Objective: To use a national endoscopy database (Clinical Outcomes Research Initiative, CORI) to determine 1) if fellow involvement increases procedure time; and 2) the financial impact of fellow participation for academic centers compared to private practice.
Methods: CORI database from 4/1/97 to 4/1/99 was used to compare endoscopists from private practices, academic medical centers, and Veterans Administration hospitals, with or without fellows-in-training. Data were captured in a computer-generated endoscopy report and transmitted to a central database for analysis. Duration of procedure (minutes) was recorded for diagnostic esophagogastroduodenoscopy (EGD), EGD with biopsy, diagnostic colonoscopy, and colonoscopy with biopsy, in ASA 1 patients. Financial outcomes used 1999 Medicare reimbursement rates for respective procedures and were calculated as procedures per hour on a theoretical practice of 4000 procedures.
Results: Teaching fellows endoscopy added 2-5 min for EGD, with or without biopsy, and 3-16 min for colonoscopy, with or without biopsy. Calculating the number of procedures/h of endoscopy, the reimbursement loss resulting from using fellows-in-training in a university setting would be half a procedure/h. In Veterans Administration hospitals, training of fellows would lose a full procedure/h. In a model of 1000 procedures each of EGD, EGD with biopsy, colonoscopy, and colonoscopy with biopsy, the reimbursement difference between private practice physicians or academic attending physicians and procedures involving fellows-in-training would be $500,000 to $1,000,000/yr.
Conclusions: Fellow involvement prolonged procedure time by 10-37%. Thus, per-hour reimbursement is reduced at teaching institutions, causing financial strain related to these time commitments.