Low-Value Care And Endoscopy In Dyspepsia: A Retrospective Observational Study From A Metropolitan Australian Hospital

INTRODUCTION: Recent literature suggests that young patients aged < 55 years without alarm features are low risk for significant endoscopic findings (SEF) including malignancy, ulceration and erosive oesophagitis. Guidelines recommend that this patient subgroup should undergo a trial of proton pump inhibitors (PPIs) before consideration for endoscopy. METHODS: We retrospectively reviewed all endoscopies at our tertiary centre between January 2018 and July 2019 for investigation of dyspepsia in patients aged 18–54. RESULTS: 302 endoscopy exams met inclusion criteria, with a mean patient age of 41 years and 43% were male. 246 (81.5%) endoscopies were performed in accordance with guideline indications, consisting of 80 (26.5%) patients with alarm features, and 226 (74.8%) patients had a trial of PPIs prior to referral. The most common alarm features were iron deficiency anaemia and dysphagia, but also included unintentional weight loss, persistent vomiting, upper gastrointestinal bleeding, family history of upper gastrointestinal malignancy and abnormal imaging of the upper gastrointestinal tract. 151 (50.0%) patients had a normal examination while 24 (7.9%) patients had at least 1 SEF finding including 1 case of gastric adenocarcinoma, 3 cases of ulceration, 2 cases of Barrett's oesophagus and 19 cases of erosive oesophagitis (LA grade B or higher). The rate of SEF in patients with alarm features was 4/80 (5.0%) compared with 20/222 (9.0%) in patients without alarm features, with odds ratio of 0.53 (0.18–1.61; P = 0.263). The rate of SEF in patients who had endoscopy performed within guidelines was 21/246 (8.5%) compared with 3/56 (5.4%) done outside of guidelines, with odds ratio of 1.65 (0.47–5.73; P = 0.432). CONCLUSION: 18.5% of endoscopies for investigation of dyspepsia in patients aged 18 to 54 years were performed outside of guidelines as they did not have any alarm features nor a trial of PPI beforehand. However, this subgroup of patients had a clinically significant SEF rate of 5.4%. A negative endoscopy itself has direct clinical utility as it relieves patient anxiety from the fear of having an underlying serious disorder and facilitates a diagnosis of functional dyspepsia so that tailored treatment can be provided. A substantial number of patients did not have a PPI trial prior to referral, suggesting that many primary care physicians are unaware of the guidelines, which can be addressed with focused education and clear referral guidelines.