Practice guidelines recommend esophagogastroduodenoscopy (EGD) screening for Barrett esophagus (BE) or esophageal cancer for patients with uncomplicated gastroesophageal reflux disease (GERD), especially in high-risk patients (symptoms for >5 years, white race, male sex, age >50 years, and family history of BE or esophageal cancer).1,2 However, the extent of using screening EGD, its predictors, and diagnostic yield are unclear. We aimed to determine prevalence, predictors, and yield of screening EGD in a large national sample of patients with uncomplicated GERD.
This study was approved by the Baylor College of Medicine Institutional Review Board and Michael E. DeBakey VA Medical Center Research and Development. This was a retrospective cohort study using national administrative (Medical SAS Inpatient and Outpatient Data sets and Decision Support System Clinical Laboratory Results and Pharmacy National Data Extracts) and clinical data (Computerized Patient Record System) from the US Department of Veterans Affairs (VA).3 Patients with a first International Classification of Diseases, Ninth Revision (ICD-9) code in 2004 through 2009 for uncomplicated GERD (ie, without alarm symptoms or signs of anemia, decompensated liver disease, gastrointestinal tract [GI] bleeding, celiac disease, any metastatic cancer, or any chemotherapy) were included. Outcomes were receipt of screening EGD (Current Procedural Terminology [CPT] codes) and yield for BE (ICD-9 code of BE combined with EGD) and esophageal, gastric, or duodenal cancer (E/GC) (all validated by medical chart review). Predictors of these outcomes, including demographic, clinical, clinical care, and facility factors (Table), were examined using hierarchical logistic regression models with a random effect for the clustering of patients within individual facilities.
Out of 499 073 patients with newly diagnosed uncomplicated GERD, 7.3% (n = 36 502) had an EGD during the year after their diagnosis, and 15.4% (n = 77 090) had an EGD during a median of 4.5 years follow-up. The yield was 10.1% for BE and 0.81% for E/GC. Patients with GERD who were male or 50 years or older were less likely to receive an EGD; however, these patients were more likely to be diagnosed as having BE or E/GC than were female patients and those younger than 50 years (Table). Nonwhite patients were less likely to receive an EGD and be diagnosed as having BE than were white patients, but race was not a significant predictor for E/GC. Other patient (chest pain, dyspepsia, and proton-pump inhibitor [PPI]/histamine-2-receptor antagonist [H2RA] use), clinical care (number of VA visits, GI clinic visit, and rural residence), and facility factors (high number of EDG procedures per facility) were also associated with an increased likelihood of receiving an EGD but either no association or a decreased likelihood for BE and E/GC.
While the yield of BE in patients with uncomplicated GERD is high in this population and comparable to other studies,4 the yield of cancer is low but still higher than reported in previous VA studies.5 Importantly, we also found that demographic as well as clinical and clinical care features that were predictive of patients receiving an EGD were discordant with the yield of BE and/or E/GC. This suggests potential underutilization of EGD among high-risk patients and overutilization in low-risk patients. Given the high BE and/or E/GC prevalence (11%) at the time of EGD, this mismatch between high-risk groups and likelihood of receiving EGD may contribute to missed opportunities for conducting effective screening EGD. Our data also suggest that EGD is likely to be performed to address symptomatic GERD or other unclear complaints more often than screening for BE and cancer. However, without alarm symptoms, the utility of EGD outside of BE and cancer screening is unknown and the volume of EGD performed in this low-risk population may crowd out availability for screening and surveillance EGD in higher-risk patients. Reasons for performing EGD in the lower-risk population may include persistent complaints about discomfort, fears of cancer or other serious illness, medical-legal concerns, and financial incentives that drive patient and physician expectations for care.6 The potential misuse of EGD in patients with uncomplicated GERD should be investigated in future studies.
Corresponding Author: Jennifer R. Kramer, PhD, MPH, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, 152, Houston, TX 77030 (firstname.lastname@example.org).
Published Online: January 27, 2014. doi:10.1001/jamainternmed.2013.13015.
Author Contributions: Dr El-Serag had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Kramer, Shakhatreh, Duan, El-Serag.
Acquisition of data: Kramer, Duan, El-Serag.
Analysis and interpretation of data: Kramer, Shakhatreh, Naik, Duan, El-Serag.
Drafting of the manuscript: Kramer, Shakhatreh, Duan, El-Serag.
Critical revision of the manuscript for important intellectual content: Kramer, Shakhatreh, Naik, El-Serag.
Statistical analysis: Kramer, Duan, El-Serag.
Obtained funding: Kramer, El-Serag.
Administrative, technical, or material support: Duan.
Study supervision: El-Serag.
Conflict of Interest Disclosures: None reported.
Funding/Support: This research was supported in part by National Institutes of Health (NIH) grant R01 NCI RC4 155844; the Center for Innovations in Quality, Effectiveness, and Safety (IQuESt) (grant CIN13-413) at the Michael E. DeBakey VA Medical Center, Houston, Texas; and the Texas Digestive Disease Center (grant NIH DK58338). Dr El-Serag is supported by grant K24-04-107 from the National Institute of Diabetes and Digestive and Kidney Diseases.
Role of the Sponsor: The funding agencies had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.
Previous Presentation: This work was presented as a poster at the annual Digestive Diseases Week conference; May 20, 2012; San Diego, California.
Additional Contributions: Marilyn Hinojosa-Lindsey, PhD, MA, was the study coordinator and assisted with administrative tasks and drafting of the manuscript. John Chen, PhD, provided methodological expertise for the data analysis. Ashley Helm, MA, and Amita Pathak, BA, conducted the medical chart reviews to confirm esophageal, gastric, or duodenal cancer diagnosis.
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