New research identifies practice changes to improve value and quality of GI procedures

May 19, 2013

There are significant cost and risk factors associated with two procedures commonly used to diagnose or treat gastrointestinal problems, according to research presented at Digestive Disease Week (DDW).

A study by New York Presbyterian Hospital and Weill-Cornell Medical College suggests that more objective testing may substantially reduce the cost and risk of managing (GERD). Although GERD is believed to affect nearly 25 percent of adults, researchers found that almost a third of patients undergoing treatment have no measurable signs of the . The study projected cost-savings of up to $7,300 per patient over 10 years if current diagnostic guidelines were changed.

"Many patients remain on proton-pump inhibitors for years after the trial period without any confirmation that they are being treated for the right diagnosis," said David Kleiman, MD, a research fellow in the department of surgery at New York Presbyterian Hospital. "A prompt pH monitoring test could help clinicians to accurately diagnosis GERD, increase healthy outcomes for patients and save people money."

GERD occurs when or bile flows back into the food pipe from the stomach, causing acid reflux and heartburn. Methods for diagnosing and treating it remain controversial. Most guidelines recommend an eight-week trial of proton-pump inhibitors (PPI) to reduce . Clinicians then observe the patient to see if symptoms subside.

The study compared this approach with 24-hour esophageal pH monitoring, in which a small tube is passed through the nose into the stomach. The tube is attached to a recorder worn at the belt to track .

"The misconceptions about pH monitoring are that it's unnecessary, expensive or too inconvenient," added Dr. Kleiman. "But, the benefits seen in our study show that pH monitoring should be strongly considered."

Using patient data from the esophageal monitoring, Dr. Kleiman and colleagues found that 32 percent of individuals who were taking PPIs had no objective signs of GERD—pointing to unnecessary spending on medication and increased risk from prolonged PPI use.

Dr. Kleiman concluded that patients should be considered for pH monitoring immediately after their eight-week PPI trial.

Data points to strategies to avoid GI surgery readmissions

Other cost-saving data presented at DDW zeros in on the risk factors associated with surgical readmission in major gastrointestinal resections. Unplanned readmissions are estimated to cost $17 billion annually in the U.S., but many are preventable. Researchers at the University of Rochester Medical Center analyzed data from nearly 45,000 patients undergoing GI surgery and found that if patients have a complication in the hospital, they are one third more likely to be readmitted. This is one of the largest studies to date to focus on readmissions following gastrointestinal surgery.

"This finding tells us that we need to take a closer look at discharge plans after complications occur," said Fergal Fleming, assistant professor of surgery and oncology and clinical director of Surgical Health Outcomes and Research Enterprise (SHORE) at the University of Rochester Medical Center.

Data from Dr. Fleming's study found the unplanned readmission rate for patients undergoing gastrointestinal resection was 12 percent. The estimated cost for a readmission ranges from $5,000 to $15,000. His analysis also identified preoperative steroid use, operative time and discharge to a facility other than home as risk factors.

"These data provide us with a roadmap for cost-saving, preventative measures that we can study to improve care and increase healthy outcomes," he said.

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