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The Costs of Esophagogastroduodenoscopy in an Outpatient Clinic: An Activity-Based Costing Study
Abstracts
M1236 Appropriateness ASGE Criteria for ERCP. A Multicenter Study Gianluca Bersani, Angelo Rossi, Luigi Solmi, Giulio Cariati, Maria Marino, Giorgio Ricci, Giovanni De Fabritiis, Vittorio Alvisi
M1238 Repeated Capsule Endoscopy: Is There a Benefit? Harry Dhaliwal, Stacey Shapira, Henry Chung, Jabar Ali, Joanna Law, Robert Enns, Mark Wood, Mark Appleyard, Victor Wong
1 Background: The evaluation of appropriateness and diagnostic yeld of endoscopic procedures is critical when assesing the costs and benefits of endoscopy. 2 Aim: The aims of this prospective study were: i) to examine the appropriate use of Endoscopic Retrograde Cholangio Pacreatography (ERCP) in 3 Italian Academic Center using the American Society of Gastrointestinal Endoscopy (ASGE) guidelines; ii) to verify whether the ASGE guidelines were associated with the endoscopic demonstration of serious diseases. 3 Methods: In a cohort of 429 consecutive patients (m/f 187/242), mean age 70 yrs, range 16-99) referred for ERCP to three University-based Italian Endoscopic Services, the percentage of patients who underwent ERCP for appropriate and inappropriate indications, was prospectively assesed. The relationship between appropriateness of use and the presence of relevant endoscopic lesions (neoplasms, biliary duct stones, stenosis, pancreatitis, biliary fistula, cholangitis) was assesed calculating the likelihood ratio (positive, LRC and negative, LRÿ). 4 Results: The rate of ERCP generally not indicated (according to the ASGE guidelines) was 3.5%. in Table 1 we compared patients with ASGE indications and those without indications. In table 2 we comapred the likelihood ratio (LR) for finding a relevant endoscopic disease. Conclusions: The use of appropriate indications can improve patients selection for ERCP, and thus can contribute to efforts aimed at enhancing the quality and efficiency of care. However in order to avoid to miss some serious diseases, this must be taylored to the specific clinical setting where the guidelines has to be applied. Table 1. Comparison between Patients with ASGE criteria and those without indications
Background: Capsule endoscopy (CE) is an ambulatory, sensitive, non-invasive technique primarily used to evaluate the small intestine. The management of a negative study, particularly if the patient continues to bleed has not been standardized and can lead to multiple additional investigations. This study reviewed all patients at two tertiary care centres that have undergone repeat capsule endoscopies to determine the clinical benefit of a repeat study. Methods: Repeat CE studies (performed between 12/01 and 09/05) completed at two tertiary care academic centres were reviewed. 43 individuals underwent two CE (3 patients underwent 3 CE and 1 underwent 4 CE). The review was performed to collect data on demographics, indications, investigations (endoscopic and non-endoscopic), transfusions and management, pre and post CE. The information was available from a prospectively collected CE database and from patient charts; however, in cases where data was absent, patients’ physicians and/or the patients themselves were contacted. Results: Of a total of 700 CE studies (505 for obscure GI Bleeding (OGIB)) forty three patients who had at least 2 CEs (mean age 59, 53% female), 40 for OGIB, 2 for Crohn’s and 1 for abdominal pain. Of patients with OGIB, 22 had occult, 11 overt and 7 patients were classified as occult on one study and overt on another. Mean transfusional requirements were 15.95 units (range 0-150) with twenty-six also receiving iron supplementation and 6 on coumadin. Prior to the first CE, the mean number of EGDs was 2.09 (range 1-6), push enteroscopies 0.70 (0-3) and colonoscopies 1.84. For the indication of OGIB, 16 had a negative first study. Of these, repeat CE found active bleeding/definite abnormality in 10 (63%). Fourteen patients had findings on the first study with the second CE clarifying the diagnosis in 9. Twelve of the first CE were incomplete and of these an abnormality was seen in 9 (75%) on repeat CE. Fifteen patients had some form of intestinal surgery before the first CE and 9 underwent surgery for further investigation or definitive management after their second CE. Another 9 patients underwent repeat therapeutic endoscopic treatment guided by their second CE. Conclusions: Repeat CE is most commonly performed for ongoing bleeding to clarify diagnosis. Positive studies are found in over 60% of negative initial studies and clarification of diagnosis in those with previous ‘suspicious’ lesions was found. Repeat CE leads to definitive management (either endoscopic or surgical) of the bleeding source in most patients with OGIB and should therefore be encouraged prior to other investigations.
