"Drop in" gastroscopy is feasible within available resource limits. The staff at the endoscopy unit was willing to extend the testing period for drop in gastroscopy even if it meant more unpredictable workloads and increased volume with no increase in personnel. Advantages were: a better service to patients (short waiting time), reduced time spent on assessment and prioritization of referral letters as well as an increased volume of procedures which were matched by an increase in pathological findings of clinical significance (Table ). Further, the re-organization of the service also reduced the problem of non-appearance for appointments. According to our previous experience up to 5% of patients do not attend for their gastroscopy appointment. This problem has been shown to be more serious with increasing waiting time from referral to time of appointment [8
The main advantage, however, is an improved service to the patient which is a declared aim proved difficult to reach for health care providers.
However, the patients' questionnaire was not able to give detailed and specified estimates of patient satisfaction as it was not designed to do so. Nevertheless, the questionnaire results clearly suggest that organizing outpatient gastroscopy as a "drop in" service is at least comparable to gastroscopy by appointment in terms of patients' acceptance.
A major concern at the start of our project was the fear of having to face an unmanageable number of "drop in" patients each morning, even though the introduction of a similar scheme in Örebro in Sweden did not lead to an increased gastroscopy-volume [9
]. However, the workload at an endoscopic unit is unpredictable anyway with a number of emergency patients to be fitted into a daily program that is already tight because of a national waiting list problem that also has affected Telemark county. "Drop in" patients can be regarded as a part of the same, normal unpredictability. As our staff got used to the new scheme, the burden of increased unpredictability became less important - and even the "unpredictability" of number of "drop in" patients became more predictable with time as attendance patterns emerged specific for each day of the week.
The increased number of procedures is justified by a simultaneous disproportionate increase in number of diagnoses, especially esophagitis and to some extent peptic ulcers. There might be claimed a risk of bias by endoscopists wishing to find lesions in the "drop in" group, at least for esophagitis. We were aware of this problem during our endoscopic procedures.
There are two clear concerns about the "drop in". The first is that patients, who are not suitable for "drop in" gastroscopy, but have a more urgent need for a gastroscopy, may be given lower priority. Even 8-9 months after starting the project, the average waiting time for a gastroscopy by appointment is still five weeks at the Hospital of Telemark (2-88 weeks in the whole area of South-East Norway) although the number of patients on the list decreased substantially. In this context it might be of importance that comorbidity in elderly patients can lead to an overrepresentation in the appointment group. In our study there was no skewed distribution of age and gender composition, but a larger patient sample might have demonstrated a difference. On the other hand, there was a non-significant overrepresentation of women in the "drop in" group, which might relate to earlier findings of women being overrepresented in the "low priority" group [2
]. If "drop-in" can contribute to easier access for low-priority groups with high medical needs, this would be in line with a policy of equality for health care services.
The other concern is that the increased number of gastroscopies due to increased referral to our center may be at the expense of other procedures such as colonoscopies. This was not the case in our unit as the number of colonoscopies also increased during the period.
We had expected a lower consumption of PPIs and H2 inhibitors among the "drop in" patients because of reduced time from GP-consultation to gastroscopy. The average time from first contact to the GP for the current problems of gastroscopy (3.6 weeks) was longer than the two weeks deadline between the date of the GP referral letter and appearance for "drop in", because the GPs did not refer an endoscopy by the first contact with the patient. In fact, the large SD of 9.7 indicates a substantial individual degree of "doctor's delay". This may indicate that a "wait-and-see" policy with prescription of acid secretion inhibitors may be difficult to change even after 8-9 months' break-in period for the "drop in" service. There is an economic potential in the ability to avoid inappropriate, symptomatic use of acid-inhibiting drugs by early diagnostic accuracy through a "drop in" service, which has not been utilized yet. The significantly shorter time from first medical contact to gastroscopy in the "drop in" group can also be thought to influence the course of the disease (prognosis and sick leave periods).
Some studies suggest that survival in gastric cancer [5
] and mortality due to NSAIDs-related peptic ulcer [6
] can be improved in connection with the organizational measures to reduce waiting times for gastroscopy. Other studies have not been able to confirm this effect and our pilot study was not designed to show this [7
]. Table shows more diagnosed gastric cancers in 2009 compared to 2008. We have no explanation for the phenomenon which may be a chance finding.