGD. The aim of this study was to determine if this new capsule is an adequate diagnostic alternative to EGD in the work-up of patients selected for bariatric surgery, particularly in the setting of COVID-19. Patients and methods From January to November 2020, 27 patients selected for bariatric surgery were enrolled in this pilot study to assess for noninferiority of VEC compared to EGD in detection of upper gastrointestinal disease. Results VEC had sensitivity, specificity, and positive and negative predictive values in identification of significant lesions of 91.3 %, 83.33 %, 98.01 %, and 51.57 %, respectively, compared with EGD as the standard criterion. The accuracy was 90.51 % (95 % CI, 73.75 %-98.18 %) and the chi-square statistic is 0.1153 ( P = 0.73). Conclusions Our report confirms the diagnostic noninferiority of VEC in preoperative work-up of patients selected for bariatric surgery, compared to EGD. This is very important, particularly during the COVID-19 pandemic, given the high risk of contamination with EGD. Larger multicenter studies are required to confirm our preliminary results.
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Affiliation(s)
- Giuseppe Galloro
- University of Naples Federico II – School of Medicine, Department of Clinical Medicine and Surgery – Surgical Endoscopy Unit, Naples, Italy
| | - Mario Musella
- University of Naples Federico II – School of Medicine, Department of Advanced Biomedical Sciences – Bariatric and Metabolic Surgery Unit, Naples, Italy
| | - Saverio Siciliano
- University of Naples Federico II – School of Medicine, Department of Clinical Medicine and Surgery – Surgical Endoscopy Unit, Naples, Italy
| | - Giovanna Berardi
- University of Naples Federico II – School of Medicine, Department of Advanced Biomedical Sciences – Bariatric and Metabolic Surgery Unit, Naples, Italy
| | - Antonio Vitiello
- University of Naples Federico II – School of Medicine, Department of Advanced Biomedical Sciences – Bariatric and Metabolic Surgery Unit, Naples, Italy
| | - Nunzio Velotti
- University of Naples Federico II – School of Medicine, Department of Advanced Biomedical Sciences – Bariatric and Metabolic Surgery Unit, Naples, Italy
| | - Fernando Rizzello
- University of Bologna Alma Mater – School of Medicine, Department of Medical and Surgical Sciences – Regional Referral Center for IBD, Bologna, Italy
| | - Paolo Gionchetti
- University of Bologna Alma Mater – School of Medicine, Department of Medical and Surgical Sciences – Regional Referral Center for IBD, Bologna, Italy
| | - Carlo Calabrese
- University of Bologna Alma Mater – School of Medicine, Department of Medical and Surgical Sciences – Regional Referral Center for IBD, Bologna, Italy
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Leal C, Almeida N, Silva M, Santos A, Vasconcelos H, Figueiredo P. Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2022; 29:5-12. [PMID: 35111959 PMCID: PMC8787496 DOI: 10.1159/000515839] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/19/2021] [Indexed: 11/01/2023]
Abstract
INTRODUCTION Advances in endoscopy and open-access systems led to an increase in endoscopic procedures. However, overuse of endoscopy has been consistently reported. This study aims to assess the appropriateness of esophagogastroduodenoscopy (EGD) and colonoscopy referral in the private and public setting. PATIENTS AND METHODS We conducted a prospective, multicenter study at 2 public and 5 private endoscopy units. Patients scheduled for elective EGD or colonoscopy were enrolled. Clinical data and endoscopy findings were recorded. Appropriateness of endoscopy was defined according to the American Society for Gastrointestinal Endoscopy guidelines (for EGD) and the European Panel on Appropriateness of Gastrointestinal Endoscopy II (for colonoscopy). RESULTS Regarding EGD: 215 patients enrolled (43.7% were males) with a mean age of 61.0 ± 15.1 years; 54.0% (n = 116) were in public hospitals. Referral by a gastroenterologist was made for 34.9% (n = 75). Appropriate indications were made for 62.3% (n = 134): 42.4% in private versus 79.3% in public endoscopy units (odds ratio [OR] 5.20; 95% confidence interval [CI] 2.85-9.49; p < 0.01). Rate of appropriate EGD was 74.7% for gastroenterologist referral and 56.1% for other specialties (OR 2.31; 95% CI 1.24-4.28; p < 0.01). Diagnostic yield for relevant findings was 47.9%. No association between indication appropriateness, gastroenterologist referral, and relevant endoscopic findings was found. Regarding colonoscopy: 287 patients enrolled (49.1% were males) with a mean age of 60.4 ± 14.4 years; 48.1% (n = 138) were in public hospitals. Referral by a gastroenterologist was made for 20.6% (n = 59). Appropriate indications were made for 70.0% (n = 201): 53.0% in private vs. 88.4% in public endoscopy units (OR 6.75; 95% CI 3.66-12.47; p < 0.01). Diagnostic yield was 57.1%. Relevant endoscopic diagnosis was associated with indication: 63.2% in the appropriate vs. 43.0% in the nonappropriate indication group (p < 0.05). DISCUSSION A significant percentage of endoscopies, mainly in the private setting, were performed without an appropriate indication. This influenced the diagnostic yield. The use of adequate criteria is fundamental for the rational use of an open-access system.
