The American Gastroenterological Association (AGA) and 24 other specialty societies have affirmed their commitment to quality care by partnering with the American Board of Internal Medicine Foundation’s Choosing Wisely® campaign, an initiative designed to engage physicians and patients in conversations to reduce the overuse of tests and procedures. The specialty societies that support the initiative have identified tests or procedures commonly used in their field, whose necessity should be questioned and discussed.
“We recognize that patients often ask for tests and treatments that are not necessarily in their best interest, and physicians often struggle with decisions about prescribing tests and procedures as a way of covering all possible bases,” said Lawrence Kosinski, MD, chair of the AGA Practice Management and Economics Committee. “In many cases, more care is not always higher-quality care.”
To this end, the AGA published a list of “Five Things Physicians and Patients Should Question.” The list is available online at www.choosingwisely.org/doctor-patient-lists/american-gastroenterological-association, and includes the following five directives:
- For pharmacologic treatment of patients with gastroesophageal reflux disease, long-term acid suppression therapy (proton pump inhibitors or histamine-2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals.
- Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.
- Do not repeat colonoscopy for at least five years for patients who have one or two small (<1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy.
- For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines.
- For a patient with functional abdominal pain syndrome (as per ROME III criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms.
At a Choosing Wisely® symposium held at the 2013 Digestive Disease Week (DDW) meeting,David Lieberman, MD, chief of the Division of Gastroenterology and Hepatology at Oregon Health & Science University in Portland, instructed attendees on proper intervals for colonoscopy screening and surveillance, while Dr. Kosinski, managing partner of the Illinois Gastroenterology Group in Elgin, discussed the overutilization of repeat CT scans for abdominal pain.
Is Colonoscopy Overutilized?
Adherence to evidence-based guidelines for colonoscopy screening and surveillance will be an important element of our future health care system, Dr. Lieberman told DDW attendees.
“Under the current fee-for-service world, more colonoscopies are better, especially if we can get paid for it,” he said. “But with the dawn of the new world of coordinated care organizations, which discourage unneeded tests, we have to ask whether we are doing too much unnecessary surveillance.”
Dr. Lieberman predicted that in the near future, payors will be expecting high-quality examinations, as well as screening and surveillance intervals consistent with evidence-based guidelines (Table). Physicians who do not adhere to recommendations will be pressed to provide reasons for deviating from the recommended standards. For those who exercise poor judgment, there may be no reimbursement, Dr. Lieberman said.
|Table. Recommended Surveillance Intervals After Colonoscopy With Adequate Bowel Preparation
|Baseline Finding (most advanced finding during colonoscopy)
Surveillance Interval, y
|Hyperplastic polyp, left-sided
|1-2 tubular adenomas, <10 mm
|3 or more tubular adenomas
|Tubular adenoma, >10 mm
|Villous adenoma (>25% villous)
|Adenoma with high-grade dysplasia
For example, Dr. Lieberman noted, the U.S. Preventive Services Task Force recommends capping the age for routine screening colonoscopy at 75 years. However, an analysis of 327,000 average-risk individuals in the Clinical Outcomes Research Initiative database revealed that 5% of those who underwent screening colonoscopy were older than 75 years, and 2% were older than 79 years.
“One might argue that, in some cases, this may represent overutilization of screening,” Dr. Lieberman said.
Another concern is the length of screening intervals. The current recommendation, which is for a 10-year interval after a negative screening colonoscopy, is based only on indirect evidence. However, the risk for an interval advanced neoplasia after five years is well established, at somewhere between 1.3% and 2.4% (Lieberman DA et al. Gastroenterology 2012;143:844-857).
In this case, “our concerns are that the baseline prep was not pristine,” Dr. Lieberman said. Indeed, studies have shown that repeat examinations after suboptimal bowel preparation can have high yields. “What we need to do instead is to make fair preps into good preps with meticulous cleaning.”
The occurrence of interval cancers is another fear that leads some endoscopists to perform too-frequent screening. This fear is based on the fact that 2% to 9% of patients with colorectal cancer who are enrolled in cancer registries report having had a colonoscopy within the prior three years.
“The recommended interval is 10 years, but in real life, the interval is often less,” Dr. Lieberman noted.
This is supported by a study in which 30% of Medicare patients underwent colonoscopy five years after a negative examination (Goodwin JS et al. Arch Intern Med 2011;171:1335-1343).
“Maybe there were good reasons, but this is potentially overutilization,” Dr. Lieberman said.
In the future, endoscopists may be held accountable for straying from guidelines for colonoscopy screening.
“Repeat procedures for poor preps will be monitored as a quality indicator, and I don’t think we will be given a green light for them because the prep was so-so,” Dr. Lieberman warned. “Coordinated care will demand that we adhere to evidence-based screening guidelines.”
There also are indications that surveillance colonoscopies occur too frequently, Dr. Lieberman noted.
“We do this out of fear over missed lesions and interval cancers. Up to 17% of polyps less than 1 cm are missed,” he said.
Endoscopists should keep in mind that different patients have varying degrees of risk for colorectal cancer and honor the established surveillance intervals based on risk stratification. This means doing colonoscopies in less than five to 10 years only in only certain subsets of patients, Dr. Lieberman said.
The evidence is less clear for surveillance in patients with serrated polyps. Guidelines suggest that when serrated polyps contain dysplasia or are larger than 10 mm in diameter, they should be treated the same as a high-risk adenoma (i.e., surveillance at three-year intervals). For serrated polyps without dysplasia or less than 10 mm in diameter, a low-risk protocol applies (i.e., surveillance at five-year intervals).
