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World J Gastroenterol. Jan 14, 2019; 25(2): 178-189
Published online Jan 14, 2019. doi: 10.3748/wjg.v25.i2.178
Prevention of overuse: A view on upper gastrointestinal endoscopy
Judith J de Jong, Marten A Lantinga, Joost PH Drenth
Judith J de Jong, Marten A Lantinga, Joost PH Drenth, Department of Gastroenterology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands
Author contributions: de Jong JJ and Lantinga MA contributed to conception and design of the work, and interpretation of the data, and drafted the manuscript; Drenth JPH contributed to conception of the work, interpretation of the data, and revised the manuscript critically for important intellectual content.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Joost PH Drenth, MD, PhD, Professor of Gastroenterology and Hepatology, Head, Department of Gastroenterology and Hepatology, Radboud University Medical Center, P.O. Box 9101, Nijmegen 6500 HB, The Netherlands. joost.drenth@radboudumc.nl
Telephone: +31-24-3613999 Fax: +31-24-3635129
Received: October 30, 2018
Peer-review started: November 1, 2018
First decision: November 22, 2018
Revised: December 6, 2018
Accepted: December 13, 2018
Article in press: December 13, 2018
Published online: January 14, 2019
Processing time: 78 Days and 23.5 Hours
Abstract

Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed Helicobacter pylori test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.

Keywords: Endoscopy; Dyspepsia; Medical Overuse; Guidelines; Proton Pump Inhibitors; Helicobacter pylori

Core tip: Strategies to halt overuse of upper gastrointestinal (GI) endoscopies are called for. Dyspepsia represents the indication for the majority of inappropriate upper GI endoscopies and provides a target for intervention. In this review, we describe four strategies that can be used to reduce upper GI endoscopies. While all strategies individually impact the number of performed endoscopies, a collaboration of improved guideline adherence, decision-making assistance, symptom management and Helicobacter pylori screening is most likely to change referral practice.