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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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Franceschi M, Rodriguez-Castro KI, Ferronato A, Massella A, Brozzi L, Panozzo MP, Antico A, Pertoldi B, Morini A, Barchi A, Russo M, Crafa P, Franzoni L, Cuoco L, Baldassarre G, Di Mario F. A non-invasive combined strategy to improve the appropriateness of upper gastrointestinal endoscopy. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022210. [PMID: 36043968 PMCID: PMC9534244 DOI: 10.23750/abm.v93i4.12772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/14/2022] [Indexed: 11/05/2022]
Abstract
Background and aim Increasing the appropriateness of upper gastrointestinal endoscopy (UGIE) improves the quality of care while containing costs. The aim of this study was to improve the appropriateness of UGIE through a process involving evaluation of prescriptions and the use of a non-invasive alternative. Materials and methods A senior endoscopist evaluated the appropriateness of all outpatient referrals for UGIE and established the proper timing. Referrals were either accepted and programmed, canceled, or substituted by a non-invasive evaluation of gastric function, determining serum levels of gastrin-17 (G17), Pepsinogen I (PGI) and II (PGII), and antibodies against Helicobacter pylori. Results A total of 5102 requests for UGIE examinations were evaluated; 540 (10.4%) were inappropriate and had been prescribed for: gastroesophageal reflux disease (n=307), surveillance with erroneous timing (n=113), dyspepsia (n=66), other indications (n=20), and absence of written indication (n=34). Gastric function was evaluated in 282/540 patients; findings included normal values in 94 patients without proton-pump inhibitor therapy (PPI) and in 48 on PPI, active H pylori infection in 56, previous H pylori infection in 30, GERD in n=50, and atrophic gastritis in n=4. UGIE was performed in the latter 4 cases. Within 2 years (range 1-22 months) of the initial refusal, 105/504 patients underwent UGIE, with normal endoscopic findings in 71/105 (67.5%), and with no cases of cancer. Conclusions This strategy, based on a strict control of prescriptions, is effective to increase the appropriateness while containing public health costs. The use of gastric function testing improves patient selection for UGIE endoscopy.
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Affiliation(s)
- Marilisa Franceschi
- Endoscopy Unit, Department of Surgery, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | | | - Antonio Ferronato
- Endoscopy Unit, Department of Surgery, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Arianna Massella
- Gastroenterology Unit, IRCCS Sacro Cuore Don Calabria, Negrar, Italy
| | - Lorenzo Brozzi
- Endoscopy Unit, Department of Surgery, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Maria Piera Panozzo
- Laboratory of Clinical Pathology, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Antonio Antico
- Laboratory of Clinical Pathology, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Barbara Pertoldi
- Pathology Unit, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Alice Morini
- Pathology Unit, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Alberto Barchi
- Gastroenterology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Michele Russo
- Gastroenterology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Pellegrino Crafa
- Pathology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Lorella Franzoni
- Section of Biotecnology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Lucio Cuoco
- Endoscopy Unit, Department of Surgery, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Gianluca Baldassarre
- Endoscopy Unit, Department of Surgery, Alto Vicentino Hospital, ULSS7 Pedemontana, Santorso (VI), Italy
| | - Francesco Di Mario
- Gastroenterology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Elmoheen A, Haddad M, Bashir K, Salem WA. Subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumoperitoneum after upper gastrointestinal endoscopy. BMJ Case Rep 2020; 13:13/11/e236369. [PMID: 33148576 PMCID: PMC7640491 DOI: 10.1136/bcr-2020-236369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Upper gastrointestinal (GI) endoscopies are performed for several reasons. The overuse of endoscopy has negative effects on the quality of healthcare and pressurises endoscopy services. It also results in the complications. These complications include pneumoperitoneum, pneumomediastinum and subcutaneous pneumomediastinum. However, it is worth noting that these complications rarely occur during endoscopy of the upper GI tract. These complications, when they occur, indicate perforation of the retroperitoneal space or peritoneal cavity. In this article, we discuss a case of pneumoperitoneum, pneumomediastinum and subcutaneous emphysema after upper GI endoscopy.
