Utilization of Upper Endoscopy for Surveillance of Gastric Ulcers: Results from the National Endoscopic Database

Abstract

Background: Despite guideline recommendations, data suggest that endoscopists frequently perform endoscopic surveillance (EGD) of gastric ulcers (GUs) to document healing, a practice that is meant to exclude underlying malignancy. The low prevalence of gastric cancer and the high diagnostic sensitivity of multiple ulcer biopsies at initial EGD make this approach unlikely to be beneficial. Despite concerns of overuse, however, no study has examined how endoscopists in the United States manage GUs. In addition, no study has looked at utilization data rather than self-reported practice patterns. Methods: The National Endoscopic Database (CORI database) was used to identify ambulatory patients diagnosed with a GU between 2001 and 2005. A surveillance EGD was defined as any EGD performed ≤3 months after this index EGD. Exclusion criteria were: (1) past history of gastric surgery; (2) past history of gastric cancer; and, (3) EGD performed within the previous 12 months. Results were stratified by: (1) patient age, ethnicity, and gender; (2) ulcer size; (3) practice setting; and, (4) geographic region. Multivariate logistic regression was performed to identify independent predictors of surveillance EGD. Results: 6113 patients with GUs meeting the aforementioned inclusion and exclusion criteria were identified in the database. Of these, 25% (n = 1510) underwent surveillance EGD. Older patients were more likely to undergo surveillance than younger patients (p < 0.0001), though a substantial minority (15%) of patients <40 years underwent a surveillance exam. Patients with ulcers ≥1 cm in size were also more likely to undergo surveillance (33% vs 22%, p < 0.0001). VA patients were significantly more likely to undergo surveillance exams than non-VA patients (37% vs 23%, p < 0.0001). Geographic variation was also noted, with surveillance rates varying from 16% to 36% across the United States (p < 0.0001). All of these factors were independently predictive of surveillance EGD in multivariate logistic regression analysis. Surveillance rates did not appear to differ substantially on the basis of gender and ethnicity. Conclusions: In contrast to guideline recommendations, >25% of ambulatory patients diagnosed with GUs undergo surveillance EGD within 3 months. This rate varies significantly by patient age, ulcer size, practice setting, and geographic location. However, young patients, those with small ulcers, and those within the VA system continue to undergo surveillance at higher than expected rates, suggesting continued overuse. Future research should study the impact of interventions designed to decrease the overuse of EGD for GU surveillance.