Treatment of GERD evolving

This article is part of the Medical Economics Business of Health: Gastrointestinal Disorders resource center.

The overuse of medical tests and procedures has become a major issue of concern in the United States as awareness grows about the fact that more medicine isn’t necessarily better medicine and concerns over ever-rising healthcare costs reach a fevered pitch.

The nonprofit Institute of Medicine estimates $765 billion worth of waste in the U.S. healthcare system annually, $210 billion of which is comprised of unnecessary medical services. And although physicians tell Medical Economics that reducing bloated healthcare costs is healthy, defensive medicine sometimes is necessary to protect against litigation and should be factored into any discussion focused on the merits, use, and cost/value proposition associated with certain diagnostic tests. (See “Addressing patient concerns,” below.)

Gastrointestinal (GI) disorders, including conditions such as gastroesophageal reflux disease (GERD), are no exception. In fact, GERD, a chronic digestive disease marked by acid reflux, is the most common GI-related diagnosis, representing 8.9 million patient visits. And outpatient GI endoscopy exams alone, which are commonly used to diagnose GERD and rule out related illness, cost the healthcare system $32.4 billion annually, according to the Centers for Disease Control and Prevention (CDC).

“I see people daily who are treated for GERD. It may not be why they are there in my clinic, but I am definitely seeing them every day,” says Dean Seehusen, MD, MPH, an American Academy of Family Physicians (AAFP) member and co-author of the AAFP paper “Managing chronic gastroesophageal reflux disease.”

Both the frequency of the ailment and the high cost of testing associated with it are particularly relevant to internal and family medicine physicians, given how common it is for patients to present with heartburn and GERD in the primary care setting.

The testing conundrum

Also relevant, but often overlooked, is the evidence demonstrating that upper GI endoscopy to diagnose GERD and/or rule out other related illnesses is performed unnecessarily in many cases.

According to Nicholas Shaheen, MD, MPH, director of Center for Esophageal Diseases and Swallowing at the University of North Carolina School of Medicine, Chapel Hill, the literature shows that 10% to 40% of upper endoscopies performed for GI concerns do not conform to clinical guidelines.

What’s more, the rate at which upper endoscopy is used is increasing. Nationwide, a 40% increase has occurred in its use in the past decade among Medicare patients. On average, upper endoscopy costs more than $800 per examination, according to the American College of Physicians (ACP).

“We’re spending a lot of money,” Shaheen adds. Much of that money is spent with scant evidence to support the use of endoscopy in diagnosing GERD, experts say.

According to Seehusen, if the clinical picture fits GERD with no other complications, such as a patient who is coughing up blood, has difficulty swallowing, or is losing weight, then it is easy and relatively inexpensive to perform a trial of treatment, including lifestyle modification and medications. “If you do a trial of treatment and it helps, then you pretty much have your diagnosis,” Seehusen says.

Still, the pressure to test can be great, particularly in patients whose conditions don’t improve over time.

“All of us want to do right by our patients but are often not sure of what’s useful and what will be helpful. There is just so much to keep up with,” says Molly Cooke, MD, president of the ACP.

When the condition is long-standing, many physicians understandably worry about the possibility of missing something more serious, such as esophageal cancer or Barrett’s esophagus.

“Heartburn is extremely common, and all physicians appreciate that some patients with chronic heartburn end up with esophageal cancer,” Cooke says. “It’s a little like the headache and brain tumor situation. The vast majority of people with a headache don’t develop a brain tumor, but many patients with tumors have headaches. To decide is hard.”

Guidelines can be tough to follow

A lack of clarity in the professional guidelines is another major cause of endoscopy overuse.

“We as a field have done a good job of confusing generalists about when to do this test. Part of what we see in terms of inappropriate utilization is our own fault for not giving people unambiguous guidance,” says Shaheen, a gastroenterologist and lead author of the ACP’s new guidelines, which indicate that endoscopy should not be used to screen for GERD in the general population. The guidelines were developed for internal medicine and family physicians as well as other clinicians who diagnose and treat GERD.

The ACP clinical guidelines, published in the December 2012 edition of the Annals of Internal Medicine (see http://annals.org/article.aspx?articleid=1470281), outline the confusion caused by competing guidelines among three major U.S. gastroenterologic professional societies.

“The American Society of Gastrointestinal Endoscopy recommends that screening upper endoscopy be considered ‘in selected patients with chronic, longstanding GERD.’ They identify frequent GERD symptoms (several times per week), chronic GERD symptoms (symptoms for >5 years), age older than 50 years, white race, male sex, and nocturnal reflux symptoms as risk factors.

American Gastroenterological Association guidelines recommend against screening the general population with GERD for Barrett esophagus and esophageal adenocarcinoma but say that it should be considered in patients with GERD who have several risk factors associated with esophageal adenocarcinoma, including age 50 years or older, male sex, white race, hiatal hernia, elevated body mass index, and intra-abdominal distribution of fat. Neither the relative importance of these risk factors nor the number of risk factors necessary to trigger screening is stated.

