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EGD, Training and Credentialing of Family Physicians In (Position Paper)
Usefulness of EGD
Improved Outcomes and Quality of Care
SECTION I - SCOPE OF PRACTICE FOR FAMILY PHYSICIANS
Benefits for Family Physicians
Furthermore, family physicians who perform this endoscopic procedure find it enhances the working relationship with their gastroenterologist colleagues. Family physicians who do upper GI endoscopy invariably note an enhanced relationship with patients, a better understanding of the pathology in individual cases, and a much greater comfort level with the chosen treatment as a direct result of having done the procedure themselves.
In a review of 793 EGDs performed by a family physician1, no major complications occurred. One patient experienced an immediate urticarial rash following IV infusion of meperidine. After treatment with IV diphenhydramine and dexamethasone, the rash promptly resolved and the procedure was completed successfully. Therefore, the complication rate in this family medicine study was 0.13%, which compares favorably with others in the GI literature. In the largest series published to date, a study of over 210,000 procedures reported an overall complication rate of 0.13% with a 0.008% death rate.
In the above study, there were 451 biopsies taken during 385 EGDs. 546 pathologic diagnoses were provided as a result of the biopsies.
Office Versus Hospital GI Lab
Currently, economics favor the GI lab setting over the office setting for many family physicians. The scope, video and photography equipment, intravenous (IV) medications and supplies, and nursing staff are provided without additional charge to the physician. Physician payment today is generally provided at the same rate regardless of where the procedure is performed. The procedure cost, however, is considerably more when done outside of the family physician's office. Many insurance companies do not pay for supplies when procedures are performed in the office, which provides another economic incentive for physicians to do the procedure in the hospital outpatient area. The overall cost to the patient and payer, however, is considerably higher when the procedure is performed outside of the family physician's office.
EGD is safe and rarely causes significant physical stress on an individual. However, IV sedation does carry a measurable risk and thus significant post-procedure observation is required. Physicians who perform procedures requiring IV sedation in their offices should provide the same level of care available in an EGD lab in the hospital or out-patient setting. This would include appropriate personnel for assistance and observation and may include oximetry monitoring and telemetry for appropriate patients.
Not all patients are candidates for office EGD, particularly when the physician is first gaining experience with the procedure. The following characteristics may, for the beginning endoscopist, preclude patients from being considered for office EGD:
Age > 70 years
Age < 12 years
Aortic stenosis, post cardiac bypass
Chronic Obstructive Pulmonary Disease (COPD)
Cerebrovascular Accident (CVA)
Of course, these are guidelines and may be altered depending on the geographic area, available facilities, and experience of the endoscopist.
The Trend in Family Medicine and AAFP Support of EGD
Family physicians have gained hospital privileges for EGD in all 50 states, and the number of family physicians performing EGD continues to grow. According to a 2006 Office Practice Characteristics Survey2, 3% of family physicians performed upper GI endoscopy in their offices. Survey data indicate that 3% of family medicine residency graduates performed EGD, while 6.2% of non-residency graduates performed EGD. Only 3.4% of family physicians surveyed had hospital privileges to perform EGD alone, and 0.4% had privileges to perform EGD under supervision or with consultation. 72.1% of family physicians had not requested privileges, while privileges had been denied to 2.6%.
A 1999 national survey of educators3 revealed that 25.7% of family medicine residencies were teaching EGD, a dramatic increase from the 3% reported in a 1988 study. Another survey indicated that 4.5% of residency graduates are now performing EGD.4
SECTION II - CLINICAL INDICATIONS
|Indication||# patients||% patients|
|Abdominal pain, dyspepsia||480||60.5|
|Abnormal upper GI radiograph||38||4.8|
|Barrett's esophagus follow-up||18||2.3|
*Total is >793 because individual procedures could have more than one indication.
Indications for Diagnostic Gastroscopy *
Crohn's disease of the upper GI tract (pre-existing or suspected)
Failed medical therapy (e.g., H-Pylori)
Gastric ulcer monitoring
Peptic ulcer disease, chronic
Chest pain, etiology uncertain
GI bleeding, gross (if not massive)
GI bleeding, occult
Loss of appetite (chronic)
Nausea, chronic (vomiting)
*Depending on factors such as severity, response to treatment, length of symptoms, etc.
- If a change in management is probable or is being considered based on results of endoscopy.
- After an empiric trial of therapy for a suspected benign digestive disorder has been unsuccessful.
- Often as the initial method of evaluation as an alternative to x-ray studies.
- When the results of study will not contribute to the management decision.
