Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data

Teleradiology-Based Referrals for Patients with Gastroenterological Diseases Between Tertiary and Regional Hospitals: A Hospital-to-Hospital Approach

Teleradiology is recognized for fostering collaboration between regional and tertiary hospitals. However, its application in gastroenterological diseases remains underexplored. This study aimed to assess the effectiveness of teleradiology in improving gastroenterological care. This retrospective study analyzed patients with gastroenterological diseases in a tertiary hospital who were referred from a regional hospital using a cloud-based radiology image-sharing system between July 2020 and June 2023. Our primary focus was to conduct a descriptive statistical analysis to evaluate patient characteristics and the referral process and analyze the timeframes from referral to transfer and from the start of treatment to discharge and the outcomes. We analyzed 56 patients, with 45 (80.4%) presenting hepatobiliary pancreatic disease. The most frequent condition was common bile duct stones (17 cases). Forty-nine cases were transferred for inpatient treatments, four underwent endoscopic examinations as outpatients, and two had imaging consultation without subsequent hospital visits. On referral day, 16 patients were transferred, and the remaining 33 (67.3%) were placed on a waiting list starting from the subsequent day. The median time from referral to admission was 1 day (range: 0-14 days), and the median time from referral to treatment was 2 days (range: 0-14 days). Remote image-sharing systems ensure accurate imaging at referral, preventing care delays. In collaboration with regional and tertiary hospitals, teleradiology may also be useful for gastroenterological diseases.

A cooling off period: decline in the use of hot biopsy forceps technique in colonoscopy in the U.S. Medicare population 2000-2019

BACKGROUND

The use of hot biopsy forceps (with electrocautery) is no longer routinely recommended given increased complications compared to cold biopsy forceps (without electrocautery). It is unknown how often the technique is currently used in the United States (U.S.) or how its usage has changed over time.

AIM

To characterize the use of hot biopsy forceps by U.S. Medicare providers over time, identify provider characteristics of those who more commonly perform this technique, and determine if there are regional differences in use of this technique within the U.S.

METHODS

We performed a retrospective cross-sectional study using U.S. Medicare summary data from 2000 to 2019 to analyze the frequency of cold and hot biopsies. We used detailed provider and state summary files to characterize providers' demographics, including geographic region, to identify regional variation in use of these techniques, and identify factors associated with use of hot biopsy forceps from 2012 to 2019.

RESULTS

The hot biopsy forceps technique peaked in 2003 (412,165/year) and declined to 108,232/year in 2019, while the cold biopsy forceps technique increased from 482,862/year in 2000 to 1,533,558/year in 2019. Use of hot biopsy forceps was more common by non-gastroenterologists and in rural practice settings. In addition, there was up to 50-fold difference in utilization in these techniques between states (on a population normalized basis), with the highest rate of use in the southeastern U.S.

CONCLUSION

Variation in the use of hot biopsy forceps by region and provider suggests a potential area for quality improvement given the comparative advantages of the cold biopsy forceps technique. De-implementation of an existing endoscopic practice may require different approaches than implementation of a new practice.

Barriers to Colonoscopy Quality Measurement in Rural Wisconsin

BACKGROUND

Patients in rural areas have limited colonoscopy access, which is critical for colorectal cancer prevention. General surgeons perform most colonoscopies in rural areas. The Surgical Collaborative of Wisconsin's Rural Task Force identified colonoscopy as a high-priority initiative due to high volume and lack of access to quality measurement, which is necessary to assess and ultimately improve colonoscopy performance.

OBJECTIVE

Assess the capacity for colonoscopy quality measurement and improvement in rural Wisconsin hospitals.

DESIGN

From October 2019 to January 2020, the Surgical Collaborative of Wisconsin, Rural Wisconsin Health Cooperative, and Wisconsin Collaborative for Healthcare Quality collaborated to design and distribute a survey to 44 Rural Wisconsin Health Cooperative hospitals. Descriptive statistics summarized survey items. Surgeons from 6 rural hospitals participated in stakeholder interviews.

SETTING

Rural Wisconsin Health Cooperative hospitals.

MAIN OUTCOME MEASURES

Colonoscopy providers, procedure volume/capacity, informatics and quality measurement infrastructure, barriers to quality measurement, and improvement.

RESULTS

Twenty-five surveys (57%) were completed. Most colonoscopy providers in rural hospitals were surgeons (66.3%), followed by family/internal medicine physicians (20.0%) and gastroenterologists (13.8%). The average hospital volume/week was 19.9 colonoscopies (SD = 13.4). Hospitals reported operating at ~75% capacity. Withdrawal time was the most tracked measure (44.0%), followed by adenoma detection (36.0%) and cecal intubation (28.0%) rates. Approximately one-third of hospitals (36.0%) used procedure-reporting software. Most hospitals (80.0%) did not have access to on-site pathology. Surgeons reported barriers to quality measurement/improvement, including insufficient resources for electronic medical record-based reporting and the need for targeted educational opportunities that do not require travel.

LIMITATIONS

Single state may not represent the experience of all rural hospitals.

CONCLUSIONS

The lack of access to colonoscopy quality measures suggests the opportunity to develop a flexible approach that considers reporting software availability and electronic medical record differences. Improving access to measures and education/training opportunities may improve the availability of high-quality colonoscopies for patients in rural Wisconsin. See Video Abstract .