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Affiliation(s)
- Carina Leal
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Nuno Almeida
- Department of Gastroenterology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Maria Silva
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Antonieta Santos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Helena Vasconcelos
- Department of Gastroenterology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Pedro Figueiredo
- Department of Gastroenterology, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Halasz JB, Burak KW, Dowling SK, Murray B, Williams J, Misra T, Veldhuyzen van Zanten SJ, Kaplan GG, Swain M, Novak KL. Do Low-Risk Patients With Dyspepsia Need a Gastroscopy? Use of Gastroscopy for Otherwise Healthy Patients With Dyspepsia. J Can Assoc Gastroenterol 2021; 5:32-38. [PMID: 35118225 PMCID: PMC8806042 DOI: 10.1093/jcag/gwab017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 06/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background Choosing Wisely Canada (CWC) recommends not to perform gastroscopy for dyspepsia in otherwise healthy adults less than 55 years of age (2014). The aim of this study was to evaluate the use of gastroscopy in a young, healthy population with uncomplicated dyspepsia. Methods A retrospective review of gastroscopies completed during 3-month periods in 2015, 2016, and 2017 identified all patients undergoing gastroscopy for the primary indication of dyspepsia. Low-risk patients for dyspepsia were defined as adults, aged 18 to 54 years without alarm symptoms, comorbidities and/or abnormal imaging findings or laboratory values. Gastroscopy and pathology reports were reviewed to identify clinically actionable findings. Clinical outcomes were followed to December 31, 2018 including gastroenterology referrals, emergency room visitation and hospitalization. Results Among 1358 patients having a gastroscopy for dyspepsia, 480 (35%) were low-risk patients. Sixteen patients 3.3% (16/480) had a clinically actionable result found on gastroscopy or biopsy. No malignant lesions were detected. Low-risk patients were followed up for an average of 2.75 years, 8% (39/480) visited the emergency department (ED), 1% (3/480) of patients were admitted to hospital and 12% (59/480) of patients were re-referred for a dyspepsia-related concern. Interpretation A high rate of low yield, high cost, invasive endoscopic investigations were performed in this population of otherwise healthy patients under age 55 years. These data suggest limited uptake of current recommendations against the routine use of gastroscopy to investigate dyspepsia.
