APPROPRIATE USE OF UPPER GASTROINTESTINAL ENDOSCOPY - A PROSPECTIVE AUDIT

Work by this group has shown that there is a wide range of opinion as to patients' suitability for endoscopy. In a recent study, 1297 questi onnaires were sent to a random selection of doctors, including 350 gen eral physicians, 400 surgeons, 477 gastroenterologists, and 70 general practitioners. The respondent was asked to indicate whether or not he would refer the patient described by each case vignette for endoscopy . Depending on the indication, the positive referral rate varied from 4.5% to 99% overall, and from 4.5% to 63.8% for all those clinical sit uations that the working party felt to be inappropriate. A second stud y examined the appropriateness of 400 consecutive cases referred from four units within one health region; these cases were judged independe ntly, and without conferring, by a panel of seven gastroenterologists. The same cases were rated by software that incorporated American opin ion (the Rand criteria). Although only 45 (11%) of the cases were clas sed as inappropriate by the British panel, 120 cases (31%) assessed by the American software were rated inappropriate. These differences occ urred largely because in the USA it is recommended that one month's an tiulcer treatment be tried before considering endoscopy for dyspepsia and thus many referrals were seen as inappropriate by the American dat abase. Of the 45 cases found to be inappropriate by the British doctor s no important abnormality was found at endoscopy; whereas of 120 case s judged inappropriate by the Rand criteria, three duodenal and two ga stric ulcers, and one gastric cancer diagnosed at gastroscopy. This at tempts a quantitative assessment of inappropriate use and serves to en courage further work to define appropriateness.