Budget-impact model for colonoscopy cost calculation and comparison between 2 litre PEG+ASC and sodium picosulphate with magnesium citrate or sodium phosphate oral bowel cleansing agents

Establishing funding rates for colonoscopy and gastroscopy procedures in Ontario

Introduction

This paper describes the funding rates established in Ontario to reflect best practices in hospital-based care delivery for these endoscopic procedures: colonoscopy, colonoscopy biopsy, gastroscopy, gastroscopy biopsy, and colonoscopy combined with gastroscopy.

Methods

The funding rates are based on direct costs and were established using a micro-costing approach after receipt of inputs from 3 working groups and a review of the administrative data and literature, where applicable. The first group advised on nursing activities, time, and staffing ratios along the patient pathway for each of the procedures. The second group provided recommendations about the duration for each procedure, and the third group provided information about supplies and equipment, their use, and costs.

Results

The resulting funding rates are $161.18 for colonoscopy and $151.08 for gastroscopy (without accompanying interventions), $16.06 for colonoscopy biopsy and $8.22 for gastroscopy biopsy (added to the respective procedures), and $207.26 for combined colonoscopy and gastroscopy. Detailed costs for each component embedded in the rates are also provided.

Conclusions

The rates came into effect in April 2018. The process and outcomes described here allowed for a transparent pricing mechanism in which funding follows the patient, clinical expert consensus is the basis for practice, and providers and payers both understand the components.

Cost-analysis model of colonoscopy preparation using split-dose reduced-volume oral sulfate solution (OSS) and polyethylene glycol with electrolytes solution (PEG-ELS)

OBJECTIVE

The study aimed to (1) develop a cost model for colonoscopy preparation among patients referred for colonoscopy using split-dose reduced-volume oral sulfate solution (OSS) and generic polyethylene glycol with electrolytes solution (PEG-ELS), (2) examine cost savings associated with OSS vs PEG-ELS, and (3) assess the robustness of the cost model.

METHODS

Efficacy of each agent was based on the results of a 541-patient clinical trial comparing OSS to PEG-ELS. Cleansing agent and colonoscopy procedure costs were calculated from OptumHealth Reporting & Insights claims data for 2010-Q12013. In the model, patients' colonoscopies were tracked over a 25 or 35 year time period until the patients reached age 75. The difference per patient per year (PPPY) in total cleansing agent and colonoscopy procedure costs over the time horizon between the OSS and PEG-ELS cohort was calculated. One-way sensitivity analyses were conducted to test the robustness of the cost model.

RESULTS

The model showed lower cost for OSS patients over the time horizon. Total PPPY costs were $280.34 for the OSS cohort and $296.36 for the PEG-ELS cohort, resulting in a cost saving of $16.01 PPPY for the OSS cohort. This was due primarily to OSS patients having fewer colonoscopies (OSS: 0.158 vs PEG-ELS: 0.170 PPPY). Over the time horizon, cost savings of $4 763 335 were observed among 10, 000 OSS patients. Cost savings switched from OSS to PEG-ELS cohort in four cases: (1) base-case cost of a completed colonoscopy decreased by 75%, (2) base-case cost of OSS increased to over $143 per usage, (3) all non-completers were lost to follow-up, and (4) OSS bowel preparation quality dropped below PEG-ELS to 70%.

CONCLUSIONS

From a payer's perspective, the model showed that the use of OSS as the cleansing agent resulted in potential cost savings compared with PEG-ELS. Cost savings under OSS remained under various sensitivity analyses.

Safety, patient's tolerance, and efficacy of a 2-liter vitamin C-enriched macrogol bowel preparation: a randomized, endoscopist-blinded prospective comparison with a 4-liter macrogol solution

BACKGROUND

Optimal bowel preparation is associated with lower polyp miss rates, but patients have difficulties in complying with the usual 4-L bowel preparation.

OBJECTIVE

This study aimed to compare the safety, acceptance, and efficacy of 2-L polyethylene glycol electrolyte solution enriched in vitamin C with 4-L polyethylene glycol electrolyte solution.

