The impact of upper GI endoscopy referral volume on the diagnosis of gastroesophageal reflux disease and its complications: a 1-year cross-sectional study in a referral area with 260,000 inhabitants.

Abstract

Less than half of patients with gastroesophageal reflux disease (GERD) have endoscopic erosive esophagitis (endoscopy positive GERD). Symptomatic GERD and Barrett's esophagus (BE), however, are risk factors for esophageal and gastric cardia adenocarcinomas. The aim of the present study was to examine the prevalence of GERD-related findings on endoscopy according to the volume of referrals to upper GI endoscopy. The following data were gathered on all GERD patients who were sent for upper GI endoscopy by general practitioners (GPs) during 1 yr in our hospital referral area of 260,000 inhabitants: the number of referrals to endoscopy in health care units, and the numbers of endoscopy positive GERD, BE, and esophageal neoplasms. Patients with symptoms or signs suggesting acute upper GI bleeding and those attending follow-up endoscopy (e.g., for BE, peptic ulcer, or dysplasia) were excluded, as were patients with previous esophagogastric surgery or Helicobacter pylori eradication therapy. The study population consisted of 3378 patients, with a mean age of 58.1 yr (95% CI = 57.5-58.6) and a male:female ratio of 1:1.3. Of the 760 patients who underwent endoscopy because of heartburn or regurgitation, 254 (33.4%) had endoscopy positive (erosive) GERD, 11 (1.4%) BE (one with esophageal adenocarcinoma), six (0.8%) esophageal ulcer, and one peptic esophageal stricture (0.1%). Between health care units, the referrals to endoscopy (number of endoscopies/population/yr) varied from 0.6 to 9.2/1000 inhabitants/yr (median 3.3/1000/yr). In health care units with "high" referral volumes (> or = 3.3 referrals/1000/yr, N = 15, 1297 patients) and "low" referral volumes (< 3.3/1000/yr, N = 15, 2081 patients), the numbers of endoscopy positive GERD were 281 (21.7%) versus 308 (14.9%, p < 0.001), esophageal ulcer 13 (1.0%) versus 14 (0.7%, p = 0.3), esophageal stricture five (0.4%) versus seven (0.3%, p = 0.4), Barrett's esophagus eight (0.6%) versus 16 (0.8%, p = 0.6), and esophageal neoplasm two (0.2%) versus six (0.3%, p = 0.2). Five of the neoplasms were squamous cell carcinomas, two were adenocarcinomas, and one was lymphoma. Multivariate analyses showed that independent risk factors for endoscopy positive GERD were male sex (OR = 1.4, 95% CI = 1.2-1.7), GERD symptoms (OR = 3.3, 95% CI = 2.7-4.0), dysphagia (OR = 1.4,95% CI = 1.0-2.1), and living in a high referral area (OR = 1.4, 95% CI = 1.2-1.7). Independent risk factors for BE were male sex (OR = 2.6, 95% CI = 1.1-6.1) and GERD symptoms (OR = 2.9, 95% CI = 1.3-6.6), whereas the only independent risk factor for esophageal neoplasm was dysphagia (OR = 40.0 (95% CI = 7.7-207.5). There is a wide variation in GPs' referrals for endoscopy. Increasing the referral volume significantly increases the proportion of endoscopy positive GERD cases, but not that of GERD complications such as BE, esophageal ulcer, peptic stricture, or esophageal neoplasms.