title: Underutilization of upper gastrointestinal endoscopy.
abstract: OBJECTIVE
  Efforts to reduce costs in health care may raise concerns about underuse of medical procedures. This study prospectively assessed underuse of upper gastrointestinal endoscopy in a cohort of patients in whom we have recently published data on overuse of endoscopy.
  
  
  METHODS
  Underuse was identified by formal necessity criteria for endoscopy, obtained by an explicit panel process. Outpatients were consecutively included in two clinical settings. Setting A consisted of 20 primary care physicians and 7215 patient visits that occurred within 1 month. Setting B consisted of 920 visits that occurred during 3 weeks at an outpatient clinic.
  
  
  RESULTS
  During these 8135 visits, 611 patients complained of upper digestive symptoms; 63 of them underwent endoscopy. Underuse was identified in 72 patients (11.8%). The two clinical situations mainly responsible for underuse of endoscopy were uninvestigated peptic symptoms resistant to treatment and dysphagia. At first follow-up, 29 of the patients with initial underuse still fulfilled criteria of necessity (underuse rate, 4.7%). One-year follow-up showed underuse of endoscopy in 5 patients.
  
  
  CONCLUSIONS
  This prospective evidence shows that underuse of a medical procedure exists. The estimated overuse and underuse of endoscopy in this cohort were approximately equal (5%). Improving quality of care will require reductions of both overuse and underuse of medical procedures.
authors.affiliation: Department of Gastroenterology, Medical Outpatient Department, University of Lausanne, Switzerland.
authors.forename: F
authors.initials: F
authors.lastname: Froehlich
authors.forename: I
authors.initials: I
authors.lastname: Pache
authors.forename: B
authors.initials: B
authors.lastname: Burnand
authors.forename: J P
authors.initials: JP
authors.lastname: Vader
authors.forename: M
authors.initials: M
authors.lastname: Fried
authors.forename: J
authors.initials: J
authors.lastname: Kosecoff
authors.forename: M
authors.initials: M
authors.lastname: Kolodny
authors.forename: R W
authors.initials: RW
authors.lastname: DuBois
authors.forename: R H
authors.initials: RH
authors.lastname: Brook
authors.forename: J J
authors.initials: JJ
authors.lastname: Gonvers
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016099:Endoscopy, Gastrointestinal; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D011787:Quality of Health Care