title: Appropriateness guidelines and predictive rules to select patients for upper endoscopy: a nationwide multicenter study.
abstract: OBJECTIVE
  Selecting patients appropriately for upper endoscopy (EGD) is crucial for efficient use of endoscopy. The objective of this study was to compare different clinical strategies and statistical methods to select patients for EGD, namely appropriateness guidelines, age and/or alarm features, and multivariate and artificial neural network (ANN) models.
  
  
  METHODS
  A nationwide, multicenter, prospective study was undertaken in which consecutive patients referred for EGD during a 1-month period were enrolled. Before EGD, the endoscopist assessed referral appropriateness according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, also collecting clinical and demographic variables. Outcomes of the study were detection of relevant findings and new diagnosis of malignancy at EGD. The accuracy of the following clinical strategies and predictive rules was compared: (i) ASGE appropriateness guidelines (indicated vs. not indicated), (ii) simplified rule (>or=45 years or alarm features vs. <45 years without alarm features), (iii) logistic regression model, and (iv) ANN models.
  
  
  RESULTS
  A total of 8,252 patients were enrolled in 57 centers. Overall, 3,803 (46%) relevant findings and 132 (1.6%) new malignancies were detected. Sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the simplified rule were similar to that of the ASGE guidelines for both relevant findings (82%/26%/0.55 vs. 88%/27%/0.52) and cancer (97%/22%/0.58 vs. 98%/20%/0.58). Both logistic regression and ANN models seemed to be substantially more accurate in predicting new cases of malignancy, with an AUC of 0.82 and 0.87, respectively.
  
  
  CONCLUSIONS
  A simple predictive rule based on age and alarm features is similarly effective to the more complex ASGE guidelines in selecting patients for EGD. Regression and ANN models may be useful in identifying a relatively small subgroup of patients at higher risk of cancer.
authors.affiliation: Gastroenterology and Digestive Endoscopy Unit, Cattinara Hospital, Trieste, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Buri
authors.forename: Cesare
authors.initials: C
authors.lastname: Hassan
authors.forename: Gianluca
authors.initials: G
authors.lastname: Bersani
authors.forename: Marcello
authors.initials: M
authors.lastname: Anti
authors.forename: Maria Antonietta
authors.initials: MA
authors.lastname: Bianco
authors.forename: Livio
authors.initials: L
authors.lastname: Cipolletta
authors.forename: Emilio
authors.initials: E
authors.lastname: Di Giulio
authors.forename: Giovanni
authors.initials: G
authors.lastname: Di Matteo
authors.forename: Luigi
authors.initials: L
authors.lastname: Familiari
authors.forename: Leonardo
authors.initials: L
authors.lastname: Ficano
authors.forename: Pietro
authors.initials: P
authors.lastname: Loriga
authors.forename: Sergio
authors.initials: S
authors.lastname: Morini
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Pietropaolo
authors.forename: Alessandro
authors.initials: A
authors.lastname: Zambelli
authors.forename: Enzo
authors.initials: E
authors.lastname: Grossi
authors.forename: Marco
authors.initials: M
authors.lastname: Intraligi
authors.forename: Massimo
authors.initials: M
authors.lastname: Buscema
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D004066:Digestive System Diseases / Q000175:diagnosis*; D016145:Endoscopy, Digestive System; D005260:Female; D006801:Humans; D007558:Italy; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016571:Neural Networks, Computer; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012372:ROC Curve; D055815:Young Adult