Start with lifestyle modifications then determine need for testing
The overuse of medical tests and procedures remains a major issue of concern in the United States. Gastrointestinal (GI) disorders, including gastroesophageal reflux disease (GERD), are an area of clinical practice in which the overuse of diagnostic procedures adds unnecessary cost. GERD is the most common GI-related diagnosis, representing 8.9 million patient visits.
According to data from the Centers for Disease Control and Prevention (CDC), outpatient GI endoscopy exams alone, which are commonly used to diagnose GERD and rule out related illness, cost the healthcare system $32.4 billion annually. The Institute of Medicine estimates $765 billion worth of waste in the U.S. healthcare system annually, $210 billion of which is comprised of unnecessary medical services.
GERD, a chronic digestive disease marked by acid reflux that irritates the lining of the esophagus, is fairly common. At least 40% of the U.S. population experiences at least one episode of heartburn monthly, according to an October 2012 paper “Managing chronic gastroesophageal reflux disease,” published by the American Academy of Family Physicians (AAFP).
“I see people daily who are treated for GERD. It may not be why they are there in my clinic, but I am definitely seeing them every day,” says Dean Seehusen, MD, MPH, an AAFP member of the and co-author of the AAFP paper.
Also relevant but often overlooked is the evidence demonstrating that, in many cases, upper GI endoscopy to diagnose GERD and/or rule out other related illnesses is performed unnecessarily.
According to Nicholas Shaheen, MD, MPH, director of Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill, the literature shows that anywhere from 10% to 40% of upper endoscopies performed for GI concerns do not conform to clinical guidelines.
What’s more, the rate at which upper endoscopy is used is increasing. Nationwide, a 40% increase has occurred in its use in the past decade among Medicare patients.
“We’re spending a lot of money,” Dr. Shaheen says.
Much of that money seems to be wasteful given scant evidence to support the use of endoscopy in diagnosing GERD, experts say.
According to Dr. Seehusen, if the clinical picture fits GERD with no other complications, such as a patient who is coughing up blood, has difficulty swallowing, or is losing weight, then it is easy and relatively inexpensive for providers to perform a trial of treatment, including lifestyle modification and medications.
“If you do a trial of treatment and it helps, then you pretty much have your diagnosis,” Dr. Seehusen says.
Still, the pressure to test can be great, particularly in patients whose conditions don’t improve over time.
“All of us want to do right by our patients but are often not sure of what’s useful and what will be helpful. There is just so much to keep up with,” says Molly Cooke, MD, president of the American College of Physicians (ACP).
When the condition is long-standing, many physicians understandably worry about the possibility of missing something more serious, such as esophageal cancer.
“Heartburn is extremely common, and all physicians appreciate that some patients with chronic heartburn end up with esophageal cancer,” Dr. Cooke says. “It’s a little like the headache and brain tumor situation. The vast majority of people with a headache don’t develop a brain tumor, but many patients with tumors have headaches. To decide is hard.”
A lack of clarity in the professional guidelines is another major cause of endoscopy overuse.
“We, as a field have done a good job of confusing generalists about when to do this test. Part of what we see in terms of inappropriate utilization is our own fault for not giving people unambiguous guidance,” says Dr. Shaheen, lead author of the ACP’s new guidelines.
The guidelines indicate that endoscopy should not be used to screen for GERD in the general population. They were developed for internal medicine and family physicians as well as other clinicians who diagnose and treat GERD.
The ACP clinical guidelines, published in the December 2012 edition of the Annals of Internal Medicine, outline the confusion caused by competing guidelines among three major U.S. gastroenterologic professional societies.
• The American Society of Gastrointestinal Endoscopy recommends that screening upper endoscopy be considered “in selected patients with chronic, longstanding GERD;”
• American Gastroenterological Assn. recommends against screening the general population with GERD for Barrett esophagus and esophageal adenocarcinoma but say that it should be considered in patients with GERD who have several risk factors associated with esophageal adenocarcinoma; and
• The American College of Gastroenterology guidelines note that “screening for Barrett's esophagus in the general population cannot be recommended at this time. The use of screening in selective populations at higher risk remains to be established, and therefore should be individualized.”
Two particular aspects of the new ACP guidelines stand out among its previous guidelines and those of the other societies: upper endoscopy should not be routinely performed in women of any age; and men under 50 years who have heartburn should not routinely be screened via upper endoscopy.
The incidence of cancer in both these populations is very low. In fact, a woman with heartburn has a lower risk of esophageal cancer than a man without heartburn.
“It doesn’t make a lot of sense to be scoping the women with heartburn but not the men without heartburn if you want to stop the cancer,” says Dr. Shaheen.
In the end, heartburn, it seems, is not a very useful marker of cancer risk. In fact, esophageal cancer in heartburn sufferers affects only about one in 2,500 patients over age 50 each year, according to a 2012 report by Consumer Reports, ACP, and the Annals of Internal Medicine. Even among people with Barrett’s esophagus-a condition in which cells change after a history of GERD-the risk of cancer is quite low.
Another possible reason cited for the over use of endoscopy ties in with physicians’ concern over missing a diagnosis of cancer. Patients with unexplored symptoms could be viewed by their providers as having a higher medical-legal risk.
Then there’s the culture of expectation among some groups of patients who want their symptoms fully explored. Americans have become accustomed to being repeatedly checked for a medical problem. In some cases, that approach is clinically advisable, but not so in the case of GERD.
Of course, the economics of testing and its benefit to endoscopists’ business cannot be overlooked as another possible cause of overuse.
As new budget-based payment models associated with accountable care organizations (ACOs), medical homes, and shared savings programs increase in prominence compared with traditional fee-for-service models, those incentives likewise will shift.
Providers can take several steps to reduce the improper use of testing in patients with GERD that can help to lower healthcare costs overall. On average, upper endoscopy costs more than $800 per examination, according to the ACP.
Dr. Shaheen says many physicians will send patients with heartburn for recurrent exams as “checkups” for heartburn.
In fact, a patient with chronic heartburn for five years who has had a single endoscopy that was clear does not need to be tested again unless other troublesome symptoms, such as anemia, weight loss, or difficulty swallowing, arise. Most cancers show up early on in a patient experiencing symptoms. If it didn’t show in the initial test, therefore, it’s unlikely to be an issue, Dr. Shaheen says.
Dr. Cooke advises providers’ use of an electronic health record (EHR) system to support effective testing.
“The holy grail would be the integration of guidelines into the medical record,” she says. “You could imagine one set up so that, if I referred a patient to a gastroenterologist with the diagnosis of GERD, that the record would just remind me that, unless the patient has red-flag symptoms, if she is a woman or a man under 50, probably he or she does not need an endoscopy.”
She points out that EHRs also can be used as a tool to educate patients who do not need further testing.
Finally, Dr. Seehusen of the AAFP suggests a general orientation toward using step therapy, in which the least expensive treatment to manage GERD is used as a first step. Members can start with lifestyle modification that will cost less than treatments.
“Limiting your diagnostics to only those patients who you have a high index of suspicion for underlying Barrett’s or underlying malignancy is the right answer,” Dr. Sheehusen says. “You do not need to do endoscopy on everyone who walks through the door.”