Office Visits Prior to Screening Colonoscopy Add to Medical Costs

Office visits prior to screening colonoscopy add to medical costs, and it's unclear whether those visits are necessary, researchers report. "Going into the project, I was expecting there to be more precolonoscopy office visits than we found," Dr. Kevin R. Riggs, from Johns Hopkins University School of Medicine, Baltimore, told Reuters Health by email. "It seems that not having a precolonoscopy office visit (open-access colonoscopy) really is the norm." Open-access colonoscopy began in the 1990s, but how widespread it is has been unclear. Dr. Riggs's team used data from MarketScan Commercial Claims and Encounters to determine the proportion of colonoscopies for colon cancer screening and polyp surveillance that were preceded by office visits and the payments associated with those visits. Among 842,849 patients who underwent colonoscopy between 2010 and 2013, 29.4% had a precolonoscopy visit, according to the February 2 JAMA online report. Among patients with office visits, two-thirds (66.4%) had no significant medical conditions, with a Charlson Comorbidity Index (CCI) of 0, but patients with office visits did have higher CCI than those without office visits. Distributed across all patients, the precolonoscopy office visits added a mean of $36.37 per colonoscopy. While this amount seems modest, it amounts to significant cumulative costs when considering the estimated 7 million screening colonoscopies performed annually in the U.S., the authors point out. The researchers were unable to determine the exact circumstances of these office visits, and they could not determine whether the visits were necessary or appropriate. "Colonoscopy is generally a very safe procedure, and it is unlikely that an office visit with the gastroenterologist beforehand makes it any safer," Dr. Riggs said. "It's possible that the office visit is an opportunity to identify patients who should not undergo colonoscopy because the risk is too high, but that is relative and depends on how much benefit can be expected." "In general, the appropriateness for colonoscopy can be made by primary care doctors, and most patients for whom colon cancer screening is recommended by practice guidelines probably don't benefit from an extra precolonoscopy office visit," he said. "Obviously, if patients don't have a primary care doctor and haven't seen a doctor recently, it's probably a good idea to get checked out before any procedure." "Open-access colonoscopy for colon cancer screening is the norm," Dr. Riggs concluded. "If gastroenterologists aren't offering it, or if primary care doctors are routinely referring their patients for whom they have decided colonoscopy is indicated for evaluation before the colonoscopy, they should consider changing their practice. Not only do these office visits waste potentially hundreds of millions of dollars annually, but requiring unnecessary office visits makes for a less pleasant patient experience." Dr. John I. Allen, clinical chief of digestive diseases at Yale University, New Haven, Connecticut, told Reuters Health by email, "I have worked for 25 years within a large private single specialty (gastrointestinal) group where 85% of endoscopy was open access and 15% was generated after a clinic visit with us. This not only saved money, but freed up clinic to see more needy patients. The no-show rate for endoscopy was 1%." "I now work at Yale - mostly a Medicaid, Marketplace, or Medicare population - where our no-show rate is >20%. Pre-endoscopy visits would be a great addition, but we are so understaffed that it would be impossible," he said. "Open access saves money and is appropriate for a population that complies with recommendations (can follow the complex process of preparation) and will show up for their appointment," Dr. Allen concluded. "Precolonoscopy visits can help prevent canceled procedures due to poor prep (up to 15% of procedures in some populations), identify patients needing more intense care, and in some cases help patients be comfortable with undergoing an invasive procedure." The National Institutes of Health supports two coauthors. One coauthor owns stock in the Advisory Board Company. JAMA 2016