Open-access upper endoscopy fast-tracks diagnosis for nonalarming symptoms in SG

Open-access esophagogastroduodenoscopy (OAE) facilitates a safe and timely evaluation of patients with nonalarming digestive issues in Singapore, according to a study.

The open-access program enables physicians to order esophagogastroduodenoscopy directly without the need for a separate gastroenterology clinic consultation. All public hospitals in Singapore have been offering this service since 2019.

Analysis of data from the Singapore General Hospital (SGH) showed that out of the 436 patients who underwent OAE, 25 (5.7 percent) had major endoscopic findings, such as upper gastrointestinal adenocarcinoma (n=3), esophageal varices (n=1), and peptic ulcer disease (n=21). [Cureus 2024;16:e54792]

Meanwhile, OAE revealed minor findings in 180 patients (41.3 percent), including gastritis/esophagitis, gastric polyps, and hiatal hernia.

According to the investigators, getting an OAE appointment took less than 6 weeks, providing patients with a timely service. The median waiting time was 23 days.

“Importantly, no adverse events occurred, thus suggesting that the safety of our patients was not compromised despite the absence of an initial specialist consultation prior to endoscopy,” they added.

The rate of re-referral to the Gastroenterology specialist outpatient clinic for dyspepsia symptoms within a year after OAE was performed was low at 3.7 percent. The majority of re-referrals were due to recurrent symptoms where the primary care provider felt a specialist input would be appropriate.

“While there is a lack of data in the literature for comparison, we believe that this rate [or re-referral] is sufficiently low, thus justifying the effectiveness of OAE for patients with dyspepsia and nonalarming symptoms,” the investigators said.

A total of 567 patients were scheduled for OAE, and 436 patients underwent the procedure. The patients were between 21 and 60 years of age (mean 45.7 years), with 36.3 percent men and 80.8 percent Chinese. These patients presented with nonalarming dyspepsia symptoms such as reflux, heartburn, recurrent abdominal pain, and bloating. And those at potentially higher risk of complications from sedation require urgent endoscopy (signs of gastrointestinal bleeding) were not eligible for the OAE service.

Appropriateness questioned

Introduced to streamline the process of diagnostic endoscopy referral as a direct-to-treat care model without using laboratory and radiological tests, OAE offers a faster referral path for endoscopy. However, the appropriateness of endoscopy in open-access programs has been questioned, as primary care providers may not have extensive knowledge of when the procedure is truly needed, the investigators noted.

There is merit to such a concern, because inappropriate referrals could lead to unnecessary procedures being booked, then cancelled, with time and resources wasted for patients and the healthcare system. This would undermine the goal of OAE to be both timely and cost-effective, the investigators said.

However, OAE has demonstrated effectiveness, with a low rate of inappropriate referrals. Only 2.6 percent of patients in the SGH OAE program did not meet the inclusion criteria and were deemed inappropriate referrals—a success that the investigators attributed to several factors.

First, the program has a lower age threshold of 21 years, as younger patients typically present with less concerning symptoms, they said. Also, there is a checklist of inclusion and exclusion criteria within the referral form, helping ensure that only suitable patients are referred for OAE procedures.

In several studies, appropriate OAE referrals were associated with a higher diagnostic yield of clinically relevant findings. For example, a large Italian study found that appropriate OAEs were much more likely to identify a diagnosis compared with inappropriate procedures (52 percent vs 29 percent). Additionally, the number of cancer diagnoses in the present cohort is comparable to that of the OAE service in Hong Kong whose model is similar to the SGH program, wherein the primary care provider is free to choose between OAE or traditional clinic referral service. [Gastrointest Endosc 2007;65:767-774; J Gastroenterol Hepatol 2000;15:1251-1256]

“This suggests that OAE programs that have high adherence to appropriate indications would be able to achieve good diagnostic yield, and this metric should be considered an appropriate quality indicator for OAE programs worldwide,” the investigators said.