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Unnecessary Procedures Not Limited to Cardiologists

Posted Aug 09 2011 10:30am
Just under a month ago , I pointed out that close to 12% of the percutaneous coronary interventions performed by cardiologists each year were actually unnecessary.  As I mentioned, when marginal utility for a procedure is measured in thousands of dollars, it's difficult to turn it down.  On the other hand, for those of us in primary care, marginal utility for an extra patient seen is measured in tens of dollars, so there's not nearly the same incentive to squeeze another patient visit into your already overcrowded schedule.

As for myself, I wondered if cardiologists are unique in this situation.  Well, in a study released in May but officially released in print earlier this week , the authors noted that a large portion of Medicare patients undergo screening colonoscopy much more frequently than advised without a compelling indication.  What this implies is that gastroenterologists are not immune to external pressures either.  Either that or they're not good at documenting & billing for diagnostic colonoscopies rather than screening ones.

For the last several decades, the standard of care has been to offer some sort of screening for colon cancer detection to low risk individuals upon turning 50yo ( revised in 2008 with an upper limit of 75yo in most ).  The idea, of course, is to look for and find (pre-)cancerous lesions early enough to make a difference in all-cause mortality.  A number of options are available from which to choose, eg fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, CT colonography, etc.  Each has it's own idiosyncratic risks & benefits, as well as recommended frequency of performance, which has not changed over this period of time.  For screening colonoscopy, it's recommended to repeat every 10yrs assuming that nothing is found.  
However, upon reviewing 5% of the national Medicare data for low risk enrollees, the authors noted that 23.5% underwent a repeat screening colonoscopy in less than 7yrs without a clear indication as to why it was being repeated early.  45.6% of those who were 75-79yo at the time of the initial negative screening colonoscopy had a repeat evaluation in less than 7yrs; 32.9% of those 80yo & greater underwent repeat evaluation in less than 7yrs.  Don't get me wrong.  If a precancerous lesion were found the first time out, then yes, the guidelines require a repeat colonoscopy sooner than 10yrs (the interval depending upon the severity of the lesion).  But this should have been well documented by the endoscopist rather than repeating a screening colonoscopy early.
After all, not only does performing unnecessary colonoscopies increase healthcare expenditures, but it also places the patient at risk for anesthetic complications, bowel perforations, bowel preparation issues, etc.  Now less I lump all gastroenterologists together in a bad light, that is not my intent.  In fact, it appears that we need to weed out a few bad apples as the frequency of this situation varied from less than 5% in some geographic regions to greater than 50% in others.  Just like most family physicians are looking out for your health, there are still some Medicare mills out there intent on separating the government from its monies (our taxes).


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