Heiko Pohl, MD; Douglas Robertson, MD, MPH; H. Gilbert Welch, MD, MPH
Disclaimer: The findings, statements, and views expressed are those of the authors and do not necessarily represent those of the Medicare Payment Advisory Commission, the U.S. Department of Veterans Affairs, or the U.S. government. All authors had full access to all of the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis.
Acknowledgment: The authors thank Mark Miller, Kevin Hayes, and Carol Frost of the Medicare Payment Advisory Commission for obtaining the data and assisting with the analysis. They also thank Dr. Corey A. Siegel and Dr. L. Campbell Levy from the Section of Gastroenterology at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, for their dedicated assistance with additional analysis in the revision process.
Financial Support: The research underlying this article was completed with support from the Medicare Payment Advisory Commission.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0046.
Reproducible Research Statement: Study protocol: Study algorithm available from Dr. Pohl (e-mail, email@example.com). Statistical code: Not available. Data set: Available from Dr. Pohl (e-mail, firstname.lastname@example.org).
Requests for Single Reprints: Heiko Pohl, MD, Department of Gastroenterology, Veterans Affairs Medical Center, 215 North Main Street, White River Junction, VT 05009; e-mail, email@example.com.
Current Author Addresses: Drs. Pohl, Robertson, and Welch: Department of Gastroenterology, Veterans Affairs Medical Center, 215 North Main Street, White River Junction, VT 05009.
Author Contributions: Conception and design: H. Pohl, D. Robertson, H.G. Welch.
Analysis and interpretation of the data: H. Pohl, D. Robertson, H.G. Welch.
Drafting of the article: H. Pohl, H.G. Welch.
Critical revision of the article for important intellectual content: H. Pohl, D. Robertson, H.G. Welch.
Final approval of the article: H. Pohl, D. Robertson, H.G. Welch.
Statistical expertise: H.G. Welch.
Administrative, technical, or logistic support: H.G. Welch.
Collection and assembly of data: H.G. Welch.
Pohl H, Robertson D, Welch HG. Repeated Upper Endoscopy in the Medicare Population: A Retrospective Analysis. Ann Intern Med. 2014;160:154-160. doi: 10.7326/M13-0046
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Published: Ann Intern Med. 2014;160(3):154-160.
Esophagogastroduodenoscopy (EGD) is done often for various indications. Little is known about the frequency of repeated EGD and the diagnoses that drive it.
To describe the frequency of repeated EGD in the Medicare population and determine diagnoses most often associated with it.
Among a 5% random sample of Medicare beneficiaries, Current Procedural Terminology (CPT) codes were used to identify patients who had an index EGD between 2004 and 2006. Diagnoses from the International Classification of Diseases, Ninth Revision, Clinical Modification, reported for the index endoscopy were divided into 3 diagnostic groups on the basis of whether the index diagnosis suggested that repeated EGD was expected, uncertain, or not expected.
Proportion of patients with repeated EGD within 3 years of an index EGD.
Approximately 12% of Medicare beneficiaries had an EGD between 2004 and 2006 (n = 108 785). Of these, 33% (n = 36 331) had at least 1 repeated EGD within 3 years. Of all patients with initial EGDs, 10% (n = 11 370) had an associated diagnosis suggesting a need for follow-up examination, whereas 61% (n = 66 307) did not. Of all patients with repeated examinations, 54% (n = 19 687) came from the group in which repeated EGD was not expected. When new clinical events were excluded, 43% of all patients with repeated EGDs (n = 15 706) did not have a diagnosis at index or repeated EGD that justified a repeated examination.
Whether individual procedures were clinically indicated cannot be verified.
One in 3 Medicare beneficiaries who received an EGD had a repeated EGD within 3 years. Nearly one half of repeated examinations were done in patients with diagnoses at index or repeated EGD that did not suggest the need for a repeated examination.
Esophagogastroduodenoscopy (EGD) is commonly done, and concerns have been raised about potential overuse. However, little is known about how frequently EGD is repeated.
This study found that approximately 12% of Medicare beneficiaries had EGD over 3 years; of these, about one third had repeated EGD within this period. About one half of all repeated EGDs followed an initial procedure coded in a manner not suggestive of a need to repeat the examination.
The accuracy of diagnostic codes for identifying the need for follow-up EGD is unknown.
A substantial proportion of Medicare recipients have repeated EGDs, many of which might not be required. Further evaluation of possible overuse is warranted.
Appendix Table 1.Upper Gastrointestinal Endoscopy CPT Codes Applied for the Analysis of Upper Endoscopy Use in the Medicare Population
Study flow diagram.
EGD = esophagogastroduodenoscopy.
* The proportions in the Repeated EGD cells do not sum to 100% because 5% of repeated examinations were in the unclassified category.
Table 1. Diagnoses at Index EGD and Frequency of Repeated Examinations
Table 2. Patients With Repeated EGD Not Expected and Diagnosis Unchanged*
Table 3. Patients With Repeated EGD Not Expected and New Clinical Event*
Appendix Table 2.Pairing of Index and Repeated EGD Diagnoses That Did or Did Not Justify a Repeated Procedure Among All Patients for Whom Repeated EGD Was Not Expected*
Repeated EGD in the Medicare population.
The left portion of the figure shows the number of beneficiaries having upper endoscopy and the proportion of procedures repeated in 3 diagnostic groups. The right portion shows the distribution of diagnostic groups among all repeated examinations. EGD = esophagogastroduodenoscopy.
Appendix Table 3. Proportions of Patients With an Intervention at Index EGD Among All Patients for Whom Repeated EGD Was Not Expected*
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Gastroenterology/Hepatology, Healthcare Delivery and Policy, Peptic Disease, Gastroesophageal Reflux Disease.
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