Endoscopy – Should Everyone Be Tested?


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Endoscopy – Should Everyone Be Tested?

  1. 1. Endoscopy – Should Everyone Be Tested? Primary Care Management of Dyspepsia Symposium Roland Valori Consultant Gastroenterologist Gloucestershire Royal Hospital December 2003
  2. 2. What will be covered <ul><li>Specific issues </li></ul><ul><li>Health economics of endoscopy </li></ul>
  3. 3. Specific issues <ul><li>Iron deficiency </li></ul><ul><li>Positive coeliac serology </li></ul><ul><li>B12 deficiency </li></ul><ul><li>Age threshold for endoscopy </li></ul><ul><li>Barrett’s oesophagus </li></ul><ul><li>Gastric ulcer </li></ul>
  4. 4. Iron deficiency selecting patients for endoscopy <ul><li>All males </li></ul><ul><li>All non-menstruating females </li></ul><ul><li>Selected menstruating females: </li></ul><ul><ul><li>positive coeliac serology </li></ul></ul><ul><ul><li>GI symptoms </li></ul></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>? older patient </li></ul></ul>
  5. 5. Positive coeliac serology <ul><li>Need for duodenal biopsy depends on </li></ul><ul><ul><li>type of serology available </li></ul></ul><ul><ul><li>degree of suspicion of coeliac </li></ul></ul>
  6. 6. Duodenal biopsy and coeliac serology when to endoscope TT-Glutaminase Anti-endomysial Anti-gliadin no no +/- - +/- yes yes + no no yes - yes yes yes + no +/- yes - yes yes yes + low medium high Degree of suspicion of coeliac
  7. 7. B12 deficiency <ul><li>Always do </li></ul><ul><ul><li>intrinsic factor antibodies </li></ul></ul><ul><ul><li>coeliac serology </li></ul></ul><ul><li>Follow rules for coeliac serology </li></ul><ul><li>Barium follow through </li></ul><ul><ul><li>if there are GI symptoms </li></ul></ul>
  8. 8. <ul><li>“The challenge for GPs is to maximise detection of serious and treatable disease while minimising cost and adverse effects of investigation” </li></ul>Logan and Delaney, BMJ 2001;323:695-7
  9. 9. Number of significant symptoms at time of diagnosis No of Patients = 25 Wt loss 14 Dysphagia 8 Anaemia 7 GI Bleed 3 Previous surgery 3 Mass 3 Perforation 1 Cerebral mets 1 No of Symptoms No of Patients Christie et al, Gut 1997;41:513-7
  10. 10. The threshold should be 55 the evidence <ul><li>Christie et al, Gut 1997;41:513-7 </li></ul><ul><li>Gillen et al, Am J Gastroenterol 1999;94:75-9 </li></ul><ul><li>Effective Health Care bulletin 2000: Volume 6 </li></ul><ul><li>Two-week wait rule for upper GI cancer </li></ul><ul><ul><li>http://www.doh.gov.uk/cancer </li></ul></ul><ul><li>Draft NICE guidelines 2003 </li></ul>
  11. 11. Barrett’s oesophagus <ul><li>Two issues </li></ul><ul><ul><li>surveillance endoscopy of Barrett's to identify early cancer </li></ul></ul><ul><ul><li>screening patients with GORD to identify Barrett's suitable for surveillance </li></ul></ul>
  12. 12. BSG Barrett’s oesophagus guidelines <ul><li>“ it is recommended that endoscopic surveillance every 2-3 years should be considered in patients with endoscopically visible CLO, particularly those fit enough to undergo oesophagectomy should HGD or carcinoma be detected” </li></ul>Draft guidance
  13. 13. BSG Barrett’s oesophagus guidelines <ul><li>Surveillance recommendation is based on case series evidence </li></ul><ul><li>Cost-effectiveness is highly sensitive to annual incidence of carcinoma in Barrett's </li></ul><ul><ul><li>>1% not too expensive </li></ul></ul><ul><ul><li>0.5-1.0% £62,000/QALY </li></ul></ul><ul><ul><li><0.5% prohibitively expensive </li></ul></ul>incidence 0.26-0.4%: BMJ 2003; 326:892-4
  14. 14. Endoscopy and bowel cancer <ul><li>Using endoscopy as part of a screening strategy, mortality from bowel cancer can be reduced by 15% </li></ul>endoscopy can prevent bowel cancer
  15. 15. Effect of FOBT screening on incidence of colorectal cancer NEJM 2000;343:1603-07 0.73 – 0.94 0.83 435 biennial screening 0.70 – 0.90 0.80 417 annual screening 507 control Confidence interval Odds ratio New cases of CRC
  16. 16. Bowel cancer screening <ul><li>In November 2002 Alan Milburn announced that there would be a bowel cancer screening programme </li></ul><ul><ul><li>£1300 – 2500/QALY </li></ul></ul><ul><ul><li>£23 – 42 million/year </li></ul></ul>
  17. 17. Bowel cancer screening <ul><li>Endoscopic workload expressed as procedures or sessions per year per million population: </li></ul>10% increase 20% increase Screening method 690 300 ‘ endoscopy sessions’ 450 1500 colonoscopy (at steady state) 6000 0 flexible sigmoidoscopy FS FOBT