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Affiliation(s)
- Jennifer B Halasz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kelly W Burak
- Department of Medicine, Division of Gastroenterology Hepatology, University of Calgary, Calgary, Alberta, Canada
- Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary, Calgary, Alberta, Canada
| | - Shawn K Dowling
- Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary, Calgary, Alberta, Canada
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Brenna Murray
- Physician Learning Program, Continuing Medical Education and Professional Development, University of Calgary, Calgary, Alberta, Canada
| | - Jennifer Williams
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Tarun Misra
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | | | - Gilaad G Kaplan
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Mark Swain
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Kerri L Novak
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
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Barret M, Chaussade S, Boustière C, Canard JM, Schott AM, Ponchon T, Rahmi G, Cellier C. Diagnostic yield of esophagogastroduodenoscopy in France. Clin Res Hepatol Gastroenterol 2021; 45:101540. [PMID: 33036954 DOI: 10.1016/j.clinre.2020.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/06/2020] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND STUDY AIMS Large scale data on esophagogastroduodenoscopy (EGD) in Western countries are scarce. We conducted a prospective study on the diagnostic yield of upper gastrointestinal endoscopy in France. PATIENTS AND METHODS An online questionnaire was sent to all French gastroenterologists practicing endoscopy. Data from EGDs performed during one week were collected. A statistical extrapolation of the results to a whole year was performed. RESULTS 342 gastrointestinal endoscopists, representative of the population of French gastroenterologists, provided data on 2735 EGDs, corresponding to 1 006 316 (95%CI=937 080-1 075 552) procedures for the entire year. 1770 (64.7%) EGDs were performed under sedation or general anesthesia, and 930 (34%) were associated with a colonoscopy. 896 (32.8%) EGDs were normal. Hiatal hernia and esophagitis were the most frequent esophageal diagnoses, in 496 (18.1%) and 374 (13.7%) cases, respectively. Barrett's esophagus was diagnosed in 109 (4%) patients. Among gastric lesions, endoscopic gastritis was reported in 572 (20.9%) patients; ulcer, polyps, and suspected malignancy in 78 (2.9%), 62 (2.3%), and 19 (0.7%), respectively. 1597 (58.4%) EGDs included mucosal biopsies, and 141 (5.1%) were associated with a therapeutic procedure. CONCLUSIONS We report nationwide prospective data on upper gastrointestinal endoscopy practice in France. Our data suggest that about 300 000 normal EGDs each year in France could potentially be avoided by a diagnostic strategy relying on upper GI capsule endoscopy, providing significant relief on healthcare practitioners.
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Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, and University of Paris, France.
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, and University of Paris, France
| | | | | | - Anne-Marie Schott
- Pôle Information Médicale Évaluation Recherche (IMER), Université Claude Bernard-Lyon 1, Lyon, France
| | - Thierry Ponchon
- Department of Gastroenterology Edouard Herriot Hospital and Université Claude Bernard-Lyon 1, Lyon, France
| | - Gabriel Rahmi
- Department of Gastroenterology and Digestive Endoscopy, George Pompidou European Hospital and University of Paris, France
| | - Christophe Cellier
- Department of Gastroenterology and Digestive Endoscopy, George Pompidou European Hospital and University of Paris, France
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Oluseyi Akande K, Oke TO, Afuwape O, Adigun TA, Akere A, Aje A, Ola SO, Otegbayo JA. Spectrum and pattern of distribution of findings in patients with dyspepsia undergoing oesophago-gastro-duodenoscopy at a Tertiary Hospital in Ibadan, south west, Nigeria. ALEXANDRIA JOURNAL OF MEDICINE 2021. [DOI: 10.1080/20905068.2021.1913890] [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: 09/30/2022] Open
Affiliation(s)
- Kolawole Oluseyi Akande
- Department of Medicine, College of Medicine, Gastroenterology & Hepatology Unit, University of Ibadan, Ibadan, Nigeria
| | - Temitope Olufemi Oke
- Department of Medicine, Gastroenterology & Hepatology Unit, University College Hospital, Ibadan, Nigeria
| | - Oludolapo Afuwape
- Department of Surgery, College of Medicine, Division of Gastrointestinal Surgery, University of Ibadan, Ibadan, Nigeria
| | | | - Adegboyega Akere
- Department of Medicine, College of Medicine, Gastroenterology & Hepatology Unit, University of Ibadan, Ibadan, Nigeria
| | - Ajibola Aje
- Department of Medicine, Gastroenterology & Hepatology Unit, University College Hospital, Ibadan, Nigeria
| | - Samuel Olawale Ola
- Department of Medicine, College of Medicine, Gastroenterology & Hepatology Unit, University of Ibadan, Ibadan, Nigeria