- For periodic follow-up of healed benign disease unless surveillance for premalignant condition is planned.
- When the risks to patient health or life are judged to outweigh the most favorable benefits of the procedure.
- When adequate patient cooperation cannot be obtained.
- When a perforated viscus is known or suspected.
Specific EGD Indications:
- Upper abdominal distress that persists despite an appropriate trial of therapy.
- Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., anorexia and weight loss).
- Dysphagia or odynophagia.
- Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy.
- Persistent vomiting of unknown cause.
- Other system disease in which the presence of upper GI pathology might modify other planned management. Examples include patients with: a history of GI bleeding who are scheduled for organ transplantation; patients receiving long-term anticoagulation or; chronic non-steroidal anti-inflammatory therapy for arthritis.
- Familial polyposis coli.
- X-ray findings of:
- A suspected neoplastic lesion, for confirmation and specific histologic diagnosis.
- Gastric or esophageal ulcer.
- Evidence of upper tract stricture or obstruction.
- Gastrointestinal bleeding:
- In most actively bleeding patients.
- When surgical therapy is contemplated.
- When re-bleeding occurs after acute self-limiting blood loss.
- When portal hypertension or aorto-enteric fistula is suspected.
- When sampling of duodenal or jejunal tissue or fluid is indicated.
- Distress that is chronic, non progressive, atypical for known organic disease, and considered functional in origin (there are occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy).
- Uncomplicated heartburn responding to medical therapy.
- Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
- X-ray findings of:
- Asymptomatic or uncomplicated sliding hiatus hernia.
- Uncomplicated duodenal bulb ulcer that has responded to therapy.
- Deformed duodenal bulb ulcer when symptoms are absent or respond adequately to ulcer therapy.
- Patients without current gastrointestinal symptoms about to undergo elective surgery for non upper GI disease.
Sequential or Periodic Diagnostic EGD
- Patients requiring periodic surveillance for proven Barrett's esophagus; familial polyposis coli.
- Follow-up of selected esophageal, gastric or stomal ulcers to demonstrate healing.
- Patients with prior adenomatous gastric polyps.
- Follow-up for adequacy of prior sclerotherapy of esophageal varices.
- Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, treated achalasia, or prior gastric operation.
- Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer.
- Surveillance during chronic repeated dilations of benign strictures unless there is a change in status.
- Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g. electrocoagulation, heater probes, laser photocoagulation or injection therapy).
- Sclerotherapy for bleeding from esophageal or proximal gastric varices.
- Foreign body removal.
- Removal of selected polypoid lesions.
- Placement of feeding tubes (peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).
- Dilation of stenotic lesions (e.g. with transendoscopic balloon dilators or dilating systems employing guide wires).
- Palliative therapy of stenosing neoplasms (e.g. laser, bipolar electrocoagulation, stent placement).
SECTION III - TRAINING METHODOLOGY
Available Training in EGD:
SECTION IV - TESTING, DEMONSTRATED PROFICIENCY AND DOCUMENTATION
Demonstration of Proficiency5
- The learner shall demonstrate adequate clinical knowledge regarding the following:
- Patient selection and contraindications (relative & absolute)
- Informed consent
- Preparation of patient
- Limitations of procedure
- Complications and their management
- Electro-surgical principles
- Indications and contraindications for simple biopsy, electro-surgical biopsy, ablation, or polypectomy
- Complications and management of biopsy
- Familiarity with disinfection preparation of equipment and Occupational Safety & Health Administration (OSHA) regulations regarding this procedure
- The learner shall demonstrate technical and clinical skills as he/she:*
- Identifies the parts of the scope and explains their use.
- Explains the equipment set up.
- Performs an oral examination on the patient.
- Inserts the scope into the patient's mouth using either the manual or the visual technique.
- Places the bite block between the patient's teeth.
- Advances the scope to the cricopharyngeus and demonstrates how it is traversed.
- Explains (or demonstrates) how he or she would handle a tracheal intubation.
- Demonstrates the passage of the scope through the esophagus.
- Discusses the decision whether or not to biopsy the distal esophagus.
- Demonstrates passage through the lower esophagus sphincter.
- Explains how the gastric pool would be aspirated upon entry into the stomach.
- Passes the scope through the stomach and demonstrates orientation and landmarks as he or she progresses.
- Demonstrates the approach to and passage through the pylorus.
- Demonstrates passage of the scope into the duodenum.
- Discusses orientation within the duodenum and the location of the papilla of Vater.
- Begins to withdraw the scope and demonstrates visualization of the duodenal bulb.
