Gastroenterology
Volume 138, Issue 1 , Pages 27-30, January 2010

Community Colonoscopy: A Gordian Knot?

  • John I. Allen

      Affiliations

    • Corresponding Author InformationReprint requests Address requests for reprints to: John I. Allen, MD, MBA, AGAF, Minnesota Gastroenterology PA and the University of Minnesota School of Medicine, PO Box 14909, Minneapolis, MN 55414

Minnesota Gastroenterology PA and University of Minnesota School of Medicine, Minneapolis, Minnesota

published online 23 November 2009.

Article Outline

 

See “Utilization of surveillance colonoscopy in community practice,” by Schoen RE, Pinsky PF, Weissfeld JL, et al, on page 73.

There are many who believe that community gastroenterologists “scope” too much, make too much, and ignore evidence-based medicine, especially when it comes to colonoscopy. Despite published guidelines, there is evidence that we order too many surveillance examinations.1 Overpayment for colonoscopy has been blamed for the disintegration of our primary care infrastructure, has been targeted by MedPAC2 and researchers,3 and is targeted frequently in the lay press.4

The article by Schoen et al in this issue of Gastroenterology reinforces these perceptions.5 They surveyed 3627 participants in the Prostate, Lung, Colorectal, and Ovarian Cancer screening trial in whom a polypoid lesion was found on sigmoidoscopy and who then underwent diagnostic colonoscopy. Participants were stratified based on colonoscopic findings and their subsequent colonoscopy examinations were documented.

Within 5 years of the initial diagnostic colonoscopy, only 58.4% of patients with advanced adenomas had a follow-up colonoscopy (underuse), 57.5% of patients with ≥3 adenomas had a follow-up examination (underuse), and 26.5% of low-risk patients (no adenomatous polyps) had ≥1 “surveillance” examinations (overuse). Of 1026 patients with no adenomas at baseline, 58% underwent another colonoscopy with a median time to the second examination of 3.9 years. A detailed analysis of records failed to justify the need for early colonoscopy based on confounding variables. The authors concluded that, “Our results among hundreds of colonoscopy practitioners in 9 regional U.S. areas demonstrate substantial over utilization of surveillance colonoscopy among low risk subjects … and significant under utilization among high-risk subjects.”

It is time to understand the root causes of endoscopy “misuse” and find solutions. Gastroenterologists can approach this issue with hard conversations, or we can continue our traditional approaches and hope for the best. As I focus on 3 areas that may influence a physician's management of postpolyp patients—science, infrastructure, and money—it is worth remembering the parable of the Gordian knot.

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Science 

Morson's description of the polyp–cancer sequence and Shinya's seminal work on endoscopic polypectomy made real the notion that gastroenterologists could prevent colorectal cancers (CRC).6, 7 The National Polyp Study, published in 1993, suggested that 76%–90% of expected cancers could be prevented when colon polyps are systematically removed.8

Surveillance guidelines for colonoscopy after polypectomy first were published in 1997, and were most recently updated in 2006.9 The weakness of these guidelines stems from their inability to help clinicians manage patients who fall outside of defined categories or when experts are confused. One need only consider “sessile serrated adenomas” or flat polyps to discern how disagreements and confusion drive competent clinicians to differ in their management of individual patients.10, 11

A negative screening colonoscopy should provide comfort for both patient and endoscopist for 5 years after an initial, high-quality, normal screening colonoscopy.12 However, less evidence is available to support a 10-year interval for screening. Community physicians are reminded frequently that their results fail to match top doctors and blame for missed lesions falls to the endoscopist.13, 14, 15 We have only surrogate markers for colonoscopy quality, and demonstrating improvement in patient outcomes with focused interventions has proven to be difficult.16 When science is lacking and blame is looming, is it any wonder that physicians choose early examinations for their patients?

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Infrastructure 

Many gastroenterologists work in an open-access endoscopy model where primary care providers refer patients without specialty triage. In this environment, compliance with surveillance guidelines is more dependent on primary care physicians than gastroenterologists. Overuse stems from several common misunderstandings about CRC prevention and its early symptoms. Examples of inappropriate primary care management include restarting annual fecal occult blood testing after a normal screening colonoscopy, early referral after diverticulitis, and confusion about what constitutes a worrisome family history.

Concern for missed lesions or early referral does not explain underuse in high-risk patients. This finding by Schoen et al5 is disturbing and likely speaks to the current state of medical records. We do not know how many times an appropriate recommendation for follow-up was lost in the interstices of a disorganized recall system. Infrastructure errors leading to loss of prevention opportunities are common in American medicine because few current health care systems are held accountable for maintaining patients' health as opposed to treating disease.17

