Archive for November, 2008

Upper GI Endoscopy and the Disappearing Barium Study III

Sunday, November 16th, 2008

Comparative Costs of Upper GI series and Endoscopy

A complete upper GI X-ray study with barium (esophagus, stomach, with “follow through” including upper intestine) costs $272; Medicare allows $155 in a relatively high cost region (Philadelphia and suburban area).

An EGD or upper GI endoscopy is anywhere from three to six times as costly. This site quotes an average $1988, another URL quotes $1065, with almost half these charges including cost of anesthesia which is used in over 98% of patients. However, a breakdown of charges by geographical areas and including use of hospital endoscopy suites is difficult to obtain.

The Big Picture

Many obvious questions arise in the area of invasive imaging of the gastrointestinal tract when non-invasive X-ray studies are available, cheaper, and in 95% of cases superior, and without risk. The problem of audacious overuse of upper EGD is not limited to the U.S., since in Europe upper endoscopy is just as prevalent. Certainly upper GI endoscopy is a crucial method in the diagnosis of some gastrointestinal conditions, but in view of the problem of complications, even death, should it be an almost routine procedure in imaging the upper GI tract, when the much less costly upper GI study with barium, a procedure virtually without risk or complication, is available in every radiology department?

This is a question to be asked every physician who orders EGD and every insurer or HMO who pays for it. Certainly, I do not argue the need for EGD in cases of foreign body, upper GI bleeding, or the presence of ominous findings on the upper GI study. But if the upper GI were done first, 9.5 million or more of 10 million yearly EGD’s could be avoided with a savings to the health care system of $12 billion to $18 billion, not to mention tens of thousands of complications, and the saving of several hundred lives.

If there is any question about risk and complications of EGD, if you are asked to undergo the procedure, make sure you ask if an X-ray study could be substituted. Also read the informed consent which reveals all.

Why EGD has virtually replaced the upper GI barium in imaging patients with gastrointestinal complaints is a complicated question with economic overtones and a “politically correct” consensus driven by specialty groups. In the meantime, perhaps we can liken the inappropriate use of invasive studies for routine problems as a form of diagnostic seduction. Better yet, how about technological exuberance or invasive imperialism?

Martin F. Sturman, MD, FACP

Upper GI Endoscopy and the Disappearing Barium Study II

Thursday, November 6th, 2008

The feasibility of an operation is not the best indication for performance.  

Lord Cohen of Birkenhead (former physician to the Queen of England.)

Over 85 million Americans are affected by digestive complaints, the vast majority of which are benign conditions. In the past 10-15 years, the indications for imaging studies have been narrowed in view of the enormous effectiveness of drugs like Zantac©, Pepcid©, and the proton pump inhibitors, (“PPI’s”), such as Prevacid©, and Prilosec© in the 30 million patients with dyspepsia, ulcer, dyspepsia and most of the 65 million with reflux. Yet the number of EGD’s continues unabated.

Risk vs. Benefit in GI Imaging

Because EGD is so unpleasant that a struggling patient without proper restraint could suffer perforation of the esophagus or stomach, the procedure is done overwhelmingly with “conscious sedation.” That this term is a euphemism for general anesthesia with loss of protective reflexes, such as movement, gagging, cough, etc., is demonstrated by the virtual routine use of EKG and pulse oxygen monitoring during the procedure. Despite precautions, a distinct risk is introduced by the use of anesthesia; moreover, rare misadventures due to the performance of the procedure itself add to the dangers. Upper GI mortality occurs between 1 in 2,000 and 1 in 12,000 and morbidity in some 1 in 200. In one study the rate of occurrence of cardiovascular complications (defined as arrhythmia, chest pain or anginal equivalent, hypotension, or myocardial infarction occurring within 24 hours after endoscopy) was 308 per 100,000 procedures or 3 per 1000 procedures, “2 to 70 times higher than previously reported”!

Numerous other statistics are available, but often hidden in the literature. Reporting rates for drug reactions is estimated at 10%, but no one, to my knowledge, has kept global or national statistics on complication and mortality rate of procedures like EGD for over 25 years.

Transmission of infection such as hepatitis C, bacterial infections and even AIDS, via endoscopic instruments has been reported in the literature. Reports of pathogen transmission resulting from these procedures are rare, and each has been associated with a breach in accepted endoscope reprocessing and infection control protocols. But are these complicated and expensive procedures performed 100% of the time? Moreover, as with other complications and mortality, there remains the reporting problem which inevitably underestimates risk and misadventures.

More to follow.