The fact that risk-based surveillance guidelines often are ignored is illustrated in the multicenter Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial sponsored by the National Cancer Institute (Schoen RE et al. Gastroenterology 2010;138:73-81). Patients in this study underwent screening sigmoidoscopy and were referred for colonoscopy if polyps were found during the examination. Researchers found that many of the polyps identified by sigmoidoscopy were not adenomas; however, 26% of patients without adenomas were examined again at five years, and 10% underwent two or more surveillance examinations within seven years. Among patients in whom one or two nonadvanced adenomas were found, 47% underwent colonoscopy within five years and 18% underwent two or more examinations within seven years.
“This is real-life evidence that there is overutilization in the community,” Dr. Lieberman said.
Is CT Scanning Overutilized?
Abdominal pain is the single most common reason for visits to the emergency room, and approximately 14% of these visits involve a CT scan. The diagnosis most likely to be made with a CT scan—for one-third of patients—is “abdominal pain”—that is, a “normal finding,” Dr. Kosinski pointed out.
The Choosing Wisely® statement suggests that for a patient with functional abdominal pain, CT scans should not be repeated unless there is a major change in clinical findings or symptoms from the initial scan, Dr. Kosinski said.
Although CT scans account for 10% of all radiology imaging, these scans are responsible for 50% of imaging radiation and have been associated with a small, but measurable, increase in risk for cancer from x-ray exposure. For example, radiation associated with an abdominal CT scan is equivalent to three years’ worth of natural background radiation, or 100 to 250 chest x-rays.
“Over a lifetime, patients who receive two or three abdominal CT scans are exposed to more radiation than many Hiroshima survivors,” Dr. Kosinski noted.
Despite this risk, the use of abdominal CT scanning is actually increasing and rising faster than the rate of emergency department visits. And many of these scans are repeat scans that are probably unnecessary, Dr. Kosinski said.
A study from Brigham and Women’s Hospital in Boston, found that 33% of patients had undergone at least five lifetime CT scans, with 5% having had between 22 and 132 scans (Sodickson A et al. Radiology 2009;251:175-184). The value of these repeat scans has been debated, with some studies showing that only 10% of repeat scans reveal a positive finding, whereas a rate as high as 23% has been reported in other studies.
“There seem to be two sides to the issue of value,” Dr. Kosinski noted.
Physicians doing workups for abdominal pain in the emergency room should follow protocols and guidelines: Apply the Alvarado score (<5 means the patient can be safely discharged); employ clinical decision support tools when available; and use limited radiation scanning, Dr. Kosinski said.
Medicolegal issues surround much of the overutilization of CT scans, Dr. Kosinski added. He quoted attorneys who have advised him to “look to published criteria, such as the Alvarado score,” understand that “unnecessary is defendable” and “use judgment, but don’t order scans because you are afraid of being sued.” Usually, clinicians who follow the standard of care, practice within the acceptable range and behave the way any reasonably careful physician would under the same or similar circumstances have little cause to worry.
“My conclusion is that it comes down to clinical judgment,” Dr. Kosinski said. “We must make sure the original CT [scan] was of good quality. If the symptoms change, you may need to repeat the CT scan, but if there is no change, there is no reason to repeat it. Finally, when in doubt, just reevaluate the patient.”
Repercussions of Payment Reform
Spencer Dorn, MD, MPH, assistant professor of medicine at the University of North Carolina at Chapel Hill School of Medicine, who has authored numerous articles on health care reform, predicted new payment models will result in a reduction in overutilization of several gastroenterology services, including colonoscopy.
“With the rapid rise in medical knowledge, we have seen increasing practice variation, and this has had significant ramifications in terms of quality and cost of care,” Dr. Dorn told DDW attendees.
“Payment reform is one strategy we are seeing in an attempt to increase the practice of evidence-based medicine.”
Under the current fee-for-service model, physicians are paid, “no matter what they do,” creating incentives to possibly overtreat, Dr. Dorn noted. Payors are taking three broad approaches to change this.
First, payors are recalibrating fee-for-service by revaluing certain expensive procedures, such as colonoscopy, in order to reduce the financial incentive for potential overuse.
“The idea is that some think colonoscopies and other commonly performed procedures are assigned too many RVUs [relative value units], and this spurs excess utilization,” Dr. Dorn explained. “The government hopes that if it pulls back the RVUs assigned to colonoscopy, then providers won’t do as many.”
Dr. Dorn told gastroenterologists to expect “significant cuts.” Currently, a colonoscopy with biopsy is valued at 45 minutes of preservice time, 51 minutes of intraservice time and 22 minutes of postservice time. When the Centers for Medicaid & Medicare Services reevaluates the procedure, as it is doing now (at press time), the RVU numbers will be dramatically lower, Dr. Dorn predicted.
Second, payors are pinning “carrots and sticks” on top of fee-for-service schedules to reward physicians for quality and to penalize those who fall short. Examples of this strategy include the Physician Quality Reporting System, the Meaningful Use Incentive Program and the upcoming Value-Based Payment Modifier system.
Lastly, in the long term, payors are moving away from fee-for-service schedules toward completely new models of payment, such as bundled payments and shared savings models.
“These new models will increase provider risk—moving from fee-for-service, where risk is low because no matter the utilization providers will get paid for their work, toward higher provider risk,” Dr. Dorn said.
“Payment reform is one way payors are attempting to ensure that we ‘choose wisely.’ It makes improving, measuring and reporting quality increasingly important,” he concluded.