Patient Outcomes and Cost of Referral Patterns of Patients With Proton Pump Inhibitor Refractory Gastroesophageal Reflux Disease Undergoing Esophageal pH and Impedance Testing

Abstract

Introduction: The American College of Gastroenterology recommends that patients with gastroesophageal reflux disease (GERD) undergo esophageal pH and impedance for symptoms persisting following an 8 week trial of proton pump inhibitor (PPI) therapy. Research suggests that early referral is cost effective in evaluating PPI refractory GERD. Methods: A retrospective chart review was performed on all patients that underwent esophageal pH/impedance studies from December 2010 to June 2015. DeMeester score, total acid and non-acid reflux events, reflux symptom index scores, demographics, prior specialty appointments, and testing related to GERD symptoms was recorded. Workup cost was estimated using the minimum Medicare facility payment. Results: A total of 119 patients underwent pH/impedance testing with a mean age of 48 years (SD 13.0, range 21 - 76). No patients had pH/impedance evaluations prior to 8 weeks of PPI therapy. 46 (39%) patients had positive DeMeester scores, and 64 (53.8%) were referred by a non-primary care provider. Non-primary care specialties and primary care managers (PCM) had 26/64 (41%) and 20/55 (36%) positive pH/impedance tests, respectively. Of 55 patients referred by a PCM, 19 were previously seen by another specialty, with 6/19 (32%) of those having positive pH/impedance studies. No significant difference was found in the prevalence of positive testing between the three referral pattern groups (χ2=0.5068; P=0.7762) (table 1). Evaluation and workup costs averaged (95% CI) $184.00($181.46 - $186.54) from primary care referrals, $420.58 ($302.14 - 539.02) for primary care with previous subspecialty evaluation, and $353.65 ($264.12 - 443.18) for subspecialty referrals independent of PPI usage. Costs differed between primary care referrals and primary care with subspecialty referrals (P=0.0005) and primary care and subspecialty referrals (P=0.0014) but not between primary care with subspecialty referrals and subspecialty referrals (P=0.3649). Conclusion: A majority of the patients referred for pH/impedance testing were previously evaluated by another medical or surgical subspecialty. There was no difference in positive study between referral patterns. Additionally, the cost of workup for the PPI refractory GERD was higher in patients with any previous subspecialty workups when compared to direct primary care referrals. Therefore, the additional cost of workup of symptoms related to GERD does not demonstrate increased prevalence of positive pH and impedance studies. Early referral from primary care to gastroenterology for patients with refractory GERD after a trial of PPIs could reduce costs by eliminating unnecessary referrals to other specialties.Table: Table. Number of positive and negative DeMeester scores based on referral pattern for pH and impedance testing