Endoscopy Utilization Research Articles

COVID-19 polymerase chain reaction testing before endoscopy: an economic analysis

Background and AimsThe novel coronavirus disease 2019 (COVID-19) pandemic has limited endoscopy utilization, causing significant health and economic losses. We aim to model the impact of polymerase chain reaction (PCR) testing into resuming endoscopy practice.MethodsWe performed a retrospective review of endoscopy utilization during the COVID-19 pandemic for a baseline reference. A computer model compared 3 approaches: strategy 1, endoscopy for urgent indications only; strategy 2, testing for semiurgent indications; and strategy 3, testing all patients. Analysis was made under current COVID-19 prevalence and projected prevalence of 5% and 10%. Primary outcomes were number of procedures performed and/or canceled. Secondary outcomes were direct costs, reimbursement, personal protective equipment used, and personnel infected. Disease prevalence, testing accuracy, and costs were obtained from the literature.ResultsDuring the COVID-19 pandemic, endoscopy volume was 12.7% of expected. Strategies 2 and 3 were safe and effective interventions to resume endoscopy in semiurgent and elective cases. Investing 22 U.S. dollars (USD) and 105 USD in testing per patient allowed the completion of 19.4% and 95.3% of baseline endoscopies, respectively. False-negative results were seen after testing 4700 patients (or 3 months of applying strategy 2 in our practice). Implementing PCR testing over 1 week in the United States would require 13 and 64 million USD, with a return of 165 and 767 million USD to providers, leaving 65 and 325 healthcare workers infected.ConclusionsPCR testing is an effective strategy to restart endoscopic practice in the United States. PCR screening should be implemented during the second phase of the pandemic, once the healthcare system is able to test and isolate all suspected COVID-19 cases.

188 – Increasing Surgeon Flexible Endoscopy Utilization: A Retrospective Review of Ten Years of Fellow Case Numbers

188 – Increasing Surgeon Flexible Endoscopy Utilization: A Retrospective Review of Ten Years of Fellow Case Numbers

Outcomes and Predictors of Readmissions with GI Bleeding in Patients with Left Ventricular Assist Devices.

Gastrointestinal (GI) bleeding is a major comorbidity in patients with left ventricular assist devices (LVADs). The study aim was to estimate the rate of hospital readmissions for GI bleeding in patients with LVADs using a nationally representative database. Additionally, we evaluated the etiologies, costs, endoscopy utilization, mortality, and predictors of GI bleeding readmissions in these patients. We analyzed data from the National Readmissions Database (NRD) from 2010 through 2014. We compared hospitalized adult patients with congestive heart failure (CHF) who underwent LVAD implantation (cases) with CHF patients without LVAD or heart transplant (controls). Three age- and sex-matched controls were randomly selected per single case. A multivariate Cox regression model was used to compare the hazards of 60-day all-cause and GI bleeding readmission between the groups, controlling for significant confounders. A total of 3293 hospitalized patients with CHF who had LVAD placement (cases) and 9879 who did not have LVADs (controls) were included in the study. At 60 days, patients with LVAD had a significantly higher readmission rate with GI bleeding (8.7% vs 2.3%, adjusted hazard ratio [aHR] 4.45, 95% confidence interval 3.71-5.33, P < 0.0001). The all-cause readmission rate also was higher (43.3% vs 35.7%, aHR 1.23, 95% confidence interval 1.12-1.34, P < 0.0001). The most common etiologies of bleeding in patients with LVADs were gastroduodenal and small intestinal arteriovenous malformations (28.6%). During bleeding readmissions, patients with LVAD were more likely to undergo endoscopy (72.1% vs 33.5%, P < 0.0001) and receive packed red blood cell transfusions (62% vs 36.6%, P< 0.0001) compared with controls. GI bleeding readmissions were more costly ($40,936 vs $35,313, P< 0.0001), and longer (12 vs 10.9 days, P< 0.0001) in patients with LVADs compared with controls. Independent risk factors for 60-day GI bleeding readmission were increasing age (aHR 1.04, P< 0.0001) and GI bleeding during index admission (aHR 2.68, P< 0.0001). In those without bleeding during index admission, increasing age and chronic anemia were associated with 60-day GI bleeding readmission. Mortality during bleeding readmission was similarly low in patients with LVADs compared with CHF controls (0.2% vs 0.3%, P = 0.14). After LVAD implantation, there is a fivefold increased risk of readmission with GI bleeding within 60 days. Gastroduodenal and small intestinal arteriovenous malformations are the most common culprit lesions. These findings suggest that small bowel enteroscopy should be considered as the initial test of choice in patients with suspected upper gastroduodenal bleeding. Readmissions with bleeding in patients with LVADs increase morbidity and cost of care but not mortality. Older patients and those with a history of bleeding during LVAD implantation are at higher risk of bleeding readmission and may benefit from close monitoring and cautious anticoagulation to prevent rebleeding.

