ARTICLE: Office Visits Prior to Screening Colonoscopy-Reply.
JOURNAL: JAMA. 2016 Jun 28;315(24):2734-2735. doi: 10.1001/jama.2016.4298.
Dr. Leow and colleagues raise several important considerations. We agree that the primary finding of our study—that among patients aged 50 to 64 years with private health insurance, nearly 30% who underwent a colonoscopy for colon cancer screening or polyp surveillance had an office visit with gastroenterology in the preceding 6 weeks—may not be generalizable to groups not represented in the cohort, particularly to people aged 65 years and older or with Medicaid. However, the majority of individuals aged 50 to 64 years have private health insurance,1 so the results are informative in this age group for whom colon cancer screening is an important consideration.
We also agree that some of the office visits were likely reasonable for medical reasons or due to patient preference. As stated in the article, the use of claims data precluded determination of what proportion of office visits were necessary or appropriate. Leow and colleagues also raise the possibility that many referrals may have been for reasons other than screening colonoscopy. We believe that this is unlikely. Over half of the office visits were associated only with diagnoses for colon cancer screening, polyp surveillance, or preoperative evaluation. Among the office visits associated with other diagnoses, the most common were constipation, gastroesophageal reflux, and benign neoplasm of the colon (ie, a history of polyps). It is possible that these diagnoses were the reason for referral, but many may have just been documented as a result of a referral for precolonoscopy evaluation.
The claim that one-fifth of open-access colonoscopies are for inappropriate indications is probably not applicable to the indication of colon cancer screening and polyp surveillance. That data came from a single institution study in the United States published in 1996,2 and few of the 36 colonoscopies deemed inappropriate in that study were related to cancer screening or polyp surveillance. Current guidelines for colon cancer screening are widely accepted and can be applied by primary care clinicians; determining whether a colonoscopy is indicated for screening should not require an additional office visit with a gastroenterologist.
We agree that the cost of unnecessary office visits may be overshadowed by the cost of unnecessary procedures, but each is important. The potential savings from reducing waste in any single area will never be significant in a health care system that spends over $3 trillion annually; only the commitment to reducing waste wherever it is found will result in substantial savings. Without evidence that routine precolonoscopy office visits save money or improve quality, their role in clinical practice should be reconsidered.
See the article published online here: http://jama.jamanetwork.com/article.aspx?articleid=2530528
Link to abstract online: http://www.ncbi.nlm.nih.gov/pubmed/27367777