Fiscal Analysis of Establishment of a Double-Balloon Enteroscopy Program and Reimbursement

CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2012;10:371–376

ENDOSCOPY CORNER Fiscal Analysis of Establishment of a Double-Balloon Enteroscopy Program and Reimbursement MARK E. BENSON,* WENDY HORTON,‡ JILL GLUTH,‡ PATRICK R. PFAU,* SIGURDUR EINARSSON,* MICHAEL R. LUCEY,* ANURAG SONI,* MARK REICHELDERFER,* and DEEPAK V. GOPAL* *Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin School of Medicine and Public Health; and ‡University of Wisconsin Hospitals and Clinics, Madison, Wisconsin

BACKGROUND & AIMS: As double-balloon enteroscopy (DBE) programs continue to be established, further research is needed to assess their financial impact. We evaluated actual financial outcomes and compared them with estimated return on investment (ROI) projections for DBE. METHODS: We retrospectively compared the predicted and actual financial results for outpatients referred for DBE at an academic tertiary referral center. RESULTS: The ROI analysis was based on a 5-year time frame. The analysis projected a net present value of $64,623 and an internal rate of return of 24.6%. The projected first-year volume was 52 outpatient cases; however, the actual experience was 20 outpatient cases. The predicted percent margin for these outpatient cases was 16.6%; the actual margin was 24.4%. After 37 months, 52 outpatient cases were completed, and the actual percent margin was 4.6%. Payer type had a significant influence on the financial outcomes when projected activity and actual activity were compared. CONCLUSIONS: Institutions interested in establishing a DBE program should be aware of the financial implications of program establishment, which can be evaluated in a return on investment analysis. Payer mix significantly influences DBE reimbursement and collection rates. Keywords: Diagnostic; Net Present Value (NPV); Health Care Resources; Cost Effective.

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ince its introduction approximately a decade ago, doubleballoon enteroscopy (DBE) has been a growing endoscopic technique that enables diagnostic and therapeutic interventions to be performed within the entire small bowel.1,2 Relative to other endoscopic procedures such as esophagogastroduodenoscopy or colonoscopy, DBE is a time-consuming and laborintensive procedure that requires utilization of specialized health care resources including fluoroscopy, general anesthesia, and additional health care personnel. Although DBE is considered a safe procedure, published literature has reported higher complication rates as compared with standard endoscopic procedures.3–5 Endoscopists performing DBE require specialized training to become competent and familiar with the novel procedure. Few studies have focused on the actual long-term financial aspects of this innovative endoscopic technique. By using financial modeling, DBE has been reported to be costeffective in the work-up and treatment of patients with obscure gastrointestinal blood loss.6,7 In addition, it has been projected

that DBE would generate a significant amount of downstream revenue in large academic medical centers; however, there have been no large studies published evaluating the long-term financial outcomes of DBE.8 However, other financial models have reported the cost of DBE to be higher with longer-duration procedures and in centers where relatively few DBEs are performed per year.9 The aim of our study was to evaluate the actual financial experience of initiating a DBE program compared with the predicted return on investment (ROI) projections at a large open-access tertiary care academic center. The University of Wisconsin Hospitals and Clinics (UWHC) Technology Assessment Program is charged with ensuring rational use and adoption of technologies at our institution. This committee is composed of 25 members and includes representatives from the medical staff, nursing, hospital administration, financial analysts, and service line leaders. Novel technologies requested for adoption are required to undergo a systematic review process that includes an evidence-based literature review to evaluate the safety, efficacy, and effectiveness of the technology. This scientific review is then partnered with an institutionspecific financial analysis. Together this information is used to make a data-driven decision on whether the technology should be adopted. After reviewing the clinical and financial information on DBE, the committee voted to recommend acquiring the technology. At the time the DBE program was developed, there were other options for resource allocation including expanding the endoscopic ultrasound and screening colonoscopy programs. However, there were no large centers locally that provided balloon-assisted therapeutic deep enteroscopy, and it was believed that this was a valuable procedure to bring to the area. The primary drivers that led to the adoption of DBE at our institution included the ability to diagnose and treat diseases of the entire small bowel, the complementary role DBE adds to capsule endoscopy, the relatively minimally invasive nature of the procedure compared with intraoperative enteroscopy, and its unique ability to allow therapeutic endoscopic interventions Abbreviations used in this paper: DBE, double-balloon enteroscopy; ERCP, endoscopic retrograde cholangiopancreatography; IRR, internal rate of return; NPV, net present value; ROI, return on investment; UWHC, University of Wisconsin Hospitals and Clinics. © 2012 by the AGA Institute 1542-3565/$36.00 doi:10.1016/j.cgh.2011.12.033