BARRERAS PARA LA MEDICIN DE LA CALIDAD DE LA COLONOSCOPIA EN LAS ZONAS RURALES DE WISCONSIN

ANTECEDENTES:Los pacientes de las zonas rurales tienen un acceso reducido a la colonoscopia, que es fundamental para la prevención del cáncer colorrectal. Los cirujanos generales realizan la mayoría de las colonoscopias en las zonas rurales. El Surgical Collaborative of Wisconsin's Rural Task Force identificó la colonoscopia como una iniciativa de alta prioridad debido al alto volumen y a la falta de acceso a medidas de calidad, ambas necesarias para evaluar y mejorar el rendimiento.OBJETIVO:Evaluar la capacidad de medición y mejora de la calidad de la colonoscopia en los hospitales rurales de Wisconsin.DISEÑO:En octubre de 2019-enero de 2020, el Surgical Collaborative of Wisconsin, el Rural Wisconsin Health Cooperative y el Wisconsin Collaborative for Healthcare Quality colaboraron para diseñar y distribuir una encuesta a 44 hospitales del Rural Wisconsin Health Cooperative (n = 25 completados, tasa de respuesta del 57%). Las estadísticas descriptivas resumieron los ítems de la encuesta. Los cirujanos de cada uno de los seis hospitales rurales participaron en entrevistas con las partes interesadas.ÁMBITOS Y PACIENTES:Hospitales rurales de la Cooperativa de Salud de Wisconsin.PRINCIPALES MEDIDAS DE VALORACIÓN:Proveedores de colonoscopia, volumen y capacidad de procedimientos, infraestructura informática y de medición de la calidad, barreras a la medición y mejora de la calidad.RESULTADOS:La mayoría de los proveedores de colonoscopias de los hospitales rurales eran cirujanos (66,3%), seguidos de médicos de familia o médicos internos (20,0%) y gastroenterólogos (13,8%). El volumen hospitalario medio por semana fue de 19,9 colonoscopias (DE = 13,4). Los hospitales declararon operar a ~75% de su capacidad. El tiempo de retirada fue la medida más seguida (44,0%), seguida de las tasas de detección de adenomas (36,0%) y de intubación cecal (28,0%). Aproximadamente un tercio de los hospitales (36,0%) utilizaba programas informáticos de notificación de procedimientos. La mayoría de los hospitales (80,0%) no tenían acceso a patología in situ. Los cirujanos señalaron obstáculos a la medición y mejora de la calidad, como la insuficiencia de recursos para la elaboración de informes basados en historias clínicas electrónicas y la necesidad de oportunidades de formación específicas que no requieran desplazamientos.LIMITACIONES:Un solo estado; puede no representar la experiencia de todos los hospitales rurales.CONCLUSIONES:La falta de acceso a las medidas de calidad de la colonoscopia sugiere la oportunidad de desarrollar un enfoque flexible que tenga en cuenta la disponibilidad de software de notificación y las diferencias en los registros médicos electrónicos. Mejorar el acceso a las medidas y las oportunidades de educación y formación puede mejorar la disponibilidad de colonoscopias de alta calidad para los pacientes de las zonas rurales de Wisconsin. (Traducción--Ingrid Melo).

Centralized Colorectal Cancer Screening Outreach in Federally Qualified Health Centers: A Randomized Clinical Trial

Importance

Colorectal cancer (CRC) screening is effective but remains underused in federally qualified health centers (FQHCs).

Objective

To assess the effectiveness of a centralized CRC screening outreach intervention involving mailed fecal immunochemical testing (FIT) outreach and patient navigation to colonoscopy after abnormal results of FIT.

Design, Setting, and Participants

A pragmatic randomized clinical trial was conducted, using intention-to-treat analysis. Participants were enrolled from July 6, 2020, to September 17, 2021, and analyses were performed from July 6, 2023, to January 31, 2024. The study was conducted at independent FQHCs comprising 12 clinical delivery sites in North Carolina. The outreach intervention was centralized at an academic cancer center. Active individuals aged 50 to 75 years at average risk for CRC and not current with screening per US Preventive Services Task Force recommendations were included.

Intervention

In addition to usual care, intervention participants received mailed screening outreach materials including an introductory letter, FIT kit packet with instructions and return postage, and 2 reminder letters if needed. Intervention participants with positive results of mailed FIT were offered navigation to facilitate follow-up colonoscopy completion. Control participants received usual care alone.

Main Outcomes and Measures

The primary outcome was completion of a US Preventive Services Task Force-recommended CRC screening test within 6 months determined by electronic health record review. Secondary outcomes were colonoscopy completion within 6 months after positive FIT results and detection of advanced colorectal neoplasia, defined as advanced adenoma or CRC.

Results

A total of 4002 participants were included (mean [SD] age, 59.6 [6.8] years; 2256 [56.4%] female; 364 (9.1%) Hispanic; 1082 [27.0%] non-Hispanic Black; 2288 [57.2%] non-Hispanic White; 1198 [29.9%] commercially insured; 617 [15.4%] Medicaid; 1227 [30.7%] Medicare; and 960 [24.0%] uninsured), with 2001 randomized to each group. Compared with controls, intervention participants were more likely to complete screening within 6 months of randomization (30.0% vs 9.7%; difference, 20.29 percentage points; 95% CI, 17.85-22.73 percentage points). The intervention was effective in all insurance types. In the intervention arm, 33 of 48 participants with positive FIT results (68.8%) completed follow-up colonoscopy within 6 months compared with 8 of 18 participants (44.4%) in the control arm (difference, 24.3 percentage points; 95% CI, -2.13 to 50.74 percentage points). Advanced colorectal neoplasia was detected in 29 intervention participants (1.4%) and 15 control participants (0.7%) (difference, 0.68 percentage points; 95% CI, 0.05-1.35 percentage points).

Conclusions and Relevance

In this randomized clinical trial of centralized screening outreach intervention in diverse patients served by independent FQHCs, CRC screening completion and advanced colorectal neoplasia detection were substantially increased. Future studies should examine the cost and scalability of this intervention in this context.

Trial Registration

ClinicalTrials.gov Identifier: NCT04406714.