ASGE criteria
non-ASGE criteria
9% 88%
23% 77%
Normal ERCP Relevant disease
p ! 0.05 p ! 0.05
Table 2. Likelihood ratio (LR) for finding relevant endoscopic disease Presence of ASGE criteria Non-ASGE criteria
LRC
LRÿ
1.26 0.44
0.44 1.26
M1237 Yield of Upper and Lower Endoscopic Biopsy in the Diagnosis of Gastrointestinal Graft-Versus-Host Disease Ron Yeh, Nighat Ullah, Lauren B. Gerson Background: Graft versus host disease (GVHD) is the leading cause of morbidity after allogeneic bone marrow transplantation (BMT). A diagnosis of gastrointestinal GVHD is difficult to establish on clinical signs alone as anorexia, nausea, and diarrhea can be caused by infections and/or medications. Aim: To determine whether biopsy from the upper or lower gastrointestinal tract has a higher yield for the diagnosis of GVHD and whether the diagnosis of GVHD can be accurately made with a single endoscopic procedure. Methods: We included BMT patients with negative stool cultures who were referred for suspected GVHD between 2000 and 2005 and had upper (EGD) or lower (COLO) endoscopy performed. We evaluated the histologic diagnosis of biopsies obtained from simultaneous EGD C COLO. A patient was classified with GVHD if a biopsy from either procedure was positive. Results: There were 195 BMT patients who had 321 endoscopic evaluations; we enrolled the 86 patients who had simultaneous EGD and COLO performed in 105 occasions. GVHD was diagnosed in 55 (52%) cases. The mean age in the GVHDC group was 46.8 yrs versus 46.3 yrs in the GVHD-group (p Z NS) and no gender differences between groups. The sensitivity of COLO in diagnosing GVHD was 89%, while the sensitivity of EGD in diagnosing GVHD was 78%. Out of 105 simultaneous procedures, 18 (17%) displayed a discrepancy in the diagnosis of GVHD (biopsies from EGD and COLO displaying different results for the diagnosis of GVHD). Only 67% of patients with GVHD had the diagnosis established on both EGD and COLO. There were no significant differences in GVHD diagnoses comparing biopsies from the right or left colon, or from any site in the upper gastrointestinal tract. (Table) Presence of diarrhea and/or bleeding was predictive of a positive biopsy on COLO (p Z 0.002) and EGD (p Z 0.001) while presence of nausea, vomiting and abdominal pain was not predictive of a positive biopsy on either EGD or COLO. Conclusions: Based on our results, patients with suspected GVHD need both EGD and COLO to evaluate for GVHD. Patients with diarrhea or GI bleeding are more likely to have a positive biopsy on either EGD or COLO. Results from Patients Undergoing EGD and COLO Biopsy Site COLO biopsy site Right colon including ileum Left Colon to Splenic Flexure EGD biopsy site Esophagus Stomach Duodenum
GVHD Present
GVHD Absent
37 (67%) 33 (60%)
35 (70%) 27 (54%)
11 (20%) 19 (35%) 54 (98%)
5 (10%) 15 (30%) 49 (98%)
All p values were non-significant between GVHDC and GVHDÿ patients
AB148 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1239 The Costs of Esophagogastroduodenoscopy in an Outpatient Clinic: An Activity-Based Costing Study Jennifer Sambrook, Winnie Chui, Hong Wang, Adrian Levy, Robert Enns, Lawrence Lo, Edwin Cheng Background: Esophagogastroduodenoscopy (EGD) is commonly performed to diagnose a range of upper gastrointestinal (GI) disorders. To date, little information is available on the costs of performing EGD. The aim of this study is to determine the per-procedure cost of performing EGD in an outpatient endoscopy clinic. Methods: An activity based costing approach was carried out using time-and-motion techniques on 70 outpatient EGD procedures performed in St. Paul’s Hospital (SPH) between July and October 2004. Each patient was observed and data was recorded on forms designed/pilot tested. Information collected included physician, nursing, and other hospital personnel time from patient registration to patient discharge; and units of supplies and drugs used. Direct costs consisting of labor, drug and supplies were calculated by applying unit costs provided by SPH to quantity consumed. Indirect costs included physician and pathology fees, scope repair and cleaning expenses. Hospital overhead costs were determined through SPH finance department. Total cost was calculated as the sum of direct, indirect and overhead costs. Student’s t-tests were performed to determine any significant differences (P ! 