The "three-day" rule in upper digestive endoscopy. A prospective controlled study [L’urgenza differita in endoscopia digestiva. Risultati di uno studio prospettico controllato della durata di 12 mesi]

A new initiative, called the Three-Day Rule (TDR), has been introduced in Lombardy in order to promote earlier diagnosis and treatment of severe diseases. It is expected that patients with symptoms/clinical be seen by a specialist or have a diagnostic procedure done within 3 working days of referral by General Practitioners (GPs). We aimed at assessing the effectiveness and compliance with TDR for upper digestive endoscopy (UDE). A prospective audit of all referrals for upper retro intestinal (GI) symptoms under the TDR initiative was done over a 12-month period at a single teaching hospital. We collected demographic data, clinical details, referral cards and final diagnoses on all patients referred for UDE by means of TDR as well as on all outpatients undergoing UDE on open access (OA)-basis during the same period. The appropriateness of the indications for each request was also reviewed. One hundred forty two patients were referred for UDE under the TDR scheme as compared with 767 patients on OA-basis. Six percent had a final diagnosis of oesophageal/gastric cancer in the TDR group as compared to only 1% in the OA-group (p<0.01). Significantly more patients referred by TDR had serious upper GI lesions in comparison with those referred on OA (p<0.05). Thirty nine percent of UDE were rated as inappropriate in the OA-group as compared with 22% in the TDR-group (p<0.01). The TDR-scheme appears to expedite the diagnosis of serious upper GI diseases. However, some GPs appear to over read alarm symptoms, and this may lead to inappropriate referrals. Better awareness of appropriate urgent referral criteria is needed in order to ensure that resources for this initiative are used efficiently.