Appropriateness Guidelines and Predictive Rules to Select Patients for Upper Endoscopy: A Nationwide Multicenter Study

OBJECTIVES: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 (≥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.

[1]  E. DeLong,et al.  Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. , 1988, Biometrics.

[2]  Politecnico di Milano,et al.  Milano , 1762, Johann Christian Nelckenbrechers Taschenbuch eines Banquiers und Kaufmanns.

[3]  British Society of Gastroenterology , 1963 .

[4]  Paolo Massimo Buscema,et al.  An optimized experimental protocol based on neuro-evolutionary algorithms: Application to the classification of dyspeptic patients and to the prediction of the effectiveness of their treatment , 2005, Artif. Intell. Medicine.

[5]  Amitabh Chak,et al.  Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model , 2003, The Lancet.

[6]  D. Palli,et al.  "Cervia Working Group Report": guidelines on the diagnosis and treatment of Helicobacter pylori infection. , 2001, Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver.

[7]  J. E. Lenard-Jones.  Provision of gastrointestinal endoscopy and related services for a district general hospital. Working Party of the Clinical Services Committee of the British Society of Gastroenterology. , 1991, Gut.

[8]  G. Ricci,et al.  ASGE guidelines for the appropriate use of upper endoscopy: association with endoscopic findings. , 2002, Gastrointestinal endoscopy.

[9]  R H Brook,et al.  Appropriateness and Diagnostic Yield of Upper Gastrointestinal Endoscopy in an Open-Access Endoscopy Unit , 1996, Endoscopy.

[10]  B. Levin,et al.  Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. , 2008, Gastroenterology.

[11]  K. Goh,et al.  Appropriateness and diagnostic yield of EGD: a prospective study in a large Asian hospital. , 2004, Gastrointestinal endoscopy.

[12]  R. Brook,et al.  Overuse of upper gastrointestinal endoscopy in a country with open-access endoscopy: a prospective study in primary care. , 1997, Gastrointestinal endoscopy.

[13]  Paolo Massimo Buscema,et al.  Genetic doping algorithm (GenD): theory and applications , 2004, Expert Syst. J. Knowl. Eng..

[14]  David H. Kim,et al.  Cost-effectiveness of upper gastrointestinal endoscopy according to the appropriateness of the indication , 2009, Scandinavian journal of gastroenterology.

[15]  P. Moayyedi,et al.  American gastroenterological association technical review on the evaluation of dyspepsia. , 2005, Gastroenterology.

[16]  Farees T. Farooq,et al.  Artificial neural network as a predictive instrument in patients with acute nonvariceal upper gastrointestinal hemorrhage. , 2008, Gastroenterology.

[17]  M. Mignon,et al.  Applicability and efficacy of qualifying criteria for an appropriate use of diagnostic upper gastrointestinal endoscopy. , 2006, Gastroenterologie clinique et biologique.

[18]  A. Al-shehri,et al.  Appropriateness of upper gastrointestinal endoscopy referrals from primary health care , 2006, Annals of Saudi medicine.

[19]  M. Wallace,et al.  Age and alarm symptoms do not predict endoscopic findings among patients with dyspepsia: a multicentre database study , 2001, Gut.

[20]  T Rokkas,et al.  Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report , 2006, Gut.

[21]  Thomas G. Dietterich.  Approximate Statistical Tests for Comparing Supervised Classification Learning Algorithms , 1998, Neural Computation.

[22]  A. Andriulli,et al.  "Appropriateness" or "prioritization" for GI endoscopic procedures? , 2006, Gastrointestinal endoscopy.

[23]  I. Russell,et al.  Improving the selection of patients for upper gastrointestinal endoscopy. , 1993, Gut.

[24]  Paolo Massimo Buscema,et al.  The Implicit Function as Squashing Time Model: A Novel Parallel Nonlinear EEG Analysis Technique Distinguishing Mild Cognitive Impairment and Alzheimer's Disease Subjects with High Degree of Accuracy , 2007, Comput. Intell. Neurosci..

[25]  M. Osterman.  Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy , 2008 .

[26]  R. Brook,et al.  Is the diagnostic yield of upper GI endoscopy improved by the use of explicit panel-based appropriateness criteria? , 2000, Gastrointestinal endoscopy.

[27]  G. Ricci,et al.  Comparison between the Two Systems to Evaluate the Appropriateness of Endoscopy of the Upper Digestive Tract , 2004, The American Journal of Gastroenterology.