| | - Jesse Abiodun Otegbayo
- Department of Medicine, College of Medicine, Gastroenterology & Hepatology Unit, University of Ibadan, Ibadan, Nigeria
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Kamran M, Fawwad A, Haider SI, Hussain T, Ahmed J. Upper gastrointestinal endoscopy; A study from a rural population of Sindh, Pakistan. Pak J Med Sci 2020; 37:9-14. [PMID: 33437243 PMCID: PMC7794160 DOI: 10.12669/pjms.37.1.3297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective: To discuss common indications and findings on upper gastrointestinal endoscopy as well as to correlate these findings with alarm symptoms in the rural population of Gadap town, Sindh. Methods: This was a retrospective study on 1288 patients conducted in the medical ward of Fatima Hospital, Baqai Medical University. Patients’ demographics and other data related to the procedure were recovered from patients’ records. SPSS version 20 was used for statistical analysis. Results: Ratio of male and female patients was approximately 1:1. Majority of the patients were young, and most procedures were done as outpatients without the requirement of conscious sedation. Epigastric pain was the primary indication for upper GI endoscopy (62.6%). One third of the procedures performed did not report any pathological finding. Probability of a positive finding was more likely if a patient presented with dysphagia, heart-burn, hematemesis, vomiting, or for screening endoscopy (for varices). Patients who were diagnosed with esophageal candidiasis, esophageal varices or esophageal growth/ ulcer had reported one or more alarm symptoms in their history. Conclusions: Upper gastrointestinal endoscopy is a useful test to diagnose disorders of the esophagus, stomach and duodenum. However, it is an expensive procedure and therefore referring physicians should keep appropriate clinical indication and ethical considerations in mind before recommending such an investigation to their patients.
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Affiliation(s)
- Muhammad Kamran
- Dr. Muhammad Kamran, FCPS. Department of Medicine, Fatima hospital, Baqai Medical University, Karachi, Pakistan
| | - Asher Fawwad
- Dr. Asher Fawwad, (PhD). Research Director (Honorary), Research Department of Baqai Institute of Diabetology and Endocrinology, Department of Biochemistry, Baqai Medical University, Karachi, Pakistan
| | - Syed Iftikhar Haider
- Dr. Syed Iftikhar Haider, MD, Department of Medicine, Fatima hospital, Baqai Medical University, Karachi, Pakistan
| | - Tahir Hussain
- Dr. Tahir Hussain, FRCP. Department of Medicine, Fatima hospital, Baqai Medical University, Karachi, Pakistan
| | - Jameel Ahmed
- Dr. Jameel Ahmed, FRCP. Department of Medicine, Fatima hospital, Baqai Medical University, Karachi, Pakistan
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12
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Almadi MA, Aljebreen AM, Azzam N, Batwa F. Response to Almalki et al.: Resuming endoscopy services during the COVID-19 pandemic. Saudi J Gastroenterol 2020; 26:285-286. [PMID: 32893842 PMCID: PMC7739994 DOI: 10.4103/sjg.sjg_455_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Majid A. Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada,Address for correspondence: Dr. Majid A. Almadi, Associate Professor of Medicine, Division of Gastroenterology, King Khalid University Hospital, King Saud University, P.O. Box 2925 (59), Riyadh - 11461, Saudi Arabia. E-mail:
| | - Abdulrahman M. Aljebreen
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Nahla Azzam
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Faisal Batwa
- King Saud Bin Abdul-Aziz University of Health Sciences, King Abdul-Aziz Medical City, Jeddah, Saudi Arabia
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13
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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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An Unusual Case of Collagenous Gastritis: Incidental Finding in a Patient Presenting with Dysphagia. Case Rep Gastrointest Med 2019; 2019:5427085. [PMID: 30805226 PMCID: PMC6360589 DOI: 10.1155/2019/5427085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 01/14/2019] [Indexed: 12/20/2022] Open
Abstract
Collagenous gastritis is a condition characterized by subepithelial deposition of collagen in the gastric mucosa. This condition is rare, with less than 100 cases reported in the literature. Patients with collagenous gastritis typically present with pain or diarrhea. Here, we present a case of a young woman with dysphagia who was found to have esophageal webs and an incidental finding of diffuse gastritis with a cobblestone appearance of the mucosa on endoscopy. Subsequent histology demonstrated features of collagenous gastritis, including mucosal inflammatory infiltrates and collagen deposition. This is one of the few case reports of incidental collagenous gastritis and highlights the importance of judicious use of biopsies.
