Upper endoscopy may be overused in patients with reflux, guidelines committee says

Routine use of upper endoscopy for most patients with gastroesophageal reflux disease (GERD) does not improve patient health, is associated with preventable harms, and may lead to unnecessary interventions and costs, according to an ACP clinical policy paper.

The policy paper from the ACP Clinical Guidelines Committee appeared in the Dec. 4 Annals of Internal Medicine.

Upper endoscopy is indicated in men and women with:

• heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss and recurrent vomiting),
• typical GERD symptoms that persist despite a therapeutic trial of four to eight weeks of twice-daily proton-pump inhibitor therapy,
• severe erosive esophagitis after a two-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett's esophagus (recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett's esophagus), or
• history of esophageal stricture and recurrent symptoms of dysphagia.

Upper endoscopy may be indicated:

• in men older than 50 years with chronic GERD symptoms (symptoms for more than five years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett's esophagus,
• for surveillance evaluation in men and women with a history of Barrett's esophagus,
• in men and women with Barrett's esophagus and no dysplasia. In these patients, surveillance examinations should occur at intervals no more frequently than three to five years. More frequent intervals are indicated in patients with Barrett's esophagus and dysplasia.

“Endoscopy has revolutionized the diagnosis and management of gastrointestinal illness,” the guidelines committee wrote. “However, inappropriate use has the potential to add cost with no benefit. Data suggest that upper endoscopy in the setting of GERD symptoms is useful only in a few, well-circumscribed situations, as previously reviewed. Avoidance of repetitive, low-yield endoscopy that has little effect on clinical management or health outcomes will improve patient care and reduce costs.”

An accompanying editorial stated, “The importance of this guidance is underscored by the cumulative financial and clinical burden of endoscopy in 2012. Gastroesophageal reflux disease afflicts more than 100 million U.S. adults and costs our health system more than $9 billion annually. It is related distantly to EAC [esophageal adenocarcinoma], a rare but deadly cancer that is increasing in annual incidence. Primary care physicians must decide how best to manage patients in a manner that provides an excellent experience but balances attention to the improvement of population health and one that uses resources efficiently.”

ACP's Performance Measurement Committee (PMC) also recently reviewed performance measures related to the use of upper endoscopy in patients with GERD that are currently endorsed by the National Quality Forum (NQF). The PMC does not support the use of the measure “NQF 0622: GERD–Upper Endoscopy Study in Adults with Alarm Symptoms.” The PMC's goal is to provide guidance on measures that are not evidence-based and should be avoided and recommend measures that are evidence-based and clinically meaningful.