Original Contribution | Published:

Endoscopy

Overuse of Repeat Upper Endoscopy in the Veterans Health Administration: A Retrospective Analysis

The American Journal of Gastroenterology volume 112, pages 16781685 (2017) | Download Citation

Abstract

Objectives:

Americans undergo 7 million esophagogastroduodenoscopies (EGDs) annually, and one-third of Medicare beneficiaries undergo a repeat EGD within 3 years. As many as 43% of these repeat EGDs are inappropriate. We aimed to determine the rate of repeat inappropriate EGD within the Veterans Health Administration (VHA), and identify factors associated with repeat EGD.

Methods:

We conducted retrospective analyses of Veterans undergoing an index EGD at 159 VHA facilities between 1 January 2003 and 30 June 2007. We excluded Veterans without regular use of VHA for health care or 5 years of follow-up. Appropriateness of repeat EGDs was classified based on diagnostic and procedure codes into three categories: Likely Appropriate, Possible Overuse, and Probable Overuse. The proportion of repeat EGDs in each category was tabulated. Multilevel logistic regression was performed to estimate the impact of patient-level and site-level factors on the odds of repeat EGD.

Results:

Of the 235,855 included Veterans, 85,690 (36.3%) underwent a repeat EGD within 5 years. Of the repeat EGDs, 42,412 (49.5%) were Likely Appropriate, 35,503 (41.4%) represented Possible Overuse, and 7,756 (9.1%) represented Probable Overuse. Patients with more frequent encounters with primary care providers and access to facilities performing EGD and with greater complexity of services were more likely to receive repeat EGD, regardless of whether the repeat EGD was appropriate or overuse. Women were slightly more likely to undergo repeat EGD in Probable Overuse situations.

Conclusions:

Overuse of repeat EGD is common in VHA despite the absence of financial incentives that promote overuse. Efforts are needed to better understand the motivations for overuse and barriers to appropriate use, and to promote appropriate use of repeat EGD.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

References

  1. 1.

    , , et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012;143:1179–87 e1-3.

  2. 2.

    , , et al. Overuse of health care services in the United States: an understudied problem. Arch Intern Med 2012;172:171–178.

  3. 3.

    , , et al. Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures. JAMA 1987;258:2533–2537.

  4. 4.

    , , et al. Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography. N Engl J Med 1990;323:1173–1177.

  5. 5.

    , , et al. Is the diagnostic yield of upper GI endoscopy improved by the use of explicit panel-based appropriateness criteria? Gastrointest Endosc 2000;52:333–341.

  6. 6.

    , , et al. Endoscopic evaluation of patients with dyspepsia: results from the national endoscopic data repository. Gastroenterology 2004;127:1067–1075.

  7. 7.

    , , et al. Barrett's esophagus on repeat endoscopy: should we look more than once? Am J Gastroenterol 2008;103:1892–1897.

  8. 8.

    , , . Repeated upper endoscopy in the Medicare population: a retrospective analysis. Ann Intern Med 2014;160:154–160.

  9. 9.

    , , et al. Role of quality measurement in inappropriate use of screening for colorectal cancer: retrospective cohort study. BMJ 2014;348:g1247.

  10. 10.

    , , et al. Changes in low-value services in year 1 of the medicare pioneer accountable care organization program. JAMA Intern Med 2015;175:1815–1825.

  11. 11.

    , , et al. Measuring low-value care in medicare. JAMA Intern Med 2014;174:1067–1076.

  12. 12.

    , , et al. Trends in the overuse of ambulatory health care services in the United States. JAMA Intern Med 2013;173:142–148.

  13. 13.

    , , et al. The quality of care provided to patients with varices in the Department of Veterans Affairs. Am J Gastroenterol 2014;109:934–940.

  14. 14.

    , . Developing quality measures to address overuse. JAMA 2013;309:1897–1898.

  15. 15.

    , , et al. The state of overuse measurement: a critical review. Med Care Res Rev 2013;70:473–496.

