Introduction Upper GI Endoscopy can generate significant income through payment by results (PBR) in the UK. Primary care physicians have a direct access for endoscopy via open access (GPOA) or 2-week rule (2WR) systems and appropriateness of these lists have been long-debated. With the current financial cut backs within the NHS, it is worthwhile to re-evaluate their effectiveness.
Aim To assess the effectiveness of GPOA/2WR upper GI Endoscopy service.
Methods Retrospective audit of GPOA and 2WR lists between April and October 2011 was performed. 483 referrals were audited (n=400 2WR, n=83 GPOA) for patient demographics, indications, significant diagnosis, additional tests and patient outcomes.
Results 2WR—Patients: Audit capture rate 86%. Median age of the patient was 65 years (range 18–96), 58% were Females, with median ASA 2. NICE criteria for referrals was not met in 12% and a further 14% had a gastroscopy within 3 years. Outcomes: Significant diagnoses (cancer, oesophagitis, Barretts, PUD, Coeliac Disease, Stricture, Helicobacter pylori gastritis) were present in 44% (cancer diagnosis 3.4%). An endoscopy urease test was performed in 48%, with a 30% positivity rate. Biopsies were taken in 64%. 86% were discharged back to the GP, 4% were referred to clinic, 6% booked for a repeat endoscopy and 4% referred to cancer MDT. GPOA Patients: Audit capture rate was 96% referrals. Patients were younger than the 2WR with median age 52 years (range 17–86) (p=0.0001), and healthier with median ASA 1 (p=0.0001). 53% were females. 31% of patients did not meet NICE guidelines and 4% had a gastroscopy within 3 years. Outcomes: Significant diagnoses were made in 29.9% (cancer diagnosis 1.2%). While the cancer diagnoses with 2WR was comparable (p=0.2), there were less benign diagnoses (p=0.01). Additional tests included urease test in 19%, positivity rate 20% and biopsies 14%. Patient outcomes were similar to 2WR with 88% of patients discharged directly back to GP, 6% booked for a repeat endoscopy, 4% referred to Gastroenterology Clinic and 2% to a cancer MDT. Overall, 51 patients (12%) had a previous endoscopy within 3 years, none of which had cancer and 83 patients (19%) did not meet NICE guidelines that is, 31% were inappropriate.
Conclusion With 31% of patients being inappropriate and low cancer pick up rate, the value of these lists may be questionable. However, benign pathology was significant in both lists and therefore process mapping the patient to see if the endoscopy changed the patient's management would be useful given the very high discharge rate to the GP. There still remains significant room for improving the effective use of these services.
Competing interests None declared.