Overutilization of endoscopic surveillance in nondysplastic Barrett's esophagus: a multicenter study

Abstract

Background Guidelines suggest that patients with non-dysplastic BE undergo endoscopic surveillance every 3–5 years, but actual utilization of surveillance endoscopy and the determinants of variation in surveillance intervals are not known. Objective To measure utilization of surveillance endoscopy and its variation in patients with non-dysplastic BE. Design Multi-center, cross-sectional study Setting Three sites in Arizona, Minnesota, and North Carolina. Patients Participants had prevalent BE without a history of high grade dysplasia or EAC. Interventions Participants were given validated measures of quality of life, numeracy, and cancer risk perception, and the total number of prior endoscopic surveillance exams was measured. Main outcome measurements Over-surveillance was defined as >1 surveillance exam per 3 year period. Results Among 235 patients with non-dysplastic BE, 76% were male and 94% Caucasian. The average duration of BE was 6.5 years (± 5.9 years). The mean number of endoscopies per 3 year period was 2.7 (± 2.6 years). Over-surveillance was present in 65% of participants, resulting in a mean of 2.3 excess endoscopies per patient. Neither numeracy skills nor patient perception of cancer risk were associated with over-surveillance. Limitations Endoscopies were measured by patient report, which is subject to error. Results may only be generalizable to patients seen in academic centers. Conclusions Most patients with non-dysplastic BE had more surveillance endoscopic exams than is recommended by published guidelines. Patient factors did not predict over-surveillance, indicating that other factors may influence decisions about the interval and frequency of surveillance exams.

Adherence to Surveillance Guidelines in Nondysplastic Barrett’s Esophagus

“…A trend towards over-surveillance was seen with private insurance, although no demographic factors, health behaviors, or symptom severity measures were associated with over-surveillance. [17] Prior VA-based studies have suggested that most veterans do not undergo regular Inconsistencies and limitations in reported surveillance practices among prior studies may be related to reliance on surveys [11,12,[16][17][18][19][20], variable inclusion criteria for surveillance endoscopies [17,18,22], and lack of histologic data [17,18]. We attempted to circumvent these issues and provide a true estimate of endoscopic surveillance by clarifying the indication of each endoscopy and measuring actual surveillance frequency by reviewing endoscopic records.…”

“…Particularly in community practice, adherence to surveillance guidelines is low. [14] One multicenter study demonstrated overutilization of endoscopic surveillance in NDBE as measured by patient report [17], whereas a previous VA-based multicenter study showed that regular surveillance was practiced in only 23% of patients who had at least 6 years of follow-up. [18] Most of the previous studies are limited by reliance on surveys and questionnaires, or by a lack of pathology.…”

Patient Experiences with Surveillance Endoscopy: A Qualitative Study

“…A recent study of three tertiary-care referral centers found high rates of adherence to surveillance EGD. 10 However, an analysis of national Department of Veterans Affairs (VA) data found relatively low rates (23%) of guideline-concordant surveillance EGD in routine care. 11 Prior work has explored the role of patients’ perceptions of cancer risk 12 and health-related quality of life, 13 and type of insurance on the utilization and psychosocial effects of surveillance EGD.…”

“…11 Prior work has explored the role of patients’ perceptions of cancer risk 12 and health-related quality of life, 13 and type of insurance on the utilization and psychosocial effects of surveillance EGD. 10 Less attention has been given to how patients frame their experiences with EGD and how these ‘patient experiences’ shape intentions to pursue BE surveillance.…”

Preference of Endoscopic Ablation Over Medical Prevention of Esophageal Adenocarcinoma by Patients With Barrett’s Esophagus

“…Moreover, the fact that subjects were recruited from a surveillance cohort is a potential source of bias in this study. There are data to suggest that endoscopic surveillance may be overutilized among patients with BE, with endoscopy performed more frequently than recommended by practice guidelines [22]. Such utilization may be driven by both physician factors (such as medical-legal fears and financial incentives) and patient factors (such as access to care and medical copayments), which may be either promoters of or barriers to use [23].…”