Patterns of endoscopy use in the United States

doi:10.1016/S0016-5085(00)70269-1

Gastroenterology

Volume 118, Issue 3, March 2000, Pages 619-624

https://doi.org/10.1016/S0016-5085(00)70269-1 Get rights and content

Abstract

Background & Aims: The aim of this study was to use a large national endoscopic database to determine why routine endoscopy is performed in diverse practice settings. Methods: A computerized endoscopic report generator was developed and disseminated to gastrointestinal (GI) specialists in diverse practice settings. After reports were generated, a data file was transmitted electronically to a central databank, where data were merged from multiple sites for analysis. Results: From April 1, 1997, to October 28, 1998, 276 physicians in 31 practice sites in 21 states provided 18,444 esophagogastroduodenoscopy (EGD) reports, 20,748 colonoscopy reports, and 9767 flexible sigmoidoscopy reports to the central databank. EGD was most commonly performed to evaluate dyspepsia and/or abdominal pain (23.7%), dysphagia (20%), symptoms of gastroesophageal reflux without dysphagia (17%), and suspected upper GI bleeding (16.3%). Colonoscopy was most often performed for surveillance of prior neoplasia (24%) and evaluation of hematochezia (19%) or positive fecal occult blood test (15%). Flexible sigmoidoscopy was most commonly performed for routine screening (40%) and evaluation of hematochezia (22%). There were significant differences between academic and nonacademic sites. Conclusions: The endoscopic database can be an important resource for future research in endoscopy by documenting current practice patterns and changes in practice over time.

GASTROENTEROLOGY 2000;118:619-624

Section snippets

Materials and methods

A computerized endoscopy report generator was designed to capture key elements of every endoscopic procedure.⁷ After a period of development and field testing, the database was disseminated to GI specialists throughout the United States who agreed to use the database for endoscopy reports and transmit the endoscopic data electronically to a central databank in Portland, Oregon. All transmitted data were encrypted and arrived in Portland without patient or physician identifiers to protect

Results

From April 1997 to October 1998, the CORI databank received 48,961 EGD, colonoscopy, and FS reports on unique patients. Reports came from 276 physicians in 31 practice sites in 21 states. We analyzed the endoscopic workload for each practice by determining the proportion of each major procedure as a fraction of the endoscopic practice. For example, some practices performed predominantly upper GI endoscopy, whereas in others, most procedures were lower GI procedures. There was geographic

Discussion

Endoscopic procedures are commonly performed in clinical practice by GI specialists. There have been very little data available to provide benchmarks for use of endoscopy in clinical practice settings. The most efficient way to collect such information is to obtain data directly from endoscopic reports. Information provided for billing and claims lacks precision and may not include overlapping indications. Data acquired from the Medicare database are not generalizable to the majority of