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Money 

The practice of gastroenterology changed in 1986 when the first Medicare-certified ambulatory surgery center (ASC) devoted to endoscopic procedures opened in Tennessee (Overholt BF, personal communication). By 1992, profit margins were attractive enough to spawn an ASC management company that became public in 1997.18 The growth of ASC's has been remarkable in this decade currently with >5100 Medicare certified ASCs. The future financial stakes are high. Despite health reform, there is still optimism within the industry because existing ASCs typically sell for 5–6 times annual earnings. The impact of ASC ownership on gastroenterology cannot be ignored. If one performs a Google Search on the term “Ambulatory Endoscopy Center,” the first result is a sponsored link to a web site that contains the following promise to physicians considering ASC ownership: “Strong yearly distributions averaging over $1.4 million to all owners per center.”19

Payment and regulatory variation across the country have influenced gastrointestinal (GI) practices to alter clinical care of patients in a manner that can run counter to national guidelines. The use of anesthesia professionals to deliver sedation to healthy and average-risk endoscopy patients conflicts with guidelines jointly supported by the American Gastroenterological Association, the American College of Gastroenterology, and the American Society for Gastrointestinal Endoscopy, adding substantial costs to CRC screening without a corresponding increase in polyp detection or disease-free survival.20, 21, 22 This change in practice did not stem from published reports identifying a medical need to add a second health care professional to the endoscopy suite and likely would not be impacted by educational efforts to promote guideline compliance.

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What Next? 

In 2010, a healthy 50-year-old patient needing colonoscopy screening can see an endoscopist whose total procedural charge is around $900 and has an adenoma find rate of >45%. In the same town, he or she might be referred to a physician whose adenoma find rate is 7%, and receive a bill for services for >$5000. Such variability has existed for years only because it has been opaque to public scrutiny and patients have not had sufficient incentive to care. Those days are gone. The Gordian knot of endoscopic utilization (where overuse, underuse, and misuse are documented) will be untied; it is too tempting a financial target to ignore. Two potential solutions come to mind—and they are not mutually exclusive.

First, physicians can lead through science and transparency by developing a community-based patient outcome registry focused on a valid episode of CRC preventive care. This registry would be useful to key stakeholders (patients, payers, and purchasers) only if it moved beyond process measures (preparation quality, completion rate, adenoma rates) and connected procedural quality with resource use, complications, and real patient outcomes (eg, missed cancers) at a level where accountability for care is real.23, 24 Complimenting such a registry would be the emergence of regional health delivery systems whose primary goal is providing high-value care with a stated goal of shared commitment to quality. Examples of such systems exist today.25

Alternatively, payers can change reimbursement suddenly from fee-for-service to value-based payments. This transformation would force creation of “accountable care organizations” who were willing to accept financial and clinical risk for a population and be paid based on episodes of care and outcomes.25, 26 A schematic comparing the 2 reimbursement methodologies is illustrated in Figure 1. If this transformation were sudden and gastroenterologists did not have time to prepare with new infrastructure and risk management skills, it would be a “game changer” for our specialty because practice costs to support sudden and forced participation in an accountable care organizations are beyond the capability of most GI groups.

  • View full-size image.
  • Figure 1. 

    Comparison of current fee-for-service reimbursement and bundled payment for episodes of care. Fee-for-service payment is not dependent on patient outcomes. Proposed episode-of-care payments often are linked with favorable outcomes or efficiency of resource use. Payments are made to groups that contract for financial and clinical risk and then divide payments internally—these are termed “accountable care organizations.”

In Greek legend, the Gordian knot was the name given to an intricate knot used by Gordius to secure his oxcart. An oracle foretold that he who untied the knot would rule all of Asia. Many people tried to undo the knot, but all to no avail. In 333 bc, Alexander the Great had invaded Asia Minor and arrived in the central mountains at the town of Gordium; he was 23. Undefeated, but without a decisive victory either, he was in need of an omen to prove to his troops and his enemies that the outcome of his mission—to conquer the known world—was possible. After this conqueror listened to his scholars advance complex solutions to solving the knot, he reportedly said “What does it matter how I loose it?” drew his sword, and severed the knot.27

The parallels between the Gordian knot and current attempts to reform the health care system seem obvious. By the way, Alexander the Great died—reputedly from complications of acute alcohol intoxication, typhoid fever, and bowel perforation.28 Too bad that he did not have the help of a skilled gastroenterologist who was concerned about outcomes.

