Appropriateness of Endoscopic Procedures: A Prospective, Multicenter Study

Abstract

<b><i>Introduction:</i></b> 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. <b><i>Patients and Methods:</i></b> 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). <b><i>Results:</i></b> Regarding EGD: 215 patients enrolled (43.7% were males) with a mean age of 61.0 ± 15.1 years; 54.0% (<i>n</i> = 116) were in public hospitals. Referral by a gastroenterologist was made for 34.9% (<i>n</i> = 75). Appropriate indications were made for 62.3% (<i>n</i> = 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; <i>p</i> &#x3c; 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; <i>p</i> &#x3c; 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% (<i>n</i> = 138) were in public hospitals. Referral by a gastroenterologist was made for 20.6% (<i>n</i> = 59). Appropriate indications were made for 70.0% (<i>n</i> = 201): 53.0% in private vs. 88.4% in public endoscopy units (OR 6.75; 95% CI 3.66–12.47; <i>p</i> &#x3c; 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 (<i>p</i> &#x3c; 0.05). <b><i>Discussion:</i></b> 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.