Response to Feldman

Letters to the Editor

pay any physician submitting colonoscopy Current Procedure Terminology codes is not sustainable in a quality system. Let the market determine appropriate fees, based on specific indications and bearing some relationship to qualifications and the costs of doing business. CONFLICT OF INTEREST The author declares no conflict of interest. REFERENCES 1. Rex DK, Rahmani EY, Haseman JH et al. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology 1997;112:17–23. 1 Practice Limited to Gastroenterology and Endoscopy, Escondido, California, USA. Correspondence: Ronald E. Feldman, MD, FACG, AGAF, FASGE, Practice Limited to Gastroenterology and Endoscopy, Parkway Medical Building, 488 East Valley Parkway, Suite 313, Escondido, California 92025, USA. E-mail: [email protected]

Response to Feldman Douglas K. Rex, MD, FACG, AGAF, FASGE1 and David G. Hewett, MBBS, MSc, PhD, FRACP2 This letter underwent AJG editorial review. doi: 10.1038/ajg.2011.13

To the Editor: Dr Feldman opines that reimbursement for colonoscopy should be linked to completion of gastroenterology fellowship or hospital credentialing (1). Such an approach could improve quality, as several studies have shown that gastroenterologists miss fewer colorectal cancers during colonoscopy than primary care physicians and surgeons (2–4), and in Ontario hospital-based colonoscopies are (on average) less likely than office-based colonoscopies to miss colorectal cancer (5). However, many studies have shown that some board certified gastroenterologists have adenoma detection rates which are below recommended thresholds (6–11), and are at levels associated with an increased risk of subsequent colorectal cancer (11). Therefore, undergoing colonoscopy by a gastroenterologist who completed fellowship is unfortunately no guarantee of a high-quality examination. © 2011 by the American College of Gastroenterology

The level of operator dependence among gastroenterologists in colonoscopy is so great (6–11) that both patients and payers could reasonably demand evidence of high-quality performance. Both the adenoma detection rate and cecal intubation rate now have been clearly shown to determine important outcomes of colonoscopy (11,12), and should be effective regardless of physician specialty. We acknowledge the potential unintended consequences and costs of quality measurement. However, the adenoma detection rate as currently defined (12) and doctors’ recommended post-polypectomy surveillance intervals are actually quite difficult to game. The cecal intubation rate, when supported by photography of the appendiceal orifice and ileocecal valve, is also difficult to game. Further, the central goal of developing quality indicators for colonoscopy is to improve the protective effect of colonoscopy against colorectal cancer. Although measuring quality has costs, the potential benefits for cancer prevention are substantial (11,12). Although we appreciate frustration with linking reimbursement to performance, economic models of human behavior suggest that financial incentives should be aligned with and explicitly linked to desired outcomes if those outcomes are to be achieved across all operators (13). We share Dr Feldman’s concerns about undertrained colonoscopists (14). However, the reality is that gastroenterologists do not exert national or regional control over endoscopic practice, and in many instances do not have institutional control of endoscopy. In the absence of a nationally recognized system of endoscopist certification, stopping undertrained colonoscopists from practicing based on their training, especially outside hospitals, has proven quite difficult. Perhaps the best way to reduce or eliminate colonoscopy by undertrained colonoscopists is for gastroenterologists to embrace quality measurements, demonstrate that we can achieve quality targets, and insist that others follow our example by either reaching targets or suffering meaningful consequences, including withdrawal from colonoscopy practice.

CONFLICT OF INTEREST

The authors declare no conflict of interest. REFERENCES 1. Feldman RE. Using reimbursement to improve colonoscopy quality. Am J Gastroenterol 2011;106:802–3 (this issue). 2. Rex DK, Rahmani EY, Haseman JH et al. Relative sensitivity of colonoscopy and barium enema for detection of colorectal cancer in clinical practice. Gastroenterology 1997;112:17–23. 3 . Rabeneck L , Paszat LF, Saskin R . Endoscopist specialty is associated with incident colorectal cancer after a negative colonoscopy. Clin Gastroenterol Hepatol 2010; 8: 275– 9. 4. Singh H, Nugent Z, Demers AA et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology 2010;139:1128–37. 5. Bressler B, Paszat L, Rothwell D et al. Predictors of missed colorectal cancer during colonoscopy: a population-based analysis. Gastrointest Endosc 2005;61:AB24. 6. Barclay RL, Vicari JJ, Doughty AS et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533–41. 7. Chen SC, Rex DK. Endoscopist can be more powerful than age and male gender in predicting adenoma detection at colonoscopy. Am J Gastroenterol 2007;102:856–61. 8. Sanchez W, Harewood GC, Petersen BT. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy. Am J Gastroenterol 2004;99: 1941–5. 9. Imperiale TF, Glowinski EA, Juliar BE et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc 2009;69:1288–95. 10. Shaukat A, Oancea C, Bond JH et al. Variation in detection of adenomas and polyps by colonoscopy and change over time with a performance improvement program. Clin Gastroenterol Hepatol 2009;7:1335–40. 11. Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010;362: 1795–803. 12. Baxter N, Sutradhar R, Forbes DD et al. Analysis of administrative data finds endoscopist quality measures asociated with post-colonoscopy colorectal cancer. Gastroenterology 2011;140:65–72. 13. Conrad DA, Perry L. Quality-based financial incentives in health care: can we improve quality by paying for it? Annu Rev Public Health 2009;30:357–71. 14. Rex DK. Three challenges: propofol, colonoscopy by undertrained physicians, and CT colonography. Am J Gastroenterol 2005;100:510–3. 1 Indiana University Hospital, Indianapolis, Indiana, USA; 2University of Queensland School of Medicine, Brisbane, Australia. Correspondence: Douglas K. Rex, MD, FACG, AGAF, FASGE, Indiana University Medical Center, Gastroenterology, 550 N University Boulevard, IU Hospital, #4100, Indianapolis, Indiana 46202, USA. E-mail: [email protected]

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