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15
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Rajan S, Amaranathan A, Lakshminarayanan S, Sureshkumar S, Joseph M, Nelamangala Ramakrishnaiah VP. Appropriateness of American Society for Gastrointestinal Endoscopy Guidelines for Upper Gastrointestinal Endoscopy: A Prospective Analytical Study. Cureus 2019; 11:e4062. [PMID: 31016089 PMCID: PMC6464286 DOI: 10.7759/cureus.4062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Extensive use of upper gastrointestinal endoscopy (UGE) with the advent of open access centers has resulted in inappropriate endoscopies. Our study aimed to evaluate the appropriateness of American Society for Gastrointestinal Endoscopy (ASGE) guidelines for UGE and to assess the diagnostic yield of endoscopy in a tertiary care center in South India. Methods The study was conducted as a prospective analytical study. Indications for endoscopy were classified as “ASGE appropriate” and “ASGE inappropriate”. The significance of association of ASGE guidelines and other categorical variables with endoscopic findings were assessed. Results ASGE appropriate indications and inappropriate indications accounted for 85.9% and 14.1% of endoscopies, respectively. The most common appropriate indication was persistent dyspepsia despite adequate proton-pump inhibitor (PPI) therapy (28.1%) and the only inappropriate indication for endoscopy was isolated dyspepsia without adequate PPI therapy (14.1%). The diagnostic yield of endoscopy for appropriate indications was 69.5% and for inappropriate indications was 55.1%, the difference was statistically significant (P= 0.003; OR-1.857). The sensitivity and specificity of ASGE guidelines was 88.5% and 19.5%, respectively. Conclusion According to our study, ASGE guidelines may be considered as appropriate guidelines for UGE in our population and these guidelines were followed 85.9% of the times in referring patients for the same. However, the high diagnostic yield even in inappropriate endoscopies indicates the necessity of further studies that might identify other relevant indications for endoscopy, thus avoiding misutilization of resources without missing out on relevant cases.
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Affiliation(s)
- Susan Rajan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Anandhi Amaranathan
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Subitha Lakshminarayanan
- Preventive Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Sathasivam Sureshkumar
- Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
| | - Manoj Joseph
- Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, IND
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16
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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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17
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Smith CF, Tompson AC, Jones N, Brewin J, Spencer EA, Bankhead CR, Hobbs FR, Nicholson BD. Direct access cancer testing in primary care: a systematic review of use and clinical outcomes. Br J Gen Pract 2018; 68:e594-e603. [PMID: 30104328 PMCID: PMC6104856 DOI: 10.3399/bjgp18x698561] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/04/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Direct access (DA) testing allows GPs to refer patients for investigation without consulting a specialist. The aim is to reduce waiting time for investigations and unnecessary appointments, enabling treatment to begin without delay. AIM To establish the proportion of patients diagnosed with cancer and other diseases through DA testing, time to diagnosis, and suitability of DA investigations. DESIGN AND SETTING Systematic review assessing the effectiveness of GP DA testing in adults. METHOD MEDLINE, Embase, and the Cochrane Library were searched. Where possible, study data were pooled and analysed quantitatively. Where this was not possible, the data are presented narratively. RESULTS The authors identified 60 papers that met pre-specified inclusion criteria. Most studies were carried out in the UK and were judged to be of poor quality. The authors found no significant difference in the pooled cancer conversion rate between GP DA referrals and patients who first consulted a specialist for any test, except gastroscopy. There were also no significant differences in the proportions of patients receiving any non-cancer diagnosis. Referrals for testing were deemed appropriate in 66.4% of those coming from GPs, and in 80.9% of those from consultants; this difference was not significant. The time from referral to testing was significantly shorter for patients referred for DA tests. Patient and GP satisfaction with DA testing was consistently high. CONCLUSION GP DA testing performs as well as, and on some measures better than, consultant triaged testing on measures of disease detection, appropriateness of referrals, interval from referral to testing, and patient and GP satisfaction.