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Affiliation(s)
- Amr Elmoheen
- Emergency Department, Hamad Medical Corporation, Doha, Qatar .,QU Health, College of Medicine, Qatar University, Doha, Qatar
| | - Mahmoud Haddad
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Bashir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar.,QU Health, College of Medicine, Qatar University, Doha, Qatar
| | - Waleed Awad Salem
- Emergency Department, Hamad Medical Corporation, Doha, Qatar.,QU Health, College of Medicine, Qatar University, Doha, Qatar
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Jung A, Reheis L, Host A, Hummel M, Billing M, Garbin O. [Retrospective evaluation of relevance of care in the management of presumed benign ovarian tumors]. ACTA ACUST UNITED AC 2020; 48:491-499. [PMID: 32243912 DOI: 10.1016/j.gofs.2020.03.020] [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: 02/03/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The relevance of care is defined by the right act, for the right patient, at the right time. We were interested in the relevance of the management of presumed benign ovarian tumors before and after the release of the CNGOF guidelines 2013 (French guidelines). METHODS This is a retrospective observational study conducted at the University Hospital in Strasburg France from 01/01/2013 to 31/12/2017 including all patients treated for a presumed benign ovarian cyst. We were interested in the diagnostic approach: relevance of the prescribed imaging and the use of CA 125 dosage, in the therapeutic approach: the relevance of the technique used as well as the relevance of the surgical indication. We compared our practices between 2013 and 2017 for these same items. RESULTS We included 682 cysts for 621 patients, the imaging performed was relevant in 55% of cases, not relevant but justified in 25% and irrelevant in 20%. The CA 125 assay or its absence of assay was relevant in 84% of cases. The surgical technique was relevant in 67% of cases and not relevant but justified in 29%. With a significant improvement 7.1% in 2013 of irrelevant against 0.9% for the year 2017. The surgical indication was relevant in 72% of cases, not relevant but justified in 20% and irrelevant in 2.7%. CONCLUSIONS The analysis of the relevance of care allows an evaluation of our practices. Professional recommendations can have an impact on the quality of care.
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Affiliation(s)
- A Jung
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur , BP 120, 67303 Schiltigheim, France.
| | - L Reheis
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur , BP 120, 67303 Schiltigheim, France
| | - A Host
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur , BP 120, 67303 Schiltigheim, France
| | - M Hummel
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur , BP 120, 67303 Schiltigheim, France
| | - M Billing
- Direction qualité, hôpitaux universitaires, Strasbourg, France
| | - O Garbin
- Pôle de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, 19, rue Louis-Pasteur , BP 120, 67303 Schiltigheim, France
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Meggio A, Mariotti G, Gentilini M, de Pretis G. Priority and appropriateness of upper endoscopy out-patient referrals: Two-period comparison in an open-access unit. Dig Liver Dis 2019; 51:1562-1566. [PMID: 31235314 DOI: 10.1016/j.dld.2019.05.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/23/2019] [Accepted: 05/26/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the early 2000s we introduced a prioritization model for referrals based on involvement of primary care physicians (PCPs) and specialists. AIMS Assess the application of that model of prioritisation, comparing gastroscopies performed 8 years apart, with respect to priority level, appropriateness and relevant endoscopic findings (REFs). METHODS The studies included 247 and 354 out-patients, who had undergone gastroscopy in 2006 and in 2014, respectively. To reduce interspecialists variability, both studies were performed by the same specialist as investigator. RESULTS In both years, most patients were assigned low-priority referral by PCPs (78.6% and 75.1% respectively). The agreement PCPs versus specialist on referral priority was moderate in 2006 (0.60, Landis-Koch scale 0.41-0.60) and high in 2014 (0.81, Landis-Koch scale 0.81-1.00). In both years we observed a similar rate of inappropriateness: 27.5% and 27.1%, respectively. Due to multiple logistic regression, the odds ratio (OR) for REF increased when: (i) very high-priority referral versus nopriority referral was indicated (8.813 OR, p = 0.0012), (ii) referral followed the guidelines (9.29 OR, p<0.0001), and (iii) agreement of priority occurred (1.911 OR, p = 0.0308). CONCLUSIONS Our findings highlighted that the issues of low-priority referrals should be addressed in order to discontinue gastroscopy overusing and reduce related operational costs.
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Affiliation(s)
- Alberto Meggio
- Department of Gastroenterology, Hospital of Rovereto, LHU APSS, Rovereto, Italy
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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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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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