Table 4.
GERD Quality Measures ranked with equivocal validity.
| Proposed Quality Measure | Median Rankings (Individual panelist rankings) | Level of evidence |
|---|---|---|
| Initial Diagnosis & Management | ||
| IF a patient has typical symptoms of heartburn and regurgitation, THEN a presumptive diagnosis of GERD can be made without the need for diagnostic testing, including endoscopy. | Round 1: 8.0 (6, 7, 9, 9, 8, 6, 8, 6) | Moderate |
| IF antisecretory drugs are being use for treatment of GERD, THEN it should be understood that PPIs are more effective than H2RAs, which are more effective than placebo. | Round 1: 8.5 (9, 6, 9, 9, 9, 8, 9, 6) | High |
| IF traditional delayed release PPIs are used, THEN they should be administered 30 to 60 minutes before a meal for maximal pH control. | Round 1: 8.5 (9, 8, 8, 9, 9, 6, 9, 6) | Moderate |
| IF a patient has partial but inadequate response to heart burn symptoms on once daily PPI therapy, THEN the next step should be increase the dose to twice daily.† | Round 1: 7.0 (7, 4, 8, 7, 5, 7, 8, 7) Round 2: 5.5 (7, 4, 4, 3, 8, 7, 6, 5) |
Low |
| IF a patient on PPI therapy has objective evidence of nighttime reflux, THEN bedtime H2RA therapy can be added if needed, but may be associated with the development of tachyphylaxis after several weeks of use. | Round 1: 7.0 (7, 6, 6, 3, 7, 8, 7, 6) | Low |
| IF a patient is on concomitant clopidogrel, THEN PPI therapy does not need to be altered as there does not appear to be an increased risk for adverse cardiovascular events. | Round 1: 7.0 (5, 8, 7, 7, 6, 5, 9, 7) | High |
| IF a patient has GERD, THEN therapy for GERD other than acid suppression, including prokinetic therapy and/or baclofen, should not be used in GERD patients without diagnostic evaluation. | Round 1: 8.0 (6, 8, 8, 8, 8, 8, 9, 2) | Moderate |
| IF a patient has GERD, THEN lifestyle modifications including elevation of the head of the bed, avoiding late meals, avoiding specific foods, or avoiding specific activities should be tailored to the circumstances of the individual patient rather than broadly advocated for all patients. | Round 1: 8.0 (8, 8, 6, 9, 9, 8, 7, 6) | Moderate |
| IF a non-pregnant patient has GERD, THEN there is no role for sucralfate in the management of GERD. | Round 1: 8.0 (8, 8, 6, 8, 8, 5, 8, 7) | Moderate |
| IF a patient has GERD, then screening for Helicobacter pylori infection is not recommended. | Round 1: 8.0 (5, 9, 7, 8, 8, 6, 9, 9) | Low |
| IF a patient has suspected GERD, THEN routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD. | Round 1: 8.0 (8, 8, 8, 1, 9, 6, 9, 8) | Moderate |
| IF a patient has uncomplicated GERD, THEN endoscopic anti-reflux therapy may be considered for selected patients after careful discussion with the patient regarding potential side effects, benefits, and other available therapeutic options. | Round 1: 6.0 (3, 3, 7, 1, 9, 6, 9, 8) | Low |
| Monitoring | ||
| IF a patient with GERD continues to have symptoms after a PPI is discontinued, THEN maintenance PPI therapy should be administered. | Round 1: 7.0 (7, 7, 8, 7, 5, 7, 9, 6) | Moderate |
| IF a patient has LA grade C or D erosive esophagitis, THEN at least daily PPI dosing should be used.† | Round 1: 6.0 (7, 8, 8, 8, 2, 5, 8, -) Round 2: 4.0 (5, 2, 2, 1, 9, 7, 6, 3) |
Low |
| IF a patient has erosive or nonerosive reflux disease, THEN routine endoscopy to assess for disease progression should not be performed. | Round 1: 8.0 (7, 8, 8, 8, 2, 5, 8, -) | Low |
| Further Diagnostic Testing | ||
| IF a patient with suspected GERD has not responded to empirical trial of twice-daily PPI and has normal findings on endoscopy, THEN manometry should be performed. | Round 1: 6.5 (8, 5, 7, 7, 5, 6, 9, 1) | Moderate |
| IF short- or long-segment Barrett's esophagus is present, THEN ambulatory reflux monitoring is not needed to establish a diagnosis of GERD. | Round 1: 6.5 (6, 6, 8, 1, 5, 9, 9, 7) | Moderate |
| Chest Pain | ||
| IF a patient has suspected reflux chest pain syndrome and a cardiac etiology has been carefully considered, THEN twice-daily PPI therapy should be started as an empiric trial. | Round 1: 7.0 (8, 4, 8, 8, 8, 6, 3, 6) | Moderate |
| IF a patient has non-cardiac chest pain suspected due to GERD, THEN diagnostic evaluation should be performed before institution of therapy.† | Round 1: 6.5 (6, 7, 4, 1, 3, 7, 7, 9) Round 2: 3.5 (5, 4, 1, 1, 3, 6, 4, 1) |
Moderate |
| Erosive Esophagitis | ||
| IF a patient has LA Grade A esophagitis, THEN further testing should be performed to confirm the presence of GERD. | Round 1: 4.0 (5, 4, 4, 1, 3, 6, 8, 1) | Low |
| Stricture/Ring | ||
| IF a patient has refractory, complex peptic strictures, THEN injection of intralesional corticosteroids can be used. | Round 1: 7.0 (7, 7, 7, 7, 6, 8, 6, 7) | Low |
| IF a patient has lower esophageal (Schatzki) rings, THEN treatment with a PPI is suggested following dilation. | Round 1: 7.0 (7, 5, 7, 1, 9, 8, 7, -) | Low |
| Surgical Therapy | ||
| IF a patient with an esophageal GERD syndrome is responsive to, but intolerant of, acid suppressive therapy, THEN anti-(-)reflux surgery should be recommended as an alternative. | Round 1: 7.5 (6, 8, 7, 9, 7, 9, 9, 6) | High |
| IF a patient with esophageal GERD syndrome is non-responsive to PPI therapy, THEN surgical therapy should generally not be recommended. | Round 1: 6.0 (5, 6, 9, 1, 5, 7, 8, -) | High |
| PPI-Refractory Symptoms | ||
| IF a patient with suspected GERD does not respond to empiric trial of twice daily PPI therapy, THEN endoscopy with biopsy of suspicious areas should be performed.† | Round 1: 7.0 (6, 7, 7, 1, 8, 9, 7, 9) Round 2: 5.5 (6, 5, 3, 1, 9, 8, 4, 7) |
Moderate |
†
Initial proposed measure was reworded during the two rounds; (-) indicates that a score was not submitted; GERD: Gastroesophageal Reflux Disease; PPI Proton Pump Inhibitor; H2RA: H2 Receptor Antagonist.