S442 Utilization of Diagnostic Testing and Indications for Long-Term Twice-Daily Proton Pump Inhibitor (PPI) Therapy for Gastroesophageal Reflux Disease (GERD) in a Large Healthcare System

Abstract

Introduction: For symptoms potentially associated with GERD, guidance recommends de-prescribing long-term PPI therapy based on symptoms if possible, particularly in the absence of objective diagnostic findings. We assessed the utilization and yield of diagnostic evaluation (upper endoscopy (EGD) and/or reflux monitoring) among patients with GERD diagnoses receiving long-term twice-daily PPI therapy. Methods: From a healthcare system database, adults with GERD diagnoses (per ICD coding) who received prescriptions for twice-daily PPI for at least 90 days from 2018-2021 were identified. CPT analyses were performed to identify the proportions who underwent EGD and reflux monitoring. Characteristics of patients who underwent diagnostic testing were compared to those who did not. Further, those with objective EGD findings potentially warranting long-term PPI (such as erosive or eosinophilic esophagitis, peptic stricture, Barrett’s esophagus, ulcer) were compared to those without such findings on EGD. Factors significant on univariate analysis were included in multivariate models to identify predictors of A) undergoing diagnostic evaluation, and B) having positive EGD findings. Results: 5565 patients (57.7±0.2 yrs; 67.4% female; BMI 31.3±0.1) met inclusion criteria. 2696 (47.7%) had upper endoscopy, 491 (8.7%) had reflux monitoring, and 2735 (48.4%) had either upper endoscopy or reflux monitoring performed. Factors associated with diagnostic testing included younger age, female gender, and non-white race (Table, Figure A). Among those who underwent EGD, 42.2% had endoscopic findings potentially warranting long-term PPI (37.7% for females vs 52.2% for males; 34.7% for non-white patients vs 47.3% for white patients). Factors associated with the presence of EGD findings included older age, male gender, and white race (Figure B). Conclusion: Among patients receiving prescriptions for long-term, twice-daily PPI for GERD diagnoses, over half did not have procedural diagnostic evaluation documented per CPT analysis, suggesting providers may rely on patient symptom reporting to guide long-term PPI prescriptions. Of those with documented EGD, less than half had objective findings to potentially corroborate the need for long-term, twice-daily PPI. These findings warrant further investigation into potential disparities in care around long-term PPI prescribing patterns based on symptoms and symptom response versus diagnostic evidence.Figure 1.: Forest Plots for Multivariate Analysis of Factors Associated with A) Diagnostic Evaluation (Upper Endoscopy and/or Ambulatory Reflux Monitoring) among Patients with GERD Diagnoses Prescribed Twice-Daily Long-Term PPI Therapy; and B) Objective Endoscopic Findings Potentially Warranting Twice-Daily Long-Term PPI Therapy. Odds Ratios are Depicted with Bars Representing Associated 95% Confidence Intervals; Values Not Crossing the Dashed Line at 1 are Significant. Odds ratios for smoking status variables are in reference to no smoking history. Table 1. - Comparisons Between Patients who Underwent Diagnostic Evaluation (with Upper Endoscopy and/or Ambulatory Reflux Monitoring) and Those Patients Who did Not Undergo Diagnostic Evaluation Evaluated (n=2735) Not Evaluated (n=2920) p Values Age (years) 57.1±0.3 58.3±0.3 0.005* Body Mass Index 31.0±0.1 31.6±0.2 0.006* Gender (female) 1898 (69.4%) 1916 (65.6%) 0.002* Race (data missing = 97) White 1681 (62.4%) 1998 (69.8%) < 0.001* Black 838 (31.1%) 672 (23.5%) Asian 62 (2.3%) 77 (2.7%) Other 115 (4.3%) 115 (4.0%) Ethnicity (data missing =109) Non-Hispanic 2505 (93.1%) 2663 (93.3%) 0.71 Hispanic or Latino 187 (7.0%) 191 (6.7%) Married (data missing =58) Married 1526 (56.2%) 1658 (57.5%) 0.32 Not Married 1189 (43.8%) 1224 (42.5%) Smoking Status (data missing = 5) Current 279 (10.2%) 390 (13.4%) < 0.001* Former 974 (35.6%) 945 (32.4%) Never 1481 (54.2%) 1581 (54.2%)