- Withdraws the scope into the stomach and identifies returning past the pylorus.
- Demonstrates the "J" or retroflexion maneuver and will visualize the cardia and the lower aspect of the gastroesophageal junction.
- At this point, or earlier when in the lower esophagus, explains how the diaphragmatic level can be identified on the esophagus or stomach.
- Straightens the scope and adequately visualizes the lining of the stomach, maintaining orientation.
- Shows/explains how a biopsy will be done.
- Correctly removes the scope from the stomach, correctly visualizing the esophagus and vocal cords.
- If administering conscious sedation, the learner shall demonstrate that he or she has performed conscious sedation during the past 24 months with cases reviewed for choice of drug, interval, dosage and outcome.
- The learner shall demonstrate proficiency in post-procedure steps through the following:
- Appropriate aftercare of patient, including use of reversal medications if appropriate, orders, medications, and instructions.
- Preparation of endoscopic report.
- Appropriate post-procedure follow-up.
Documentation can be performed by dictating a complete report or by using an endoscopy report form that allows notation of findings by circling the appropriate indications, medications, findings, and pathology. This type of documentation is also helpful when further clinical privileges are being requested and in clinical studies on EGD. A sample endoscopic report form is included as Appendix A.
SECTION V - CREDENTIALING AND PRIVILEGES
The 2008 Accreditation Manual for Hospitals6, written by the JC, states that clinical privileges are based on the individual's current licensure, relevant training or experience, current competence, and the ability to perform the privileges requested (MS.5.15.1).
MS.4.15.5 Ability to perform privileges requested. The decision to grant or deny a privilege(s), and/or to renew an existing privilege(s), is an objective, evidenced-based process.
Physicians must be judged according to their peers for the granting of privileges.
The American Association for Primary Care Endoscopy (AAPCE) recommends, “Credentialing should be based upon demonstrated proficiency rather than a specified number of procedures performed during training. Credentialing should not be limited to specific medical specialties. For hospitals that choose to require specified numbers of procedures during training, these requirements should not exceed 50 colonoscopies or 35 esophagogastroduodenoscopies. Additional, well-designed scientific studies are needed on the optimal methods and quantity of training needed in GI endoscopy.”
The Joint Commission's standards create no barriers to granting privileges for one activity to more than one clinical specialty (for example, privileges to perform endoscopies granted to both surgeons and gastroenterologists). The overriding concern is that the practitioner demonstrate the appropriate education, training, and current competence to perform the procedure in question. The specific criteria regarding education, training, and current competence should be developed by the individual departments and should be, as specified in standard.4,15,2 "Each of the criteria used are consistently evaluated for all practitioners holding that privilege."
Physician candidates may be required to provide written documentation of additional training beyond the core curriculum of family medicine residency. This training can include, but is not necessarily limited, to the following:
- Special selective training within a family medicine residency.
- Accredited continuing medical education.
- Verified preceptorship with a licensed physician.
Privileges for invasive procedures are usually granted on a provisional status requiring physicians to submit progress reports at designated time intervals (for example, three, six, and 12 months). The family medicine department would monitor these progress reports and make recommendations for advancement from provisional privileges to active privileges.
During the provisional period, the family medicine department should assign a physician for proctoring all family physicians while they are being monitored.
To ensure continuous monitoring of quality, physicians may be required to submit an annual census of all invasive procedures listing many or all complications should they arise. This list should be reviewed by the department chair (or his or her designee). Active privileges are renewed every one to two years by the authority of the department chair.
Applying for GI Endoscopy Privileges
- Prepare a brief resume that describes your educational background including college, medical school, residency, board certification, and recertification.
- Include your affiliations with hospitals, state and national medical societies, and the duration of these affiliations. Include any professional honors, elected offices, or committee chair positions.
- Describe the accredited CME courses you have taken that pertain to GI endoscopy. Include CME and/or self study of gastrointestinal illness (atlases, articles, etc).
- Describe your years of practice and your record in providing high-quality care for a variety of complicated cases. Physicians with a record of exemplary service can point to these experiences as evidence of professional excellence.
- Include a summary letter from your residency or state AAFP chapter that supports these privileges as being within the scope of the specialty of family practice.
- Describe the number of rigid sigmoidoscopies, flexible sigmoidoscopies, colonoscopies, and/or upper GI endoscopies that you have performed. Include an inventory that lists the patients by name, age, sex, and indication. Provide diagnostic findings and prominently highlight your lack of complications.
