Colonoscopy screening gains momentum, but problems remain
By Phyllis Maguire
Even as physicians, public health organizations and insurers embrace colonoscopy as an option in colorectal cancer screening, experts worry that mediocre reimbursements and a waning supply of gastroenterologists may keep the technology from being more widely implemented.
Only 10 years ago, relatively few GIs advocated screening colonoscopy for colorectal cancer. Recent studies, however, indicate that colonoscopy can be a more comprehensive one-time or infrequent screening procedure.
Expert groups increasingly include colonoscopy screening in their recommendations: The U.S. Preventive Services Task Force (USPSTF), for instance, published screening guidelines in the July 16, 2002, Annals of Internal Medicine that included colonoscopy for the first time. And recent celebrity endorsements of the procedure have helped raise public awareness about the need for more widespread colorectal cancer screening.
Because colonoscopy uses longer screening intervals and sedation, experts say the procedure may be more stress-free than other screening options for many patients—a factor that might improve screening compliance. And more insurers are getting on board to pay for colonoscopy screening.
In 2001, Medicare began reimbursing for screening colonoscopy every 10 years, as well as for annual fecal occult blood tests (FOBTs) and flexible sigmoidoscopies at five-year intervals. At least a dozen states now require private insurers to pay for screening colonoscopy for average risk patients age 50 and older.
Despite these developments, colonoscopy faces some serious obstacles to wider use. Many parts of the country have a shortage of gastroenterologists to perform the procedure, while some health systems simply lack the funds to offer it. As GIs explore new ways to screen more people despite these barriers, some say that the number of Americans getting screened for colorectal cancer may not substantially rise until new screening methods get developed.
An increasingly popular procedure
Talk to generalists who perform sigmoidoscopies, and many are quick to say they now view screening colonoscopy as the standard of care, even though colonoscopy is not "preferred" by the USPSTF or other recommending organizations. "To be honest," said Frank J. Landry, FACP, Governor-elect of the Vermont Chapter, "I felt uncomfortable doing a less complete procedure."
That attitude is leading some general internists to steer patients toward screening colonoscopy, particularly when patients have insurance coverage for the procedure. Some generalists also admit they are increasingly reluctant to do biopsies during sigmoidoscopy, citing a worsening malpractice environment. And general internists point to another reason they're glad to refer patients to GIs for screening colonoscopy: doing sigmoidoscopies just doesn't pay.
"Medicare pays $96 for flexible sigmoidoscopies in the office, so you lose money if you spend more than eight or 10 minutes on the procedure," explained Thomas F. Alguire, FACP, a primary care physician in Grand Haven, Mich. He pointed out that overhead and stringent cleaning requirements make the procedure even more costly.
Dr. Alguire said he continues to do sigmoidoscopies for patients who aren't covered for colonoscopy screening, but he now does far fewer of them. He added that he would be happy to turn screening over completely to GIs.
But gastroenterologists have their own reimbursement problems. Medicare reimbursement for colonoscopy has dropped almost 30% in the last four years, said Paul J. Berggreen, ACP-ASIM Member, one of four gastroenterologists with Gastrointestinal Associates in Phoenix, Ariz. His professional fee for colonoscopy is now only $204.
Boosting colonoscopy volume
To offset falling reimbursements, Dr. Berggreen said that he and other gastroenterologists are trying to boost their efficiency to increase their volume of screening procedures.
One strategy is to consolidate the number of places where they do colonoscopies. "Instead of traveling to seven different hospitals," he said, "we're using one hospital as our 'mother ship' and trying to concentrate all our procedures there."
"Open-access" colonoscopy is another tactic being used across the country. According to James T. Frakes, FACP, one of 12 GIs with Rockford Gastroenterology Associates Ltd. in Rockford, Ill., and past president of the American Society for Gastrointestinal Endoscopy, GIs using open access colonoscopy rely on primary care physicians to supply patients' complete, up-to-date history and medication details.
Nurses meet with patients before screening to double-check their health status and medications so that GIs don't have to schedule pre-procedure consults. Such strategies free up more time to do procedures, and help make the most of the limited supply of gastroenterologists in some parts of the country.
