A non-invasive combined strategy to improve the appropriateness of upper gastrointestinal endoscopy

Main Article Content

Kryssia Rodriguez
Marilisa Franceschi
Antonio Ferronato
Lorenzo Brozzi
Antonio Antico
Maria Piera Panozzo
Arianna Massella
Barbara Pertoldi
Alice Morini
Alberto Barchi
Michele Russo
Pellegrino Crafa
Lorella Franzoni
Lucio Cuoco
Gianluca Baldassarre
Francesco Di Mario

Keywords

upper gastrointestinal endoscopy, appropriateness, non-invasive, gastric function, gastric atrophy, helicobacter pylori

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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References

1. García-Alonso FJ, Hernández Tejero M, Rubio Benito E, Valer P, Guerra I, García Ceballos VG, et al. Implementation and evaluation of early gastroscopy for patients with dyspepsia and warning signs in Primary Care. Gastroenterol Hepatol. 2017 May 1;40(5):331–8.
2. Goni E, Riccò M, Franceschi M, Baldassarre G, Panozzo M, Antico A, et al. Gastrin 17 as non invasive marker of reflux disease. United Eur Gastroenterol J. 2015;3(5(S)):A653.
3. Franceschi M, Masella A, Panozzo M, Baldassarre G, Sella D, Antico A, et al. GastroPanel serum markers as a non-invasive method for the diagnosis of H. pylori-related Gastritis. Helicobacter. 2015;20(Suppl 1):86.
4. Di Mario F, Curlo M, Cavestro G, Morana E, Savarino V, Rugge M, et al. “GastroPanel Test” in the clinical outcome of GERD. Gastroenterology. 2009;136(5):A-293 (S1921).
5. Väänänen H, Vauhkonen M, Helske T, Kääriäinen I, Rasmussen M, Tunturi-Hihnala H, et al. Non-endoscopic diagnosis of atrophic gastritis with a blood test. Correlation between gastric histology and serum levels of gastrin-17 and pepsinogen I: a multicentre study. Eur J Gastroenterol Hepatol. 2003 Aug;15(8):885–891.
6. Kazumasa M. Gastric cancer screening using the serum pepsinogen test method. Gastric Cancer. 2006 Nov;9(4):245–53.
7. Iijima K, Abe Y, Kikuchi R, Koike T, Ohara S, Sipponen P, et al. Serum biomarker tests are useful in delineating between patients with gastric atrophy and normal, healthy stomach. World J Gastroenterol. 2009 Feb 21;15(7):853–9.
8. Anderson LA, Murphy SJ, Johnston BT, Watson RGP, Ferguson HR, Bamford KB, et al. Relationship between Helicobacter pylori infection and gastric atrophy and the stages of the oesophageal inflammation, metaplasia, adenocarcinoma sequence: Results from the FINBAR case-control study. Gut. 2008 Jun;57(6):734–9.
9. Fujiwara. Y, Higuchi K, Shiba M, Yamamori K, Watanabe Y, Sasaki E, et al. Differences in clinical characteristics between patients with endoscopy-negative reflux disease and erosive esophagitis in Japan. Am J Gastroenterol. 2005 Apr;100(4):754–8.
10. Schistosomes, liver flukes and Helicobacter pylori. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Lyon, 7-14 June 1994. IARC Monogr Eval Carcinog Risks Hum. 1994;61(1):1–241.
11. Suerbaum S, Michetti P. Helicobacter pylori infection. N Engl J Med. 2002 Oct 10;347(15):1175–86.
12. Nordenstedt H, Nilsson M, Johnsen R, Lagergren J, Hveem K. Helicobacter pylori infection and gastroesophageal reflux in a population-based study (The HUNT Study). Helicobacter. 2007 Feb;12(1):16–22.
13. De Bastiani R, Bacchin P, Bortot M, Polizzi G, Benedetto E, Sanna G, et al. Il Gastropanel: un test di diagnostica gastrica prezioso e poco conosciuto in medicina generale. Il Caduceo. 2014;16(2).
14. Di Mario F, Cavallaro LG, Moussa AM, Franze A. Serological diagnosis of atrophic gastritis. G Ital di Endosc Dig. 2003;26(4).
15. Nieuwenburg SAV, Waddingham WW, Graham D, Rodriguez-Justo M, Biermann K, Kuipers EJ, et al. Accuracy of endoscopic staging and targeted biopsies for routine gastric intestinal metaplasia and gastric atrophy evaluation study protocol of a prospective, cohort study: the estimate study. BMJ Open. 2019 Sep 1;9(9).
16. Rugge M, Meggio A, Pennelli G, Piscioli F, Giacomelli L, De Pretis G, et al. Gastritis staging in clinical practice: The OLGA staging system. Gut. 2007;56(5):631–6.
17. P, Pimentel-Nunes P, D, Libânio D, Marcos-Pinto R, Areia M, Leja M, Esposito G, et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Port. Endoscopy. 2019;51(4):365–88.
18. Kurata JH, Nogawa AN, Everhart JE. A prospective study of dyspepsia in primary care. Dig Dis Sci. 2002;47(4):797–803.
19. Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: A systematic review. Vol. 54, Gut. 2005. p. 710–7.
20. Hamashima C, Shibuya D, Yamazaki H, Inoue K, Fukao A, Saito H, et al. The Japanese guidelines for gastric cancer screening. Jpn J Clin Oncol. 2008;38(4):259–67.
21. Choi KS, Jun JK, Lee HY, Park S, Jung KW, Han MA, et al. Performance of gastric cancer screening by endoscopy testing through the National Cancer Screening Program of Korea. Cancer Sci. 2011;102(8):1559–64.
