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Hidden costs of endoscopic ultrasound
"3291 E s o P H A G E A L DILATION IS SAFE D E S P I T E INCREASING cOMPLEXITY OF STRICTURES Ronald J. Lew, Gregory G. Ginsberg, William B. Long, David C. Metz, David A. Katzka, Michael L. Kochman, Univ of Pennsylvania, Philadelphia, PA Background: Esophageal dilation continues to be an effective therapy for the treatment of esophageal strictures. It is a relatively safe procedure, with the most significant risk being esophageal perforation. The indication for esophageal dilation has changed with the use of proton pump inhibitors, with the proportion of non-peptic etiologies for dilation increasing. Dilations that are more technically difficult, complicated, and refractory are more frequently encountered. We ascertained whether the complication rate of esophageal dilations remains steady despite changing indications. Methods: All esophageal dilations performed from March 1994 to July 2000 were reviewed for complications. Details regarding stricture type, stricture location, type of dilator used, and necessity for fluoroscopic guidance were also noted. Complications reported to the Endoscopy CQI Committee were also reviewed and matched .to relevant procedures. 85.8% tJf all dilations were performed for causes other than peptic stricture, with the most common being anastomotic, malignant, and radiotherapy-related strictures. Results: 992 dilations were performed in 435 patients. 4 perforations were noted during the study period. Two of the perforations occurred in dilations done for non-achaiasia indications, yielding a 0.2% rate of perforation in this subset. Two perforations occurred out of 25 dilation procedures for achaiasia, yielding an 8% rate of perforation. All achalasia dilations were performed by 3 physicians with expertise in motility disorders. Complications included a Mallory-Weiss tear (1) and a mueosal tear (1) (both non-achalasia dilations). Savary-Gillard polyvinyl dilators were used in 58.1%, 37.8% utilized through-the-scope dilators, and the remainder used both types (4.1%). Accepted techniques for dilation were adhered to+ Fluoroscopic guidance provided assistance in 324/972 (33.3%) procedures, supporting the notion that while dilations of esophageal lesions are often technically difficult, the complication rate has not increased. Conclusions: 1) Esophageal dilation continues to be a safe therapeutic tool despite more frequent use in complicated non-peptic patholo-~y. 2) Fluoroscopy continues to provide technical guidance in technically difficult strictures, especially with more refractory types (228 dils). 3) Pneumatic dilation for achalasia still carries an increased risk of perforation. 4) Both balloon dilators and Savary-Gillard dilators are safe when :tpplied using current technique guidelines.
*3292 PROSPECTIVE BLINDED ASSESSMENT OF THE EFFECT OF EXPERIENCE AND PATHOLOGY INTERPRETATION ON .kCCURACY OF ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION BIOPSY OF PANCREATIC MASSES t]avin C. Harewood, Maurits J. Wiersema, Amy C. Hailing, Gary L. Keeney, I]iva R. Salamao, Lisa M. Wiersema, Mayo Clin, Rochester, MN Background: A learning curve exists for mastering endoscopic ultrasound , EUS). Identification, staging and biopsy of pancreatic mass lesions are the most technically demanding EUS skills. Aims: To evaluate the effect of an ";-month learning phase on the diagnostic accuracy of EUS fine needle ~tspiration biopsy (FNA) of pancreatic masses and to assess the source of varying diagnostic accuracy between initial and later procedures. Methods: 65 patients (pts) with pancreatic masses underwent EUS FNA between 4/98 and 8/99, 20 of whom were examined by 3 endosonographers without prior EUS FNA procedural experience. Their initial experience, 4/98 1~98 (group A) including a formal training period in 11/98, and their advanced experience, 1/99 - 8/90 (group B), were prospectively evaluated. The training period comprised formal reentering of 3 - 5 pancreatic EUS FNA examinations. The pts final diagnoses were determined by surgical pathology or clinical follow-up. All EUS FNA samples were re-reviewed by -1 blinded pathologists to determine the relative contribution of pathologist interpretation error to varying accuracy of EUS FNA yield. Results: After a short training period, a significant improvement in accuracy was identilied, 33% vs 91%, p = 0.004 (table). Good agreement was identified between original FNA interpretation and pathology re-review, kappa = 0.6 (95% C.I.:0.25 - 0.95). There were differences between the mean cellulm'ity score 12.8 vs 1.8, p = 0.01) and mean number of passes (5.1 vs 2.8, p = n.s.) for
V O L U M E 53, NO. 5, 2001
correct vs incorrect FNA specimens. Conclusion: Significant improvements in accuracy of EUS FNA can occur ~vith a short period of mentored training. EUS FNA inaccuracy during the initial learning phase is primarily due to inadequate specimens. Pathology interpretation of pancreatic EUS FNA specimens is consistent.