In rural states like Mississippi, for example, there are simply not enough GIs to perform colonoscopy screening. While some general internists there do colonoscopies, according to Joseph C. Files, FACP, Governor for the Mississippi Chapter, much of the screening available in the state does not include the colonoscopy option.
Nationwide, the number of gastroenterology fellowship slots was cut in the mid-1990s, contributing to a GI shortage. That shortage is expected to worsen over the next 10 years as GIs who trained in the 1970s and 1980s—when the highest number of gastroenterology fellows graduated—start to retire.
To offset that shortage, GIs are looking for ways to free up even more time for screening procedures. Studies are underway, for instance, to see if intervals for surveillance colonoscopy for patients with small polyps—which some experts now recommend every three to six years—can be extended, letting GIs shift more resources away from surveillance toward screening.
Dr. Frakes also said that GIs in many states are using another tactic to screen more patients with the existing pool of physicians: establishing endoscopic ambulatory surgery centers.
He estimated that there are now about 400 of these centers throughout the country. The facilities' staffing levels and layout—with each GI typically assigned two procedure rooms—allow physicians to perform more procedures. A gastroenterologist working in an endoscopy center six mornings a week can perform more than 60 colonoscopies a week, Dr. Frakes said. (By comparison, most primary care physicians perform only two or three flexible sigmoidoscopies a week.)
Endoscopy centers give GIs another big plus: better reimbursement, a fact that has led entrepreneurial-minded gastroenterologists around the country to open physician-owned centers. In their own facilities, GIs recoup not only professional fees, but facility fees as well. As a result, they receive about three times the reimbursement they would receive from Medicare for performing the same procedure in a hospital.
As hospitals lose facility fees to endoscopy centers, many hospital organizations have lobbied against allowing the centers to open. That is unfortunate, Dr. Frakes argued, because the more procedures GIs can perform, the less time patients have to wait to get screened—a big factor in screening compliance.
"When Medicare started covering colonoscopy screening, our waiting list jumped to almost 1,000 people," Dr. Frakes said. "We had to stretch those out over many months. Unfortunately some people lose interest when they have to wait."
Even as GIs try to boost efficiency, patients now face waiting times for screening colonoscopy that range from several weeks to several months. As more insurers begin reimbursing for screening colonoscopy, experts warn those waiting times may get much worse.
One solution to the looming availability crunch won't be to increase the number of GIs being trained or to encourage primary care physicians—who often lack the time, as well as the technical or diagnostic skills—to perform colonoscopy. Instead, experts expect technologies that will emerge over the next 10 years to radically transform colorectal cancer screening.
Virtual colonography using computed tomography (CT) may be one technological solution—although no guideline group has endorsed the procedure. While clinical trial results of the technology have been mixed so far, virtual colonography is now part of a massive ongoing National Cancer Institute trial.
The most promising new screening tool on the horizon is stool DNA tests that detect gene mutations. According to Douglas K. Rex, MD, director of endoscopy at Indiana University Hospital in Indianapolis, stool DNA tests will be more expensive than FOBTs.
They will also be less sensitive than colonoscopy initially, he said, because "individual tumors can have mutations in a whole variety of different genes. The commercialized tests will check for mutations in only three genes as well as two other DNA abnormalities, so colonoscopy will remain the preferred test for patients willing to undergo it."
Still, he expects the test to replace FOBT as the most effective non-invasive screening option. The fact that it is non-invasive may dramatically boost the number of patients who opt to get screened.
Dr. Rex envisions the DNA mutation test being part of a kit that primary care doctors would give patients to complete at home and send to a central processing lab, which would then send results back to the physician.
"In that case," Dr. Rex said, "colorectal cancer screening will come full circle, and an important screening tool will be implemented largely by primary care physicians."
While colorectal cancer kills more than 56,000 Americans every year, few Americans are getting screened for the disease—a fact that frustrates many public health experts.
The Centers for Medicare and Medicaid Services estimates that only 14% of the Medicare population has had any form of colorectal cancer screening, while the American Cancer Society claims that only 26% of eligible average risk patients have opted to be screened. By contrast, 70% of eligible women get mammograms and 80% have Pap smears.
Cynthia M. Jorgensen, DrPH, a behavioral scientist with the CDC's division of cancer prevention and control, said both physicians and patients engage in mutual finger-pointing when it comes to explaining why colorectal cancer screening percentages are low. "Patients say that physicians don't talk to them about screening," Dr. Jorgensen said, "while physicians complain that patients don't comply."
