ORIGINAL ARTICLE
Nonneoplastic polypectomy during screening colonoscopy: the impact on polyp detection rate, adenoma detection rate, and overall cost Mary A. Atia, MD, Neal C. Patel, MD, Shiva K. Ratuapli, MBBS, Erika S. Boroff, MD, Michael D. Crowell, PhD, Suryakanth R. Gurudu, MD, Douglas O. Faigel, MD, Jonathan A. Leighton, MD, Francisco C. Ramirez, MD Scottsdale, Arizona, USA
Background: The frequency of nonneoplastic polypectomy (NNP) and its impact on the polyp detection rate (PDR) is unknown. The correlation between NNP and adenoma detection rate (ADR) and its impact on the cost of colonoscopy has not been investigated. Objective: To determine the rate of NNP in screening colonoscopy, the impact of NNP on the PDR, and the correlation of NNP with ADR. The increased cost of NNP during screening colonoscopy also was calculated. Design: We reviewed all screening colonoscopies. PDR and ADR were calculated. We then calculated a nonneoplastic polyp detection rate (patients with R1 nonneoplastic polyp). Setting: Tertiary-care referral center. Patients: Patients who underwent screening colonoscopies from 2010 to 2011. Interventions: Colonoscopy. Main Outcome Measurements: ADR, PDR, NNP rate. Results: A total of 1797 colonoscopies were reviewed. Mean ( standard deviation) PDR was 47.7% 12.0%, and mean ADR was 27.3% 6.9%. The overall NNP rate was 10.4% 7.1%, with a range of 2.4% to 28.4%. Among all polypectomies (n Z 2061), 276 were for nonneoplastic polyps (13.4%). Endoscopists with a higher rate of nonneoplastic polyp detection were more likely to detect an adenoma (odds ratio 1.58; 95% confidence interval, 1.11.2). With one outlier excluded, there was a strong correlation between ADR and NNP (r Z 0.825; P! .001). The increased cost of removal of nonneoplastic polyps was $32,963. Limitations: Retrospective study. Conclusion: There is a strong correlation between adenoma detection and nonneoplastic polyp detection. The etiology is unclear, but nonneoplastic polyp detection rate may inflate the PDR for some endoscopists. NNP also adds an increased cost. Increasing the awareness of endoscopic appearances through advanced imaging techniques of normal versus neoplastic tissue may be an area to improve cost containment in screening colonoscopy. (Gastrointest Endosc 2015;-:1-6.)
Colonoscopy is the principal modality for detection and removal of precancerous lesions and subsequent prevention of colorectal cancer1,2dthe third leading etiology of
cancer-related mortality in the United States in men and women.3 Although it represents a cost-effective means of screening for colorectal neoplasia,4 colonoscopy still
Abbreviations: ADR, adenoma detection rate; ASGE, American Society for Gastrointestinal Endoscopy; NNP, nonneoplastic polypectomy; PDR, polyp detection rate.
Current affiliations: Department of Medicine, Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona.
DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2015.01.016
Reprint requests: Francisco C. Ramirez, MD, Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ 85259. If you would like to chat with an author of this article, you may contact Dr Ramirez at [email protected].
Received July 3, 2014. Accepted January 4, 2015.
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constitutes an invasive examination with inherent costs and risks. Additionally, the quality of the procedure is variable and depends on many factors at both the patient5,6 and endoscopist7-10 levels. As a result, it is imperative to focus on both the quality as well as cost-effectiveness of colonoscopy, which is a major point of emphasis for organizations such as the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology.11,12 The adenoma detection rate (ADR) has been validated as an independent predictor of risk for interval colorectal cancer.13,14 Developing medical literature also discusses the role of sessile serrated adenoma detection, further emphasizing a meticulous examination.15-17 However, given the increasing pressure to find adenomatous polyps to meet accepted standards (ADR R25% in men, 15% in women), endoscopists may be tempted to remove polypoid, nonneoplastic lesions (normal mucosa, lymphoid aggregates). With the increasing scrutiny regarding the rising costs in healthcare, it is critical to deliver high-quality screening colonoscopy in a cost-effective manner. Although much of the current medical literature has centered on increasing polyp detection and ADR as a sign of quality, little research has focused on reducing the cost of colonoscopy. In order to decrease the overall cost, it is important to identify opportunities for cost containment during screening colonoscopy. The frequency of nonneoplastic polypectomy (NNP) of tissue constituting normal colon mucosa or lymphoid aggregates and its impact on PDR (a proposed surrogate of ADR)18 is unknown. The correlation between NNP rate and ADR has not been investigated. The aim of this study was to determine the rate of NNP in screening colonoscopy, the impact of NNP on PDR, and the correlation of NNP with ADR. The subsequent associated increased cost of NNP during screening colonoscopy also was calculated.
