Clinical research study
Specialty Differences in Polyp Detection, Removal, and Biopsy during Colonoscopy

https://doi.org/10.1016/j.amjmed.2010.01.016Get rights and content

Abstract

Background

Colonoscopy is a technically complex procedure commonly performed to detect and remove colorectal pathology. This study examined the influence of provider characteristics on polyp detection, polyp removal, and diagnostic biopsy rates.

Methods

We conducted a retrospective cross-sectional study using a 20% sample of 2003 Medicare claims. Primary outcome measures were use of diagnostic biopsy, polyp detection, and polyp removal. We used generalized estimating equations to identify independent predictors of the outcomes, adjusting for patient and provider characteristics.

Results

Among 328,167 outpatient colonoscopies, polyp detection and removal rates were significantly lower for nongastroenterologists than gastroenterologists, with adjusted relative risk for polyp detection between 0.80 (95% confidence interval [CI], 0.77-0.83) for general surgeons and 0.93 (95% CI, 0.89-0.98) for internists. Compared with gastroenterologists, diagnostic biopsy was significantly less likely for general (relative risk [RR] 0.69; 95% CI, 0.65-0.74) or colorectal surgeons (RR 0.58; 95% CI, 0.52-0.65). The likelihood of polyp detection and removal was higher for physicians in the middle 2 quartiles of annual colonoscopy volume, but similar for physicians in the highest and lowest volume quartiles. Polyp detection and removal were significantly less likely for examinations in ambulatory surgery centers or offices than hospital outpatient settings, while diagnostic biopsy was significantly less likely in office settings.

Conclusions

Physician specialty, annual colonoscopy volume, and site of service are significant predictors of polyp detection, polyp removal, and diagnostic biopsy. These findings may have important implications for the effectiveness of colonoscopy.

Section snippets

Identification of Claims

We conducted a retrospective cohort study using a 20% nationally representative sample of claims in the Medicare Carrier and Medicare Provider Analysis and Review files. We included Medicare beneficiaries aged 66 years and over who had a colonoscopy claim submitted during 2003. Beneficiaries were excluded if they were ineligible for both Medicare Parts A and Part B for the entire 12 months before and after the index colonoscopy or if they enrolled in a Medicare health maintenance organization

Results

We identified 382,426 colonoscopies. After excluding 54,259 inpatient examinations, 328,167 outpatient examinations conducted by 12,910 providers were included in this analysis. Characteristics of eligible patients and providers are shown in Table 2.

Significant differences in practice location of colonoscopies, annual colonoscopy volume, and colonoscopy site of service were found between providers' specialties (Table 3). For example, gastroenterologists had the highest median annual colonoscopy

Discussion

Colonoscopy is a high volume and costly procedure, but the training and facilities to do this procedure are quite variable. In this study, we found significant relationships between diagnostic biopsy, polyp detection, and polyp removal and provider specialty, provider annual colonoscopy volume, and endoscopy site of service. Overall, gastroenterologists were more likely to detect and remove polyps and perform diagnostic biopsies than other specialties. Gastroenterologists generally receive the

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    Funding: This work was funded by the American College of Gastroenterology. Dr. Dominitz was supported by the American Society for Gastrointestinal Endoscopy Endoscopic Research Career Development Award. This material is the result of work supported in part by resources from the VA Puget Sound Health Care System, Seattle, Washington. The views and opinions of authors expressed herein do not necessarily state or reflect those of the United States Government or the Department of Veterans Affairs.

    Conflict of Interest: The authors have no conflicts of interest.

    Authorship: All authors had access to the data and role in writing the manuscript.

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