What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?

The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.

Less Is More: A Minimalist Approach to Endoscopy

A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.

Colonoscopy and sigmoidoscopy use among older adults in different countries: A systematic review.

Screening for colorectal cancer (CRC) by colonoscopy and sigmoidoscopy has been demonstrated to be effective in reducing CRC incidence and mortality, and they are increasingly employed as screening tests and for diagnostic purposes in many countries. We conducted a systematic review to provide up-to-date estimates on the utilization of lower gastrointestinal endoscopy (colonoscopy and sigmoidoscopy) in the general average-risk population in different countries. PubMed and Web of Science were searched for relevant articles published between 1 September 2008 and 31 October 2016. A total of 23 studies from the US and 20 studies from other countries were included in this review. Estimates from the US were highest, continued to increase over the past decade and reached 62% for colonoscopy use within 10years in people aged 50-75years in 2012. Endoscopy use in other countries was substantially lower (12-44% for lifetime colonoscopy use and 13-30% for recent colonoscopy use), except for Germany, where 55% of the screening-eligible population reported colonoscopy utilization within the previous 10years in 2008-2011. Both lifetime and recent endoscopy use increased with age and peaked at approximately 70-75years. Although several European and Asian countries have started to collect endoscopy utilization data through periodic national health surveys, more data are still much needed from non-US countries. With the implementation of CRC screening programs in an increasing number of countries, especially European countries, an increase in endoscopy use and subsequent reduction in CRC incidence and mortality in the years to come might be expected in those countries.

Medicare modernization and diffusion of endoscopy in FFS medicare

ObjectiveTo examine how FFS Medicare utilization of endoscopy procedures for colorectal cancer (CRC) screening changed after implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) in 2006, which provided subsidized drug coverage and expanded the geographic availability of Medicare managed care plans across the US.Data Sources/Study Setting. Using secondary data from 100% FFS Medicare enrollees, we analyzed endoscopy utilization during two intervals, 2001-2005 and 2006-2009.Study designWe examined change in predictors of county-level endoscopy utilization rates based on a conceptual model of market supply and demand with spillovers from managed care practices. The equations for each period were estimated jointly in a spatial lag regression model that properly accounts for both place and time effects, allowing robust assessment of changes over time.Data collection/Extraction methodsAll Medicare FFS enrollees with both Parts A and B coverage who were age 65+, remained alive and living in the same state over the interval were included in the analyses. The later interval used a new cohort defined the same as the earlier interval. 100% Medicare denominator files were also used, providing county of address to use for county-level aggregation. The outcome variable was defined as county-level proportion of enrollees who ever used endoscopy over the interval.Principal findingsEndoscopy utilization by FFS Medicare increased, and became more accessible across the US. Medicare managed care plan spillovers onto FFS Medicare endoscopy utilization changed over time from a significant negative (restraining) effect in the early period to no significant effect by the later period.ConclusionsThe MMA eased budget constraints for seniors, making endoscopic CRC screening more affordable. The MMA policies also strengthened managed care business prospects, and enrollments in Medicare managed care escalated. The change in managed care spillover effects reflects the gradual acceptance of endoscopic CRC screening procedures, as they emerged as the gold standard during the period.