MATERIALS AND METHODS Endoscopy and pathology reports were reviewed at a single, tertiary-care referral center for all patients undergoing screening colonoscopy from October 1, 2010 to September 30, 2011. Our institutional review board granted permission for this minimal risk study to retrospectively review our endoscopic database, analyze de-identified patient data, and report our findings. The procedure was classified as screening if patients were asymptomatic and without a history of polyps. Either a board certified gastroenterologist or gastroenterology fellow under the direct supervision of an attending physician was included; colorectal surgeons were excluded. Historical data of our endoscopists from 2009 indicated that the PDR range was 27% to 55%, and the ADR range was 2 GASTROINTESTINAL ENDOSCOPY Volume
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16% to 38%.18 All physicians are salaried and without incentive for number of procedures completed and/or polypectomy. All patients received polyethylene glycol–based bowel preparations and were provided printed instructions on the split-dose preparation.19 Informed consent was obtained, and patients received conscious sedation with a combination of midazolam and either fentanyl or meperidine, per performing endoscopist preference. Only high-definition colonoscopes were used (Olympus PCF-Q180AL, CF-Q180AL; Olympus America). For each procedure, data on patient demographics, quality of bowel preparation, completion of colonoscopy, and polyp characteristics (location, number, size, type of polyp) were abstracted. The relevant polyp details as mentioned earlier are according to the American and European guidelines for quality assurance in colorectal screening20,21 The number of specimen bottles sent to pathology from each colon segment was recorded. Pathology data were obtained by retrospective review of electronic medical records. The histology of polyps contained in each specimen bottle was recorded manually by location. Experienced GI pathologists reviewed all biopsy specimens. Adenomas included pathology findings of tubular adenoma, tubulovillous adenoma, high-grade dysplasia, and traditional and sessile serrated adenoma. Hyperplastic polyps were categorized separately. NNP was defined as histology indicating normal colon tissue or lymphoid aggregate. If the pathologist did not identify an adenomatous or serrated lesion within the polyp initially, then examination of additional levels was requested to ensure the absence of neoplastic tissue. PDR and ADR were calculated for each endoscopist individually and for the entire group. We then calculated a nonneoplastic polyp detection rate (proportion of patients with R1 nonneoplastic polyp). A subgroup of patients with only nonneoplastic polyps (no concomitant adenoma or hyperplastic polyps) was evaluated to assess the impact on overall PDR. Colonoscopies meeting criteria for NNP were reviewed again for method of polypectomy and number of specimen bottles sent to pathology containing only nonneoplastic tissue. Procedures with polypectomy of both nonneoplastic and neoplastic lesions with the same method were excluded from the increased method of polypectomy cost calculation. Cost analysis was calculated by using the 2010 Medicare fee schedule for each specimen bottle ($114.26) as well as for Current Procedural Terminology codes with screening colonoscopy ($794.04), colonoscopy with forceps polypectomy ($847.97), and colonoscopy with snare polypectomy ($885.33). Pathology costs were estimated by multiplying the number of specimen bottles sent to pathology by $114.26 (the 2010 Medicare fee schedule for our institution).
Statistical analysis Data were entered manually and were statistically assessed by using IBM SPSS version 20.0 (SPSS Inc, Chicago, www.giejournal.org
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Nonneoplastic polypectomy during screening colonoscopy
TABLE 2. Overall quality metrics (n [ 1797)
TABLE 1. Colonoscopies sorted by PDR Endoscopist
Total no. of colonoscopies
Experience, PDR ADR NNP y (%) (%) rate (%)
8
141
22
67.38 24.82
28.37
4
85
3
64.71 41.18
11.76
2
132
9
62.88 46.97
20.45
1
180
5
58.89 35.56
19.44
12
35
7
57.14 37.14
17.14
10
116
20
56.90 32.76
13.79
17
24
16
54.17 37.50
4.17
3
123
2
50.41 25.20
11.38
15
50
8
50.00 34.00
4.00
20
127
9
49.61 29.92
15.75
13
37
20
48.65 29.73
8.11
7
141
21
43.26 35.46
8.51
5
140
23
40.71 23.57
8.57
19
82
3
40.24 26.83
2.44
16
55
22
40.00 20.00
12.73
6
118
18
38.98 20.34
6.78
14
52
10
36.54 21.15
3.85
9
76
35
35.53 19.74
6.58
11
41
14
29.27 24.39
2.44
18
42
15
26.19 19.05
2.38
PDR, Polyp detection rate; ADR, adenoma detection rate; NNP, nonneoplastic polypectomy.
