University of California San Francisco San Francisco, California
Vivek Rudrapatna, MD, PhD, Myung Ko, MD, Arman Mosenia, MSE, Kavita Radhakrishnan, MD, Atul Butte, MD, PhD, Priya Kathpalia, MD; University of California San Francisco, San Francisco, CA
Introduction: Direct-access referrals for endoscopy can reduce outpatient waiting times by bypassing specialty clinic evaluation. However, this can result in resource misutilization and increased costs if these referrals are inappropriate. This is particularly relevant for referrals related to dyspepsia and heartburn, two common complaints rarely associated with significant endoscopic findings. Although gastroenterology society guidelines exist concerning the appropriate use of endoscopy for these symptoms, these are not well-known by non-specialists. We quantified inappropriate endoscopic referrals at our medical center and intervened using our electronic health records (EHR) system. Methods: We identified all referrals for uncomplicated dyspepsia and heartburn in Jan-Feb 2019. Records were tabulated by heartburn referrals without a proton-pump inhibitor (PPI) trial and dyspepsia referrals lacking a non-invasive H. Pylori test and PPI trial. Referrals of patients under 60 who met these criteria and lacked red-flag symptoms were deemed inappropriate. In Aug 2019, we designed and deployed a modification to our EHR referral system and re-quantified inappropriate referrals in the two subsequent months. To assess the durability of our intervention, we quantified inappropriate endoscopies following referral at baseline (Jan-Feb 2019) and one year later (Jan-Feb 2020). P-values were calculated by Fisher’s exact test. Results: 32 out of 62 direct referrals during the pre-intervention period were appropriate (52%): Of the 36 patients under age 60, 30 (83%) lacked H. Pylori testing and 13 (36%) lacked a PPI trial. In the two months following our intervention, 48 out of 61 referrals (79%) were appropriate: Of the 31 patients under age 60, 12 (39%) had not completed H. Pylori testing and 6 (19%) lacked a PPI trial. This difference was significant (p=0.002). We examined referrals that led to performed exams. 21 of 34 pre-intervention endoscopies were appropriate (62%). Of the 21 patients under age 60, 11 (52%) failed to complete H. Pylori testing and 5 (24%) did not receive a PPI. Post-intervention, 20 of 24 endoscopies (83%) were appropriate. Of the 14 patients under age 60, 3 (21%) failed to complete H. Pylori testing and 1 (7%) did not receive a PPI. This trended towards significance (p=0.09). Discussion: A low-cost, EHR-based intervention reduced inappropriate referrals and improved the utilization of direct-access outpatient endoscopy. Future studies with larger numbers are needed to confirm these results.
Disclosures: Vivek Rudrapatna indicated no relevant financial relationships. Myung Ko indicated no relevant financial relationships. Arman Mosenia indicated no relevant financial relationships. Kavita Radhakrishnan indicated no relevant financial relationships. Atul Butte indicated no relevant financial relationships. Priya Kathpalia indicated no relevant financial relationships.