Colorectal cancer is the second leading cause of cancer-related mortality in the United States.1 Screening for colon cancer significantly reduces mortality at costs comparable to other cancer screening procedures.2 However, compliance with screening examinations for colon cancer is low in the United States.3 In 1997, the Balanced Budget Act established conditions for coverage of various colorectal screening examinations, including colonoscopy.
Patients and Methods
Since 1986, all colonoscopy and flexible sigmoidoscopy procedures at the Mayo Clinic in Jacksonville, Fla., have been performed in the ambulatory surgery center. This is a closed-unit staffed by 15 gastroenterologists which have permitted open-access endoscopy for patients referred by Mayo Clinic staff since 1995. The six-room unit is staffed to a level that permits completion of requested endoscopic procedures within 72 hours. We prospectively tabulated the number of procedures to determine the impact of screening colonoscopy on endoscopy volumes in our unit by comparing the annual numbers of diagnostic colonoscopies and flexible sigmoidoscopies for the years 1996-2000. The aim of this study was to determine the impact of screening colonoscopy procedures in our open-access endoscopy unit from 1996 to 2000.
The numbers of all diagnostic colonoscopy and flexible sigmoidoscopy procedures for the calendar years 1996 through 2000 were compared (See Figure 1). The data documents a more than two-fold increase in the number of colonoscopy procedures while the number of flexible sigmoidoscopy procedures decreased by two-thirds or 67 percent.
While screening procedures such as colonoscopy are known to decrease colon cancer-related mortality, a minority of patients actually undergoes the examinations.2,4 According to the 1997 Behavioral Risk Factor Surveillance System 20 percent of respondents reported having annual fecal occult blood testing during the previous year and 30 percent reported having a proctoscopy or flexible sigmoidoscopy in the preceding 5 years.3 The U.S. Congress addressed this issue in the 1997 Balanced Budget Act that provided funding for Medicare coverage of colon cancer screening examinations for high-risk patients, including colonoscopy.5 Our study has attempted to measure the impact of these changes on procedural volumes at our open-access endoscopy unit. This study was not able to specifically determine the numbers of screening exams alone because of inadequate and non-specific pre-procedure chart documentation. Instead, we have tabulated the numbers of all diagnostic colonoscopy and sigmoidoscopy exams, using the annual changes as an indicator of the impact of screening procedures. We believe this to be a valid approximation because the size, configuration, procedural protocol, and endoscopist staffing levels have not changed significantly during the study period. Our unit has a staff of 15 gastroenterologists who rotate through a six-room ambulatory surgery center which is staffed to a level that permits completion of requested endoscopic procedures within 72 hours. Importantly, this unit is an “open access” endoscopy unit so the majority of endoscopic procedures performed are done at the request of a referring physician without prior gastroenterology consultation. According to a recent American Society for Gastrointestinal Endoscopy (ASGE) survey, such open access endoscopy is now offered by a majority of gastrointestinal endoscopists.6
Our study found a dramatic increase in diagnostic colonoscopy procedures and a corresponding decrease in sigmoidoscopy procedures which we attribute to the use of screening examinations. Recently, however, the Health Care Financing Administration has issued new rules for Medicare insurance carriers to implement coverage for screening colonoscopy exams in average-risk patients every 10 years or four years after a previous sigmoidoscopy screening. These new guidelines, which go into effect July 1, 2001, are likely to generate another large incremental increase in endoscopy procedural volume. Meeting this demand will be progressively more difficult since most inefficiencies in high-volume endoscopy units have already been eliminated and physician/nursing productivity has been maximized. Further increases in endoscopic procedural capacity will likely require redesign and ongoing expansion of endoscopy units, as well as the purchase or lease of increasing numbers of colonoscopies. These items will involve significant capital expense outlay.
In addition, research may find shorter acting, safe-to-use sedative medicines that will allow patients to awaken more quickly and decrease their time spent in the unit’s recovery area. The final and perhaps most challenging aspect of this situation is the number of available gastrointestinal endoscopists.7,8 While the number of “help wanted” advertisements for gastroenterologists has steadily increased, the Council on Graduate Medical Education has elected to continue its efforts to reduce the number of U.S. gastroenterology postgraduate training positions based on previous predictions of an oversupply of subspecialists.9 Based on the procedural demands of colonoscopic cancer screening alone, this policy may need to be revised.10-12
Frank J Lukens, MD, is a native of Guatemala City, Guatemala, and received his medical education at the University of Missouri School of Medicine. After completing a gastroenterology fellowship at the Mayo Clinic in Jacksonville, Fla., he is taking additional training in advanced interventional endoscopy techniques at the Maine Medical Center in Portland, Maine. Herbert Wolfsen, MD, is the director of the Esophageal Disease Group at the Mayo Clinic in Jacksonville, Fla., and has been using the Stretta procedure since January 2001.