Primary Care Physician (PCP) Attitudes Towards Unsedated Endoscopy (UE) and Screening Practices for Barrett's Esophagus (BE): A Survey Study

Abstract

Background: Present screening strategies for BE, which rely on referral from PCPs to gastrointestinal specialists for sedated EGD, are inadequate. Unsedated endoscopy, performed either by PCPs or by gastrointestinal endoscopists, is a lower-cost screening alternative. Aims: To determine 1) PCP referral patterns for screening EGD; 2) Barriers to screening; 3) PCP interest in performing UE; and 4) The effect of availability of UE on PCP referral patterns. Methods: A one-page survey was initially administered to PCP practices within our institution. Questions on the survey that produced ambiguous answers were then modified. A random sample of 500 family practitioners and 500 internists was obtained from the American Academy of Family Physicians and American College of Physicians- American Society of Internal Medicine, respectively. The revised, validated, one-page survey was mailed, utilizing the Total-Design Approach, to this group of PCPs with a token financial incentive. A repeat mailing was sent to those who did not respond. Results: The overall response rate was 52.6% (73% men). Of the respondents, 49% are in group practice, 23% are solo practitioners, and 43% see 5 to 10 patients per week with GERD. The majority (71%) refer 10-75% of their GERD patients for EGD, however 28% refer patients for barium studies >10% of the time. More than 70% of PCPs cited alarm symptoms, refractory symptoms, chronicity and severity of symptoms as reason for referral for EGD. Gender, age, obesity and tobacco use were cited by less than 45% of PCPs. Cost of endoscopy was the most common reason cited for non-referral for EGD, the second most common reason being poor patient acceptance. A majority of PCPs (62%) indicated that the availability of UE would increase referral rates for the procedure. Overall, 52% would be willing to perform UE in their office, however newer PCPs (in practice <5) were more willing than older PCPs (in practice >20 years) (p=0.0005). PCPs with practices comprised of patients >50 years old had higher referral rates for EGD (p=0.009), although age was cited only 43% of the time as a reason for referral. Conclusions: Although symptomatic GERD was generally cited, other risk factors for BE, such as gender and age, were not cited as reasons to refer patients for EGD by a majority of PCPs. Cost of endoscopy is the greatest barrier to endoscopic screening. PCPs indicated referrals would increase with the availability of UE, which many would be willing to perform in their office.