Cost of detecting malignant lesions by endoscopy in 2741 primary care dyspeptic patients without alarm symptoms.
OBJECTIVE
Current guidelines recommend empirical, noninvasive approaches to manage dyspeptic patients without alarm symptoms, but concerns about missed lesions persist; the cost savings afforded by noninvasive approaches must be weighed against treatment delays. We investigated the prevalence of malignancies and other serious abnormalities in patients with dyspepsia and the cost of detecting these by endoscopy.


METHODS
We studied 2741 primary-care outpatients, 18-70 years in age, who met Rome II criteria for dyspepsia. Patients with alarm features (dysphagia, bleeding, weight loss, etc) were excluded. All patients underwent endoscopy. The cost and diagnostic yield of an early endoscopy strategy in all patients were compared with those of endoscopy limited to age-defined cohorts. Costs were calculated for a low, intermediate, and high cost environment.


RESULTS
Endoscopies detected abnormalities in 635 patients (23%). The most common findings were reflux esophagitis with erosions (15%), gastric ulcers (2.7%), and duodenal ulcers (2.3%). The prevalence of upper gastrointestinal malignancy was 0.22%. If all dyspeptic patients 50 years or older underwent endoscopy, 1 esophageal cancer and no gastric cancers would have been missed. If the age threshold for endoscopy were set at 50 years, at a cost of $500/endoscopy, it would cost $82,900 (95% CI, $35,714-$250,000) to detect each case of cancer.


CONCLUSIONS
Primary care dyspeptic patients without alarm symptoms rarely have serious underlying conditions at endoscopy. The costs associated with diagnosing an occult malignancy are large, but an age cut-off of 50 years for early endoscopy provides the best assurance that an occult malignancy will not be missed.
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53233, USA. nvakil@wisc.edu
Nimish
N
Vakil
Nicholas
N
Talley
Sander Veldhuyzen
SV
van Zanten
Nigel
N
Flook
Tore
T
Persson
Ewa
E
Björck
Tore
T
Lind
Elisabeth
E
Bolling-Sternevald
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D004381:Duodenal Ulcer / Q000175:diagnosis / Q000191:economics; D004415:Dyspepsia / Q000150:complications*; D004724:Endoscopy / Q000191:economics*; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000191:economics; D005260:Female; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000191:economics; D005770:Gastrointestinal Neoplasms / Q000175:diagnosis* / Q000191:economics* / Q000517:prevention & control; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000379:methods*; D013274:Stomach Neoplasms / Q000175:diagnosis / Q000191:economics; D013276:Stomach Ulcer / Q000175:diagnosis / Q000191:economics; D055815:Young Adult