DESIGN

This study is an endoscopist-blinded randomized controlled trial.

SETTINGS

The study was conducted at a tertiary referral hospital.

PATIENTS

Consecutive outpatients were randomly assigned to receive 4-L polyethylene glycol electrolyte solution or 2-L polyethylene glycol electrolyte solution enriched in vitamin C with 2 L of clear fluids in a single-dose or a split-dose regime.

MAIN OUTCOME MEASURES

Safety was assessed by blood sampling before and after the preparation and by a 30-day postcolonoscopy chart and complication database review. Acceptance was investigated by questionnaires, and the adequacy of bowel preparation was assessed by the Aronchick and Ottawa scales.

RESULTS

One hundred eighty-eight patients, 98 in the polyethylene glycol electrolyte solution enriched in vitamin C group and 90 in the polyethylene glycol electrolyte solution group, participated. Although changes in bicarbonate blood concentrations with polyethylene glycol electrolyte solution enriched in vitamin C were seen to such an extent that the blinded investigator correctly guessed the preparation in 75.6%, no unsafe values were observed. A 30-day chart and complication database review revealed 1 severe adverse event of a myocardial infarction in the polyethylene glycol electrolyte solution enriched in vitamin C group. Patient acceptance and compliance were significantly higher with the polyethylene glycol electrolyte solution enriched in vitamin C group. The impact on sleep, daily activities, and physical complaints were similar in both groups. Polyethylene glycol electrolyte solution enriched in vitamin C was noninferior to polyethylene glycol electrolyte solution in cleansing efficacy, but the segmental rating of excellent and good preparation in right and transverse colon was significantly better for polyethylene glycol electrolyte solution, especially when taken as a split dose.

LIMITATIONS

The results cannot be extrapolated to immobile inpatients with comorbidities. Another limitation of our study was the inability to determine plasma vitamin C concentrations and to assess the quality of colonoscopy performance.

CONCLUSIONS

Two-liter polyethylene glycol electrolyte solution enriched in vitamin C is a safe and patient-friendly alternative to the 4-L polyethylene glycol electrolyte solution. Endoscopists slightly preferred the 4-L polyethylene glycol electrolyte solution.

Consensus guidelines for the use of bowel preparation prior to colonic diagnostic procedures: colonoscopy and small bowel video capsule endoscopy

BACKGROUND

Adequate bowel preparation prior to colonic diagnostic procedures is essential to ensure adequate visualisation.

SCOPE

This consensus aims to provide guidance as to the appropriate use of bowel preparation for a range of defined clinical circumstances. A consensus group from across Europe was convened and met to discuss appropriate bowel preparation. The use of polyethylene glycol (PEG), sodium picosulphate and sodium phosphate (NaP), together with other agents, prokinetics and simethicone, in colonoscopy and small bowel video capsule endoscopy were considered. A systematic review of the literature was carried out and additional unpublished data was obtained from the members of the consensus group where required. Recommendations were graded according to the level of evidence.

FINDINGS

PEG-based regimens are recommended first line for both procedures, since their use is supported by good efficacy and safety data. Sodium-picosulphate-based regimens are recommended second line as their cleansing efficacy appears less than PEG-based regimens. NaP is not recommended for bowel cleansing due to the potential for renal damage and other adverse events. However, the use of NaP is acceptable in patients in whom PEG or sodium picosulphate is ineffective or not tolerated. NaP should not be used in patients with chronic kidney disease, pre-existing electrolyte disturbances, congestive heart failure, cirrhosis or a history of hypertension. The timing of the dose, dietary restrictions, use in special patient groups and recording of the quality of bowel preparation are also considered for patients undergoing colonoscopy. During the development of the guidelines the European Society of Gastrointestinal Endoscopy (ESGE) issued guidance on bowel preparation for colonoscopy. The ESGE guidelines and these consensus guidelines share many recommendations; differences between the guidelines are reviewed.

CONCLUSION

The use of bowel preparation should be tailored to the individual patient and their specific clinical circumstances.