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References 

  1. Mysliwiec PA, Brown ML, Klabunde CN, et al. Are physicians doing too much colonoscopy? (A national survey of colorectal surveillance after polypectomy). Ann Intern Med. 2004;141:264–271
  2. Hayes K, Winter A. Pricing services in Medicare's physician fee schedule (MedPAC meeting, October 8, 2008). http://www.medpac.gov/transcripts/Pricing%20phys%20svcs%20Oct%2009%20pres.pdfAccessed October 21, 2009
  3. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med. 2007;146:301–306
  4. Kluger J. Is there a better way to pay doctors? (Time Magazine, October 26, 2009). http://www.time.com/time/magazine/article/0,9171,1930501,00.htmlAccessed October 21, 2009
  5. Schoen RE, Pinsky PF, Weissfeld JL, et al. Utilization of surveillance colonoscopy in community practice. Gastroenterology. 2010;138:73–81
  6. Morsen BS. Genesis of colorectal cancer. In:  Sherlock P,  Zamcheck N editor. Clinics in gastroenterology. Philadelphia: WB Saunders; 1976;505525
  7. Shinya H, Wolff WI. Morphology, anatomic distribution and cancer potential of colonic polyps—an analysis of 7000 polyps endoscopically removed. Ann Surgery. 1979;190:679–683
  8. Winamer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. New Eng J Med. 1993;329:1977–1981
  9. Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal cancer and the American Cancer Society. Gastroenterology. 2006;130:1872–1885
  10. East JE, Saunders BP, Jass JR. Sporadic and syndromic hyperplastic polyps and serrated adenomas of the colon: classification, molecular genetics, natural history, and clinical management. Gastroenterol Clin North Am. 2008;37:25–46
  11. Kudo S, Lambert R, Allen JI, et al. Nonpolypoid lesions of the colorectal mucosa. Gastrointest Endosc. 2008;68(4 Suppl):S3–S47
  12. Imperiale TF, Glowinski EA, Lin-Cooper C, et al. Five-year risk of colorectal neoplasia after a negative colonoscopy. N Engl J Med. 2008;359:1218–1224
  13. Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol. 2007;102:856–861
  14. Feld AD. Malpractice risks associate with colon cancer and inflammatory bowel disease. Am J Gastroenterol. 2004;99:1641–1644
  15. Baxter NN, Goldwasser MA, Paszat LF, et al. Association of colonoscopy and death from colorectal cancer. Ann Intern Med. 2009;150:1–8
  16. Shaukat A, Oancea C, Bond JH, et al. Variation in detection of adenomas and polyps by colonoscopy and change over time with a performance improvement program. Clin Gastroenterol Hepato. 2009 Aug 7;[Epub ahead of print]
  17. McNeil BJ. Shattuck lecture—hidden barriers to improvement in the quality of care. N Engl J Med. 2001;345:1612–1619
  18. About AMSURG: history. http://www.amsurg.com/about/history.aspAccessed October 14, 2009
  19. PE: physicians endoscopy. http://www.endocenters.com/owning_a_center.htmlAccessed October 14, 2009
  20. Recommendations on the administration of sedation for the performance of endoscopic procedures. http://www.gastro.org/wmspage.cfm?parm1=371Accessed October 20, 2009
  21. Aisenber J, Brill JV, Ladabaum U, et al. Sedation for gastrointestinal endoscopy: new practices, new economics. Am J Gastroenterol. 2005;100:996–1000
  22. Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology. 2009;137:1220–1237
  23. Minnesota State Colon Cancer Initiative through the Institute for Clinical Systems Improvement and Minnesota Community Measurement. Available from: www.icsi.org and www.mnhealthscores.org.
  24. Digestive Health Outcomes Registry. American Gastroenterological Association. http://www.gastro.org/wmspage.cfm?parm1=7868Accessed October 20, 2009
  25. Larson EB. Group health cooperative—one coverage and delivery model for accountable care.
  26. Fisher ES, McClellan MB, Bertko J, et al. Fostering accountable health care: moving forward in Medicare. Health Affairs. 2009;28:w219–w231
  27. Alexander the Great and the Gordian knot. http://www.alexander-the-great.co.uk/gordian_knot.htmAccessed October 21, 2009
  28. Oldach DW, Richard RE, Borza EN, et al. A mysterious death. N Engl J Med. 1998;338:1764–1769

 Conflicts of interest The majority of the author's annual income is derived from performing screening and surveillance colonoscopy under a fee for service reimbursement model. He is a partner in Minnesota Gastroenterology PA, and a part owner of 5 ambulatory endoscopy centers and a pathology laboratory.

 Dr Allen is a subcontractor to Dr Timothy Church (co-author of the discussed article) on 3 on-going research studies and has co-authored papers with Dr Church.

 Dr Allen was the original trainer for nurses performing sigmoidoscopy in the Prostate, Lung, Colorectal and Ovarian Cancer screening trial at the Minnesota site and received many of the participants referred for colonoscopy.

 Dr Allen has chaired or participated in a number of state and national initiatives investigating resource use, guideline compliance and/or performance measurement as they pertain to screening or surveillance colonoscopy.

 Dr Allen is a member of the Executive Committee that oversees the AGA's Digestive Health Outcomes Registry.

PII: S0016-5085(09)02052-6

doi:10.1053/j.gastro.2009.11.035

Refers to article:

  • CME QuizEditorial Accompanies Article Utilization of Surveillance Colonoscopy in Community Practice , 09 October 2009

    Robert E. Schoen, Paul F. Pinsky, Joel L. Weissfeld, Lance A. Yokochi, Douglas J. Reding, Richard B. Hayes, Timothy Church, Susan Yurgalevich, V. Paul Doria–Rose, Tom Hickey, Thomas Riley, Christine D. Berg
    Gastroenterology January 2010 (Vol. 138, Issue 1, Pages 73-81)

Gastroenterology
Volume 138, Issue 1 , Pages 27-30, January 2010

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