Trends in Open and Endoscopic Cubital Tunnel Release in the Medicare Patient Population.

Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release. We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated. Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the <65 years age range. Despite the unexpectedly lower reimbursement rate with endoscopic release, endoscopy utilization is growing faster than open releases in the Medicare population. Lower reimbursement is likely related to lack of a dedicated current procedural terminology code for endoscopic cubital tunnel release.

495 Predictive Overbooking Maximizes Endoscopy Utilization in an Outpatient Clinic

495 Predictive Overbooking Maximizes Endoscopy Utilization in an Outpatient Clinic

Endoscopy Utilization in Veterans with Newly Diagnosed PTSD

Endoscopy Utilization in Veterans with Newly Diagnosed PTSD

Gastric cancer incidence estimation in a resource-limited nation: use of endoscopy registry methodology

Cancer epidemiology is challenging in developing nations, in the absence of reliable pathology-based cancer registries. Clinical experience suggests that the incidence of gastric cancer is high in Honduras, in contrast to the limited available national statistics at the time of study initiation (IARC GLOBOCAN 2002: males 15.2, females 10.8). We estimate the incidence of gastric cancer for Honduras using an endoscopy registry as a complimentary resource. We conducted a retrospective analysis of incident noncardia gastric adenocarcinoma cases in western Honduras for the period 2000-2009. This region is well circumscribed geopolitically with a single district hospital and established referral patterns, to provide a unique epidemiological niche to facilitate estimation of incidence rates. A prospective, comprehensive database of all endoscopy procedures from this hospital was utilized at the primary data source. The catchment area for gastroenterology services for the at-risk population was validated by calculating the overall endoscopy utilization rates for each municipality in western Honduras. Incident cases of gastric adenocarcinoma were determined by the endoscopic diagnosis. Pathology services are not financed by the Ministry of Health, and histology data were incorporated when available. Population statistics were obtained from the Honduras National Statistics Institute (INE). Age-standardized incidence rates (ASIRs) were calculated using world standard population fractions. The catchment area for western Honduras was validated with the municipality threshold of 30 endoscopies per 10(6) person-years, with inclusion of a total of 40 municipalities. In the western Honduras catchment area, there were 670 incident cases (439 M, 231 F) of noncardia gastric adenocarcinoma during the study decade 2000-2009. Notably, 67 (10.0 %) and 165 (24.6 %) of cases were under the ages of 45 and 55, respectively. The case-finding rate was 5.1 endoscopies performed for each new diagnosis of gastric cancer. The ASIRs for the decade were 30.8 for males and 13.9 for females. Clinically, 60.3 % of gastric cancers were Borrmann type 3 (ulcerated mass), and evidence of advanced disease with pyloric obstruction was common (35.2 %). Subtypes by the Lauren classification were distributed among diffuse (56 %), intestinal (34 %), and indeterminate (9.9 %), in subjects with available pathology (526/670). The endoscopy procedure registry may serve as a complimentary data resource for gastric cancer incidence estimation in resource-limited nation settings wherein pathology services and cancer registries are absent. The results remain an underestimation in this setting due to the challenges of access to care and related factors. The methodology helps to more fully characterize the high incidence of gastric cancer in western Honduras and this region of Central America and demonstrate the need for additional epidemiology research, and interventions focused on prevention and treatment.

Validation of administrative data sources for endoscopy utilization in colorectal cancer diagnosis