Ill). The normality of distributions for the data sets was determined by using SPSS Explore, Descriptive, and Graph functions. Patient and clinical endoscopic characteristics were summarized by using point estimates and interval estimates for all descriptive data and were presented as means, medians, or proportions and the standard deviation (SD), ranges, or 95% confidence intervals (CIs). The relationship between the quality metrics was evaluated by using the Pearson correlation coefficient. The ADR was plotted against the NNP rate for individual endoscopists and was evaluated by using least-squares regression. Statistical significance was defined as P % .05.
RESULTS A total of 1797 screening colonoscopies performed by 20 gastroenterologists were analyzed. The mean ( SD) patient age was 59.1 9.1 years, and 52% were male. Completion to the cecum overall was 98% (37 incomplete examinations). The distribution of bowel preparation quality among all procedures is as follows: 1.3% (21) poor, 2.8% (46) fair-inadequate, 35.7% (595) fair-adequate, 53.4% (889) good, and 6.9% (115) excellent. Table 1 lists the number of procedures and calculated PDR, ADR, and NNP rate per endoscopist, sorted by decreasing PDR. Nineteen of www.giejournal.org
PDR, mean ( SD)
47.7% ( 12.0%)
ADR, mean ( SD)
27.3% ( 6.9%)
NNP rate, mean ( SD)
10.4% ( 7.1%)
NNP only, mean ( SD)
5.6% ( 4%)
PDR, Polyp detection rate; SD, standard deviation; ADR, adenoma detection rate; NNP, nonneoplastic polypectomy.
Figure 1. Locations of nonneoplastic polypectomy.
the 20 gastroenterologists performed R30 procedures during the study period (range 24-180). Overall, mean ( SD) for PDR was 47.7% 12.0%, with a range from 26.2% to 67.4%. Average ( SD) ADR was 27.3% 6.9%, with a range from 19% to 47%. The overall NNP rate (ie, histology showing only normal mucosa or lymphoid aggregates) was 10.4% 7.1%, with a range of 2.4% to 28.4% (Table 2). Among all polypectomies (n Z 2061), 276 were for nonneoplastic polyps (13.4%). Mean ( SD) size of nonneoplastic polyps was 2.9 2.2 mm, and the distribution was similar in the proximal (48.9%) and distal (51.1%) colon. Figure 1 illustrates the location of NNPs. One hundred patients had only NNPs, representing a mean ( SD) overestimation of 5.6% 4% in the overall PDR (range 0%-12%). The proportion of polyp histology per endoscopist is displayed in Figure 2. The range for NNP per endoscopist was 2.38% to 28.37%, with an SD of 7.08%. Endoscopists with a higher rate of NNP were more likely to detect an adenoma (odds ratio 1.58; 95% CI, 1.1-1.2). A trend toward a positive correlation was observed between ADR and NNP (r Z 0.363; P Z .058). One endoscopist (no. 8) appeared to be an outlier with an exceptionally high NNP rate. Removing this endoscopist from the analysis resulted in a very strong, positive correlation between ADR and NNP (r Z 0.825; P ! .001) (Fig. 3). Chi-square testing for Volume
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50%
47%
45%
41%
40%
38%
35% 24%
25%
30%
27% 24%
21%
19%
20% 20%
25%
11% 12% 13%
10%
7% 7%
28%
25% 20%
15%
5% 2% 2% 2%
36%
33% 30%
30%
20%
37%
35%
34%
14%
16%
17%
19% 20%
8% 9% 9%
4% 4% 4%
0% 1
2
3
4
5
6
7
8
9
10 11 12 13 14 Endoscopist
NonNeoplastic Polypectomy Rate
15 16 17 18
19 20
Adenoma Detection Rate
Figure 2. Distribution of polyp pathology per endoscopist.
50
TABLE 3. Nonneoplastic polypectomy characteristics (n [ 203) Size of polyp, mean ( SD)
Adenoma Detection Rate
45
40
35
2.90 mm ( 2.2 mm)
Location proximal to splenic flexure, no. (%)
103 (50.7)
Biopsy forceps polypectomy, no. (%)
121 (59.6)
Snare polypectomy, no. (%)
18 (8.9)
Fellow participation, no. (%)
30 (15)
SD, Standard deviation.
