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Ultrathin Esophagoscopy in Screening for Barrett's Esophagus at a Veterans Administration Hospital

Easy Access Does Not Lead to Referrals

Atkinson, Matt, M.D.; Das, Ananya, M.D.; Faulx, Ashley, M.D.; Kinnard, Margaret, M.D.; Falck-Ytter, Yngve, M.D.; Chak, Amitabh, M.D.

American Journal of Gastroenterology: January 2008 - Volume 103 - Issue 1 - p 92–97

OBJECTIVE Unsedated, ultrathin esophagoscopy has been shown to be tolerable, safe, and accurate. Survey data have suggested that accessibility of unsedated esophagoscopy would increase referrals for Barrett's esophagus (BE) screening. Our purpose was to evaluate primary-care physician referrals for BE screening when unsedated esophagoscopy is made available.

METHODS We studied primary-care referrals for unsedated esophagoscopy in a VA internal medicine clinic. Patients over age 45 with chronic heartburn for >5 yr or >3 times weekly and who had no previous EGD were eligible for screening with unsedated esophagoscopy. All primary providers received a 15-min education session on screening. Baseline referral rate was determined retrospectively. Longitudinal data were then collected during three phases of the study: (a) primary provider-initiated referrals, (b) primary provider-initiated referrals with weekly reminders from investigators, and (c) investigator recruitment.

RESULTS Baseline referral rate averaged 0.5 patients per month. Availability of unsedated esophagoscopy and an education session increased the rate of referral to 0.66 patients per month. Weekly reminders to primary physicians further increased the rate to 1.33 referrals per month. Investigator recruitment produced a rate of 2.67 referrals per month. Of the 77 patients offered screening, 25 (32%) declined. Of the 52 patients screened, three (5.8%) were diagnosed with BE.

CONCLUSIONS Accessibility of unsedated esophagoscopy itself does not lead to a large increase in the number of primary care referrals for BE screening. Factors that prevent primary care physicians from referring patients for screening need to be identified and effective interventions to change referral patterns need to be implemented for unsedated screening programs to be successful.

Case Western Reserve University, Cleveland, Ohio

Reprint requests and correspondence: Amitabh Chak, M.D., University Hospitals of Cleveland-Mather Pavilion, Suite 1300, Cleveland, OH 44106.

Received March 28, 2007; accepted July 18, 2007.

CONFLICT OF INTERESTGuarantor of the article: Matt Atkinson, M.D.

Specific author contributions: Matt Atkinson contributed to patient recruitment, data collection and organization, and writing of the manuscript; Ananya Das contributed to the design of the study, initial IRB approval, performance of unsedated endoscopy, and editing of the manuscript; Ashley Faulx contributed to the design of the study, initial IRB approval, education sessions to the primary care physicians, performance of unsedated endoscopy, and editing the manuscript; Margaret Kinnard contributed to the performance of unsedated endoscopy and data collection; Yngve Falck-Ytter contributed to data collection and organization, maintaining IRB approval, and editing the manuscript; Amitabh Chak contributed to design of the study, initial IRB approval, performance of unsedated endoscopy, data collection, and editing the manuscript.

Financial support: Olympus America, Inc. provided the ultrathin endoscopes. Otherwise, no financial support was received for this study.

Potential competing interests: None.

© The American College of Gastroenterology 2008. All Rights Reserved.
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