To help break that impasse, here are some tips to steer more of your patients toward colorectal cancer screening.
Educate patients. Many patients still harbor misconceptions and myths about colorectal cancer, Dr. Jorgensen said.
First, patients aren't aware that colorectal cancer is the nation's second biggest cancer killer after lung cancer. In addition, some patients still believe that screening is ineffective.
And many patients still don't know that screening can detect polyps before they become cancerous. "While other types of screening detect early cancers, colon cancer screening is unique," said Dr. Jorgensen. "The fact that we can remove polyps before they become cancerous needs to be part of the screening message for patients who think they should wait for symptoms to develop before they get screened."
Printed educational materials for your waiting room or office can help. The CDC offers free brochures, posters and fact sheets through its "Screen for Life" program.
Use ancillary staff. In the age of eight-minute office visits, it's hard to spend five of them explaining different screening options. Consider making a discussion about screening part of nurses' or assistants' protocol when they're taking vital signs at the beginning of a visit.
And once patients choose a screening method, make sure staff is available to explain what's involved. That's particularly true for fecal occult blood tests (FOBTs), Dr. Jorgensen said.
"In our research on screening, we ran into patients who joked about how many FOBT kits they have at home in a drawer," she said. "You can't just hand patients a kit and tell them to follow directions, because for many patients those directions just aren't clear."
Pick a screening strategy that works for you. The fact that patients can choose among a menu of screening methods can be a plus: If patients are uncomfortable with one approach, they can always choose another. But the sheer number of screening options may be a big reason why some patients don't get screened.
"Transmitting the message that 'you can do one of five different things and you need to decide,' may be too complex for many patients," said gastroenterologist Theodore R. Levin, FACP, staff physician at Kaiser Permanente's Walnut Creek Medical Center in Walnut Creek, Calif. "Physicians need to select the best screening strategy for their setting, then strongly recommend it to patients."
In the case of Kaiser Permanente, a group model HMO, sigmoidoscopy is the preferred method, even though patients can request FOBT or screening colonoscopy. Dr. Levin readily admits that the structure and size of the Kaiser system makes effective sigmoidoscopy screening possible.
The HMO has the resources to invest in video, not fiber optic, sigmoidoscopy, for instance, and has a large enough patient population so that internists as well as registered nurses are proficient in the technique. Kaiser has also lengthened the interval for sigmoidoscopy screening from five to 10 years for average risk patients, finding that patients appreciate the longer screening interval.
"An individual doctor in an individual office may not be able to deliver sigmoidoscopy effectively, just because the reimbursement per procedure may be too low," Dr. Levin said. For Kaiser, however, the strategy has been a success: In Northern California, the HMO screens 70% of its eligible enrollees, roughly twice as many as the national average.
Use reminder systems. Evidence suggests that reminder systems work, said Dr. Jorgensen of the CDC. You should make a colorectal cancer screening reminder part of your preventive health care checklist at the front of every patient's chart.
The CDC is also examining the effectiveness of different types of follow-up interventions. "We're looking at sending patients some sort of information at home to prime them for a screening discussion before their visit," she said. "Then if FOBT is chosen, we'll send them a reminder to return the FOBT after a set amount of time." Researchers make follow-up phone calls to patients who do not return the test.
Get outside help. Talk to local medical groups, hospital systems or health plans about ways to coordinate efforts to boost screening percentages. Any increase in screening figures can be good for both quality improvement and marketing efforts.
Experts say that organizational commitment is key to screening success—and the lack of it is a major reason why colorectal cancer screening rates lag far behind screening for other cancers. However, screening may soon become a standard performance measure.
Earlier this year, for instance, California's department of managed health care, which regulates the state's HMOs, proposed requiring health plans to develop strategies to boost colorectal cancer screening. And while the National Committee on Quality Assurance does not yet include colorectal cancer screening as a HEDIS performance measure for health plans, a spokesperson said it is considering doing so.
"We're in the beginning stages of public awareness about colorectal cancer screening," said Dr. Jorgensen, who pointed out that screening wasn't even recommended by leading medical groups until relatively recently. "I'd say it's parallel to where breast cancer screening was 20 years ago."
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