2014-09-16 19:15:34 UTC

Choosing Wisely: How to Practice Cost-Effective GI Medicine

Sept. 16, 2014


Rajeev Jain, MD, FACP, AGAF, FASGE

Partner, Texas Digestive Disease Consultants

In a national effort to promote awareness about the importance of stewardship of health-care resources, the American Board of Internal Medicine (ABIM) Foundation with specialty societies, including AGA, launched the Choosing Wisely campaign in 2012.

AGA’s five recommendations for the Choosing Wisely campaign are aimed at common disorders with the goal of minimizing unnecessary testing and/or treatment (low-value care). With health care in the U.S. consuming nearly one-fifth of our gross domestic product, patients, insurers and the government are demanding better outcomes at same or lower costs (high-value care).

We all try to practice high-value gastroenterology. During a busy clinic or endoscopy schedule, it can be difficult to follow every guideline or recommendation, especially for less common disorders. In order to implement these and other guideline recommendations, clinical decision support tools need to be available that seamlessly integrate into our electronic health record (EHR) and workflow. AGA is creating evidence-based guidelines with companion clinical decision support tools as part of the AGA Roadmap to the Future of GI strategic plan.

I try to incorporate all five of these recommendations into my daily practice. For me, the most commonly used recommendations are those for colonoscopy intervals. Our practice is incorporating these colonoscopy interval recommendations into our EHR by creating guideline-based, templated messages to push to our patients via the patient portal and to create a colonoscopy recall within our EHR. The pre-populated messages in the EHR will be organized by the pathology results so that the appropriate guideline-based interval for the next colonoscopy is generated. Unfortunately, our EHR will require the physician to perform a three-step process of selecting the portal message, letter to the referring physician and recall reminder. Ideally, a more robust EHR system would allow one “click” to generate all three messages.

With regards to GERD and acid suppression therapy, I try to have a common-sense discussion with my patients on why they take these medications, and specifically, the duration, severity and prior complications of GERD. Often patients will have been empirically placed on acid suppression for mild GERD or dyspepsia. I take the opportunity to discuss the benefits and risks of therapy while raising the possibility of titrating off acid suppression. I find most patients are appreciative of the attempt to minimize or even stop a medication. For the patient initially diagnosed with Barrett’s esophagus, I will have the patient follow up with our physician assistant within one to two weeks after the new diagnosis to discuss the diagnosis, prognosis and treatment plan. Using the AGA guideline on Barrett’s esophagus, the EHR will be populated with an assessment and plan that is evidence-based and follows the Choosing Wisely campaign’s recommendation.

AGA contributed to the Choosing Wisely campaign with the following five recommendations:

  1. For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine-2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
  2. Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
  3. Do not repeat colonoscopy for at least five years for patients who have one or two small (< 1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy.
  4. For a patient who is diagnosed with Barrett’s esophagus, and who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years, as per published guidelines.
  5. For a patient with functional abdominal pain syndrome (as per ROME III criteria), CT scans should not be repeated unless there is a major change in clinical findings or symptoms.

IBS can be a challenging disorder to manage. At the time of this AGA Perspectives article submission, AGA has submitted IBS guidelines for public comment. The fifth recommendation from the Choosing Wisely campaign reminds us to minimize harm of radiation in young patients with functional bowel syndromes by avoiding unnecessary CT scans. It is always easier to order a test than explain the rationale for not performing some diagnostic intervention including laboratory studies, radiology and endoscopy. However, in my opinion, both physicians and patients need to find a more reasonable level of uncertainty to accept in the diagnostic evaluation of symptoms of presumed IBS that lack alarm features.

AGA’s contribution to the Choosing Wisely campaign has highlighted recommendations for gastroenterologists to deliver high-value care to our patients. By following these recommendations, gastroenterologists can reduce potential harms (i.e. radiation exposure), reduce costs (i.e., minimizing overutilization of medication and procedures) and standardize the management of common disorders.

Dr. Jain is chair of the AGA Institute Practice Management and Economics Committee.

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