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Table 1. Projected and Actual Financial Experience 1 Year After Adopting a DBE Program at UWHC Projected activity Volume (n) Revenue ($) Cost ($) Margin ($) Margin (%)

52 89,433 74,605 14,828 16.6%

Actual experience in 1st year 20 43,252 41,025 13,277 24.4%

in special circumstances such as endoscopic retrograde cholangiopancreatography (ERCP)–assisted DBE.

Methods The financial modeling was based on 3 underlying assumptions: (1) DBE is a minimally invasive procedure performed primarily on an outpatient basis; (2) it was estimated that two-thirds of the center’s capsule endoscopy cases would be referred for DBE, on the basis of the previously published literature as well as prior institution experience showing that approximately 65% of the capsule endoscopy cases had findings warranting further diagnostic or therapeutic evaluation10,11; and (3) DBE would replace a proportion of both the inpatient and outpatient push enteroscopy cases. It was predicted that most of the DBE procedure indications would be for occult or obscure gastrointestinal bleeding, however, noting that non– small bowel sources are sometimes found in such patients.12 The ROI analysis evaluated the financial implications to the hospital during a 5-year period. The analysis calculated the net present value (NPV), defined as the difference between the program’s future net financial value and the hospital’s initial investment for the program, as well as the internal rate of return (IRR), the return rate at which the NPV equals zero, for the DBE program. The findings from both the clinical review and the financial analysis led to the hospital-supported adoption of the DBE technology. For this study, we retrospectively compared our predicted and actual financial experience between May 1, 2007, and June 30, 2010. At the University of Wisconsin, the financial payment structure for endoscopic procedures includes both professional fees and technical (or facility) fees. The costs for the procedures include all direct and indirect costs for providing the patient care. Indirect or “institutional” costs are determined and allocated on the basis of system-generated statistics of the institution’s cost-accounting system. Direct costs are costs borne by the patient care departments and include variable direct costs (supplies, patient care labor, etc) as well as fixed direct costs (patient care capital equipment depreciation and maintenance, patient care department supervisory labor, etc). This analysis includes the fees and costs for DBEs performed in the outpatient setting.

Results The ROI analysis, which was based on a 5-year time frame, predicted an NPV of $64,623 for the DBE technology. Furthermore, the predicted IRR was projected at 24.6%. On the basis of the institution’s push enteroscopy and capsule endoscopy program, the DBE case volume projected 52 outpatient

cases would be performed during the first year of acquiring the technology. However, the actual outpatient case volume performed during the first year was 20 patients. The predicted percent margin, expressed as percent of net revenue, for outpatient cases was 16.6%, whereas the actual percent margin was 24.4% for outpatient cases during the first year after adoption. The first-year projected and actual volumes, revenue, costs, and margin are detailed in Table 1. The revenue collected was from payers for the hospital fees (including supplies, facilities, nursing, technicians etc). The IRR and NPV do not consider professional billing revenues or costs. It was not until June 2010, 37 months after the initiation of the DBE program, that our institution completed 52 outpatient cases, which was the projected volume to be completed in the first year of the program. Approximately 90% of the DBE procedure indications were for occult or obscure gastrointestinal bleeding. Because of the length and invasiveness of the procedure as well as local expertise, general anesthesia was used for outpatient DBE procedures, similar to other institutions.13,14 Although nurse- or physician-assisted propofol sedation has been used safely for DBE, propofol use in Wisconsin can only be administered by an anesthesiologist.13 Eighty-three percent of the DBE procedures were antegrade, and 17% were retrograde. The actual percent margin was 4.6% for the 52 outpatient cases. The predicted and actual volumes, revenues, costs, and margin for the 52 outpatient cases are detailed in Table 2. Both the revenue generated and the costs for the outpatient DBE procedures were higher than projected. Impacting the margin is the total cost for patient care that includes direct costs, fixed and variable operational costs, and indirect costs, which represent the allocation of overhead costs. A percentage breakdown of the costs of outpatient DBE is provided in Supplementary Table 1 along with a comparison of percentage cost breakdown for inpatient cases.