30
25
DISCUSSION 20
Y = 21.4406 + 0.8252 (X) r = 0.825; p < .001
15 0
5
10
15
20
25
30
NonNeoplastic Polypectomy
Figure 3. Scatter diagram and regression plot excluding endoscopist number 8 (outlier).
several variables was performed. Patient age (P Z .27) and sex (P Z .48), presence of a fellow (P Z .67), and bowel preparation quality (P Z .98) did not affect the rate of NNP. Sub-group analysis of NNP found 203 (11%) procedures that met the criteria of at least one specimen bottle with nonneoplastic tissue. Characteristics of these polyps are reported in Table 3. The increased Medicare pathology fee of 217 specimen bottles was $24,794.42, whereas the increased Medicare fee for polypectomies was $8,168.75. The total increased cost of NNPs was $32,963.17 (Appendix 1, available online at www.giejournal.org). Ultimately, NNP increased the cost of screening colonoscopy by 2% to 3%. 4 GASTROINTESTINAL ENDOSCOPY Volume
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In this series of over 1500 screening colonoscopies among 20 providers, we described the variation in PDR, ADR, and NNP individually and as a group. Our PDR and ADR from this study are comparable to prior data.7,10,22 During screening colonoscopy, 13% of polyps removed are nonneoplastic, consisting of only normal mucosa or lymphoid aggregates without hyperplastic or adenomatous features. Nonneoplastic polyps tend to be !5 mm (Fig. 4). There is a strong correlation between adenoma detection and nonneoplastic polyp detection, which is in agreement with similar studies.9 The reasons for the wide variation in NNP among endoscopists and the correlation with ADR are unclear. Possibilities include misinterpretation of enhanced mucosa with the use of high-definition imaging, higher vigilance when an adenoma is detected, or inherent meticulous personality of the endoscopist. It is possible that the pathologist may have misinterpreted the histology of the polyps classified as nonneoplastic. However, at our institution, our pathologists specialize in GI pathology. Furthermore, if, on first inspection, no adenoma or hyperplastic tissue is www.giejournal.org
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Nonneoplastic polypectomy during screening colonoscopy
Figure 4. Nonneoplastic polyps.
identified, the slide is returned for further evaluation of deeper layers to ensure that no abnormal tissue has been lost. Given the wide variation in the proportion of NNP by endoscopist, this could make the PDR a less-accurate surrogate of the ADR for some providers. Moreover, removal of these lesions may lead to postpolypectomy adverse events such as bleeding, postpolypectomy syndrome, or even perforation. This also may lead to patient distress about the potential of precancerous lesions. If visual interpretation were used, and pathology examination were omitted, surveillance recommendations would be a shorter time interval, thereby unnecessarily exposing patients to increased costs and risks associated with more procedures. Ultimately, NNP significantly increases the cost of screening colonoscopy by 2% to 3%. The motivation for NNP is unknown. Prior medical literature has addressed that gastroenterologists often recommend surveillance endoscopy sooner than recommended by established guidelines, and those motives also may have an influence on NNP.23,24 Some NNP reflects genuine error. Higher-quality colon cleansing with a split-dose preparation and the use of high-definition colonoscopy likely contribute to the rate of NNP. Endoscopists with www.giejournal.org
less experience may have difficulty differentiating between normal and preneoplastic mucosa. Further education may be required on pit patterns.25 The introduction of sessile serrated adenomas may cause an endoscopist to be prone to removing more polyps, given concern for these subtle lesions. However, with the increasing external and internal pressure to meet ADR requirements, some gastroenterologists may feel compelled to envision the presence of a polyp. Concern about medical liability may influence the rate of NNP as well. The ASGE has advocated real-time assessment of polyp histology to reduce the cost associated with colonoscopy, particularly in regard to pathology fees.26 Two strategies suggested include leaving distal diminutive polyps in place without resection versus the resect-and-discard approach without histology interpretation for these polyps that inherently have a low malignant potential. Interestingly, our study has shown a relatively equal distribution of NNP in the proximal and distal colon. This further supports the demand for better technology to assist in the differentiation of lesions during endoscopy, such as chromoendoscopy or narrow-band imaging.27-30 Increasing the awareness of endoscopic appearances of normal versus neoplastic tissue and the cost incurred by NNP may be a potential area of focus to improve cost containment in screening colonoscopy. There are some limitations to our study. This was a retrospective review with potential for incomplete data collection and associated bias. Colonoscopies were performed in a tertiary-care referral center; therefore, results may not be generalizable. Nonetheless, this study was restricted to patients requiring screening, which likely reflects the general population. It is not known what proportion of patients had a normal colonoscopy previously, and this subset of patients may have a lower before-test probability of polyps and/or adenomas. Patient-related factors such as tobacco use, nonsteroidal anti-inflammatory drug use, and body mass index, which may contribute to the risk of colorectal neoplasia, were not obtained. Finally, the use of narrow-band imaging is available to our endoscopists, but their use of this technology was not documented. To our knowledge, this study is the first to examine the rate of NNPs of lesions that are neither hyperplastic nor adenomatous. Although prior medical literature has evaluated the detection of nonadenomatous polyps,9 hyperplastic polyps were included in their analysis. Currently, however, proximal serrated polyps may represent a subset of hyperplastic polyps that are now understood to have neoplastic potential via the CpG island methylator phenotype pathway and therefore should be excluded.31,32 NNP may be a useful separate quality metric to ensure polypectomy only when appropriate. Further studies should evaluate NNP to assess its role as a marker of efficiency. Studies with a larger sample size of endoscopists should be evaluated, and the traits Volume
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of those who are able to maintain a satisfactory ADR with a low NNP should be identified. These predictive factors could then be used in education modules to promote cost effectiveness.
