Same-Day vs Different-Day Elective Upper and Lower Endoscopic Procedures by Setting

Abstract

Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied. OBJECTIVES To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days. DESIGN, SETTING, AND PARTICIPANTS A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices. MAIN OUTCOMES AND MEASURES Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated. RESULTS A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD:

Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians

“…37 In this context of absent or conflicting recommendations, most respondents in the present survey study nonetheless reported they would obtain screening CBCs for patients who were pregnant or not pregnant. Prior work 38,39 has also reported underuse of bidirectional endoscopy, although not to the extent found in our study. Although previous guidelines recommended bidirectional endoscopy for men and postmenopausal women, 11 subsequent American Gastroenterological Association guidelines, published after this survey was conducted, recommend bidirectional endoscopy regardless of menopausal status for those without an alternate explanation for IDA.…”

“…For example, in some practice settings, insurance reimbursements may disincentivize combined EGD and colonoscopy, and physicians may not offer the combined procedures in a single appointment. 38,39 However, a serial diagnostic testing approach may lead to increased costs and require that patients undergo a second episode of sedation. In addition, if there is a substantial time interval between the colonoscopy and the EGD, there is the theoretical potential for a delay in diagnosis (although serial testing was not directly assessed in this survey study).…”

Improving the Delivery of Common Medical Procedures to Achieve Value-Based Care

“…In this edition of JAMA Internal Medicine, Wang et al 5 highlight a third and novel approach to understanding how we could improve the value of care, focusing on medical procedures (Table ). Rather than focusing on frequency (how often the procedure occurs) or price (how much was paid for each procedure), they assessed the timing of concurrent procedures.…”

“…In some clinical scenarios (eg, iron deficiency anemia, where there is a higher risk of gastrointestinal malignant neoplasms), it is inappropriate to not perform both procedures on the same day. In this context, Wang et al 5 found wide variation in how often upper and lower endoscopic procedures were performed together (on the same day) vs on different days. Specifically, they reported a greater than 3-fold variation in different-day procedure rates when stratified by practice environment (47.7 % in physician offices vs 22.2% in ambulatory surgery centers vs 13.6% in hospital outpatient departments).…”

“…It is quite possible that some of the observed variation in practice patterns may be clinically appropriate. As Wang et al 5 appropriately concede, some patients may not be able to safely undergo concurrent upper and lower endoscopic procedures. Others may opt for an upper endoscopic procedure first, deferring (in hopes of avoiding) the bowel preparation associated with colonoscopy.…”