Use of open access in GI endoscopy at an academic medical center

Background: Open access endoscopy systems (those in which endoscopy is performed without prior gastroenterology consultation) are becoming more common in the current cost-conscious environment. The aim of this study was to compare appropriateness and yield of endoscopy for patients referred for open access endoscopy with those for patients who had prior contact with a gastroenterologist. We also evaluated patients' preference for undergoing open access endoscopy as opposed to having prior consultation with a gastroenterologist and compared preparedness for endoscopic procedures between the two groups. Methods: The cases of all outpatients referred for upper endoscopy and colonoscopy were assessed prospectively over a 5-month period. American Society for Gastrointestinal Endoscopy (ASGE) guidelines for indications for gastrointestinal endoscopy were used to determine appropriateness of referrals. Significant pathologic findings were rated independently by two investigators using defined criteria. Patients' opinions regarding preparedness for endoscopy and referral preference were measured by means of questionnaires administered before endoscopy. Results: Eighty-six percent of endoscopies after consultation with gastroenterologists were performed for accepted indications compared with 65% of open access procedures (p < 0.01). Significant pathologic findings were present in 40% of the former group compared with 28% of those undergoing open access endoscopy (p < 0.01). Significant pathologic findings were found in 37% of endoscopies performed for indications listed in the ASGE guidelines compared with 20% for unlisted indications (p < 0.01). Forty percent of patients referred for open access endoscopy would have preferred prior consultation with a gastroenterologist. Conclusion: Patients initially seen by a gastroenterologist are more likely to undergo endoscopy for accepted indications, and the yield of endoscopy is higher than among patients referred through an open access system. The system of open access endoscopy as currently practiced may have to be reassessed.