22. Gupta N, Bansal A, Wani SB, Gaddam S, Rastogi A, Sharma P. Endoscopy for upper GI cancer screening in the general population: A cost-utility analysis. Gastrointest Endosc. 2011;74(3).
23. Broe M, Barry M, Patchett S, Hill ADK. Evaluating the clinical efficacy and cost effectiveness of direct access endoscopy. Surgeon. 2013;11(6):304–8.
24. Johnston SD, Kirby J, Mackle E, Robinson TJ. A comparison of open access endoscopy and hospital-referred endoscopy in a district general hospital. Ulster Med J. 1999;68(2):73–8.
25. Minoli G, Prada A, Gambetta G, Formenti A, Schalling R, Lai L, et al. The ASGE guidelines for the appropriate use of upper gastrointestinal endoscopy in an open access system. Gastrointest Endosc. 1995;42(5):387–9.
26. Gonvers JJ, Burnand B, Froehlich F, Pache I, Thorens J, Fried M, et al. Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy unit. In: Endoscopy. 1996. p. 661–6.
27. Rossi A, Bersani G, Ricci G, DeFabritiis G, Pollino V, Suzzi A, et al. ASGE guidelines for the appropriate use of upper endoscopy: Association with endoscopic findings. Gastrointest Endosc. 2002 Nov 1;56(5):714–9.
28. Tahir M. Appropriateness of Upper Gastrointestinal Endoscopy: Will the Diagnostic Yield Improve by the use of American Society of Gastroenterology Guidelines? Euroasian J hepato-gastroenterology. 2016;6(2):143–8.
29. Keren D, Rainis T, Stermer E, Lavy A. A nine-year audit of open-access upper gastrointestinal endoscopic procedures: Results and experience of a single centre. Can J Gastroenterol. 2011;25(2):83–8.
30. Hassan C, Bersani G, Buri L, Zullo A, Anti M, Bianco MA, et al. Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy. Gastrointest Endosc. 2007;65(6):767–74.
31. Voutilainen M, Kunnamo I. A survey of open-access endoscopy in primary health care centres: Outcome of gastric carcinoma patients diagnosed by general practitioners compared with hospital-referred endoscopy. Dig Liver Dis. 2005;37(2):119–23.
32. Franceschi M, Antico A, Panozzo M, Tomba F, Ferronato A, Sella D, et al. Serological Diagnosis of Upper GI Diseases in Primary Care Setting. 2015;148(4):S-322.
33. Coelho MCF, Ribeiro HG, Gomes CGDO, Marinho FP, Barbosa AJA, Coelho LGV. Helicobacter pylori chronic gastritis on patients with premalignant conditions: Olga and olgim evaluation and serum biomarkers performance. Arq Gastroenterol. 2021;58(1):39–47.
34. Enríquez-Sánchez LB, Gallegos-Portillo LG, Camarillo-Cisneros J, Cisneros-Castolo M, Montelongo-Santiesteban JJ, Aguirre-Baca DA, et al. Cost-benefit of serum pepsinogen screening for gastric adenocarcinoma in the Mexican population. Rev Gastroenterol Mex. 2021;Nov 15(21):S2255-543X.
35. Tu H, Sun L, Dong X, Gong Y, Xu Q, Jing J, et al. A Serological Biopsy Using Five Stomach-Specific Circulating Biomarkers for Gastric Cancer Risk Assessment: A Multi-Phase Study. Am J Gastroenterol. 2017 May 1;112(5):704–15.
36. Saito S, Azumi M, Muneoka Y, Nishino K, Ishikawa T, Sato Y, et al. Cost-effectiveness of combined serum anti-Helicobacter pylori IgG antibody and serum pepsinogen concentrations for screening for gastric cancer risk in Japan. Eur J Heal Econ. 2018 May 1;19(4):545–55.
37. Park CH, Kim EH, Jung DH, Chung H, Park JC, Shin SK, et al. The new modified ABCD method for gastric neoplasm screening. Gastric Cancer. 2016 Jan 1;19(1):128–35.
38. Kazumasa M. Gastric cancer screening by combined assay for serum anti-Helicobacter pylori IgG antibody and serum pepsinogen levels-"ABC method". Vol. 87, Proceedings of the Japan Academy Series B: Physical and Biological Sciences. Proc Jpn Acad Ser B Phys Biol Sci; 2011. p. 405–14.
39. Di Mario F, Crafa P, Franceschi M, Rodriguez-Castro K, Baldassarre G, Ferronato A, et al. Low Levels of Gastrin 17 are Related with Endoscopic Findings of Esophagitis and Typical Symptoms of GERD. J Gastrointestin Liver Dis. 2021 Feb 12;30(1):25–9.
40. Harewood GC. Economic comparison of current endoscopic practices: Barrett’s surveillance vs. ulcerative colitis surveillance vs. biopsy for sprue vs. biopsy for microscopic colitis. Dig Dis Sci. 2004;49(11–12):1808–14.
41. Peery AF, Dellon ES, Lund J, Crockett SD, McGowan CE, Bulsiewicz WJ, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology. 2012;143(5).
42. Roth LS, Adams PC. Variation in physician reimbursement for endoscopy across Canada. Can J Gastroenterol. 2009;23(7):503–5.
43. Teriaky A, Alnasser A, Mclean C, Gregor J, Yan B. The Utility of Endoscopic Biopsies in Patients with Normal Upper Endoscopy. Can J Gastroenterol Hepatol. 2016;2016(3026563):1–7.
44. Yeh JM, Hur C, Ward Z, Schrag D, Goldie SJ. Gastric adenocarcinoma screening and prevention in the era of new biomarker and endoscopic technologies: A cost-effectiveness analysis. Gut. 2016 Apr 1;65(4):563–74.

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