Group A Group B p value
N
Orig. Acc."
R~review Acc?"
Cellularity, meant
No. needle passes, mean
9 11
33% 91% 0.004
44% 82% 0.04
2.3 2.8 n.s.
2.9 5.3 0.03
• Accuracy of original pathology *' Accuracy of pathology re-review t 1 = <5 diagnostic cells: 2 = 5-10 diagnostic calls; 3 = >10 diagnostic ceils
*3293 HIDDEN COSTS OF ENDOSCOPIC ULTRASOUND Timothy P. Kinney, Drew B. Schembre, Patti A. Wilbur, Virginia Mason Medical Ctr, Seattle, WA Background: Many factors contribute to the higher costs of performing endoscopic ultrasound (EUS) compared with standard endoscopic procedures. Obvious expenses include high purchase price, longer procedure time, high maintenance costs, and the frequent use of two endoscopes and/or two nurses during the procedure. EUS per se harbors other hidden costs, including disposable equipment expenses, extra time required for room setup, and labor intensive endoscope reprocessing. We analyzed these hidden costs of performing EUS compared with standard esophagogastrodudenoscopy (EGD). Materials and Methods: Data was collected on the costs of disposable items unique to EUS. Nurses and technicians were timed during room setup and scope reproeessing. Labor costs were determined by multiplying the time spent on these activities by the nurses'/technicians' average hourly wage (including 20% for benefits). Results:Compared with per procedure costs for EGD, $23.65 more was spent on disposable items for EUS. These items include the balloon ($16.75), one-way stopcock ($3.00), irrigation ($1.00), extension tubing ($0.6), and routine replacement of suction and air/water valves ($480 & $440: replaced every 400 procedures at our institution = $2.30 per procedure). Room setup time averaged 12 minutes longer for EUS. Endoscopic cleaning took 18 minutes of extra technician time per echoendoscope because of the necessity to manually reprocess the device. Added labor cost for room setup was $7.20 (nursing hourly wage/benefits of $36 x extra setup time of 12 minutes). Reprocessing cost $4.32 extra per procedure (technician wage/benefit of $14.40 x extra reprocessing time of 18 minutes). Excluding the additional factors noted earlier (increased procedure time, etc.), the "hidden costs" of EUS totaled $35.17 per case. Conclusions: 1) There are hidden costs associated with performing EUS. Setup time, reprocessing costs, and disposable items--all contribute to the overall expense of performing this procedure. 2) These are added on the wellestablished costs of high initial purchase price, endoscope maintenance, longer procedure time, and the fact that both linear array and radial scan devices are frequently used on a single case. 3) Medicare and other thirdparty payers should take these hidden factors into consideration when determing appropriate room fee reimbursement.
