30% of digestive endoscopies have questionable indications

@varelalaf

In an article in the series "Less is More" by Gastroenterology, three digestiologists, Shaheen, Fennerty and Bergman, after an extensive review of the literature, conclude that 30% of digestive endoscopies have questionable indications. According to the authors, many clinical practice guidelines stimulate the exaggerated consumption of these tests in clinical situations of doubtful indication, such as recommendations for the follow-up of low-risk patients of Barrett's disease (oesophageal reflux), which they say they are "carefully misleading." On the other hand, the prevailing cancer phobia places a lot of pressure on the examination rooms, which are permanently overwhelmed, not only by inappropriate requests but by follow-up guidelines that anticipate the requirements demanded by the clinical practice guidelines themselves.

The impact of excess endoscopy for patients

Direct iatrogenesis attributable to endoscopies (perforation or pancreatitis) is catastrophic but fortunately rare. Without underestimating these risks, it should be noted that the biggest problem for the population attracted by these tests knows what to do next with the occasional findings, such as subsequent monitoring of polyps, most of them without any clinical relevance. For this, there are some guidelines that, according to the authors, were elaborated long ago when there was a diagnostic technology that is now redundant and the continued use of, only induce inappropriate treatments. The referenced article offers data from a systematic review of CT colonography studies that, despite not being an endoscopic technique, explain the phenomenon very well. This work concludes that approximately half (40-70%) of the colonography find incidentalomas, a good part of which require new tests and more follow-ups, which creates over-diagnosis and over-treatment.

The impact of excess endoscopies for healthcare systems

In the absence of a reliable record, based on the activity reports of several endoscopy units, I have concluded that the number of endoscopies performed in Spain should be of the order of three million annually and, based on the referenced review, it could be estimated that the number of these tests with questionable indications would reach one million each year, a waste that would have direct costs of 500 million euros, apart from the indirect ones produced by overdiagnosis and unnecessarily induced treatments.

Health authorities are well aware of waiting lists, but it should also take a look at the lack of rigour in the indication of diagnostic tests. As citizens and as taxpayers we would appreciate it.

Jordi Varela

Editor