Push Enteroscopies and Capsule Endoscopy It was estimated in the financial model that DBE would replace a portion of the inpatient and outpatient push enteroscopies. Contrary to the predicted model, the annual number of push enteroscopies completed actually increased. Furthermore, the financial model assumed that approximately two-thirds of the institution’s capsule endoscopy cases would be referred for DBE; however, only a small minority of the center’s capsule endoscopy cases (4.2%) proceeded on to DBE. Table 3 details the annual number of push enteroscopies, capsule endoscopies, and capsule endoscopies leading to DBE procedures before and after the initiation of the DBE program. Table 2. Projected and Actual Financial DBE Experience Between May 1, 2007, and June 30, 2010, at UWHC

Volume (n) Revenue ($) Total cost ($) Margin ($) Margin (%)

Projected activitya

Actual experience

52 89,433 74,605 14,828 16.6

52 131,376 125,312 6064 4.6

NOTE. Technology investment was $148,277. depreciation was $14,569 annual depreciation in the direct cost and depreciated over 5 years.

aEquipment

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Table 3. Annual Number of Push Enteroscopies and Capsule Endoscopies Completed at UWHC Year

2006

2007a

2008

No. of push enteroscopies completed No. of capsule endoscopies completed No. (%) of capsule endoscopies leading to DBE

18 121

33 132

40 120

5 (3.8)

5 (4.2)

aYear

0

DBE program was initiated.

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Table 5. Collection Rate by Payer for DBE Procedures Between May 1, 2007, and June 30, 2010, at UWHC Payer

No. of cases

Collection rate (%)

Medicare Private Other Total

18 27 7 52

29 70 36 50

Payer Mix Results Payer mix modeling was based on historical institutionspecific experience for push enteroscopy, intraoperative enteroscopy, and capsule endoscopy. The ROI projected that the DBE payer mix would include 39% Medicare patients. However, from the time the original projections were made, there was a payer mix shift that resulted in a higher proportion of outpatient DBE procedures being reimbursed by Medicare in the first year. The model predicted 50% of the procedures would be reimbursed from private payers, whereas the actual rate was 46% for the first year and 52% for the first 3 years. The projected and actual payer mix proportions for the first year and for the first 3 years are shown in Table 4. The level of reimbursement for the enteroscopy varied significantly depending on the type of payer, with Medicare having the lowest collection rate of 29% and private having the highest reimbursement rate at 70%. The DBE payer collection rates are shown in Table 5.

Cost Results The initial endoscopic equipment expense was depreciated over 5 years. The assumed cost of capital for the initial investment was $148,277. As a part of the initial DBE program establishment, 2 endoscopists and technicians were trained to safely perform the procedure by attending a hands-on university-based weekend course that included didactic lectures, hands-on experience, and knowledge about DBE learning curve.15 Two subsequent endoscopists were trained in a similar fashion. All of the DBE endoscopists had experience and interest in advanced therapeutic endoscopy. The total cost for patient care for patients undergoing DBE included direct costs including both fixed and variable institution costs associated with providing patient care as well as indirect costs that included the allocation of overhead costs. For outpatient procedures, the largest proportion of costs was generated from the institution’s ambulatory procedure center facility as well as the facility’s patient preparation and recovery areas. As the DBE program began, a proportion of the outpatients were admitted for postprocedure observation because of their age and medical comorbidities, thus influencing the costs. As the program ma-

