Objectives: The initial diagnostic approach for dysphagia is controversial. The choices include barium swallow (BaS) versus esophagogastroduodenoscopy (EGD). The aim of this study was to determine the clinical cost of establishing a diagnosis and treating dysphagia based on initial diagnostic approach (BaS vs EGD).
Methods: Clinical outcome of patients with undiagnosed dysphagia evaluated by either internists in a primary care clinic (n = 100) or gastroenterologists (n = 120) were determined based on the initial diagnostic test: BaS versus EGD. Final diagnoses in each group were determined based on any testing performed subsequent to the initial studies. Total cost in achieving the final diagnosis for each group were determined based on 2002 Medicare reimbursement cost.
Results: BaS (66% and 62%) and EGD (34% and 38%) were ordered in equal prevalence by gastroenterologists and internists, respectively. Final diagnoses included: benign obstruction (37% and 36%), gastroesophageal reflux disease (GERD) (18% and 44%), achalasia (17% and 1%), nonspecific esophageal motility disorder (NSEMD) (17% and 11%), neoplasm (7% and 6%), and infectious esophagitis (4% and 2%) in subspecialty and primary care clinics, respectively. Motility disorders (NSEMD and achalasia) was diagnosed more often by gastroenterologists (40 of 120, 34%) than by internists (12 of 100, 12%) (p < 0.001). GERD was the predominant diagnosis made by internists (44 of 100, 44%) compared to gastroenterologists (22 of 120, 18%) (p < 0.001). Although the cost of diagnosing benign obstruction was less for BaS ($73 +/- 13) than EGD ($370 +/- 5, p < 0.001), subsequent therapy with dilation increased the cost for barium testing first (BaS $602 +/- 22 vs EGD $515 +/- 5, p < 0.02). Cost of diagnosis or treatment of esophageal dysmotility (achalasia/NSEMD) was significantly (p < 0.001) less using BaS as the initial test.
Conclusions: 1) BaS is less costly than EGD for diagnoses and treatment involving abnormal motility. 2) Initial EGD with therapeutic intent is less costly for patients with history suggesting benign obstruction. 3) Primary care physicians identified GERD and benign obstructions as the cause of dysphagia more often in their patient group than the gastroenterologists, making EGD a reasonable initial test in this setting instead of currently practiced BaS.