REFERENCES 1. Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012;366:687-96. 2. Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013;369: 1095-105. 3. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29. 4. Sonnenberg A, Delco F, Inadomi JM. Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med 2000;133:573-84. 5. Froehlich F, Wietlisbach V, Gonvers JJ, et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005;61:378-84. 6. Serper M, Gawron AJ, Smith SG, et al. Patient factors that affect quality of colonoscopy preparation. Clin Gastroenterol Hepatol 2014;12:451-7. 7. Imperiale TF, Glowinski EA, Juliar BE, et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc 2009;69:1288-95. 8. Kahi CJ, Hewett DG, Norton DL, et al. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 2011;9:42-6. 9. Chen SC, Rex DK. Variable detection of nonadenomatous polyps by individual endoscopists at colonoscopy and correlation with adenoma detection. J Clin Gastroenterol 2008;42:704-7. 10. Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533-41. 11. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002;97: 1296-308. 12. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873-85. 13. Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010;362: 1795-803. 14. Corley DA, Levin TR, Doubeni CA. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370:2541. 15. Hetzel JT, Huang CS, Coukos JA, et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol 2010;105:2656-64. 16. Rex DK, Ahnen DJ, Baron JA, et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012;107:1315-29; quiz 1314, 1330.
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17. Yamada A, Notohara K, Aoyama I, et al. Endoscopic features of sessile serrated adenoma and other serrated colorectal polyps. Hepatogastroenterology 2011;58:45-51. 18. Patel NC, Islam RS, Wu Q, et al. Measurement of polypectomy rate by using administrative claims data with validation against the adenoma detection rate. Gastrointest Endosc 2013;77:390-4. 19. Gurudu SR, Ramirez FC, Harrison ME, et al. Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. Gastrointest Endosc 2012;76:603-8; e601. 20. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844-57. 21. Vieth M, Quirke P, Lambert R, et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition dannotations of colorectal lesions. Endoscopy 2012;44(suppl 3): SE131-9. 22. Sanchez W, Harewood GC, Petersen BT. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy. Am J Gastroenterol 2004;99:1941-5. 23. Mysliwiec PA, Brown ML, Klabunde CN, et al. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004;141:264-71. 24. Saini SD, Nayak RS, Kuhn L, et al. Why don’t gastroenterologists follow colon polyp surveillance guidelines? Results of a national survey. J Clin Gastroenterol 2009;43:554-8. 25. Li M, Ali SM, Umm-A-OmarahGilani S, et al. Kudo’s pit pattern classification for colorectal neoplasms: a meta-analysis. World J Gastroenterol 2014;20:12649-56. 26. Rex DK, Kahi C, O'Brien M, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011;73:419-22. 27. Axelrad AM, Fleischer DE, Geller AJ, et al. High-resolution chromoendoscopy for the diagnosis of diminutive colon polyps: implications for colon cancer screening. Gastroenterology 1996;110:1253-8. 28. East JE, Ignjatovic A, Suzuki N, et al. A randomized, controlled trial of narrow-band imaging vs high-definition white light for adenoma detection in patients at high risk of adenomas. Colorectal Dis 2012;14:e771-8. 29. Hewett DG, Huffman ME, Rex DK. Leaving distal colorectal hyperplastic polyps in place can be achieved with high accuracy by using narrowband imaging: an observational study. Gastrointest Endosc 2012;76: 374-80. 30. Fu KI, Sano Y, Kato S, et al. Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study. Endoscopy 2004;36:1089-93. 31. Brenner H, Hoffmeister M, Arndt V, et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010;102:89-95. 32. Arain MA, Sawhney M, Sheikh S, et al. CIMP status of interval colon cancers: another piece to the puzzle. Am J Gastroenterol 2010;105: 1189-95.