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Affiliation(s)
| | - Alice C Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Nicholas Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Josh Brewin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Elizabeth A Spencer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Brian D Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
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18
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Crouwel F, Meurs-Szojda MM, Klemt-Kropp M, Fockens P, Grasman ME. The diagnostic yield of open-access endoscopy of the upper gastrointestinal tract in the Netherlands. Endosc Int Open 2018; 6:E383-E394. [PMID: 29607389 PMCID: PMC5876021 DOI: 10.1055/s-0043-123185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 10/26/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Since the introduction of open-access esophago-gastroduodenoscopy (OAE) there is an increase in the total number of performed OAEs whilst the frequency of clinical relevant findings has decreased. The aim of this study was to assess the appropriate use and the diagnostic yield of OAE in the Netherlands and to determine which patient variables are able to predict a malignant finding. PATIENTS AND METHODS A retrospective chart review of all referrals for diagnostic OAE between October 2012 and October 2016 at the Northwest Clinics was performed. The indications were recorded from the referral letter and were classified as "appropriate" or "inappropriate" according to the NHG guideline. Logistic regression was used to detect significant predictive variables for a malignancy. RESULTS A total of 2006 patients were included, of whom 59.6 % had an 'appropriate' referral indication. The diagnostic yield of finding a clinical relevant finding was significantly higher for OAEs with an "appropriate" referral indication. Independent risk factors for malignancy were alarm symptoms, age and male gender with a combined AUC of 0.868. CONCLUSIONS Only 3.8 % of the malignancies would be missed by strict adherence to the guideline. This indicates that the open-access system in the Netherlands works well. Further improvement of the system can be achieved by only accepting appropriate indications for OAE and by treating patients under the age of 40 without OAE. We showed that a risk-prediction model based on the variables age, alarm symptoms and male gender is a good predictor of malignant finding.
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Affiliation(s)
- Femke Crouwel
- Department of Gastroenterology and Hepatology, Northwest Clinics, Alkmaar, The Netherlands,Corresponding author Femke Crouwel Noordwest Ziekenhuisgroep – Gastroenterology and hepatologyWilhelminalaan 12 Alkmaar 1815 JDNetherlands+0725484444
| | - M. M. Meurs-Szojda
- Department of Gastroenterology and Hepatology, Northwest Clinics, Alkmaar, The Netherlands
| | - M. Klemt-Kropp
- Department of Gastroenterology and Hepatology, Northwest Clinics, Alkmaar, The Netherlands
| | - P. Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Centre, University of Amsterdam, Amsterdam-Zuidoost, The Netherlands
| | - M. E. Grasman
- Department of Gastroenterology and Hepatology, Northwest Clinics, Alkmaar, The Netherlands
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O'Sullivan JW, Albasri A, Nicholson BD, Perera R, Aronson JK, Roberts N, Heneghan C. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open 2018; 8:e018557. [PMID: 29440142 PMCID: PMC5829845 DOI: 10.1136/bmjopen-2017-018557] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 12/12/2017] [Accepted: 12/13/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Health systems are currently subject to unprecedented financial strains. Inappropriate test use wastes finite health resources (overuse) and delays diagnoses and treatment (underuse). As most patient care is provided in primary care, it represents an ideal setting to mitigate waste. OBJECTIVE To identify overuse and underuse of diagnostic tests in primary care. DESIGN Systematic review and meta-analysis. DATA SOURCES AND ELIGIBILITY CRITERIA We searched MEDLINE and Embase from January 1999 to October 2017 for studies that measured the inappropriateness of any diagnostic test (measured against a national or international guideline) ordered for adult patients in primary care. RESULTS We included 357 171 patients from 63 studies in 15 countries. We extracted 103 measures of inappropriateness (41 underuse and 62 overuse) from included studies for 47 different diagnostic tests.The overall rate of inappropriate diagnostic test ordering varied substantially (0.2%-100%)%).17 tests were underused >50% of the time. Of these, echocardiography (n=4 measures) was consistently underused (between 54% and 89%, n=4). There was large variation in the rate of inappropriate underuse of pulmonary function tests (38%-78%, n=8).Eleven tests were inappropriately overused >50% of the time. Echocardiography was consistently overused (77%-92%), whereas inappropriate overuse of urinary cultures, upper endoscopy and colonoscopy varied widely, from 36% to 77% (n=3), 10%-54% (n=10) and 8%-52% (n=2), respectively. CONCLUSIONS There is marked variation in the appropriate use of diagnostic tests in primary care. Specifically, the use of echocardiography (both underuse and overuse) is consistently poor. There is substantial variation in the rate of inappropriate underuse of pulmonary function tests and the overuse of upper endoscopy, urinary cultures and colonoscopy. PROSPERO REGISTRATION NUMBER CRD42016048832.
