ABSTRACT
Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a "center of excellence" (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD. Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery. Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, <10% had GERD for <1 year, ~60% had GERD for 1-11 years, and ~30% had GERD for ≥12 years. More than one-quarter had atypical GERD symptoms (27.6%). Only 6.4% had been on PPIs for <1 year and >20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution. Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.