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APPENDIX 1 Cost analysis calculation (2010 Medicare fee schedule) – Pathology cost: $114.26 per specimen bottle – Increased cost of forceps polypectomy Z Current Procedural Terminology (CPT) code for colonoscopy with forceps polypectomy ($847.97)- CPT for screening colonoscopy ($794.04) – Increased cost of snare polypectomy Z CPT code for colonoscopy with snare polypectomy ($885.33)- CPT for screening colonoscopy ($794.04)
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Increased Medicare fee for pathology – 217 specimen bottles $114.26 Z $24,794.42 Increased Medicare fee for forceps polypectomy – 121 forceps $53.93 Z $6525.53 Increased Medicare fee for snare polypectomy – 18 snares $91.29 Z $1643.22 Total increased cost of nonneoplastic polypectomies – $24,794.42 þ $6525.53 þ $1643.22 Z $32,963.17
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Nonneoplastic polypectomy during screening colonoscopy: the impact on polyp detection rate, adenoma detection rate, and overall cost Mary A. Atia, MD, Neal C. Patel, MD, Shiva K. Ratuapli, MBBS, Erika S. Boroff, MD, Michael D. Crowell, PhD, Suryakanth R. Gurudu, MD, Douglas O. Faigel, MD, Jonathan A. Leighton, MD, Francisco C. Ramirez, MD Scottsdale, Arizona, USA
Background: The frequency of nonneoplastic polypectomy (NNP) and its impact on the polyp detection rate (PDR) is unknown. The correlation between NNP and adenoma detection rate (ADR) and its impact on the cost of colonoscopy has not been investigated. Objective: To determine the rate of NNP in screening colonoscopy, the impact of NNP on the PDR, and the correlation of NNP with ADR. The increased cost of NNP during screening colonoscopy also was calculated. Design: We reviewed all screening colonoscopies. PDR and ADR were calculated. We then calculated a nonneoplastic polyp detection rate (patients with R1 nonneoplastic polyp). Setting: Tertiary-care referral center. Patients: Patients who underwent screening colonoscopies from 2010 to 2011. Interventions: Colonoscopy. Main Outcome Measurements: ADR, PDR, NNP rate. Results: A total of 1797 colonoscopies were reviewed. Mean ( standard deviation) PDR was 47.7% 12.0%, and mean ADR was 27.3% 6.9%. The overall NNP rate was 10.4% 7.1%, with a range of 2.4% to 28.4%. Among all polypectomies (n Z 2061), 276 were for nonneoplastic polyps (13.4%). Endoscopists with a higher rate of nonneoplastic polyp detection were more likely to detect an adenoma (odds ratio 1.58; 95% confidence interval, 1.11.2). With one outlier excluded, there was a strong correlation between ADR and NNP (r Z 0.825; P! .001). The increased cost of removal of nonneoplastic polyps was $32,963. Limitations: Retrospective study. Conclusion: There is a strong correlation between adenoma detection and nonneoplastic polyp detection. The etiology is unclear, but nonneoplastic polyp detection rate may inflate the PDR for some endoscopists. NNP also adds an increased cost. Increasing the awareness of endoscopic appearances through advanced imaging techniques of normal versus neoplastic tissue may be an area to improve cost containment in screening colonoscopy. (Gastrointest Endosc 2015;-:1-6.)
Colonoscopy is the principal modality for detection and removal of precancerous lesions and subsequent prevention of colorectal cancer1,2dthe third leading etiology of
cancer-related mortality in the United States in men and women.3 Although it represents a cost-effective means of screening for colorectal neoplasia,4 colonoscopy still
Abbreviations: ADR, adenoma detection rate; ASGE, American Society for Gastrointestinal Endoscopy; NNP, nonneoplastic polypectomy; PDR, polyp detection rate.
Current affiliations: Department of Medicine, Division of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona.
DISCLOSURE: All authors disclosed no financial relationships relevant to this article. Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2015.01.016
Reprint requests: Francisco C. Ramirez, MD, Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 East Shea Blvd, Scottsdale, AZ 85259. If you would like to chat with an author of this article, you may contact Dr Ramirez at [email protected].
Received July 3, 2014. Accepted January 4, 2015.
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constitutes an invasive examination with inherent costs and risks. Additionally, the quality of the procedure is variable and depends on many factors at both the patient5,6 and endoscopist7-10 levels. As a result, it is imperative to focus on both the quality as well as cost-effectiveness of colonoscopy, which is a major point of emphasis for organizations such as the American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology.11,12 The adenoma detection rate (ADR) has been validated as an independent predictor of risk for interval colorectal cancer.13,14 Developing medical literature also discusses the role of sessile serrated adenoma detection, further emphasizing a meticulous examination.15-17 However, given the increasing pressure to find adenomatous polyps to meet accepted standards (ADR R25% in men, 15% in women), endoscopists may be tempted to remove polypoid, nonneoplastic lesions (normal mucosa, lymphoid aggregates). With the increasing scrutiny regarding the rising costs in healthcare, it is critical to deliver high-quality screening colonoscopy in a cost-effective manner. Although much of the current medical literature has centered on increasing polyp detection and ADR as a sign of quality, little research has focused on reducing the cost of colonoscopy. In order to decrease the overall cost, it is important to identify opportunities for cost containment during screening colonoscopy. The frequency of nonneoplastic polypectomy (NNP) of tissue constituting normal colon mucosa or lymphoid aggregates and its impact on PDR (a proposed surrogate of ADR)18 is unknown. The correlation between NNP rate and ADR has not been investigated. The aim of this study was to determine the rate of NNP in screening colonoscopy, the impact of NNP on PDR, and the correlation of NNP with ADR. The subsequent associated increased cost of NNP during screening colonoscopy also was calculated.