- Describe hands-on proctorship experiences and/or identify someone who is willing to do cases with you. A hands-on proctorship is not necessarily a prerequisite if you have equivalent training and/or experience.
- Identify the fact that the ASGE standard. Be prepared, if necessary, to discuss the criteria for EGD suggested by the ASGE. It is the AAFP’s position that the ASGE has adopted a stance that is not supported by current clinical evidence, and may reasonably be interpreted as more aligned with competitive marketplace concerns than patient access to quality care.
- Describe your plan for quality assurance. This should mean tracking your cases, and providing these data to your department chair after a period of six to 12 months.
- Provide evidence of your ability to obtain malpractice insurance coverage.
- Be able to demonstrate an ongoing commitment to GI-related CME.
- Be cooperative, yet persistent, during the privileging process. Become thoroughly familiar with your hospital’s by-laws and processes related to credentialing and privileging. Review and understand the privileging materials available from the Academy.
SECTION VI - MISCELLANEOUS ISSUES
Public Health Implications
Current Research Agenda
Statement of Research Needs
Potential Measures to Encourage Research Development in Upper GI Endoscopy
- Target research support from existing sources, such as the AAFP and AAFP/Foundation (AAFP/F).
- Develop alliances with equipment or pharmaceutical manufacturers or other proprietary entities.
- Develop grant funding via the AAFP-F for procedural skills research.
- Work with HMOs, insurance corporations or health systems to develop funding.
- Work with the Agency for Healthcare Research and Quality (AHRQ), the National Institute of Health (NIH) or other Federal granting agencies to develop requests for proposals (RFPs) centering on procedural skills.
- Approach foundations for funding.
- Explore opportunities to publish results of procedural skills research and experiences.
Relationship Between the AAFP and Other Organizations (e.g., ASGE, ACP-ASIM)
SECTION VII - REFERENCES
- Pierzchajlo PJ, Ackerman RJ & Vogel RL. Esophagogastroduodenoscopy performed by a family physician: a case series of 793 procedures. J Fam Pract 1998;46(1):41-6.
- American Academy of Family Physicians. Facts about family practice. Leawood, KS: American Academy of Family Physicians 2006.
- American Academy of Family Physicians. Survey of procedural skills, residency directors. Leawood, KS: American Academy of Family Physicians 1999.
- American Academy of Family Physicians. 2001 hospital privileges of 1999 family practice residency program graduates. Leawood, KS: American Academy of Family Physicians 2001.
- American Academy of Family Physicians. Esophagogastroduodenoscopy: a syllabus for the family physician interested in performing this technique. Leawood, KS: American Academy of Family Physicians 1999.
- Joint Commission on Accreditation of Healthcare Organizations. 2008 hospital accreditation standards. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations 2008.
UPPER GI ENDOSCOPY PROCEDURE DESCRIPTION
Date: _____________ Age: _______ Sex: M or F
Race: _____________ Physician:______________________
Office/Hospital ID# (if any): ______________ Assistant(s): ___________________
Pertinent Patient History (e.g., illnesses, medicines, surgery, allergies, duration of problem):
Has the patient completed 7-10 days of medical therapy ? Yes No
Circle the categories of drugs used and indicate the drug, dosage and duration of therapy, if known:
Antacid / Antibiotic / Cytotec / Bismuth / Carafate
PPI:_______________ H2 blocker:_______________ Other:________________
Has the patient been using over the counter or prescription NSAIDs or other known gastric irritants?
If so, please list:____________________________________________________
|Indications||ICD 9 Codes||Indications||ICD 9 Codes|
|1. Abdominal Mass||789.3||17. Cancer Surveillance||V67.9|
|2. Anemia, Unexplained||280.9||in High Risk Patients|
|3. GI Bleeding, Acute||578.9||(e.g., Barrett's, Menetrier's|
|4. GI Bleeding, Occult||578.1||Disease, Polyposis)|
|5. X-Ray Abnormality||793.4||18. Esophageal Stricture||564.2|
|19. Gastric Retention||782.0|
|Symptoms||20. History of Duodenitis||535.6|
|6. Dyspepsia, Severe||536.8||21. History of Esophagitis||530.1|
|7. Dysphagia/Odynophagia||787.2||22. History of Gastritis||535.4|
|8. Early Satiety||789.0||23. History of Hiatal Hernia||553.3|
|9. Epigastric Pain||789.0||24. Monitoring a Gastric Ulcer||531.9|
|10. Food Slicking||787.2||25. Peptic Ulcer Disease||533.0|
|11. Heartburn, Meal Related||787.1||26. Pyloroduodenal Stenosis||537.0|
|12. Indigestion, Severe||787.3||27. Varices||456.0|
|13. Nausea, Chronic (Vomiting)||787.0|
|14. Pain (Substernal/Paraxiphold)||786.5||Any Other Indications (please describe)|
|15. Reflux of Food (Regurgitation)||787.0||28. ___________________________|
|16. Weight Loss, Severe||783.2||29. ___________________________|
Medications Used: (Circle drugs used and indicate total dosage.)