tured and the experience of the endoscopists grew, fewer outpatients were admitted after procedure for observation. Table 6 details the institution’s costs for the DBE procedures compared with the ROI model, with actual experience having used higher costs within the recovery rooms and anesthesia. Applying a cost inflation rate to the ROI model to make a year-to-date comparison shows the cost per procedure to be 34% lower in the model compared with actual experience.

Patient Origin Results Approximately 22% of the patients were from our local market (Dane County), 28% of the patients were referred from ring markets that include the counties surrounding Dane County, Wisconsin, and 7% were from tertiary markets. The tertiary markets were identified by UWHC as priority markets on the basis of payer mix, population size, and the level of acute care cases being referred from these markets. Approximately 20% of the patients were from markets from the northernmost counties of Wisconsin, and 24% of the patients were from out of state. The UWHC has a strong referral pattern that is demonstrated by the patients seeking this procedure, with approximately 75% originating from Wisconsin and 25% from out of state (Supplementary Figure 1). Patient origin influences our institutional payer mix because UWHC’s local market contains a high percentage of managed care, which dictates where patients seek care.

Age Results The majority of the patients who had DBE procedures completed were older than 50 years of age. The largest proportion of procedures performed, 51%, was on patients older than 60 years of age. There was 1 pediatric patient and 9 octogenarian patients. Population growth trends are an important factor to consider when planning a program. For example, during the next 5 years it is anticipated that the population in Wisconsin will grow by nearly 6%, with the fastest growing population group (18%) in the age range of 55– 69. This information will be needed to project future volumes and predict the proportion of reimbursement coming from government payers.

Table 4. ROI Projected and Actual DBE Payer Mix at UWHC

Payer Medicare Private Other

ROI assumption Year 1, 20 outpatient Year 3, 52 outpatient (%) actual cases (%) actual cases (%) 39 50 11

46 46 7

35 52 13

Discussion Double-balloon enteroscopy is a growing endoscopic technique that allows for both diagnostic and therapeutic interventions within the small bowel. As DBE continues to be adopted nationally, research regarding the financial implications of DBE program establishment will need to be considered. In this article, we present a DBE program financial analysis

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Table 6. Total Cost for DBE Activity: Actual Compared With ROI Model Department group

Per case cost ($)

Total cost ($)

Percent of total (%)

Actual experience, May 1, 2007, and June 30, 2010 Ambulatory procedure center Preparation/recovery room Anesthesia Total

1380 658 372 2410

71,735 34,220 19,357 125,312

57 27 15 100

Modeled cost inflated by 3 yearsa

Modeled cost

Department group

Per case cost ($)

Total cost ($)

Per case cost ($)

Total cost ($)

Percent of total cost (%)

ROI modeled cost Ambulatory procedure center Preparation/recovery room Anesthesia Fluoroscopy ⬍1h Total

801 234 304 96 1435

41,634 12,153 15,820 4998 74,605

888 259 337 107 1591

46,160 13,475 17,540 5542 82,716

56 16 21 7 100

aCost

inflation factor applied to bring cost to calendar year 2010 equivalent.

