Department of Gastroenterology, Radboud University Medical Center, Nijmegen 6500 HB, The Netherlands.
World J Gastroenterol. 2019 Jan 14;25(2):178-189. doi: 10.3748/wjg.v25.i2.178.
Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.
世界上许多上消化道（GI）内窥镜检查是针对不适当的适应症进行的。这种医疗保健的过度使用对医疗保健质量产生负面影响，并给内窥镜服务带来压力。消化不良是上消化道内窥镜检查最常见的不适当适应症之一，因为诊断率较低。转介不及时的原因是：不熟悉消化不良指南、对症状病因不确定以及治疗失败。未经过滤的开放转诊导致上消化道内窥镜检查过度使用。这篇综述强调了用于减少消化不良上消化道内窥镜检查使用的策略。首先，我们描述了积极实施指南的影响。我们发现了对指南的更好的遵守，但在这个过程中遇到了阻力。其次，我们展示了几种临床评估形式。虽然使用算法减少了上消化道内窥镜检查的数量，但对个别患者的转诊评估的影响较小。第三个建议的策略是对所有消化不良患者进行“测试和治疗”。使用这种策略可以避免许多上消化道内窥镜检查，但结果可能与患病率有关。最后，质子泵抑制剂的经验性治疗缓解了消化不良的症状，并避免了大约三分之二的患者进行上消化道内窥镜检查。改变转诊行为是复杂的，因为影响因素很多。多种策略的合作最有可能取得成功。
