TIME TO FUNDOPLICATION: AN ANALYSIS OF REFERRAL PATTERN AND CO-MORBIDITY BURDEN OF PATIENTS WITH MEDICALLY REFRACTORY GERD
Berna F. Buyukozturk*, Caleb P. Maness, Peter W. Callas, Conor H. O'Neill
Surgery, University of Vermont Larner College of Medicine, Burlington, VT
BACKGROUND: Surgical anti-reflux procedures remain the definitive treatment for chronic, medically refractory gastroesophageal reflux disease (GERD), according to consensus guidelines. Patients with GERD frequently present with extra-esophageal manifestations, such as laryngopharyngeal reflux. It may be difficult to discern GERD as the cause of the patient's condition, and multiple specialist consultations may occur to rule out other etiologies. The choice of initial referral, the timing of referral from diagnosis, and the patient's comorbidity burden may impact timing of the definitive management—fundoplication. This study aims to examine referral patterns and co-morbidity status to identify factors that influence duration of time between GERD diagnosis and anti-reflux surgery.
METHODS: A retrospective, 10-year review was performed examining patients ages 18-64 with GERD who underwent Nissen fundoplication between January 1, 2010 and January 1, 2020 at a single tertiary referral center. Patients with peptic stricture, esophageal adenocarcinoma, or Barrett's esophagus with high grade dysplasia were excluded. Patient demographics and clinical variables were collected. Kaplan Meier estimates and linear regression analyses were performed to analyze the association between initial referral type and time to surgery, number of co-morbidities and time to surgery, PCP type and time to general surgery and/or GI referral, and number of co-morbidities and time to general surgery and/or GI referral.
RESULTS: A total of 426 patients were identified with 37 excluded. Analyses were performed of referrals to otolaryngology (ENT), gastroenterology (GI), or general surgery for ICD codes associated with GERD. Referral to ENT delayed time to surgical treatment by 1.3 years compared to those who were initially referred to GI or general surgery (3.4 vs 2.1 years) (p<0.05). A greater co-morbidity burden strongly delayed anti-reflux surgery from initial GERD diagnosis (p < 0.001). Linear regression analysis found that for each individual co-morbidity, the predicted time from GERD diagnosis to fundoplasty increased by 146 days (Fig. 1 and 2). This relationship was maintained when controlling for the association between number of comorbidities and time to either general surgery or GI referral (p < 0.001). There was no association found between type of PCP (MD, nurse practitioner, or physician assistant) and time to referral (p = 0.72).
CONCLUSION: Our results emphasize the importance of deliberate referral practices for patients with GERD to minimize duration of reflux and mitigate potential complications. A large portion of ENT referrals are made for reflux symptoms, yet our data may indicate a need for a change to local referral patterns, as it suggests that initial referral to gastroenterology and/or general surgery may shorten the time to definitive treatment.
Kaplan Meier estimates showing time in days from GERD diagnosis to fundoplication (x-axis) and probability of having undergone fundoplication (y-axis) and influence of comorbidity burden.
Lowess smoother plot showing a strongly positive correlation between co-morbidity burden (x-axis) and time in days between GERD diagnosis and fundoplication (y-axis).
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