evaluating the predicted and actual financial outcomes at a large open-access tertiary care academic center. In 2007, the UWHC Technology Assessment Committee approved the adoption of a DBE program after the completion of a thorough clinical and financial review. An ROI analysis is an accepted approach to evaluating the financial outcomes of a health care investment.16 –19 The ROI analysis was based on a 5-year time frame and estimated the NPV of the DBE program to be $64,623. The NPV is defined as the difference between the program’s future net financial value and UWHC’s initial investment for the program. The estimated DBE IRR was 24.6%. The IRR was the return rate at which the NPV equals zero or the rate at which the discounted future financial value is equal to the initial investment. An IRR was used in conjunction with the NPV to evaluate the DBE capital investment. On the basis of UWHC’s previous push enteroscopy and capsule endoscopy volumes, the DBE case volume was predicted to be 52 outpatient cases for the first year after adoption. However, the actual outpatient case volume was only 20 procedures. Initially, 2 gastroenterologists were trained to perform DBE. Because of unforeseen circumstances, one of the DBEtrained gastroenterologists left the institution for personal reasons. As a result, the number of DBE procedures completed within the first year was limited because of the time constraints of scheduling all of the procedures for one gastroenterologist. If the second DBE-trained gastroenterologist had remained at UWHC, it is likely that the actual DBE case volume would have been similar to the originally estimated number. Currently, there are 3 academic gastroenterologists who regularly perform DBE at UWHC in both the inpatient and outpatient settings. There were a number of differences in the key assumptions of the DBE financial projection versus actual experience, which lead to a material variance between the estimated and actual financial results. DBE was a relatively new procedure at the time of the ROI development; therefore, payer reimbursement was modeled after the institution’s reimbursement on historical outpatient push enteroscopy procedures. Similarly, costs were estimated on the basis of historical direct and indirect costs. Assumptions applied to the ROI analysis overstated the vol-

umes for the first year of implementation and underestimated the length of recovery time and use of sedation and anesthesia. The ROI also did not take into account the costs of patient short-stay/observation days on nursing units. The model estimated that approximately 65% of the institution’s capsule endoscopy cases would proceed to DBE; however, only a small minority of the center’s capsule endoscopy cases (4.2%) was actually followed by a DBE. The model’s estimate was based on the institution’s initial 3-year case volume of 240 capsule endoscopy cases from 2002–2005.10 Of these, 41% had positive findings, and 8% had equivocal findings that typically proceeded to more diagnostic testing. Of the normal capsule cases, 16% were for obscure gastrointestinal bleeding, which was assumed to need DBE to evaluate further. In addition, most of the initial UWHC capsule endoscopy cases were for evaluating obscure gastrointestinal blood loss. Currently, the indications for capsule endoscopy have grown to include other small bowel pathology not needing subsequent deep enteroscopy; thus, the two-thirds estimate used for the financial model was too high in retrospect. The financial model also assumed that a proportion of the push enteroscopies would be replaced with DBE because it has been shown to more deeply evaluate the small bowel and to have a higher diagnostic yield as compared with push enteroscopy.20 However, the actual number of push enteroscopies completed after the initiation of the DBE program increased. The institution’s push enteroscopy numbers were not significantly influenced by the DBE program possibly because of the unique endoscopic aspects push enteroscopy offers. Compared with DBE, push enteroscopy is less invasive, does not require general anesthesia, and does not require the type of specialized equipment needed for DBE procedures. Furthermore, push enteroscopy can thoroughly evaluate for and detect many proximal small bowel lesions, obviating the need for a DBE.12 As a result, DBE did not replace a significant proportion of the institution’s push enteroscopy procedures. Finally, since the inception of the DBE program, the institution has implemented an electronic patient medical record system. This system impacted all hospital departments with an increased allocation to the indirect cost.