GASTROINTESTINAL ENDOSCOPY
AB77
*3292 PROSPECTIVE BLINDED ASSESSMENT OF THE EFFECT OF EXPERIENCE AND PATHOLOGY INTERPRETATION ON .kCCURACY OF ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION BIOPSY OF PANCREATIC MASSES t]avin C. Harewood, Maurits J. Wiersema, Amy C. Hailing, Gary L. Keeney, I]iva R. Salamao, Lisa M. Wiersema, Mayo Clin, Rochester, MN Background: A learning curve exists for mastering endoscopic ultrasound , EUS). Identification, staging and biopsy of pancreatic mass lesions are the most technically demanding EUS skills. Aims: To evaluate the effect of an ";-month learning phase on the diagnostic accuracy of EUS fine needle ~tspiration biopsy (FNA) of pancreatic masses and to assess the source of varying diagnostic accuracy between initial and later procedures. Methods: 65 patients (pts) with pancreatic masses underwent EUS FNA between 4/98 and 8/99, 20 of whom were examined by 3 endosonographers without prior EUS FNA procedural experience. Their initial experience, 4/98 1~98 (group A) including a formal training period in 11/98, and their advanced experience, 1/99 - 8/90 (group B), were prospectively evaluated. The training period comprised formal reentering of 3 - 5 pancreatic EUS FNA examinations. The pts final diagnoses were determined by surgical pathology or clinical follow-up. All EUS FNA samples were re-reviewed by -1 blinded pathologists to determine the relative contribution of pathologist interpretation error to varying accuracy of EUS FNA yield. Results: After a short training period, a significant improvement in accuracy was identilied, 33% vs 91%, p = 0.004 (table). Good agreement was identified between original FNA interpretation and pathology re-review, kappa = 0.6 (95% C.I.:0.25 - 0.95). There were differences between the mean cellulm'ity score 12.8 vs 1.8, p = 0.01) and mean number of passes (5.1 vs 2.8, p = n.s.) for
V O L U M E 53, NO. 5, 2001
correct vs incorrect FNA specimens. Conclusion: Significant improvements in accuracy of EUS FNA can occur ~vith a short period of mentored training. EUS FNA inaccuracy during the initial learning phase is primarily due to inadequate specimens. Pathology interpretation of pancreatic EUS FNA specimens is consistent.
Group A Group B p value
N
Orig. Acc."
R~review Acc?"
Cellularity, meant
No. needle passes, mean
9 11
33% 91% 0.004
44% 82% 0.04
2.3 2.8 n.s.
2.9 5.3 0.03
• Accuracy of original pathology *' Accuracy of pathology re-review t 1 = <5 diagnostic cells: 2 = 5-10 diagnostic calls; 3 = >10 diagnostic ceils
*3293 HIDDEN COSTS OF ENDOSCOPIC ULTRASOUND Timothy P. Kinney, Drew B. Schembre, Patti A. Wilbur, Virginia Mason Medical Ctr, Seattle, WA Background: Many factors contribute to the higher costs of performing endoscopic ultrasound (EUS) compared with standard endoscopic procedures. Obvious expenses include high purchase price, longer procedure time, high maintenance costs, and the frequent use of two endoscopes and/or two nurses during the procedure. EUS per se harbors other hidden costs, including disposable equipment expenses, extra time required for room setup, and labor intensive endoscope reprocessing. We analyzed these hidden costs of performing EUS compared with standard esophagogastrodudenoscopy (EGD). Materials and Methods: Data was collected on the costs of disposable items unique to EUS. Nurses and technicians were timed during room setup and scope reproeessing. Labor costs were determined by multiplying the time spent on these activities by the nurses'/technicians' average hourly wage (including 20% for benefits). Results:Compared with per procedure costs for EGD, $23.65 more was spent on disposable items for EUS. These items include the balloon ($16.75), one-way stopcock ($3.00), irrigation ($1.00), extension tubing ($0.6), and routine replacement of suction and air/water valves ($480 & $440: replaced every 400 procedures at our institution = $2.30 per procedure). Room setup time averaged 12 minutes longer for EUS. Endoscopic cleaning took 18 minutes of extra technician time per echoendoscope because of the necessity to manually reprocess the device. Added labor cost for room setup was $7.20 (nursing hourly wage/benefits of $36 x extra setup time of 12 minutes). Reprocessing cost $4.32 extra per procedure (technician wage/benefit of $14.40 x extra reprocessing time of 18 minutes). Excluding the additional factors noted earlier (increased procedure time, etc.), the "hidden costs" of EUS totaled $35.17 per case. Conclusions: 1) There are hidden costs associated with performing EUS. Setup time, reprocessing costs, and disposable items--all contribute to the overall expense of performing this procedure. 2) These are added on the wellestablished costs of high initial purchase price, endoscope maintenance, longer procedure time, and the fact that both linear array and radial scan devices are frequently used on a single case. 3) Medicare and other thirdparty payers should take these hidden factors into consideration when determing appropriate room fee reimbursement.
GASTROINTESTINAL ENDOSCOPY
AB77