  16. 16.

    , , . Response of regurgitation to proton pump inhibitor therapy in clinical trials of gastroesophageal reflux disease. Am J Gastroenterol 2011;106:1419–1425 quiz 1426.

  17. 17.

    , , . Response of unexplained chest pain to proton pump inhibitor treatment in patients with and without objective evidence of gastro-oesophageal reflux disease. Gut 2011;60:1473–1478.

  18. 18.

    , , et al. The efficacy of proton pump inhibitors in nonulcer dyspepsia: a systematic review and economic analysis. Gastroenterology 2004;127:1329–1337.

Download references

Acknowledgements

VHA OIA reviewed the manuscript before submission. The opinions expressed in this paper are of the authors and do not necessarily reflect those of the Department of Veterans Affairs..

Author information

Affiliations

  1. Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA

    • Joel H Rubenstein
    • , Megan A Adams
    • , Eve Kerr
    • , Robert Holleman
    • , Sandeep Vijan
    •  & Sameer D Saini
  2. Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA

    • Joel H Rubenstein
    • , Megan A Adams
    • , Eve Kerr
    • , Sandeep Vijan
    •  & Sameer D Saini
  3. Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA

    • Joel H Rubenstein
    • , Megan A Adams
    • , Eve Kerr
    • , Sandeep Vijan
    •  & Sameer D Saini
  4. White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA

    • Heiko Pohl
  5. Division of Gastroenterology, Dartmouth Medical School, Lebanon, New Hampshire, USA

    • Heiko Pohl
  6. VA Puget Sound Healthcare System, Seattle, Washington, USA

    • Jason A Dominitz
  7. Division of Gastroenterology, Department of Internal Medicine, University of Washing Medical School, Seattle, Washington, USA

    • Jason A Dominitz
    •  & John M Inadomi
  8. Durham Veterans Affairs Medical Center, Durham, North Carolina, USA

    • Dawn Provenzale
  9. Division of Gastroenterology, Department of Internal Medicine, Duke University Medical School, Durham, North Carolina, USA

    • Dawn Provenzale
  10. Veterans Health Administration, Washington, District of Columbia, USA

    • Joseph Francis

Authors

  1. Search for Joel H Rubenstein in:

  2. Search for Heiko Pohl in:

  3. Search for Megan A Adams in:

  4. Search for Eve Kerr in:

  5. Search for Robert Holleman in:

  6. Search for Sandeep Vijan in:

  7. Search for Jason A Dominitz in:

  8. Search for John M Inadomi in:

  9. Search for Dawn Provenzale in:

  10. Search for Joseph Francis in:

  11. Search for Sameer D Saini in:

Competing interests

Guarantor of the article: Joel H. Rubenstein, MD, MS.

Specific author contributions: J.H.R.: design, analysis, interpretation of data, and drafting the manuscript; H.P. and S.D.S.: design, interpretation of data, and critical revision of the manuscript; M.A.A.: acquisition of data, interpretation of data, and critical revision of the manuscript; E.K. and J.F.: interpretation of data, critical revision of the manuscript, and obtaining funding; R.H.: acquisition and analysis of data and critical revision of the manuscript; S.V.: design, interpretation of data, and critical revision of the manuscript; J.A.D., J.M.I., and D.P.: interpretation of data and critical revision of the manuscript.

Financial support: Funding for this work was provided in part by the Veterans Health Administration (VHA) Office of Informatics and Analytics (OIA). J.H.R. was supported by VHA grant I01-CX000899. S.D.S. was supported by VA Health Services Research and Development grant CDA 09-213-2. These funding agencies had no role in the design and conduct of the study.

Potential competing interests: None.

Corresponding author

Correspondence to Joel H Rubenstein.

Supplementary information

About this article

Publication history

Received

Accepted

Published

DOI

https://doi.org/10.1038/ajg.2017.192

SUPPLEMENTARY MATERIAL is linked to the online version of the paper at http://www.nature.com/ajg