Z Gastroenterol 2020; 58(07): 652-658
DOI: 10.1055/a-1153-9295
Übersicht

Klug entscheiden – Perspektiven: Was sind die entscheidenden Ansätze (Key Questions) für die Zukunft?

Choosing wisely – perspectives: what are the key questions?
Axel Holstege

Zusammenfassung

Die Gastroenterologie bietet ein weites Feld für zukünftige „Klug-entscheiden-Empfehlungen“ (KEE), die nicht nur den gesicherten Einsatz diagnostischer Tests wie Laboruntersuchungen oder bildgebende Verfahren betreffen, sondern auch medikamentöse Therapien und die gastroenterologische Endoskopie. Dem zu häufigen Einsatz von Medikamenten wie Antibiotika und Protonenpumpenhemmern steht ihr zu seltener Einsatz bei gesicherten Indikationen gegenüber. Ähnliches trifft auf die abdominelle Bildgebung zu, insofern bei vielen Fragestellungen zu häufig der Computertomografie der Vorzug vor einer qualifizierten Sonografie gegeben wird. Laborwerte wie Lipase oder Amylase sind beim asymptomatischen Patienten nicht weiterführend und verursachen u. U. eine Vielzahl von unnötigen weiteren diagnostischen Maßnahmen. Bei akuter Pankreatitis bringt die Bestimmung beider Enzyme keinen additiven diagnostischen Nutzen. Ähnlich wenig hilfreich ist der unkritische Einsatz von weiteren für die Gastroenterologie relevanten Laborparametern wie CEA, Ammoniak oder Procalcitonin. In der Endoskopie ist eine „Vorsorgegastroskopie“ bei asymptomatischen Patienten ohne Risikofaktoren nicht sinnvoll, während die Koloskopie als Vorsorgeuntersuchung auf ein Kolonkarzinom zu selten von über 50-Jährigen wahrgenommen wird.

Die sich dramatisch entwickelnde Adipositaspandemie und der damit einhergehende massive Anstieg an fortgeschrittenen nichtalkoholischen Fettlebererkrankungen mit entsprechender Morbidität und Mortalität machen KEE erforderlich, die nicht nur Empfehlungen für den einzelnen Patienten geben, sondern auch Maßnahmen zur Regulierung des Verkaufs hochverarbeiteter Lebensmittel oder zuckerreicher Softdrinks darlegen. Auch zukünftig werden sich die „Key Questions“ für KEE in der Gastroenterologie aus der Erstellung von Leitlinien heraus ergeben. Dennoch sind auch KEE für Situationen im klinischen Alltag wünschenswert, für die es keine Leitlinienempfehlungen gibt. Durch interdisziplinären Expertenkonsens und Berücksichtigung vorhandener wissenschaftlicher Daten kann diesen KEE eine sichere Basis verschafft werden.

Abstract

Gastroenterology offers a wide field for future „choosing wisely“ recommendations (CWR). They should refer not only to an under- or overuse of diagnostic tools like laboratory or imaging tests but also to an evidence-based application of drug therapies und endoscopic interventions. Drugs like antibiotics or proton pump inhibitors are both often prescribed in the absence of clearly defined underlying diseases and not given when an indication is clear. Similar is true for the ordering of abdominal imaging methods. Computerized tomography of the abdomen too often is preferred over a qualified ultrasound study. Laboratory tests like amylase or lipase should not be ordered for asymptomatic patients since false positive values often end up with further useless and occasionally invasive examinations. Ordering both enzymes in acute pancreatitis will not provide any additional information. Similarly, CEA, ammonia or procalcitonin have either limited or no value in gastroenterology. Upper gastrointestinal endoscopy should not be performed in asymptomatic people without any risk factors. On the other hand, colonoscopy is still underused as a valuable screening tool for detection and secondary prevention of colorectal carcinomas in people over 50 years old.

The dramatic rise in people suffering from obesity is paralleled by an enormous increase in severe cases of non-alcoholic fatty liver disease associated with high morbidity and mortality. This calls for CWRs addressing this causal relationship and offering not only patient centered therapeutic solutions but also calling for effective measures to regulate the marketing of highly processed food or sugar enriched soft drinks. Published guidelines in Gastroenterology will continue to be a rich source for delineating new CWRs. Nevertheless, CWRs are also needed in daily practice offering solutions for clinical problems not covered by guidelines. These, however, have to be based both on a broad interdisciplinary consent of experts in the field and on scientific evidence.



Publication History

Received: 17 February 2020

Accepted: 05 April 2020

Article published online:
13 July 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 
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