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Affiliation(s)
- Jack W O'Sullivan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Ali Albasri
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Brian D Nicholson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Rafael Perera
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
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20
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Appropriateness of Indications of Upper Gastrointestinal Endoscopy and its Association With Positive Finding. JNMA J Nepal Med Assoc 2018; 56:504-509. [PMID: 30058633 PMCID: PMC8997324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Upper Gastrointestinal Endoscopy is a frequently advised investigation for upper abdominal symptoms. Studies have questioned the appropriateness of indications for upper gastrointestinal endoscopy and have shown that inappropriate indications range from 5% to 49%. The unnecessary upper gastrointestinal endoscopy expose patients to the risk. The number of upper gastrointestinal endoscopy is rising in our region and we assume so is the number of unnecessary upper gastrointestinal endoscopy. With an aim to find out the appropriateness of the indications of upper gastrointestinal endoscopy and compare its association with positive findings, we conducted a cross-sectional descriptive study. METHODS All patients undergoing diagnostic upper gastrointestinal endoscopy during study period were included in the study. Appropriateness of indications for upper gastrointestinal endoscopy was defined as per American Society for Gastrointestinal Endoscopy criteria as "appropriate" and "inappropriate". Upper gastrointestinal endoscopy findings were classified as "significant" and "insignificant" based on endoscopy findings. The extent of this association between appropriateness of indications and upper gastrointestinal endoscopy findings was expressed as the odds ratio of finding a relevant diagnosis in patients with an ''appropriate'' indication compared with those with an 'inappropriate'' indication. RESULTS Seventy-nine patients were included in the study. Fifty- two (65.8%) of the indications were considered appropriate as per American Society for Gastrointestinal Endoscopy guidelines. Thirty-three (63.5%) of the appropriate indications has clinically significant finding as compared to seven (25.9%) of inappropriate indication with an odds ratio of 4.962 (95% CI:1.773 - 13.890, P=0.002) which is statistically significant. CONCLUSIONS Appropriate indications have significantly higher rates of clinically significant findings. Use of guidelines may decrease the number of unnecessary procedures.
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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Bendvold B, Weberg R, Husby A, Refsum A, Brudvik KW. Nomogram predicting macroscopic finding with limited or no clinical implication in 19175 patients referred to esophagogastroduodenoscopy. COGENT MEDICINE 2016. [DOI: 10.1080/2331205x.2016.1203174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Bo Bendvold
- Department of Surgery, Diakonhjemmet Hospital, Oslo, Norway
| | - Ragnar Weberg
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - Anders Husby
- Department of Surgery, Diakonhjemmet Hospital, Oslo, Norway
| | - Arne Refsum
- Department of Surgery, Diakonhjemmet Hospital, Oslo, Norway
| | - Kristoffer Watten Brudvik
- Department of Surgery, Diakonhjemmet Hospital, Oslo, Norway
- Department of Gastrointestinal Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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23
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Satisfaction in open access versus traditional referral for upper endoscopy in children. J Pediatr Gastroenterol Nutr 2015; 60:637-41. [PMID: 25522310 DOI: 10.1097/mpg.0000000000000677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES In traditional access endoscopy (TAE), patients are booked for endoscopy following a gastroenterology clinic assessment. In contrast, open access endoscopy (OAE) patients are seen for the first time on the day of the procedure, providing same day procedural consent. Controversy exists over the use of OAE in adults, both with the consent process and with patient satisfaction. No literature exists describing satisfaction with OAE in pediatrics. We therefore aimed to assess pediatric patient and caregiver satisfaction in OAE compared with TAE. METHODS Consecutive pediatric patients, and their caregivers, undergoing elective upper endoscopy from May to December 2012 at the Stollery Children's Hospital (Edmonton, Alberta, Canada) were consented for a cross-sectional survey. Seven preprocedure and 5 postprocedure questions were completed regarding mood and satisfaction with the wait time and the information provided. Group demographics and endoscopy wait times were collected. RESULTS Median wait time with OAE was less compared with TAE (57 days vs 196 days, P < 0.001). OAE patients reported worse mood preprocedure than TAE patients (35.3% vs 10.7%, P = 0.046). OAE caregivers and patients reported more mood disturbance if required to wait longer for endoscopy by attending clinic preprocedure (OAE caregivers 62.2%, OAE patients 64.7%). CONCLUSIONS OAE is associated with worse preendoscopy patient mood; however, children and caregivers seem concerned about longer wait times associated with TAE. Given the significantly shorter wait times in OAE, identifying methods to minimize present limitations of OAE will be useful to improve clinical practices in pediatric gastroenterology.