MATERIALS AND METHODS Endoscopy and pathology reports were reviewed at a single, tertiary-care referral center for all patients undergoing screening colonoscopy from October 1, 2010 to September 30, 2011. Our institutional review board granted permission for this minimal risk study to retrospectively review our endoscopic database, analyze de-identified patient data, and report our findings. The procedure was classified as screening if patients were asymptomatic and without a history of polyps. Either a board certified gastroenterologist or gastroenterology fellow under the direct supervision of an attending physician was included; colorectal surgeons were excluded. Historical data of our endoscopists from 2009 indicated that the PDR range was 27% to 55%, and the ADR range was 2 GASTROINTESTINAL ENDOSCOPY Volume
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16% to 38%.18 All physicians are salaried and without incentive for number of procedures completed and/or polypectomy. All patients received polyethylene glycol–based bowel preparations and were provided printed instructions on the split-dose preparation.19 Informed consent was obtained, and patients received conscious sedation with a combination of midazolam and either fentanyl or meperidine, per performing endoscopist preference. Only high-definition colonoscopes were used (Olympus PCF-Q180AL, CF-Q180AL; Olympus America). For each procedure, data on patient demographics, quality of bowel preparation, completion of colonoscopy, and polyp characteristics (location, number, size, type of polyp) were abstracted. The relevant polyp details as mentioned earlier are according to the American and European guidelines for quality assurance in colorectal screening20,21 The number of specimen bottles sent to pathology from each colon segment was recorded. Pathology data were obtained by retrospective review of electronic medical records. The histology of polyps contained in each specimen bottle was recorded manually by location. Experienced GI pathologists reviewed all biopsy specimens. Adenomas included pathology findings of tubular adenoma, tubulovillous adenoma, high-grade dysplasia, and traditional and sessile serrated adenoma. Hyperplastic polyps were categorized separately. NNP was defined as histology indicating normal colon tissue or lymphoid aggregate. If the pathologist did not identify an adenomatous or serrated lesion within the polyp initially, then examination of additional levels was requested to ensure the absence of neoplastic tissue. PDR and ADR were calculated for each endoscopist individually and for the entire group. We then calculated a nonneoplastic polyp detection rate (proportion of patients with R1 nonneoplastic polyp). A subgroup of patients with only nonneoplastic polyps (no concomitant adenoma or hyperplastic polyps) was evaluated to assess the impact on overall PDR. Colonoscopies meeting criteria for NNP were reviewed again for method of polypectomy and number of specimen bottles sent to pathology containing only nonneoplastic tissue. Procedures with polypectomy of both nonneoplastic and neoplastic lesions with the same method were excluded from the increased method of polypectomy cost calculation. Cost analysis was calculated by using the 2010 Medicare fee schedule for each specimen bottle ($114.26) as well as for Current Procedural Terminology codes with screening colonoscopy ($794.04), colonoscopy with forceps polypectomy ($847.97), and colonoscopy with snare polypectomy ($885.33). Pathology costs were estimated by multiplying the number of specimen bottles sent to pathology by $114.26 (the 2010 Medicare fee schedule for our institution).
Statistical analysis Data were entered manually and were statistically assessed by using IBM SPSS version 20.0 (SPSS Inc, Chicago, www.giejournal.org
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Nonneoplastic polypectomy during screening colonoscopy
TABLE 2. Overall quality metrics (n [ 1797)
TABLE 1. Colonoscopies sorted by PDR Endoscopist
Total no. of colonoscopies
Experience, PDR ADR NNP y (%) (%) rate (%)
8
141
22
67.38 24.82
28.37
4
85
3
64.71 41.18
11.76
2
132
9
62.88 46.97
20.45
1
180
5
58.89 35.56
19.44
12
35
7
57.14 37.14
17.14
10
116
20
56.90 32.76
13.79
17
24
16
54.17 37.50
4.17
3
123
2
50.41 25.20
11.38
15
50
8
50.00 34.00
4.00
20
127
9
49.61 29.92
15.75
13
37
20
48.65 29.73
8.11
7
141
21
43.26 35.46
8.51
5
140
23
40.71 23.57
8.57
19
82
3
40.24 26.83
2.44
16
55
22
40.00 20.00
12.73
6
118
18
38.98 20.34
6.78
14
52
10
36.54 21.15
3.85
9
76
35
35.53 19.74
6.58
11
41
14
29.27 24.39
2.44
18
42
15
26.19 19.05
2.38
PDR, Polyp detection rate; ADR, adenoma detection rate; NNP, nonneoplastic polypectomy.
