Socioeconomic Disparities in the Use of Catheter-Free Esophageal pH Testing

Abstract

Purpose: Literature on reflux disease in African Americans (AA) is scant. Temple Hospital is unique in that we serve a local community which is predominantly AA and impoverished, as well as a wealthy tertiary care referral population. Our purpose was to compare the presentation and evaluation of white and AA patients with chronic reflux symptoms to our hospital. Methods: We reviewed the records of all patients endoscopically evaluated for chronic reflux between 1/06 and 8/07. We identified individuals without erosions to determine whether they subsequently underwent a Bravo® pH capsule study (off PPI) to clarify reflux status. Patients were thus classified as either: Erosive esophagitis (EE); Bravo Negative (BN); or Bravo Positive (BP). Our unit now rarely orders catheter-based pH studies and therefore these were not studied. The patient's zip code was used to estimate median household income. Results: Total of 550 patients with chronic reflux underwent endoscopy. There were N = 295 (53.6%) diagnosed with EE. Of the remaining 255, N = 133 (52.2%) underwent pH testing (BN = 68; BP = 65) to confirm reflux. Patients with EE were significantly older (53 ± 16) than those who were BN (47 ± 15) or BP (47 ± 16) (P= 0.003). BMI (overall mean 27.3 ± 6.8) did not differ between groups or between AA and whites. Patients with EE were significantly poorer (median income 32,600 USD) than those who underwent BRAVO testing (56,400 USD; P < 0.001). Males were more likely to have EE (82% vs. 58%), while females were more likely to be EE (−) and categorized as either BN or BP (P < 0.001). Univariate analysis also revealed that beta blockers, diabetes, and tobacco use were associated with EE. By logistic regression, tobacco use (OR = 8.1; P= 0.006) and AA race (OR = 5.0; P= 0.002) were associated with having either EE or a BP result. Overall, 83.9% of pH studies were performed in whites while only 7.4% of AA underwent pH testing. Only 13.6% of patients who underwent pH testing did not have commercial insurance. There were no pH studies in patients with city-supplied insurance or no insurance. Conclusion: Tobacco use, and AA race were strongly associated with erosive esophagitis/positive pH test. Results suggest an access limitation to catheter-free esophageal pH testing in the AA community. At Temple payment for the capsule is usually out-of-pocket because it is not covered by most health insurance plans (however, the EGD portion usually is covered). This limitation precludes it's widespread use for patients living in poverty.