Screening for Barrett's Esophagus.

Barrett's esophagus (BE) increases the risk for development of esophageal adenocarcinoma. Because of the rapid rise in incidence of esophageal adenocarcinoma, screening for BE with subsequent surveillance when found has been proposed as a method of early detection. Sedated endoscopy, however, is too expensive for wide spread screening. As a result, other techniques including unsedated transnasal esophagoscopy and capsule esophagoscopy have been proposed to expand screening programs.

Downstream hospital charges generated from endoscopic ultrasound procedures are greater than those from colonoscopies.

BACKGROUND & AIMS: Endoscopic ultrasound is a clinically valuable endoscopic platform, although a potential barrier to its widespread use is the modest reimbursement to the hospital, compared with that of standard endoscopy. However, the downstream procedures generated by endoscopic ultrasound findings might offset its modest procedural reimbursement for a hospital or health care system. We compared the number of hospital procedures that resulted from endoscopic ultrasound findings with those from colonoscopy findings and also compared the downstream hospital charges generated by endoscopic ultrasounds with those from colonoscopies. METHODS: We retrospectively reviewed data from 920 consecutive endoscopic ultrasounds and 920 consecutive colonoscopies performed at University Hospital in Cincinnati, Ohio to determine the downstream procedures generated within 18 months of the index procedure. Total hospital charges were determined for the index procedures, as well as all downstream surgeries, endoscopic procedures, and radiation therapy, chemotherapy, and interventional radiology procedures. RESULTS: Endoscopic ultrasounds led to a greater number of downstream procedures than colonoscopies (198 vs 34). Hospital charges for downstream procedures that arose from endoscopic ultrasounds were 2.63-fold greater than those of colonoscopies ($4,068,115 vs $1,546,291). Hospital charges that resulted from the 920 index endoscopic ultrasounds were 1.34-fold greater than those of the index colonoscopies ($3,194,715 vs $2,381,745). Thus, the total hospital charges (index procedures plus downstream procedures) that arose from endoscopic ultrasounds were 1.85-fold greater than those of colonoscopies ($7,262,830 vs $3,928,036). CONCLUSIONS: Endoscopic ultrasounds generate greater downstream hospital charges than colonoscopies. These downstream charges attenuate the higher procedure-related charges of colonoscopy for a hospital.

Ultrathin esophagoscopy in screening for Barrett's esophagus at a Veterans Administration Hospital: easy access does not lead to referrals.

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.