乌鸦传媒

LITTLE FALLS, N.J., May 18 -- Electronic records indicating a diagnosis of Barrett's esophagus were wrong more than one-third of the time in a new study.

A manual review of the records of patients with either an electronic billing or pathology code indicating a diagnosis of Barrett's esophagus revealed that only 61.9% of the patients actually had the disease, according to Douglas Corley, M.D., Ph.D., of Kaiser Permanente in Oakland, Calif., and colleagues.

This is "a number that is likely too low by itself for either clinical or research uses without supplemental manual verification," Dr. Corley said.

However, when both billing and pathology codes indicating a diagnosis were present, 85.4% were confirmed, they reported in the May issue of Gastrointestinal Endoscopy.

"These results can help inform diagnoses of Barrett's esophagus for patient care, health policy, and clinical research," they said.

Accurate reporting of diagnoses is important for patient management, reimbursement, identification of patients for clinical research, and the assignment of human resources, according to the researchers.

To explore the accuracy of diagnoses for Barrett's esophagus, Dr. Corley and colleagues reviewed the endoscopy and pathology records of 2,470 patients with electronic billing or pathology codes -- or both -- for the disease. All patients were treated in Kaiser Permanente's Northern California region.

The diagnosis was confirmed "if the endoscopist clearly described a visible length of columnar-type epithelium proximal to the gastroesophageal junction/gastric folds, this area was biopsied, and the pathologist reported specialized intestinal epithelium," the researchers said.

Overall, 61.9% of diagnoses were confirmed, 34.3% were rejected, and 3.7% had insufficient data.

The most common reasons for a rejected diagnosis were the lack of definitive endoscopic findings and the lack of intestinal metaplasia on biopsy.

Of those patients who did not have Barrett's esophagus, 25% had hiatal hernia and 26% had esophagitis, both of which can be confused with Barrett's.

The researchers also assessed the reproducibility of a pathologic diagnosis of Barrett's esophagus between two pathologists and between two readings by a single pathologist.

Two different pathologists agreed on the diagnosis 88.3% of the time, and the single pathologist made the same diagnosis 88.6% of the time.

"The modest intraobserver variation observed for a single pathologist suggests that a proportion of the discordance for pathology reviews between different pathologists may result from somewhat random misclassification rather than from an incorrect reading by the original pathologist," the researchers said.

In an accompanying editorial, Joel Rubenstein, M.D., of the University of Michigan in Ann Arbor, said the issue with diagnostic coding identified in the study is a problem for clinicians, patients, and researchers alike.

"Furthermore," he said, "it is a symptom of the embarrassing inefficiency in our healthcare system."

Although the assignment of a unique billing code for Barrett's esophagus was an important step toward fixing the problem, he said, "it by no means was a panacea," as Dr. Corley and colleagues showed.

An incorrect diagnosis can lead to inappropriate referrals for follow-up endoscopy, he said, which exposes patients to procedural complications, higher insurance costs, and possible denial of coverage, and leads to higher costs for employers, medical insurance policy holders, and taxpayers.

Dr. Rubenstein offered some recommendations for endoscopists and pathologists to address the problem.

Endoscopists should be careful when choosing the site for a biopsy and should take extra time to examine the gastroesophageal junction to rule out other diagnoses, he said.

In addition, he said, there should be clear communication between the endoscopist and pathologist about where the biopsy came from, and both should be aware of the potential deficiencies in each other's reports.

Finally, patients must be better informed about what needs to be done to confirm a diagnosis of Barrett's esophagus, he said.

Referring to a limitation of the study, Dr. Corley and colleagues said "the accuracy of a Barrett's esophagus diagnosis likely represents the minimum number, given the strict criteria."