Ultrathin esophagoscopy in screening for Barrett's esophagus at a veterans administration hospital: Easy access does not lead to referrals

OBJECTIVE: Unsedated, ultrathin esophagoscopy has been shown to be tolerable, safe, and accurate. Survey data have suggested that accessibility of unsedated esophagoscopy would increase referrals for Barrett's esophagus (BE) screening. Our purpose was to evaluate primary-care physician referrals for BE screening when unsedated esophagoscopy is made available. METHODS: We studied primary-care referrals for unsedated esophagoscopy in a VA internal medicine clinic. Patients over age 45 with chronic heartburn for > 5 yr or > 3 times weekly and who had no previous EGD were eligible for screening with unsedated esophagoscopy. All primary providers received a 15-min education session on screening. Baseline referral rate was determined retrospectively. Longitudinal data were then collected during three phases of the study: (a) primary provider-initiated referrals, (b) primary provider-initiated referrals with weekly reminders from investigators, and (c) investigator recruitment. RESULTS: Baseline referral rate averaged 0.5 patients per month. Availability of unsedated esophagoscopy and an education session increased the rate of referral to 0.66 patients per month. Weekly reminders to primary physicians further increased the rate to 1.33 referrals per month. Investigator recruitment produced a rate of 2.67 referrals per month. Of the 77 patients offered screening, 25 (32%) declined. Of the 52 patients screened, three (5.8%) were diagnosed with BE. CONCLUSIONS: Accessibility of unsedated esophagoscopy itself does not lead to a large increase in the number of primary care referrals for BE screening. Factors that prevent primary care physicians from referring patients for screening need to be identified and effective interventions to change referral patterns need to be implemented for unsedated screening programs to be successful.