title: The challenge of protocols for reflux disease: a review and development of a critical pathway.
abstract: OBJECTIVE
  Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) are very common and controversial diseases. The authors have previously reviewed clinical practice guidelines (CPGs) on reflux disease, and these major consensus statements differ on what constitutes ideal management. The aim is to critically review existing protocols for reflux based on CPG recommendations and to present a refined protocol that may be further used to develop a critical pathway for reflux in ambulatory medical practice.
  
  
  METHODS
  Literature review with discussion.
  
  
  METHODS
  A PubMed search was used to identify current clinical protocols or algorithms for reflux disease, and the principal elements of each were compared.
  
  
  RESULTS
  Of the 828 articles identified in the search, 11 met the search criteria. Together with 4 articles previously identified, 15 were analyzed. All protocols discuss the important role of empiric therapy, although with differences in use. Only 5 protocols (33%) were based on systematic review such as CPGs. Eight protocols (53%) used alarm symptoms to prompt a workup. For these patients, upper endoscopy was by far the most common diagnostic method. The use of other modalities varies significantly between protocols. The authors propose a standard protocol based on patient risk factors that employs CPG recommendations and may be used for critical pathway outcomes measures.
  
  
  CONCLUSIONS
  There are major differences between existing protocols for reflux disease in the literature, reflecting many clinical controversies. Outcomes of different protocols have not been extensively studied. The authors propose a new protocol that is a synthesis of those reviewed and based on risk stratification.
authors.affiliation: Department of Otolaryngology, Mount Sinai School of Medicine, New York, New York, USA. kenneth.altman@mountsinai.org
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Altman
authors.forename: Neil
authors.initials: N
authors.lastname: Prufer
authors.forename: Michael F
authors.initials: MF
authors.lastname: Vaezi
mesh_terms: D000465:Algorithms; D000553:Ambulatory Care; D019091:Critical Pathways; D016145:Endoscopy, Digestive System; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D006801:Humans; D057045:Laryngopharyngeal Reflux / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D007828:Laryngoscopy; D017410:Practice Guidelines as Topic; D000078202:Systematic Reviews as Topic; D016896:Treatment Outcome