Rubenstein Joel H, Pohl Heiko, Adams Megan A, Kerr Eve, Holleman Robert, Vijan Sandeep, Dominitz Jason A, Inadomi John M, Provenzale Dawn, Francis Joseph, Saini Sameer D
Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.
Am J Gastroenterol. 2017 Nov;112(11):1678-1685. doi: 10.1038/ajg.2017.192. Epub 2017 Jul 11.
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.
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.
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.
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.
美国人每年接受约700万次食管胃十二指肠镜检查（EGD），三分之一的医疗保险受益人在3年内接受重复EGD检查。这些重复EGD检查中多达43%是不恰当的。我们旨在确定退伍军人健康管理局（VHA）内重复不恰当EGD检查的发生率，并确定与重复EGD检查相关的因素。
我们对2003年1月1日至2007年6月30日期间在159个VHA机构接受首次EGD检查的退伍军人进行了回顾性分析。我们排除了未定期使用VHA进行医疗保健或无5年随访记录的退伍军人。根据诊断和程序代码，将重复EGD检查的适宜性分为三类：可能适宜、可能过度使用和很可能过度使用。列出了每类重复EGD检查的比例。进行多水平逻辑回归以估计患者层面和机构层面因素对重复EGD检查几率的影响。
在纳入的235,855名退伍军人中，85,690人（36.3%）在5年内接受了重复EGD检查。在重复EGD检查中，42,412人（49.5%）可能适宜，35,503人（41.4%）代表可能过度使用，7,756人（9.1%）代表很可能过度使用。与初级保健提供者接触更频繁、能够使用进行EGD检查的机构且服务更复杂的患者更有可能接受重复EGD检查，无论重复EGD检查是否恰当或属于过度使用。在很可能过度使用的情况下，女性接受重复EGD检查的可能性略高。
尽管缺乏促进过度使用的经济激励措施，但VHA中重复EGD检查的过度使用情况仍然常见。需要努力更好地了解过度使用的动机和恰当使用的障碍，并促进重复EGD检查的恰当使用。