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Despite the lower than expected first-year volume of outpatient DBE procedures, the ROI model predicted percent margin and actual margin were similar, 16.6% and 24%, respectively. Interestingly, the actual first-year payer mix proportions were higher for Medicare (a less favorable payer) and slightly lower for private (a more favorable payer) (Table 4). A majority of the payer mix was through private payers, thus reflecting the institution’s referral pattern. Despite the discrepancy in the payer mix proportion, the first-year outpatient DBE procedures yielded an overall positive and similar financial outcome for the institution compared with the financial model. To compare the actual and predicted financial results with similar case volumes, we compared the financial outcomes of the first 52 DBE outpatient cases that were completed at our institution with the ROI model. It took approximately 3 years after the initiation of the DBE program to complete 52 outpatient cases. As noted above, the institution’s DBE volumes were less than predicted because of the unforeseen circumstance of one DBE-trained gastroenterologist leaving the institution. The ROI predicted margin was 16.6% for the 52 cases, and the actual margin was 4.6% for the outpatient cases (Table 2). There are several possible reasons for the discrepancy between the predicted and actual financial margins. Both the revenue generated and the costs were underestimated within the financial model. Specifically, the ambulatory procedure center preparation and recovery costs were significantly underestimated in the model as well as the use of sedation and anesthesia. Also, there was a small discrepancy in the estimated payer mix. During the same time period, the percentage margin for endoscopic ultrasound was 2.2% and for ERCP was 12%. Although ERCP had the highest margin, the outcomes for these procedures were greatly influenced by the payer mix. Similarly, the level of reimbursement for the DBE procedures varied significantly depending on the type of payer (Table 4). Last, DBE did not significantly influence the number of push enteroscopies completed, and there was a less-than-anticipated referral for DBE from the center’s capsule endoscopy procedures. DBE is a relatively novel and growing endoscopic procedure. DBE has unique health care resource demands because of the specialized nature and complexity of the procedure relative to other endoscopic procedures such as esophagogastroduodenoscopy or colonoscopy. Establishing a DBE program has significant financial implications that are dependent on institution volume, payer mix, and procedure location. UWHC is currently 1 of 3 tertiary care referral centers that perform DBE in the entire state of Wisconsin and continues to be the only local regional referral center for DBE in Madison and surrounding Dane county, south-central, north-central, and western Wisconsin. However, it is likely that other local medical institutions will adopt a small bowel, balloon-assisted, or deep enteroscopy program in the near future, and as the technology becomes more available and mainstream, this might significantly impact our DBE program. The downstream effects of establishing a DBE program are clearly not limited to the financial aspects outlined within this article. For example, many patients with therapeutic DBE procedures for small bowel polypectomies avoid the need for intraoperative procedures. An intraoperative enteroscopy at our institution costs approximately 4 times the amount of an outpatient DBE procedure. Furthermore, therapeutic DBE procedures (ie, control of hemorrhage with argon plasma coagulation, snare polypectomy, stricture dilation) were

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performed on approximately 50% of patients referred for occult or obscure gastrointestinal bleeding, and we have shown that ablating small bowel angiectasis through DBE leads to a decrease in subsequent patient transfusion requirements.21 Despite accurate and thorough modeling, predicting the financial outcomes of DBE program establishment can be challenging. We did not compare the facility fees or professional fees for our DBE program, which is a limitation because this information is specific to our institution. Moreover, the percentage costs breakdown, as provided in Supplementary Table 1, might vary on the basis of inpatient versus outpatient DBE cases, and this might also influence the fee structure. However, this was not a part of our original ROI model, although we acknowledge that it might be an important factor in program planning and establishment. Our results are institution-specific, and similar results for DBE program establishment will likely vary for other institutions with different referral patterns. Endoscopists who wish to perform DBE should be aware of and clearly understand the unique financial aspects of this procedure before program adoption.

