Overuse and underuse of diagnostic upper gastrointestinal endoscopy in various clinical settings.

OBJECTIVES To describe and compare both overuse and underuse of diagnostic upper gastrointestinal endoscopy in different settings. DESIGN Merging of data from three prospective observational studies. The appropriateness and necessity of indications for gastroscopy were evaluated using explicit criteria developed by a standardized expert panel method (RAND-UCLA). Inappropriate endoscopies represent overuse. Necessary indications not referred for the procedure constitute underuse. SETTING Three primary care outpatient clinics, 20 general practices, three gastroenterology practices, two district and one university hospitals. SUBJECTS A third of the collective were consecutive ambulatory patients with upper abdominal complaints, whereas the other two thirds were ambulatory and hospitalized patients referred for the procedure. MAIN OUTCOME MEASURES Proportions of overuse and underuse in the different settings. RESULTS A total of 2885 patients were included (mean age, 49 years, 52% male, 2442 outpatients), 1858 patients underwent > or = 1 endoscopy. Among 2086 endoscopies, 805 (39%) were inappropriate, most of which were performed for dyspepsia (83%). Overuse was higher in young, foreign, female patients and lower in inpatient settings, the latter reflecting a different distribution of presenting symptoms. Among 1646 patient visits in primary care, overuse represented 148 endoscopies (9%). Underuse was identified in 104 of the same patient visits (6%) and was higher as patient age increased; there were no significant differences between men and women. CONCLUSIONS Rates of overuse and underuse depend mainly on case presentation and patient characteristics. Both over- and underuse should be addressed to maintain and improve quality of care.