Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study

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.

Introdução: O avanço em endoscopia digestiva e a existência de sistemas open-acess levaram a um aumento quantitativo de endoscopias. Porém, a sobreutilização da endoscopia tem sido reportada na literatura. Este estudo tem como objetivo aferir prospectivamente as indicações para endoscopia digestiva alta (EDA) e endoscopia digestiva baixa (EDB) em unidades de saúde públicas e privadas. Doentes e métodos: Estudo prospetivo, multicêntrico, que incluiu doentes submetidos a endoscopia digestiva alta (EDA) ou baixa (EDB) com intuito não terapêutico em 2 unidades hospitalares públicas e 5 unidades privadas. Adequabilidade da indicação definida pelas recomendações da American Society for Gastrointestinal Endoscopy (EDA) e do European Panel on Appropriateness of Gastrointestinal Endoscopy II (EDB). Resultados: EDA: Incluídos 215 doentes (masculino – 43.7%; idade média – 61.0 ± 15.11 anos), 54.0% (n = 116) em unidades hospitalares públicas. Referenciação por gastrenterologista em 34.9% (n = 75). Indicação considerada adequada em 62.3% (n = 134): 42.4% em unidades privadas versus 79.3% em unidades públicas (odds ratio [OR] 5.20, 95% confidence interval [CI] 2.85–9.49, p < 0.01). Indicação adequada em 74.7% com referenciação por gastrenterologista versus 56.1% por não-gastrenterologista (OR 2.31, 95% CI 1.24–4.28; p < 0.01). Identificados achados endoscópicos relevantes em 47.9%. EDB: Incluídos 287 doentes (masculino – 49.1%; idade média – 60.4 ± 14.4 anos), 48,1% (n = 138) em unidades públicas. Referenciação por gastrenterologista em 20.6% (n = 59). A indicação foi considerada adequada em 70.0% (n = 201): 53.0% em unidade privada versus 88.4% em unidade pública (OR 6.75, 95% CI 3.66–12.47; p < 0.01). Achados endoscópicos relevantes em 57.1%: 77.7% (n = 129) em exames com indicação adequada vs 22.3% (n = 37) sem indicação adequada (p < 0.05). Conclusões: Neste estudo, uma percentagem significativa dos procedimentos endoscópicos foi realizada sem indicação apropriada, especialmente no sector privado, o que influenciou a rentabilidade diagnóstica. A prescrição tendo por base critérios definidos é fundamental para o uso racional de um sistema de acesso livre.