Supplementary Material Note: To access the supplementary material accompanying this article, visit the online version of Clinical Gastroenterology and Hepatology at www.cghjournal.org, and at doi:10.1016/ j.cgh.2011.12.033. References 1. Yamamoto H, Sekine Y, Sato Y, et al. Total enteroscopy with a nonsurgical steerable double-balloon method. Gastrointest Endosc 2001;53:216 –220. 2. Yamamoto H, Yano T, Kita H, et al. New system of double-balloon enteroscopy for diagnosis and treatment of small intestinal disorders. Gastroenterology 2003;125:1556 –1557. 3. Gerson LB, Tokar J, Chiorean M, et al. Complications associated with double balloon enteroscopy at nine US centers. Clin Gastroenterol Hepatol 2009;7:1177–1182. 4. Maaser C, Schmedt A, Bokemeyer M, et al. Long-term efficacy and safety of double balloon enteroscopy: prospective and retrospective data from a single center study. Scand J Gastroenterol 2010;45:992–999. 5. May A, Nachbar L, Pohl J, et al. Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol 2007;102:527–535. 6. Somsouk M, Gralnek IM, Inadomi JM. Management of obscure occult gastrointestinal bleeding: a cost-minimization analysis. Clin Gastroenterol Hepatol 2008;6:661– 670. 7. Gerson L, Kamal A. Cost-effectiveness analysis of management strategies for obscure GI bleeding. Gastrointest Endosc 2008; 68:920 –936. 8. Ross A, Roth J, Dye C, et al. The downstream economics of double balloon enteroscopy. Presented at the American College of Gastroenterology, October 2006, Las Vegas, Nevada. 9. Albert JG, Nachtigall F, Wiedbrauck F, et al. Minimizing procedural cost in diagnosing small bowel bleeding: comparison of a strategy based on initial capsule endoscopy versus initial double-balloon enteroscopy. Eur J Gastroenterol Hepatol 2010;22:679 – 688. 10. Dureja P, Agarwal RR, Said A, et al. Capsule endoscopy in the evaluation of obscure GI bleeding, Crohn’s disease and other small bowel pathology: diagnostic yield, and comparison with endoscopic & CT-radiographic studies in a tertiary care referral center. Gastrointest Endosc 2006;63:AB171. 11. Triester S, Leighton J, Leontiadis G, et al. A meta-analysis of the

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yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding. Am J Gastroenterol 2005;100:2407–2418. Fry LC, Bellutti M, Neumann H, et al. Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding. Aliment Pharmacol Ther 2009;29: 342–349. Zubek L, Szabo L, Lakatos P, et al. Double balloon enteroscopy in general anesthesia. World J Gastroenterol 2010;16:3418 – 3422. Lo SK. Technical matters in double balloon enteroscopy. Gastrointest Endosc 2007;66:S15–S18. Fry LC, Monkemuller K, Neumann H, et al. Learning curve of double balloon enteroscopy. Tech in Gastrointest Endosc 2008; 10:59 – 61. Long DA, Sheehan P. A case study of population health improvement at a Midwest regional hospital employer. Popul Health Manag 2010;13:163–173. Kaufmann SH, Hussey G, Lambert PH. New vaccines for tuberculosis. Lancet 2010;375:2110 –2119. DeSilets LD. Calculating the financial return on educational programs. J Contin Educ Nurs 2010;41:149 –150.

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19. Perryman MR, Gleghorn V. Obesity-related costs and the economic impact of laparoscopic adjustable gastric banding procedures: benefits in the Texas Employees Retirement System. J Med Econ 2010;13:339 –350. 20. Matsumoto T, Moriyama T, Esaki M, et al. Performance of antegrade double-balloon enteroscopy: comparison with push enteroscopy. Gastrointest Endosc 2005;62:392–398. 21. Benson M, Barancin C, Gamarra R, et al. Therapeutic double balloon enteroscopy reduces transfusion requirements in the management of occult or obscure gastrointestinal bleeding. Gastrointest Endosc 2009;69:AB194.

Reprint requests Address requests for reprints to: Deepak V. Gopal, MD, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, 4th Floor MFCB, 1685 Highland Avenue, Madison, Wisconsin 53705. e-mail: [email protected]; fax: (608) 265-5677. Conflicts of interest The authors disclose no conflicts.

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Supplementary Figure 1. Map of DBE procedural volume activity referred to UWHC by county.

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Supplementary Table 1. Cost as Percentage of Total Cost for Inpatient and Outpatient DBE Activity Department group Outpatient Ambulatory procedure center Ambulatory procedure center preparation and recovery Anesthesiology Pharmacy Laboratory Ancillary services Total Inpatient Inpatient nursing Laboratory Ambulatory procedure center Ancillary services Pharmacy Anesthesiology Other Total

Percent of total (%)

44 27 15 8 3 2 100 53 11 10 10 7 4 4 100

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