Ambulatory Care / Community Centres the way forward for Colonoscopies?


An article published in takes a look at this issue from a US point of view…
Colonoscopies performed in ambulatory surgery centers (ASCs) are cheaper, require fewer resources and are as safe as hospital outpatient colonoscopies, according to data presented at the 2011 Digestive Disease Week meeting (abstract 678). The results support the ongoing shift of outpatient colonoscopies away from hospital departments and to ASCs.

“If future studies demonstrate adenoma detection rates and adherence to screening intervals in the two environments are equal, then there would seem to be a cost incentive to send Medicare patients to ambulatory surgical centers,” said lead investigator Fuad Azrak, MD, a fellow in the Division of Digestive Diseases, Emory University School of Medicine, Atlanta, and guest researcher at the Centers for Disease Control and Prevention.

Dr. Azrak team’s analyzed a random sample of Medicare beneficiaries from the Surveillance, Epidemiology and End Results cancer registry who received colonoscopies, 104,861 of which were performed in hospital outpatient units and 55,022 of which were conducted at ASCs. Subjects were at least 66 years of age, had no personal history of inflammatory bowel disease or colorectal cancer and were mostly white and female. The investigators conducted both univariate and multivariate analyses of the data, controlling for age, gender, race, geographic region, comorbidities, physician specialty and type of colonoscopy performed.

The initial univariate analysis showed 3.5% of hospital-based colonoscopy patients required emergency room visits or hospital admissions, significantly greater than the 2.4% rate observed with colonoscopies performed at ASCs (P<0.001). The adverse events associated with emergency room visits and hospital admissions, including perforations, gastrointestinal bleeding, diverticulitis, syncope, myocardial infarction, arrhythmias and stroke, all occurred at a significantly higher rate among hospital-based colonoscopies compared with ASCs. However, after a multivariate analysis, there were no significant differences in the rates of adverse events between hospital colonoscopies and ASCs, Dr. Azrak reported (odds ratio, 1.04).

Although the presentation did not include a parsing of the data on polypectomies, the investigators found that 34% of colonoscopies included at least one polypectomy.
According to Jerome Waye, MD, who moderated the press briefing, comparing the number of polypectomies and related complications between settings may have yielded important findings.
“I would suspect fewer polypectomies were done in ASCs and that rates of bleeding and perforations paralleled the number of polyps removed,” said Dr. Waye, clinical professor in the Department of Gastroenterology at Mount Sinai Medical Center, New York City.

Although the safety data support the continued swing away from conducting colonoscopies in hospitals, Dr. Azrak said, the trend he observed may have changed since the end of his study period in 2007.

“Medicare reimbursement has gone up for hospital colonoscopies and down for ASCs,” he said, adding that ASCs now receive $250 less than hospitals for each colonoscopy. “There’s the possibility that this practice has already increased or will increase referrals to hospital outpatient units. My group will be reevaluating the market share distribution within the next few years to find out the answer.”