  18. 18. Waiting list: second wave pilot site X (population of 330,000) total waiting = 937 waiting >13 weeks = 247
  19. 19. Implementing screening <ul><li>Not until the symptomatic service is ‘sorted’: </li></ul><ul><ul><li>modernisation of endoscopy services </li></ul></ul><ul><ul><li>more and better trained endoscopists </li></ul></ul><ul><ul><li>quality assurance process </li></ul></ul>@
  20. 20. Modernisation <ul><li>Is all about </li></ul><ul><ul><li>getting it right for the patient </li></ul></ul><ul><ul><li>using capacity efficiently </li></ul></ul><ul><ul><li>controlling demand using cost/benefit evidence </li></ul></ul><ul><ul><li>resourcing the demand capacity gap properly </li></ul></ul>
  21. 21. Modernisation <ul><li>Is all about </li></ul><ul><ul><li>getting it right for the patient </li></ul></ul><ul><ul><li>using capacity efficiently </li></ul></ul><ul><ul><li>controlling demand using cost/benefit evidence </li></ul></ul><ul><ul><li>resourcing the demand capacity gap properly </li></ul></ul>
  22. 22. Annual open access endoscopy referral rate for West Gloucestershire GP practices (1996-7) Endoscopy referrals per 1000 patients per year Practices (Intervention arm of serology RCT) 2 x 4 x 0.65%/year 1x
  23. 23. Endoscopic findings in a random adult population <ul><li>Sweden </li></ul><ul><li>Random sample invited for OGD* </li></ul><ul><li>1001/1363 accepted </li></ul><ul><li>Age range 20-81 </li></ul><ul><li>Mean age 53.5 </li></ul><ul><li>51.3% women </li></ul>* Independent of symptoms Aro P et al, DDW 2002
  24. 24. Endoscopic diagnosis Stroud (344) Sweden (1001) Forest of Dean (391) Waldon, Aro and Wilkinson Stroud and FOD - symptom-based selection Swedish study - random selection
  25. 25. Problems with nihilistic approach <ul><li>Dealing with people </li></ul><ul><li>Dealing with GPs who are dealing with people </li></ul><ul><li>Endoscoping influences behaviour, it may lead to: </li></ul><ul><ul><li>reduced worry </li></ul></ul><ul><ul><li>fewer symptoms </li></ul></ul><ul><ul><li>reduced consultation </li></ul></ul><ul><ul><li>reduced medication use </li></ul></ul>
  26. 26. Alternative strategies to manage dyspepsia <ul><li>Early endoscopy </li></ul><ul><li>Empirical treatment </li></ul><ul><li>Test and treat </li></ul><ul><li>Test and ‘scope </li></ul>
  27. 27. Alternative strategies to manage dyspepsia <ul><li>Early endoscopy </li></ul><ul><li>Empirical treatment </li></ul><ul><li>Test and treat </li></ul><ul><li>Test and ‘scope </li></ul>Choices Health economics
  28. 28. Choices (decisions) Efficacy Cost Resource Beliefs Willingness to pay Perspectives
  29. 29. Cost Efficacy LOSER WINNER x
  30. 30. Cost £ Efficacy Patient Sx-free at 12/12 BMJ 2002;324:1012-6 T/T vs treat Endo vs treat >50 T/T vs Endo Endo vs treat <50 x x
  31. 31. Conclusions <ul><li>Do not ignore iron deficiency </li></ul>
  32. 32. Conclusions <ul><li>Beware of Barrett's propaganda </li></ul><ul><ul><li>surveillance can do harm as well as good </li></ul></ul><ul><ul><li>we do not know the balance of good and harm </li></ul></ul><ul><ul><li>cost-effectiveness depends on the incidence of cancer in the population surveyed </li></ul></ul><ul><ul><ul><li>Whatever, it is hugely expensive compared with other interventions </li></ul></ul></ul>
  33. 33. Conclusions <ul><li>Early endoscopy for patients with dyspepsia aged >55 </li></ul><ul><ul><li>it appears to be ‘cost-effective’ </li></ul></ul><ul><ul><li>cancer is much more likely to be found </li></ul></ul>
  34. 34. Conclusions <ul><li>For younger patients: </li></ul><ul><ul><li>if typical reflux symptoms treat empirically </li></ul></ul><ul><ul><li>if non-specific dyspepsia test for Hp and treat </li></ul></ul><ul><ul><li>endoscope if </li></ul></ul><ul><ul><ul><li>patient or doctor has concerns about cancer </li></ul></ul></ul><ul><ul><ul><li>patient needs to take regular NSAIDs </li></ul></ul></ul>
  35. 35. Conclusions <ul><li>If you want to save the life of a patient with dyspepsia arrange a flexible sigmoidoscopy </li></ul>
  36. 36. Hp and reflux disease <ul><li>The net effect is to reduce the number of subjects with milder GORD symptoms, but to increase the (smaller) number with more severe symptoms </li></ul>Richard Harvey, DDW/SWGG 2002