BackgroundValidation of administrative data is important to assess potential sources of bias in outcome evaluation and to prevent dissemination of misleading or inaccurate information. The purpose of the study was to determine the completeness and accuracy of endoscopy data in several administrative data sources in the year prior to colorectal cancer diagnosis as part of a larger project focused on evaluating the quality of pre-diagnostic care.MethodsPrimary and secondary data sources for endoscopy were collected from the Alberta Cancer Registry, cancer medical charts and three different administrative data sources. 1672 randomly sampled patients diagnosed with invasive colorectal cancer in years 2000–2005 in Alberta, Canada were included. A retrospective validation study of administrative data for endoscopy in the year prior to colorectal cancer diagnosis was conducted. A gold standard dataset was created by combining all the datasets. Number and percent identified, agreement and percent unique to a given data source were calculated and compared across each dataset and to the gold standard with respect to identifying all patients who underwent endoscopy and all endoscopies received by those patients.ResultsThe combined administrative data and physician billing data identified as high or higher percentage of patients who had one or more endoscopy (84% and 78%, respectively) and total endoscopy procedures (89% and 81%, respectively) than the chart review (78% for both).ConclusionsEndoscopy data has a high level of completeness and accuracy in physician billing data alone. Combined with hospital in/outpatient data it is more complete than chart review alone.

67 A Decade of Increased Gastrointestinal Endoscopy Utilization and Costs in the United States, 2000-2009

67 A Decade of Increased Gastrointestinal Endoscopy Utilization and Costs in the United States, 2000-2009

S1972 Increasing Incidence of Eosinophilic Esophagitis: A Persistent Trend After Accounting for Procedure Indication and Biopsy Rate

Background:Multiple studies document the increasing incidence of eosinophilic esophagitis (EoE). However, most are unable to control for the overall increase in endoscopy utilization, or to adjust for differences due to evolving diagnostic practices, for example performing biopsies of an endoscopically normal esophagus in patients with dysphagia. Aim: To assess trends in the annual incidence of EoE, after taking into to account changes in EGD volume, indication and biopsy rate over time. Methods: We performed a retrospective study of all upper endoscopies performed at University of North Carolina (UNC) Hospitals between 1/ 1/2002 and 12/31/2006. Our health system provides both primary and tertiary care for gastroenterology patients. Cases of EoE, defined as ≥ 20 eosinophils/high-powered field, were identified from the UNC pathology database reporting system. The total number of upper endoscopies performed each year was recorded, as were the number of procedures performed for an indication of dysphagia, the number of esophageal biopsies performed overall, and the number of esophageal biopsies performed during procedures evaluating dysphagia. Incidence rates for each category were calculated. This study was approved by the UNC IRB. Results: EoE was diagnosed in 2, 5, 9, 15, and 48 patients from 2002 to 2006, a 2400% increase over 5 years. During this time frame, the total number of upper endoscopies also increased from 2949 to 4228 (43%), the number of upper endoscopies for dysphagia increased from 516 to 797 (54%), the total number of endoscopies obtaining esophageal biopsies increased from 525 to 717 (37%), and the total number endoscopies during which esophageal biopsies were taken for evaluation for dysphagia increased from 91 to 134 (47%). The incidence of EoE per 1000 EGDs performed increased from 0.68 to 11.2 from 2002 to 2006, the incidence per 1000 procedures with esophageal biopsies performed increased from 3.8 to 67.8, and the incidence per 1000 biopsies in patients with dysphagia increased from 22.0 to 358.2. Conclusions: The incidence of EoE has increased markedly at our center from 2002 through 2006. This increase far outstrips the relatively modest increases seen in procedure and biopsy volume, indicating that the increase is not due to detection bias alone.

Time Trends in Colon Cancer Incidence and Distribution and Lower Gastrointestinal Endoscopy Utilization in Manitoba

