Failure of cost-benefit analysis in gastrointestinal endoscopy

Abstract

Background and study aims We discuss the occurrence of two cases, where the endoscopic pursuit of diagnostic certainty resulted in adverse events that exceeded the clinical relevance of the endoscopic diagnosis itself. In both instances, physicians were hesitant to subject their patients to a necessary surgical intervention before gastrointestinal endoscopy had provided them with absolute assurance that no other mitigating factors could possibly jeopardize the success of a planned intervention. In trying to avoid a single and potentially bad outcome of a necessary medical intervention, the physicians exposed their patients to many more additional and unnecessary risks. As key players in clinical decision-making, physicians sometimes may find it difficult to disentangle their own risk-benefit considerations from those of their patients.

• References

• 1 Hassan C, Di Giulio E, Marmo R. et al. Appropriateness of the indication for colonoscopy: systematic review and meta-analysis. J Gastrointest Liver Dis 2011; 20: 279-286
• 2 Rubenstein JH, Pohl H, Adams MA. et al. Overuse of repeat upper endoscopy in the Veterans Health Administration: a retrospective analysis. Am J Gastroenterol 2017; 112: 1678-1685
• 3 Rábago LR, Vicente C, Soler F. et al. Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy 2006; 38: 779-786
• 4 Schwed AC, Boggs MM, Pham XD. et al. Association of admission laboratory values and the timing of endoscopic retrograde cholangiopancreatography with clinical outcomes in acute cholangitis. JAMA Surg 2016; 151: 1039-1045
• 5 Kapur S, Barbhaiya C, Deneke T. et al. Esophageal injury and atrioesophageal fistula caused by ablation for atrial fibrillation. Circulation 2017; 136: 1247-1255
• 6 Sonnenberg A, Pohl H. ‘Do no harm’: an intuitive decision tool to assess the need for gastrointestinal endoscopy. Endosc Int Open 2019; 7: E384-E388
• 7 Kahneman D, Tversky A. Prospect theory: an analysis of decision under risk. Econometrica 1979; 47: 263-292
• 8 Wikipedia contributors. Law of the instrument. Wikipedia, The Free Encyclopedia. Available at https://en.wikipedia.org/wiki/Law_of_the_instrument [Accessed Jan 27, 2019]