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Azzam NA, Almadi MA, Alamar HH, Almalki LA, Alrashedi RN, Alghamdi RS, Al-hamoudi W. Performance of American Society for Gastrointestinal Endoscopy guidelines for dyspepsia in Saudi population: Prospective observational study. World J Gastroenterol 2015; 21:637-643. [PMID: 25605988 PMCID: PMC4296026 DOI: 10.3748/wjg.v21.i2.637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 07/07/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate adherence of primary care physicians (PCPs) to international guidelines when referring patients for upper-gastrointestinal endoscopy (UGE), evaluate the importance of alarm symptoms and the performance of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines in a Saudi population.
METHODS: A prospective, observational cross-sectional study on dyspeptic patients undergoing UGE who were referred by PCPs over a 4 mo period. Referrals were classified as appropriate or inappropriate according to adherence to ASGE guidelines.
RESULTS: Total of 221 dyspeptic patients was enrolled; 161 patients met our inclusion criteria. Mean age was 40.3 years (SD ± 18.1). Females comprised 70.1%. Alarm symptoms included low hemoglobin level (39%), weight loss (18%), vomiting (16%), loss of appetite (16%), difficulty swallowing (3%), and gastrointestinal bleeding (3%). Abnormal endoscopy findings included gastritis (52%), duodenitis (10%), hiatus hernia (7.8%), features suggestive of celiac disease (6.5%), ulcers (3.9%), malignancy (2.6%) and gastroesophageal reflux disease (GERD: 17%). Among patients who underwent UGE, 63% met ASGE guidelines, and 50% had abnormal endoscopic findings. Endoscopy was not indicated in remaining 37% of patients. Among the latter group, endoscopy was normal in 54% of patients. There was no difference in proportion of abnormal endoscopic findings between two groups (P = 0.639).
CONCLUSION: Dyspeptic patients had a low prevalence of important endoscopic lesions, and none of the alarm symptoms could significantly predict abnormal endoscopic findings.
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Affiliation(s)
- Charles R Boardman
- Portland VA Medical Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Amnon Sonnenberg
- Portland VA Medical Center, Oregon Health & Science University, Portland, Oregon, USA
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Lawson-Ananissoh LM, Bouglouga O, Bagny A, Kaaga L, Redah D. [Upper gastrointestinal endoscopy in 2795 patients at the university campus hospital of Lomé: peculiarities according to sex]. Pan Afr Med J 2014; 19:262. [PMID: 25852805 PMCID: PMC4382069 DOI: 10.11604/pamj.2014.19.262.4512] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 10/09/2014] [Indexed: 11/11/2022] Open
Abstract
Introduction Méthodes Résultats Conclusion
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Affiliation(s)
| | | | - Aklesso Bagny
- Service d'Hépato-gastro-entérologie du CHU Campus de Lomé, Togo
| | - Laconi Kaaga
- Service d'Hépato-gastro-entérologie du CHU Campus de Lomé, Togo
| | - Datouda Redah
- Service d'Hépato-gastro-entérologie du CHU Campus de Lomé, Togo
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