“Lastly, the American College of Gastroenterology guidelines note that ‘screening for Barrett’s esophagus in the general population cannot be recommended at this time. The use of screening in selective populations at higher risk remains to be established, and therefore should be individualized.’ They, too, note GERD symptoms and body mass index as risk factors for Barrett esophagus. As acknowledged by the authors, formulation of these guidelines was hampered by the generally poor quality of data about the use of endoscopic screening and surveillance programs. In many cases, expert opinion formed the basis for specific recommendations.”

Two particular aspects of the new ACP guidelines stand out among its previous guidelines and those of the other societies:

• Upper endoscopy should not be routinely performed in a woman of any age.

• Men aged fewer than 50 years who have heartburn should not routinely be screened via upper endoscopy.
   

The incidence of cancer in both these populations is very low.

“Before this guideline, people didn’t make that much note of gender,” Shaheen says.

In fact, a woman with heartburn has a lower risk of esophageal cancer than a man without heartburn. “It doesn’t make a lot of sense to be scoping the women with heartburn but not the men without heartburn if you want to stop the cancer,” Shaheen says.

In the end, heartburn, it seems, is not a very useful marker of cancer risk. In fact, esophageal cancer in heartburn sufferers affects only about one in 2,500 patients aged more than 50 each year, according to a 2012 report by Consumer Reports, the ACP, and the Annals. Even among people with Barrett’s esophagus, the risk of cancer is quite low.

The new aspects of the ACP guidelines that address upper endoscopy use in women and men aged fewer than 50 years are impactful, Cooke says. “From my perspective as a clinician, I didn’t appreciate how vanishingly low the risk of esophageal cancer is in women.”

Other pressures that push doctors to scope

Another possible reason cited for the use of endoscopy ties in with physicians’ concern over missing a diagnosis of cancer. People with unexplored symptoms could be viewed by their doctors as having a higher medical-legal risk.

Then there’s the culture of expectation among some groups of patients that their symptoms be fully explored. Americans have become accustomed to being repeatedly checked for a medical problem. In some cases, that approach is clinically advisable, but not so in the case of GERD.

Of course, the economics of testing and its benefit to endoscopists’ business cannot be overlooked as another possible cause of overuse.

As new budget-based payment models associated with accountable care organizations, medical homes, and shared savings programs increase in prominence compared with traditional fee-for-service models, those incentives likewise will shift.

Helping to reduce unnecessary testing

Physicians can examine the use of tests for patients with GERD in several ways:

A patient with chronic heartburn for 5 years who has had a single endoscopy that was clear does not need to be tested again unless other troublesome symptoms, such as anemia, weight loss, or difficulty swallowing, arise. Most cancers show up early on in a patient experiencing symptoms. If it didn’t show in the initial test, therefore, it’s unlikely to be an issue, Shaheen says. “That’s an easy one to get rid of.”

Eliminate endoscopy testing for women without red-flag symptoms and men aged fewer than 50 years.

Use your electronic health record (EHR) system to support effective testing. “The holy grail would be the integration of guidelines into the medical record,” Cooke says. EHRs can be used as a powerful education tool for patients with GERD.

Consider step therapy, in which the least expensive treatment to manage GERD is used as a first step, Seehusen of the AAFP suggests.

Helping patients make lifestyle changes also could help reduce short- and long-term costs.

“Limiting your diagnostics to only those patients who you have a high index of suspicion for underlying Barrett’s or underlying malignancy is the right answer,” Seehusen adds. 

Addressing patient demands

In an era in which patients often read about conditions and treatments before visiting a physician’s office, how can you reassure a patient who insists on a particular treatment when current guidelines and your judgment determine that is not warranted?

Medical guidelines such as those related to upper endoscopy can serve as a good starting point for a discussion, and the American College of Physicians has created a video (see www.MedicalEconomics.BOHGERD) and patient materials (www.acponline.org/clinical_information/gerd_patient_brochure.pdf) to help you explain current medical thinking about appropriate and necessary treatment and the evidence behind that thinking. Viewing these materials can help your patients understand the approach you are recommending-which you should arrive at after considering guidelines, applying medical knowledge and skill, and exercising reasonable care and best judgment. A strong physician-patient relationship can build trust.

If patient education is not successful and you’re worried that you could be sued for malpractice if you don’t acquiesce to patient demands, following the standard of care-and documenting in the medical record that you have done so-can be protective, according to Lee J. Johnson, JD, a health law attorney in Mount Kisco, New York, and a Medical Economics editorial consultant. You meet the standard of care if you:

• Did something a “reasonably prudent” physician would do under similar circumstances.

• Didn’t do something a reasonably prudent doctor would not have done under similar circumstances.

• Demonstrate the knowledge and ability that is expected of doctors who provide the service in question.

For resource centers related to gastroesophageal reflux disease and other topics in our Business of Health series, including hypertension, obesity, immunization, pain management, and circulatory disorders, as well as collections of articles related to our EHR Best Practices Study, Patient-Centered Medical Homes, and accountable care organizations, see www.MedicalEconomics.com/ResourceCenterIndex.