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Original Investigation
May 13, 2019

Same-Day vs Different-Day Elective Upper and Lower Endoscopic Procedures by Setting

Author Affiliations
  • 1Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 2Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 4Peninsula Regional Gastroenterology, Salisbury, Maryland
  • 5Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2019;179(7):953-963. doi:10.1001/jamainternmed.2018.8766
Key Points

Question  In different outpatient settings, how often are an elective upper endoscopy and an elective lower endoscopy performed on 2 separate days when they could potentially be performed on the same day?

Findings  In this cohort study of all paired upper and lower endoscopic procedures performed within a 90-day period among Medicare beneficiaries from January 1, 2011, to June 30, 2018, the different-day procedure rate was significantly higher in physician offices (47.7%) and freestanding ambulatory surgery centers (22.2%) compared with hospital outpatient departments (13.6%).

Meaning  This disparity in practice pattern by practice setting may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

Abstract

Importance  Performing elective upper and lower endoscopic procedures on the same day is a patient-centered and less costly approach than a 2-stage approach performed on different days, when clinically appropriate. Whether this practice pattern varies based on practice setting has not been studied.

Objectives  To estimate the rate of different-day upper and lower endoscopic procedures in 3 types of outpatient settings and investigate the factors associated with the performance of these procedures on different days.

Design, Setting, and Participants  A retrospective analysis was conducted of Medicare claims between January 1, 2011, and June 30, 2018, for Medicare beneficiaries who underwent a pair of upper and lower endoscopic procedures performed within 90 days of each other at hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs), and physician offices.

Main Outcomes and Measures  Undergoing an upper and a lower endoscopic procedure on different days, adjusted for patient characteristics (age, sex, race/ethnicity, residence location and region, comorbidity, and procedure indication) and physician characteristics (sex, years in practice, procedure volume, and primary specialty). Adjusted odds ratios (aORs) and 95% CIs were calculated.

Results  A total of 4 028 587 procedure pairs were identified, of which 52.5% were performed in HOPDs, 43.3% in ASCs, and 4.2% in physician offices. The rate of different-day procedures was 13.6% in HOPDs, 22.2% in ASCs, and 47.7% in physician offices. For the 7564 physicians who practiced at both HOPDs and ASCs, their different-day procedure rate changed from 14.1% at HOPDs to 19.4% at ASCs. For the 993 physicians who practiced at both HOPDs and physician offices, their different-day procedure rate changed from 15.8% at HOPDs to 37.4% at physician offices. Patients were more likely to undergo different-day procedures at physician offices and ASCs compared with HOPDs, even after adjusting for patient and physician characteristics (physician office vs HOPD: aOR, 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR, 1.27; 95% CI, 1.23-1.32). Older age (85-94 years vs 65-74 years: aOR, 1.10; 95% CI, 1.08-1.11; 95 years or older vs 65-74 years: aOR, 1.14; 95% CI, 1.03-1.26), black and Hispanic race/ethnicity (black: aOR, 1.15; 95% CI, 1.12-1.17; Hispanic: aOR, 1.12; 95% CI, 1.10-1.14), and residing in the Northeast region (adjusted OR, 1.32; 95% CI, 1.28-1.36) were risk factors for undergoing different-day procedures. Micropolitan location (aOR, 0.94; 95% CI, 0.92-0.96) and rural location (aOR, 0.91; 95% CI, 0.89-0.93), more comorbidities (≥5: aOR, 0.75; 95% CI, 0.74-0.76), physician’s fewer years in practice (aOR, 0.84; 95% CI, 0.81-0.87), physician’s higher procedure volume (aOR, 0.65; 95% CI, 0.62-0.68), and physician’s specialty of general surgery (aOR, 0.86; 95% CI, 0.80-0.91) were protective factors.

Conclusions and Relevance  Physician offices and ASCs had much higher different-day procedure rates compared with HOPDs. This disparity may represent an opportunity for quality improvement and financial savings for common endoscopic procedures.

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