Overuse and underuse of diagnostic upper gastrointestinal endoscopy in various clinical settings

Objectives. To describe and compare both overuse and underuse of diagnostic upper gastrointestinal endoscopy in different settings. Design. Merging of data from three prospective observational studies. The a ppropriateness and necessity of indications for gastroscopy were evaluated using explicit criteria developed by a standardized expert panel method (RA ND-UCLA. eas Inappropriate endoscopies represent overuse. Necessary indicat ions not referred for the procedure constitute underuse. Setting. Three primary care outpatient clinics, 20 general practices, three gastroenterology practices, two district and one university hospitals. Sub jects. A third of the collective were consecutive ambulatory patients with upper abdominal complaints, whereas the other two-thirds were ambulatory an d hospitalized patients referred for the procedure. Main outcome measures. Proportions of overuse and underuse in the different settings. Results. A total of 2885 patients were included (mean age, 49 years, 52% ma le, 2442 outpatients), 1858 patients underwent greater than or equal to 1 e ndoscopy. Among 2086 endoscopies, 805 (39%) were inappropriate, most of whi ch were performed for dyspepsia (83%). Overuse was higher in young, foreign , female patients and lower in inpatient settings, the latter reflecting a different distribution of presenting symptoms. Among 1646 patient visits in primary care, overuse represented 148 endoscopies (9%). Underuse was ident ified in 104 of the same patient visits (6%) and was higher as patient age increased; there were no significant differences between men and women. Conclusions. Rates of overuse and undemse depend mainly on case presentatio n and patient characteristics. Both over-and underuse should be addressed t o maintain and improve quality) of care.