|Conscious Sedation||Topical Anesthetic||Reversal||Other|
|1. Morphine||1. Cetacaine||1. Naloxone||1. Atropine|
|2. Fentanyl||2. Lidocaine||2. Romazicon||2. Simethicone|
|3. Demerol||3. Other___________||3. Glucagon|
|4. Nubain||4. Other___________|
Findings: (Circle one for each question)
|1. Was esophagus well visualized?||Yes||No|
|2. Was pylorus well visualized?||Yes||No|
|3. Was duodenum entered?||Yes||No|
|4. Was Papilla of Vater seen?||Yes||No|
|5. Did you do a turnaround maneuver to see cardia/fundus?||Yes||No|
Pathology Code: (Applies to immediately below.)
1. Mild erythema, patchy, no ulcers
2. Moderate erythema, diffuse in area, some petechiae, no ulcers
3. Severe erythema, limited focal mucosal degeneration (i.e., 1-3 ulcers are seen)
4. Severe erythema with diffuse mucosal degeneration (more than 3 ulcers)
5. Other (polyps, cancer, atrophy, or miscellaneous)
Circle one inflammation code for each area: (See above.)
|Esophagus||None 1 2 3 4 5||Pylorus||None 1 2 3 4 5|
|Gastric Area||None 1 2 3 4 5||Duodenum||None 1 2 3 4 5|
|Number of biopsies: (Circle one.)||0 1 2 3 4 5 6 7 8 9 10 More|
|Pathology: (location, size)||_____________________________|
|Did you biopsy an area that appeared normal (i.e., control)?||Yes||No|
|Will you be requesting confirmation for the presence of the H. pylori?||Yes||No|
What is your post-endoscopy working diagnosis? (Circle those that apply.)
|ICD 9 Code||ICD 9 Code|
|Tumor Growth||M8230/9||AV Malformation||447.0|
Will you or did you order upper GI x-rays or barium swallow to confirm and/or complement your endoscopy findings?
(Circle one.) Yes No
Were there any complications? (Circle one.) Yes No
Did this procedure change your management plan? (Circle one.) Yes No
Comments - Circle how management plan or diagnosis changed: (Circle those that apply.)
|1. New diagnosis||6. Suspected diagnosis now confirmed|
|2. Medication added/deleted||7. Previous diagnosis deleted|
|3. Medication will be continued||8. Diagnostic tests added or deleted|
|4. Consultation will be requested||9. Other (describe)________________|
|5. Endoscopy consult not necessary now|
Exam performed as above,
Please check to see that all items have been completed. Complete information strengthens our ability to document a high quality of care.
What are the benefits of EGD?
What are the risks of EGD?
1. Infection can occur, although this is rare. You might need medications after the procedure.
2. Bleeding is rare. It is possible you could have some spotting or even enough bleeding to need a transfusion. This is not common, but it is possible.
3. Perforation (putting a hole in the intestine) is a serious complication, but it is also not common. If a perforation occurs, you would need to go to the hospital and might need an operation.
4. Side effects from medications are possible, but your doctor will take steps to lower the risk. The medications your doctor will give you to prevent pain can cause a reaction. One rare side effect is a swelling and redness in the arm. Another might be a severe allergic reaction to the medications. Your doctor will take precautions to minimize this risk.
What are my choices?
1. If you feel your questions have been answered and you understand and accept the risks and benefits, you can agree to have an EGD by signing the bottom of this sheet.
2. If you are not yet ready to decide to have an EGD, you can ask for more time to think about it and discuss it with your doctor.
3. You can refuse to have an EGD, but you should understand that not having the procedure may also involve some risk. For example, your doctor may not be able to diagnose your problem or the diagnosis may be delayed. In the case of cancer, delaying the diagnosis could mean that treatment isn't started soon enough to cure the cancer.
4. You can talk with your doctor about alternatives to EGD. If there are alternatives that your family, friends, or other doctors have discussed with you, tell your family doctor about them so you can discuss whether they would be right for you.
(August Board 2002) (2010 COD)