Volume 7, Issue 7 , Pages 756-761, July 2009
Cost of Detecting Malignant Lesions by Endoscopy in 2741 Primary Care Dyspeptic Patients Without Alarm Symptoms
Background & Aims
Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy.
Methods
We studied 2741 primary-care outpatients, 18–70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment.
Results
Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714–$250,000) to detect each case of cancer.
Conclusions
Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.
Abbreviations used in this paper: GI, gastrointestinal, NSAIDs, nonsteroidal anti-inflammatory drugs
Conflicts of Interest The authors disclose the following: Nicholas J. Talley, MD–Consultant: Altana, AstraZeneca, Axcan, Chugai, EBMed, Giaconda, GlaxoSmithKline, Kosan, KV Pharmaceuticals, Medscape, ProEd Communications, Renovis, Inc, Solvay, Strategic Consultants International, Takeda Pharmaceuticals, TAP Pharmaceutical Products, Inc, Therapeutic Gastrointestinal Group, Theravance, and Yamanouchi; Research Support: Merck, Novartis, Tap Pharmaceuticals, Axcan, Bohringer-Ingelheim, and Forest. Nimish Vakil, MD–Consultant: AstraZeneca, Takeda, Axcan, Xenoport, Orexo, and Merlion; Grant support: Astra-Zeneca, AGI, Xenoport, Eisai, and Addex. Sander Veldhuyzen van Zanten, MD–Research support: AstraZeneca; Speaker: AstraZeneca; Advisory Boards: National (in Canada) and International for AstraZeneca. Nigel Flook, MD–Continuing Medical Learning–Development: Abbott, Altana, AstraZeneca, Axcan, Bristol-Meyers Squibb, GlaxoSmithKline, Hoffman La Roche, McNeill, Janssen-Ortho, Merck, Novartis, Oryx, Parkhurst, Pfizer, Sanofi Aventis, Schering, Whitehall Robins, and Wyeth; Speaker: Abbott, AstraZeneca, Bristol-Meyers Squibb, GlaxoSmithKline, Hoffman La Roche, McNeill, Janssen-Ortho, Merck, Novartis, Pfizer, Sanofi Aventis, Whitehall Robins, and Wyeth; Advisory Board Member: AstraZeneca, Bristol-Meyers Squibb, Janssen-Ortho, Oryx, and Pfizer; Research: AstraZeneca, Novartis, and Sanofi Aventis. The remaining authors disclose no conflicts.
Funding This research was supported by AstraZeneca R&D Sweden. The sponsor did not play any role in the calculations or in the writing of the manuscript.
PII: S1542-3565(09)00317-6
doi:10.1016/j.cgh.2009.03.031
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
Volume 7, Issue 7 , Pages 756-761, July 2009
