Reply

We thank Dr. Weiss for his response to our study and agree that insurer-driven hard lines based on a theoretical “average patient” and enforced without interface with the ordering physician appear problematic.^1–3 In finding that strict adherence to guidelines may increase insurer and patient costs over a year, our study quantifies the rationale against blanket prior authorization requirements from all perspectives, advocating for flexibility of management strategy based on the patient-physician relationship rather than replacement of one one-size-fits-all approach with another. ⁴ This is similar to Ford, et al. finding that a number-needed-to-diagnose to identify erosive esophagitis (pooled prevalence of 11.0%) or peptic ulcer disease (4.4%) would be 6.9 among patients with dyspepsia⁵, yet not advocating routine index endoscopy for uninvestigated dyspepsia in recent guidelines (strong recommendation and very low level of evidence).⁶

Evidence-based medicine is not at odds with value/experience-based medicine. Instead, we propose that consideration of currently opaque patient-level contexts is an important next step for scientific inquiry and worthy of discussion.⁷ Why do costs appear to increase when up-front endoscopy is avoided? Why does patient satisfaction tend to decrease? Why do gastroenterologists still offer endoscopy, even in non-invasive diagnostic arms of clinical trials? Does there exist a true average patient? The contexts of daily practice and individual patients are difficult to capture in quantitative studies. This truism underpins the conclusion of our article that clinical care should best remain in the hands of gastroenterologists (the primary intended audience for practice guidelines⁸) and their patients. And, when index endoscopy is offered across indications of dyspepsia¹, heartburn⁹, or dysphagia¹⁰: Do it once, and do it right.