0.10) of mean total cost (2004 Canadian dollars) between groups derived from baseline variables. Linear regression analysis of cost and time were also conducted. Results: Mean age of patients was 58 (19; 93) years and 39% of patients were male. Mean total time for EGD was 186 (96; 308) minutes of which scope time was 7 (2; 17) minutes. Patients spent majority of time, 82 (13; 172) minutes, in post-procedure and discharge. Mean total cost was $405.36 ($237.51; $582.43) with physician/pathology fees accounting for 49%. Other cost components were supplies (11%), drugs (3%), hospital personnel (26%), scope cleaning (2%), scope depreciation/repair (7%), and overhead (2%). Significant differences in mean total cost were observed between patients with no biopsy or at least one biopsy (p ! 0.001). Sex, number of biopsies and total time are statistically significant on regression of total cost. Age is the only significant factor to predict total time. Conclusion: EGD patients spent only 4% of total time undergoing the procedure itself and sedation may contribute to increased costs in personnel required for postprocedure monitoring. On regression analysis total time is a key factor in calculating the costs. Such detailed accounting of costs in this routine medical procedure can assist in budget and staff planning in order to maximize health care resources. This costing approach can be used to improve reliability of costs for EGD procedures in an outpatient setting.
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M1236 Appropriateness ASGE Criteria for ERCP. A Multicenter Study Gianluca Bersani, Angelo Rossi, Luigi Solmi, Giulio Cariati, Maria Marino, Giorgio Ricci, Giovanni De Fabritiis, Vittorio Alvisi
M1238 Repeated Capsule Endoscopy: Is There a Benefit? Harry Dhaliwal, Stacey Shapira, Henry Chung, Jabar Ali, Joanna Law, Robert Enns, Mark Wood, Mark Appleyard, Victor Wong
1 Background: The evaluation of appropriateness and diagnostic yeld of endoscopic procedures is critical when assesing the costs and benefits of endoscopy. 2 Aim: The aims of this prospective study were: i) to examine the appropriate use of Endoscopic Retrograde Cholangio Pacreatography (ERCP) in 3 Italian Academic Center using the American Society of Gastrointestinal Endoscopy (ASGE) guidelines; ii) to verify whether the ASGE guidelines were associated with the endoscopic demonstration of serious diseases. 3 Methods: In a cohort of 429 consecutive patients (m/f 187/242), mean age 70 yrs, range 16-99) referred for ERCP to three University-based Italian Endoscopic Services, the percentage of patients who underwent ERCP for appropriate and inappropriate indications, was prospectively assesed. The relationship between appropriateness of use and the presence of relevant endoscopic lesions (neoplasms, biliary duct stones, stenosis, pancreatitis, biliary fistula, cholangitis) was assesed calculating the likelihood ratio (positive, LRC and negative, LRÿ). 4 Results: The rate of ERCP generally not indicated (according to the ASGE guidelines) was 3.5%. in Table 1 we compared patients with ASGE indications and those without indications. In table 2 we comapred the likelihood ratio (LR) for finding a relevant endoscopic disease. Conclusions: The use of appropriate indications can improve patients selection for ERCP, and thus can contribute to efforts aimed at enhancing the quality and efficiency of care. However in order to avoid to miss some serious diseases, this must be taylored to the specific clinical setting where the guidelines has to be applied. Table 1. Comparison between Patients with ASGE criteria and those without indications
