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New evidence-based paper aims to inform patients and
physicians about current and effective standards of care
Video News Story | Patient
PHILADELPHIA, December 4, 2012 -- Heartburn is one of the most
common reasons for people to see a doctor, and some physicians
often use upper endoscopy to diagnose and manage gastroesophageal
reflux disease (GERD). But most patients do not require the
procedure unless other serious symptoms are present, according to
the American College of Physicians (ACP) Clinical Guidelines
Committee in a new evidence-based clinical policy paper published
today in Annals of Internal Medicine.
"The evidence indicates that upper endoscopy is indicated in
patients with heartburn only when accompanied by other serious
symptoms such as difficult or painful swallowing, bleeding, anemia,
weight loss, or recurrent vomiting," said David L. Bronson, MD,
FACP, president, ACP. "The procedure is not an appropriate first
step for most patients with heartburn."
ACP advises that screening with upper endoscopy should not be
routinely performed in women of any age or in men under the age of
50 with heartburn because the incidence of cancer is very low in
Upper endoscopy is indicated in patients with heartburn who are
unresponsive to medicine (proton pump inhibitors) to reduce gastric
acid production for a period of four to eight weeks or who have a
history of narrowing or tightening of the esophagus with recurrent
difficult or painful swallowing.
Screening with upper endoscopy may be indicated in men over 50
with multiple risk factors for Barrett's esophagus, which include
heartburn for more than five years, nocturnal reflux symptoms,
hiatal hernia, elevated body mass index, tobacco use, and fat
within the abdominal cavity. If an initial screening exam is
negative for Barrett's esophagus or esophageal cancer, recurrent
periodic upper endoscopy is not indicated.
Among patients found to have Barrett's esophagus, upper
endoscopy is indicated every three to five years. More frequent
endoscopic examinations are reserved for patients with low- or
high-grade dysplasia because of the higher risk of progression to
Physicians should utilize education strategies to inform
patients about current and effective standards of care. Medicine to
reduce gastric acid production is warranted in most patients with
typical GERD symptoms such as heartburn or regurgitation.
"Inappropriate use of upper endoscopy does not improve the
health of patients, exposes them to preventable harms, may lead to
additional unnecessary interventions, and results in unnecessary
costs with no benefit," said Dr. Bronson.
Factors that contribute to overuse of upper endoscopy include
differing recommendations from professional medical organizations,
medico-legal liability concerns, and patient and caregiver
Unnecessary costs include the procedure itself (excess of $800
per exam) when it is not indicated and downstream costs of
unnecessary follow up tests because of an original
"Upper Endoscopy for Gastroesophageal Reflux: Best Practice
Advice from the American College of Physicians" and a corresponding
patient summary appear in the December 4 issue of Annals of
Internal Medicine, published by ACP.
As part of the collaboration between ACP and Consumer Reports, a
Value Care: Upper Endoscopy for GERD" brochure is available to
help patients understand the benefits, harms, and costs of upper
endoscopy for GERD.
ACP launched a High Value
Care initiative in 2010 to help physicians provide the best
possible care to their patients while simultaneously reducing
unnecessary health care costs. ACP defines high value care as the
delivery of services providing benefits that make their harms and
Value is not merely cost. Some expensive tests and treatments
have high value because they provide high benefit and low harm.
Conversely, some inexpensive tests or treatments have low value
because they do not provide enough benefit to justify even their
low costs and might even be harmful.
ACP's evidence-based recommendations aim to educate physicians
and patients about how to pursue care together that improves
health, avoids harms, and eliminates wasteful practices.
About the American College of Physicians
The American College of Physicians is
the largest medical specialty organization and the second-largest
physician group in the United States. ACP members include 133,000
internal medicine physicians (internists), related subspecialists,
and medical students. Internal medicine physicians are specialists
who apply scientific knowledge and clinical expertise to the
diagnosis, treatment, and compassionate care of adults across the
spectrum from health to complex illness. Follow ACP on Twitter and Facebook.