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Table 1.  
Demographic Characteristics of Patients With Colonoscopy for Colon Cancer Screening (N = 842 849)a
Demographic Characteristics of Patients With Colonoscopy for Colon Cancer Screening (N = 842 849)a
Table 2.  
Diagnoses in the Precolonoscopy Office Visits
Diagnoses in the Precolonoscopy Office Visits
1.
Burt  RW, Cannon  JA, David  DS,  et al; National Comprehensive Cancer Network.  Colorectal cancer screening. J Natl Compr Canc Netw. 2013;11(12):1538-1575.
PubMed
2.
Allen  JI.  The value of colonoscopy. Gastroenterology. 2014;146(2):573-575.
PubMedArticle
3.
Goodwin  JS, Singh  A, Reddy  N, Riall  TS, Kuo  YF.  Overuse of screening colonoscopy in the Medicare population. Arch Intern Med. 2011;171(15):1335-1343.
PubMedArticle
4.
Liu  H, Waxman  DA, Main  R, Mattke  S.  Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA. 2012;307(11):1178-1184.
PubMedArticle
5.
Mahajan  RJ, Marshall  JB.  Prevalence of open-access gastrointestinal endoscopy in the United States. Gastrointest Endosc. 1997;46(1):21-26.
PubMedArticle
6.
Seeff  LC, Richards  TB, Shapiro  JA,  et al.  How many endoscopies are performed for colorectal cancer screening? results from CDC’s survey of endoscopic capacity. Gastroenterology. 2004;127(6):1670-1677.
PubMedArticle
Research Letter
February 2, 2016

Prevalence and Cost of Office Visits Prior to Colonoscopy for Colon Cancer Screening

Author Affiliations
  • 1Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA. 2016;315(5):514-515. doi:10.1001/jama.2015.15278

Colonoscopy is increasingly the preferred method for colon cancer screening,1 but its high cost in the United States has been scrutinized.2 Unnecessary colonoscopies contribute to societal costs,3 and the cost per procedure is high. For example, anesthesiologists or nurse anesthetists often administer sedation for endoscopies in low-risk patients, adding more than $1 billion of potentially unnecessary costs annually.4 The cost of gastroenterology office visits before colonoscopy has received less attention.

Widely accepted guidelines for colon cancer screening and polyp surveillance and the generally low risk of colonoscopy may obviate the need for many of these visits. Open-access endoscopy, which allows patients to be referred for endoscopies without a prior gastroenterology office visit, began in the United States in the 1990s,5 though recent estimates of the prevalence of the practice are lacking. We analyzed billing data to determine the proportion of colonoscopies for colon cancer screening and polyp surveillance that were preceded by office visits and the associated payments for those visits.

Methods

We used MarketScan Commercial Claims and Encounters (Truven Health Analytics) from 2010 through 2013. The database contains use and expenditure data for individuals with employer-sponsored private health insurance from several hundred US employers and health plans and includes approximately 43 to 55 million beneficiaries each year from all 50 states. We included patients aged 50 to 64 years with continuous insurance coverage for 12 months prior to an outpatient colonoscopy performed in the gastroenterology setting that included a diagnosis for screening or polyp surveillance. This study was deemed exempt by the Johns Hopkins University institutional review board.

We excluded patients with diagnosis codes for colon cancer or inflammatory bowel disease in the preceding 12 months and patients who underwent esophagogastroduodenoscopy on the same day as colonoscopy. Gastroenterology office visits were identified by outpatient evaluation and management codes (new patient, established patient, or consultation) in the 6 weeks prior to colonoscopy. To increase the likelihood that office visits were related to colonoscopy, we excluded patients with gastroenterology office visits between 6 weeks and 1 year prior to colonoscopy. Total payments included those made by insurance plans and patients for those office visits.

Results

Of 842 849 patients who underwent colonoscopy, 247 542 (29.4%; 95% CI, 29.3%-29.5%) had a precolonoscopy office visit (Table 1). Patients with office visits had a higher Charlson Comorbidity Index (CCI) and were more likely to reside in the South. Of patients with office visits, 66.4% had a CCI of 0. Of the office visits, 77.4% were associated with a diagnosis of either screening or preoperative evaluation (Table 2). Mean payment for office visits was $123.83. Distributed across all patients, precolonoscopy office visits added a mean of $36.37 per colonoscopy.

Discussion

Even though open-access colonoscopy has been available in the United States for more than 20 years, we found that approximately 30% of colonoscopies for colon cancer screening and polyp surveillance were preceded by a gastroenterology office visit.

The primary limitation of this study is that we were unable to determine the exact circumstances of office visits. Patients or referring clinicians may have requested office visits prior to the procedure, and we did not determine whether individual office visits were necessary or appropriate. The higher CCI among patients with office visits indicates some selection of patients at higher risk of adverse events for office visits, suggesting that our estimate is likely the upper limit of office visits that could be averted through increased direct access.

We were unable to determine whether office visits prevented any unnecessary colonoscopies or improved the safety or clinical value of the colonoscopy. Our population included only younger individuals (<65 years) with private insurance, so our findings may not be generalizable to other populations.

Although the precolonoscopy office visits added a modest $36 per colonoscopy in this population, there are an estimated 7 million screening colonoscopies performed in the United States annually,6 so the cumulative costs are significant. Identifying which patients benefit from a precolonoscopy office visit and targeting those patients could increase the value of colon cancer screening.

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Article Information
Section Editor: Jody W. Zylke, MD, Deputy Editor.

Corresponding Author: Kevin R. Riggs, MD, MPH, Division of General Internal Medicine, Johns Hopkins University School of Medicine, 2024 E Monument St, Baltimore, MD 21287 (kriggs3@jhmi.edu).

Author Contributions: Dr Riggs had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Riggs, Shin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Riggs.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Riggs.

Study supervision: Segal, Shin, Pollack.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Pollack reported owning stock in the Advisory Board Company. No other disclosures were reported.

Funding/Support: Dr Riggs’ salary is supported by grant T32HL007180 from the National Institutes of Health. Dr Pollack’s salary is supported by grant K07 CA151910 from the National Cancer Institute, Office of Behavioral and Social Sciences.

Role of the Funder/Sponsor: The National Institutes of Health and National Cancer Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Burt  RW, Cannon  JA, David  DS,  et al; National Comprehensive Cancer Network.  Colorectal cancer screening. J Natl Compr Canc Netw. 2013;11(12):1538-1575.
PubMed
2.
Allen  JI.  The value of colonoscopy. Gastroenterology. 2014;146(2):573-575.
PubMedArticle
3.
Goodwin  JS, Singh  A, Reddy  N, Riall  TS, Kuo  YF.  Overuse of screening colonoscopy in the Medicare population. Arch Intern Med. 2011;171(15):1335-1343.
PubMedArticle
4.
Liu  H, Waxman  DA, Main  R, Mattke  S.  Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA. 2012;307(11):1178-1184.
PubMedArticle
5.
Mahajan  RJ, Marshall  JB.  Prevalence of open-access gastrointestinal endoscopy in the United States. Gastrointest Endosc. 1997;46(1):21-26.
PubMedArticle
6.
Seeff  LC, Richards  TB, Shapiro  JA,  et al.  How many endoscopies are performed for colorectal cancer screening? results from CDC’s survey of endoscopic capacity. Gastroenterology. 2004;127(6):1670-1677.
PubMedArticle
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