Prevention of overuse: A view on upper gastrointestinal endoscopy

Table 1 Description of studies using a guideline implementation strategy to reduce upper gastrointestinal endoscopies

Study	Country	Sample	Strategy	Effect on UGIE referrals
Cardin et al[18], 2005	Italy	2098 patients	Distribution of a locally adapted international guideline, changing referral criteria.	Reduction: 63% (at first) and 42% (at repeat presentation)
Elwyn et al[20], 2007	United Kingdom	215 PCPh, 359 hospital physicians	Feedback on referrals after distribution of adapted guideline.	Reduction: PCPh 9% (NS), Hospital physicians 31%
Banait et al[21], 2003	United Kingdom	114 PCPr	Educational program, including workshops, hand-outs, and reinforcement visit (intervention), vs passive guideline dissemination (control)	Appropriateness of referrals: Intervention 73%, Control 50%
Shaw et al[22], 2006	United Kingdom	47 PCPr	Promotion of HP testing, serology service, and treatment advice (intervention), vs reserved approach to HP testing	Reduction: Intervention: 27%, Control: 4%

PCPh: Primary care physicians; PCPr: Primary care practices; NS: Non-significant; HP: Helicobacter pylori; UGIE: Upper gastrointestinal endoscopy.

Table 2 Description of studies using a clinical assessment strategy to reduce upper gastrointestinal endoscopies

Study	Country	Sample	Strategy	Effect on UGIE referrals
Rutter et al[30], 1998	United Kingdom	485 visits	Patient assessment in one-stop dyspepsia clinic	Cancelled: 6%
Mourad et al[31], 1998	United Kingdom	272 visits	Patient assessment in one-stop dyspepsia clinic	Cancelled: 14%
Baldasarre et al[32], 2016	Italy	5192 referrals	Assessment of referral letters and biomarker panel for atrophic gastritis	Cancelled: 10%
Pelitari et al[33], 2017	United Kingdom	14,245 patients	Virtual assessment system to decide on best pathway for dyspeptic patients	32% no face-to-face appointment (not UGIE specific)
Horowitz et al[34], 2007	Israel	138 patients	Decision tree for symptom management, based on presenting symptoms	Reduction: 35%

UGIE: Upper gastrointestinal endoscopy.

Table 3 Description of studies using a Helicobacter pylori test and treat strategy to reduce upper gastrointestinal endoscopies

Study	Country	Sample	Strategy	No endoscopy after HP test and treat
Hu et al[43], 2006	China	161 patients	UGIE vs HP testing (UBT) + eradication (HP+) or Cisapride (HP-).	Symptom relief: 44%. Endoscopy for all after 6 weeks.
Mahadeva et al[44], 2008	Malaysia	432 patients	UGIE vs HP testing (UBT) + eradication (HP+) or reassurance and/or empirical treatment (HP-)	89%
Arents et al[45], 2003	Netherlands	270 patients	UGIE vs HP testing (serology) + eradication (HP+) or Cisapride (HP-)	68%
Laheij et al[46], 2004	Netherlands	199 patients	UGIE vs omeprazole 2 wk followed by UGIE (no improvement) or HP serology testing (relapse) + eradication (HP+)	94%
Duggan et al[47], 2008	United Kingdom	584 patients	UGIE vs HP test + endoscopy (HP+) vs HP testing (serology) + eradication and/or endoscopy (HP+) or Lanzoprazole (HP-).	73%
Heaney et al[49], 1999	United Kingdom	104 patients	All received HP testing (UBT). Randomization of HP+ patients: UGIE or eradication therapy.	73%
McColl et al[50], 2002	United Kingdom	708 patients	UGIE vs HP testing (UBT) + eradication (HP+).	92%
Lassen et al[51], 2000	Denmark	500 patients	UGIE vs HP testing (UBT) + eradication (HP+), PPI (HP-, NSAID-, reflux+), or lifestyle advice (HP-, NSAID-, reflux-)	60%
Fraser et al[48], 2003	New Zealand	173 patients	All received UBT and eradication if HP+	76%
Slade et al[53], 1999	United Kingdom	232 patients	All received HP serology testing + UGIE (HP equivocal), eradication (HP+), or usual care (HP-).	73%
Patel et al[54], 1995	United Kingdom	183 patients	All received serology testing + UGIE for HP+, sinister symptoms, or NSAID use.	37% (after HP-)

UGIE: Upper gastrointestinal endoscopy; HP: Helicobacter pylori; UBT: Urea breath test, NSAID: Nonsteroidal anti-inflammatory drugs.

Table 4 Description of studies using an empirical treatment strategy to reduce upper gastrointestinal endoscopies

Study	Country	Sample	Strategy	UGIE avoided
Laheij et al[59], 1998	Netherlands	80 patients	2-wk PPI treatment. HP test and treat for persistent symptoms.	69%
Kjeldsen et al[60], 2007	Denmark	184 patients	UGIE vs 2-wk PPI treatment and HP testing + UGIE (no improvement, recurrence at age ≥ 45, or HP- and age < 45 yr), eradication (HP+ and age < 45 yr), or PPI 2 additional weeks (HP-, age < 45 yr, and reflux+)	63%
Bytzet et al[62], 1994	Denmark	206 patients	4 weeks H2RA treatment	34%

UGIE: Upper Gastrointestinal endoscopy; PPI: Proton pump inhibitor; HP: Helicobacter pylori; H2RA: Histamine-2 receptor antagonists.