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Use of GI endoscopy is historically lower in nonwhite ethnic and racial groups compared with whites. These disparities are multifactorial but likely contribute to differences in GI clinical outcomes. We sought to improve endoscopy uptake overall and in minorities by predictive overbooking and active recruitment in a hospital-based GI clinic.
From January to October 2014, we alternated between traditional booking for Veterans Affairs Healthcare Network patients with a physician recommendation for endoscopy and active recruitment of patients to fill projected open endoscopy appointment slots. On intervention weeks, patients attending a GI clinic were given the opportunity to “fast track” to an endoscopy appointment on short notice. During control weeks, patients were not actively recruited. We compared uptake of endoscopy appointments in both groups and performed logistic regression to determine predictors of participation in fast-track active recruitment.
During fast-track active recruitment for endoscopy, the clinic recruited an additional 111 patients for endoscopy over passive recruitment, including 46 African Americans (41.4%). In a logistic regression model controlling for demographic and clinical characteristics, African Americans were twice as likely (adjusted OR, 1.99; 95% CI, 1.26-3.17) than whites to participate in the fast-track option for recommended endoscopy.
Interventions to actively recruit patients for endoscopy increased the overall percentage of GI clinic patients undergoing endoscopy and disproportionately improved endoscopy appointment uptake in African Americans.
A systematic review of splenic injuries during colonoscopies: Evolving trends in presentation and management
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Although uncommon, the incidence of splenic injury from colonoscopy has been increasing significantly since first being reported in 1974. Early recognition is critical because mortality may be as high as 5%.
We systematically searched PubMed and EMBASE to identify English-language cases of splenic injury from colonoscopy from inception until January 26, 2015. We used descriptive statistics to characterize the identified cases.
A total of 172 cases from 122 reports were included. The mean age was 64 years and 70.8% were females. Prior abdominal or pelvic surgeries were identified in 63.8%. 57.3% of patients underwent polypectomies or biopsies. There was a statistically significant increase in use of computerized tomography for diagnosis in the past 5 years (81.8% versus 65.2%). 76.1% patients received transfusions. Mean inpatient length of stay was 7.83 ± 5.32 days. A non-significant trend toward conservative management was noted in the past 5 years (37.7% versus 23.1%), and a non-significant drop in mortality was noted (4.9% versus 5.4%).
Our data support prior literature suggesting a higher incidence of splenic injuries during colonoscopies in females, advanced age, prior history of abdominal/pelvic surgeries and biopsies/polypectomies during the procedure.
Significant mortality associated with splenic injuries during colonoscopies warrants prompt recognition of this potentially life threatening, albeit uncommon, complication.
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Although the adherence to post-polipectomy recommendations is advocated as a quality indicator of colonoscopy programmes, prospective data on actual use of surveillance are lacking.
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In community practice, post-polipectomy surveillance colonoscopy is often performed earlier than recommended, especially in low-risk subjects. Interventions to improve adherence to guidelines and to reduce unnecessary examinations are needed.
Diagnostic yield of colonoscopy to evaluate melena after a nondiagnostic EGD
2012, Gastrointestinal Endoscopy
Citation Excerpt :
The CORI database is an endoscopic database that collects data from community, academic, and Veterans Affairs settings across a broad geographic area in the United States. The composition of the endoscopic reporting sites in the CORI database has been previously described.7 During this time period, 67 sites submitted 724,700 colonoscopy and 406,821 EGD reports.
Melena can be caused by bleeding from lower GI sources. Colonoscopy is frequently used to investigate melena after a nondiagnostic EGD.
To determine the diagnostic yield and rate of therapeutic intervention during colonoscopy in patients with melena and a nondiagnostic EGD.
Retrospective case-control study.
Community and academic centers over a diverse geographic area in the United States.
This study involved patients in the Clinical Outcomes Research Initiative database with a colonoscopy performed to investigate melena within 30 days of a nondiagnostic EGD for the same indication. A control group had colonoscopies performed for average-risk screening.
The endoscopic finding of a suspected bleeding source defined as right-sided arteriovenous malformation, colitis, polyp ≥ 20 mm, tumor, or ulcer. Rate of therapeutic intervention during colonoscopy.
Colonoscopy found a suspected bleeding source in 4.8% of patients with melena, more frequently than in the control group (odds ratio [OR] 2.17; 95% confidence interval [CI], 1.65-2.86; P < .0001). The rate of therapeutic intervention during melena-related colonoscopy was 1.7%. Patients with melena were more likely to have a colon tumor (OR 2.87; 95% CI, 1.82-5.51; P < .0001) than were control patients.
Retrospective design, conclusions being dependent on the accuracy of database input, and lack of pertinent clinical data (eg, hemoglobin).
The diagnostic yield of colonoscopy to investigate melena after nondiagnostic EGD is low. The need for therapeutic intervention during colonoscopy for this indication is very low. This population should undergo colonoscopy because they are at increased risk of colorectal cancer. Colonoscopy can potentially be performed electively in stable patients without continued bleeding.
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^☆: Supported by the American Digestive Health Foundation (ADHF) from unrestricted grants from Astra Pharmaceuticals and by Bard International.

^☆☆: Address requests for reprints to: David Lieberman M.D., Division of Gastroenterology, Department of Medicine, Oregon Health Sciences University, Portland VA Medical Center P3-GI, P.O. Box 1034, Portland, Oregon 97207. e-mail: [email protected]; fax: (503) 273-5348.

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Special Reports and ReviewsPatterns of endoscopy use in the United States☆,☆☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

J Am Coll Cardiol

Gastrointestinal endoscopy

N Engl J Med

Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography

N Engl J Med

The use and misuse of upper gastrointestinal endoscopy

Ann Intern Med

Standard format and content of the endoscopic procedure report

Special Reports and Reviews
Patterns of endoscopy use in the United States☆,☆☆