There are limited data on recent trends in subsite-specific colon cancer incidence and utilization of lower gastrointestinal endoscopy from Canada. The aim of our study was to determine the concomitant trends in right-sided colon cancer incidence and utilization of colonoscopy and flexible sigmoidoscopy (FS) in Manitoba. Cases of colon cancer diagnosed from 1964 to 2004 were identified from the Manitoba Cancer Registry. Lower gastrointestinal endoscopies performed between 1984 and 2003 were identified from Manitoba Health's Physician Claims database. Trends of age-standardized incidence rates were determined using Joinpoint analyses. Rates of right-sided colon cancer showed a monotonic increase in both sexes (annual percent change [APC] in both sexes 1.04%, P < 0.001). The most rapid increase (200%) occurred in individuals of 70 yr of age and older. While rates of colonoscopies without polypectomies quadrupled between 1985 (257 per 100,000) and 2003 (1,083 per 100,000, APC 8.89%, P < 0.001), rates of colonoscopies with polypectomies quadrupled from 35 per 100,000 in 1985 to 140 per 100,000 in 2000, and then increased more rapidly in the subsequent 4 yr (233 per 100,000 in 2003, APC 20%, P < 0.001). Rates of FS declined between 1999 (342 per 100,000) and 2003 (257 per 100,000, APC -6.68%, P= 0.01). The rates of right-sided colon cancer are continuing to increase in Manitoba, with the most rapid increase occurring in older individuals. Reasons for the increasing incidence of right-sided colon cancer despite increasing rates of colonoscopy need to be further explored, and may reflect increased detection of asymptomatic cancers or a real increase in right-sided colon cancer incidence.

Colorectal cancer screening in Canada: results of a national survey

Canadian guidelines recommend colorectal-cancer (CRC) screening for individuals aged 50 to 74 years. The study objective was to estimate rates of CRC screening according to individual and geographical characteristics, and of adherence to current CRC screening guidelines. Respondents to the 2003 Canadian Community Health Survey Cycle 2.1 (aged >or= 50 years, without past or present CRC) participated. Fecal occult blood test (FOBT) and endoscopy utilization and screening rates were calculated. The sample included 16,747 residents of Newfoundland, Ontario, Saskatchewan and British Columbia. Overall, the FOBT screening rate was 7.7% in the past year, and the endoscopy screening rate was 8.8% in the past 5 years. FOBT screening rates were higher in older and male respondents; endoscopy screening rates were higher in older respondents. Individuals aged 50 to 59 and over 90 years were least likely to have been screened. Approximately 70% of respondents were non-adherent to current CRC screening guidelines. Non-adherence rates were higher in most health regions of British Columbia. National survey data suggest CRC screening in Canada is low; younger persons and residents of British Columbia were least likely to report CRC screening.

Capsule endoscopy in clinical practice

Capsule endoscopy is a new technology that is changing the diagnostic endoluminal approach to a variety of disorders and conditions. Initially introduced for the evaluation of the small bowel, endoscopic imaging now can visualize the esophagus and the colon. Any assessment of a new technology should focus on its feasibility, patient tolerance and acceptance, safety, and value in terms of diagnostic or therapeutic use. Since the introduction of capsule endoscopy in 2000, considerable data have become available regarding these issues. This article will review the clinical applications and issues concerning capsule endoscopy utilization

Trends in Diagnostic Testing Following a National Guideline for Evaluation of Dyspepsia

The extent to which national guidelines affect actual clinical practice is largely unknown. To gauge the impact of a national guideline about dyspepsia on subsequent clinical practice. We compared trends in the rates of the two principal diagnostic tests used to evaluate dyspepsia: upper gastrointestinal tract series (UGI) and endoscopy. We used the Health Care Financing Administration's (Baltimore, Md) 100% National Medicare part B file to determine annual counts for the two procedures in each of 10 years (1984 through 1993). To calculate procedure rates, we divided the number of procedures in each year by the total population enrolled in Medicare part B in that year. In 1984, before publication of the guideline, the UGI rate was more than triple the rate of endoscopy (UGI rate, 59 per 1000 beneficiaries; endoscopy rate, 17 per 1000). Subsequent to publication of the guideline in 1985, UGI use slowly decreased while endoscopy utilization slowly increased. The rate of change for both procedures was steady over the 10-year period. Endoscopy rates finally exceeded UGI in 1993 (endoscopy, 37 per 1000; UGI, 36 per 1000). Despite a prominent national guideline, UGI utilization remains high and is slowly decreasing. Because utilization data before 1984 are incomplete, we cannot isolate the precise impact of the guideline. However, the slow decline in UGI utilization suggests that, at best, the guideline had limited impact on clinical practice. If this response is representative of other guidelines, alternative approaches to change clinical practice will need to be found.