Background: Capsule endoscopy (CE) is an ambulatory, sensitive, non-invasive technique primarily used to evaluate the small intestine. The management of a negative study, particularly if the patient continues to bleed has not been standardized and can lead to multiple additional investigations. This study reviewed all patients at two tertiary care centres that have undergone repeat capsule endoscopies to determine the clinical benefit of a repeat study. Methods: Repeat CE studies (performed between 12/01 and 09/05) completed at two tertiary care academic centres were reviewed. 43 individuals underwent two CE (3 patients underwent 3 CE and 1 underwent 4 CE). The review was performed to collect data on demographics, indications, investigations (endoscopic and non-endoscopic), transfusions and management, pre and post CE. The information was available from a prospectively collected CE database and from patient charts; however, in cases where data was absent, patients’ physicians and/or the patients themselves were contacted. Results: Of a total of 700 CE studies (505 for obscure GI Bleeding (OGIB)) forty three patients who had at least 2 CEs (mean age 59, 53% female), 40 for OGIB, 2 for Crohn’s and 1 for abdominal pain. Of patients with OGIB, 22 had occult, 11 overt and 7 patients were classified as occult on one study and overt on another. Mean transfusional requirements were 15.95 units (range 0-150) with twenty-six also receiving iron supplementation and 6 on coumadin. Prior to the first CE, the mean number of EGDs was 2.09 (range 1-6), push enteroscopies 0.70 (0-3) and colonoscopies 1.84. For the indication of OGIB, 16 had a negative first study. Of these, repeat CE found active bleeding/definite abnormality in 10 (63%). Fourteen patients had findings on the first study with the second CE clarifying the diagnosis in 9. Twelve of the first CE were incomplete and of these an abnormality was seen in 9 (75%) on repeat CE. Fifteen patients had some form of intestinal surgery before the first CE and 9 underwent surgery for further investigation or definitive management after their second CE. Another 9 patients underwent repeat therapeutic endoscopic treatment guided by their second CE. Conclusions: Repeat CE is most commonly performed for ongoing bleeding to clarify diagnosis. Positive studies are found in over 60% of negative initial studies and clarification of diagnosis in those with previous ‘suspicious’ lesions was found. Repeat CE leads to definitive management (either endoscopic or surgical) of the bleeding source in most patients with OGIB and should therefore be encouraged prior to other investigations.
ASGE criteria
non-ASGE criteria
9% 88%
23% 77%
Normal ERCP Relevant disease
p ! 0.05 p ! 0.05
Table 2. Likelihood ratio (LR) for finding relevant endoscopic disease Presence of ASGE criteria Non-ASGE criteria
LRC
LRÿ
1.26 0.44
0.44 1.26
M1237 Yield of Upper and Lower Endoscopic Biopsy in the Diagnosis of Gastrointestinal Graft-Versus-Host Disease Ron Yeh, Nighat Ullah, Lauren B. Gerson Background: Graft versus host disease (GVHD) is the leading cause of morbidity after allogeneic bone marrow transplantation (BMT). A diagnosis of gastrointestinal GVHD is difficult to establish on clinical signs alone as anorexia, nausea, and diarrhea can be caused by infections and/or medications. Aim: To determine whether biopsy from the upper or lower gastrointestinal tract has a higher yield for the diagnosis of GVHD and whether the diagnosis of GVHD can be accurately made with a single endoscopic procedure. Methods: We included BMT patients with negative stool cultures who were referred for suspected GVHD between 2000 and 2005 and had upper (EGD) or lower (COLO) endoscopy performed. We evaluated the histologic diagnosis of biopsies obtained from simultaneous EGD C COLO. A patient was classified with GVHD if a biopsy from either procedure was positive. Results: There were 195 BMT patients who had 321 endoscopic evaluations; we enrolled the 86 patients who had simultaneous EGD and COLO performed in 105 occasions. GVHD was diagnosed in 55 (52%) cases. The mean age in the GVHDC group was 46.8 yrs versus 46.3 yrs in the GVHD-group (p Z NS) and no gender differences between groups. The sensitivity of COLO in diagnosing GVHD was 89%, while the sensitivity of EGD in diagnosing GVHD was 78%. Out of 105 simultaneous procedures, 18 (17%) displayed a discrepancy in the diagnosis of GVHD (biopsies from EGD and COLO displaying different results for the diagnosis of GVHD). Only 67% of patients with GVHD had the diagnosis established on both EGD and COLO. There were no significant differences in GVHD diagnoses comparing biopsies from the right or left colon, or from any site in the upper gastrointestinal tract. (Table) Presence of diarrhea and/or bleeding was predictive of a positive biopsy on COLO (p Z 0.002) and EGD (p Z 0.001) while presence of nausea, vomiting and abdominal pain was not predictive of a positive biopsy on either EGD or COLO. Conclusions: Based on our results, patients with suspected GVHD need both EGD and COLO to evaluate for GVHD. Patients with diarrhea or GI bleeding are more likely to have a positive biopsy on either EGD or COLO. Results from Patients Undergoing EGD and COLO Biopsy Site COLO biopsy site Right colon including ileum Left Colon to Splenic Flexure EGD biopsy site Esophagus Stomach Duodenum
GVHD Present
GVHD Absent
37 (67%) 33 (60%)
35 (70%) 27 (54%)
11 (20%) 19 (35%) 54 (98%)
5 (10%) 15 (30%) 49 (98%)
All p values were non-significant between GVHDC and GVHDÿ patients
AB148 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
M1239 The Costs of Esophagogastroduodenoscopy in an Outpatient Clinic: An Activity-Based Costing Study Jennifer Sambrook, Winnie Chui, Hong Wang, Adrian Levy, Robert Enns, Lawrence Lo, Edwin Cheng Background: Esophagogastroduodenoscopy (EGD) is commonly performed to diagnose a range of upper gastrointestinal (GI) disorders. To date, little information is available on the costs of performing EGD. The aim of this study is to determine the per-procedure cost of performing EGD in an outpatient endoscopy clinic. Methods: An activity based costing approach was carried out using time-and-motion techniques on 70 outpatient EGD procedures performed in St. Paul’s Hospital (SPH) between July and October 2004. Each patient was observed and data was recorded on forms designed/pilot tested. Information collected included physician, nursing, and other hospital personnel time from patient registration to patient discharge; and units of supplies and drugs used. Direct costs consisting of labor, drug and supplies were calculated by applying unit costs provided by SPH to quantity consumed. Indirect costs included physician and pathology fees, scope repair and cleaning expenses. Hospital overhead costs were determined through SPH finance department. Total cost was calculated as the sum of direct, indirect and overhead costs. Student’s t-tests were performed to determine any significant differences (P ! 0.10) of mean total cost (2004 Canadian dollars) between groups derived from baseline variables. Linear regression analysis of cost and time were also conducted. Results: Mean age of patients was 58 (19; 93) years and 39% of patients were male. Mean total time for EGD was 186 (96; 308) minutes of which scope time was 7 (2; 17) minutes. Patients spent majority of time, 82 (13; 172) minutes, in post-procedure and discharge. Mean total cost was $405.36 ($237.51; $582.43) with physician/pathology fees accounting for 49%. Other cost components were supplies (11%), drugs (3%), hospital personnel (26%), scope cleaning (2%), scope depreciation/repair (7%), and overhead (2%). Significant differences in mean total cost were observed between patients with no biopsy or at least one biopsy (p ! 0.001). Sex, number of biopsies and total time are statistically significant on regression of total cost. Age is the only significant factor to predict total time. Conclusion: EGD patients spent only 4% of total time undergoing the procedure itself and sedation may contribute to increased costs in personnel required for postprocedure monitoring. On regression analysis total time is a key factor in calculating the costs. Such detailed accounting of costs in this routine medical procedure can assist in budget and staff planning in order to maximize health care resources. This costing approach can be used to improve reliability of costs for EGD procedures in an outpatient setting.
www.giejournal.org