In the Journals

Different-day endoscopic procedures more common in physician offices

Photo of Martin Makary
Martin Makary

The rate of different-day elective upper and lower endoscopic procedures was 3.5 times higher in physician’s offices than in hospital outpatient departments, according to results from a recent study published in JAMA Internal Medicine.

Endoscopic procedures that could be performed on one day but are instead performed on two different days are considered low-value care because they are associated with unnecessary repeated venipuncture and sedation, use of the endoscopy suite, additional physician’s fees and patient inconvenience.

“While some upper and lower endoscopy pairs need to be performed separately for clinical reasons, separating the procedure for financial reasons is a trend that should be called out,” Martin Makary, MD, MPH, of the department of Surgery at Johns Hopkins University, told Healio Primary Care.

To address this concern, researchers conducted a retrospective analysis of all Medicare fee-for-service carrier claims from Jan. 1, 2011 to June 20, 2018. The Healthcare Common Procedure Coding System and Current Procedural Terminology were used to identify upper and lower endoscopy procedures that were performed within 90 days of each other. Patients who underwent procedures in hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs) and physician’s offices were included in the study. Patients with same-day and different-day procedures were paired for analyses.

Researchers identified 4,028,587 procedure pairs that were performed in HOPDs (52.5%), ASCs (43.3%) and physician’s offices (4.2%). Overall, HOPDs had a different-day procedure rate of 13.6%, ASCs had a rate of 22.2% and physician’s offices had a rate of 47.7%.

The different-day procedure rate was 15.8% at HOPDs and 37.4% in physician offices among the 993 physicians who practiced in both settings. For the 7,564 physicians who practiced at HOPDs and ASCs, the rate of different-day procedures was 14.1% in HOPDs and 19.4% in ASCs.

After adjusting for patient and physician characteristics, patients were more likely to undergo different-day procedures at physician’s offices and ASCs than at HOPDs (physician’s office vs HOPD: adjusted OR = 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR = 1.27; 95% CI, 1.23-1.32).

The study included 1,587 physicians who each performed more than 10 procedures in their offices. Among those, 44% had a different-day procedure rate greater than 50%, 27.3% had a rate greater than 90% and 11.6% had a different-day procedure rate of 100%.

Different-day procedures were more likely among patients who had older age, had black and Hispanic race/ethnicity or lived in the Northeast region of the United States. Different-day procedures were less likely in micropolitan or rural locations, in patients having more comorbidities, among physicians with fewer years of experience in medical practice and among physicians specializing in general surgery.

“Primary care doctors are in a great position to oversee quality among the specialists they refer to,” Makary said. “Inquiring about the indications for different-day endoscopy is a powerful screening question. With increased awareness and education, more appropriate care is being delivered.” – by Erin Michael

Disclosures: Makary has no relevant financial disclosures. He has written about low-value care in his book The Price We Pay: What Broke American Healthcare – and How to Fix It.

Photo of Martin Makary
Martin Makary

The rate of different-day elective upper and lower endoscopic procedures was 3.5 times higher in physician’s offices than in hospital outpatient departments, according to results from a recent study published in JAMA Internal Medicine.

Endoscopic procedures that could be performed on one day but are instead performed on two different days are considered low-value care because they are associated with unnecessary repeated venipuncture and sedation, use of the endoscopy suite, additional physician’s fees and patient inconvenience.

“While some upper and lower endoscopy pairs need to be performed separately for clinical reasons, separating the procedure for financial reasons is a trend that should be called out,” Martin Makary, MD, MPH, of the department of Surgery at Johns Hopkins University, told Healio Primary Care.

To address this concern, researchers conducted a retrospective analysis of all Medicare fee-for-service carrier claims from Jan. 1, 2011 to June 20, 2018. The Healthcare Common Procedure Coding System and Current Procedural Terminology were used to identify upper and lower endoscopy procedures that were performed within 90 days of each other. Patients who underwent procedures in hospital outpatient departments (HOPDs), freestanding ambulatory surgery centers (ASCs) and physician’s offices were included in the study. Patients with same-day and different-day procedures were paired for analyses.

Researchers identified 4,028,587 procedure pairs that were performed in HOPDs (52.5%), ASCs (43.3%) and physician’s offices (4.2%). Overall, HOPDs had a different-day procedure rate of 13.6%, ASCs had a rate of 22.2% and physician’s offices had a rate of 47.7%.

The different-day procedure rate was 15.8% at HOPDs and 37.4% in physician offices among the 993 physicians who practiced in both settings. For the 7,564 physicians who practiced at HOPDs and ASCs, the rate of different-day procedures was 14.1% in HOPDs and 19.4% in ASCs.

After adjusting for patient and physician characteristics, patients were more likely to undergo different-day procedures at physician’s offices and ASCs than at HOPDs (physician’s office vs HOPD: adjusted OR = 2.02; 95% CI, 1.85-2.20; ASC vs HOPD: aOR = 1.27; 95% CI, 1.23-1.32).

The study included 1,587 physicians who each performed more than 10 procedures in their offices. Among those, 44% had a different-day procedure rate greater than 50%, 27.3% had a rate greater than 90% and 11.6% had a different-day procedure rate of 100%.

Different-day procedures were more likely among patients who had older age, had black and Hispanic race/ethnicity or lived in the Northeast region of the United States. Different-day procedures were less likely in micropolitan or rural locations, in patients having more comorbidities, among physicians with fewer years of experience in medical practice and among physicians specializing in general surgery.

“Primary care doctors are in a great position to oversee quality among the specialists they refer to,” Makary said. “Inquiring about the indications for different-day endoscopy is a powerful screening question. With increased awareness and education, more appropriate care is being delivered.” – by Erin Michael

Disclosures: Makary has no relevant financial disclosures. He has written about low-value care in his book The Price We Pay: What Broke American Healthcare – and How to Fix It.