Ill). The normality of distributions for the data sets was determined by using SPSS Explore, Descriptive, and Graph functions. Patient and clinical endoscopic characteristics were summarized by using point estimates and interval estimates for all descriptive data and were presented as means, medians, or proportions and the standard deviation (SD), ranges, or 95% confidence intervals (CIs). The relationship between the quality metrics was evaluated by using the Pearson correlation coefficient. The ADR was plotted against the NNP rate for individual endoscopists and was evaluated by using least-squares regression. Statistical significance was defined as P % .05.
RESULTS A total of 1797 screening colonoscopies performed by 20 gastroenterologists were analyzed. The mean ( SD) patient age was 59.1 9.1 years, and 52% were male. Completion to the cecum overall was 98% (37 incomplete examinations). The distribution of bowel preparation quality among all procedures is as follows: 1.3% (21) poor, 2.8% (46) fair-inadequate, 35.7% (595) fair-adequate, 53.4% (889) good, and 6.9% (115) excellent. Table 1 lists the number of procedures and calculated PDR, ADR, and NNP rate per endoscopist, sorted by decreasing PDR. Nineteen of www.giejournal.org
PDR, mean ( SD)
47.7% ( 12.0%)
ADR, mean ( SD)
27.3% ( 6.9%)
NNP rate, mean ( SD)
10.4% ( 7.1%)
NNP only, mean ( SD)
5.6% ( 4%)
PDR, Polyp detection rate; SD, standard deviation; ADR, adenoma detection rate; NNP, nonneoplastic polypectomy.
Figure 1. Locations of nonneoplastic polypectomy.
the 20 gastroenterologists performed R30 procedures during the study period (range 24-180). Overall, mean ( SD) for PDR was 47.7% 12.0%, with a range from 26.2% to 67.4%. Average ( SD) ADR was 27.3% 6.9%, with a range from 19% to 47%. The overall NNP rate (ie, histology showing only normal mucosa or lymphoid aggregates) was 10.4% 7.1%, with a range of 2.4% to 28.4% (Table 2). Among all polypectomies (n Z 2061), 276 were for nonneoplastic polyps (13.4%). Mean ( SD) size of nonneoplastic polyps was 2.9 2.2 mm, and the distribution was similar in the proximal (48.9%) and distal (51.1%) colon. Figure 1 illustrates the location of NNPs. One hundred patients had only NNPs, representing a mean ( SD) overestimation of 5.6% 4% in the overall PDR (range 0%-12%). The proportion of polyp histology per endoscopist is displayed in Figure 2. The range for NNP per endoscopist was 2.38% to 28.37%, with an SD of 7.08%. Endoscopists with a higher rate of NNP were more likely to detect an adenoma (odds ratio 1.58; 95% CI, 1.1-1.2). A trend toward a positive correlation was observed between ADR and NNP (r Z 0.363; P Z .058). One endoscopist (no. 8) appeared to be an outlier with an exceptionally high NNP rate. Removing this endoscopist from the analysis resulted in a very strong, positive correlation between ADR and NNP (r Z 0.825; P ! .001) (Fig. 3). Chi-square testing for Volume
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50%
47%
45%
41%
40%
38%
35% 24%
25%
30%
27% 24%
21%
19%
20% 20%
25%
11% 12% 13%
10%
7% 7%
28%
25% 20%
15%
5% 2% 2% 2%
36%
33% 30%
30%
20%
37%
35%
34%
14%
16%
17%
19% 20%
8% 9% 9%
4% 4% 4%
0% 1
2
3
4
5
6
7
8
9
10 11 12 13 14 Endoscopist
NonNeoplastic Polypectomy Rate
15 16 17 18
19 20
Adenoma Detection Rate
Figure 2. Distribution of polyp pathology per endoscopist.
50
TABLE 3. Nonneoplastic polypectomy characteristics (n [ 203) Size of polyp, mean ( SD)
Adenoma Detection Rate
45
40
35
2.90 mm ( 2.2 mm)
Location proximal to splenic flexure, no. (%)
103 (50.7)
Biopsy forceps polypectomy, no. (%)
121 (59.6)
Snare polypectomy, no. (%)
18 (8.9)
Fellow participation, no. (%)
30 (15)
SD, Standard deviation.
30
25
DISCUSSION 20
Y = 21.4406 + 0.8252 (X) r = 0.825; p < .001
15 0
5
10
15
20
25
30
NonNeoplastic Polypectomy
Figure 3. Scatter diagram and regression plot excluding endoscopist number 8 (outlier).
several variables was performed. Patient age (P Z .27) and sex (P Z .48), presence of a fellow (P Z .67), and bowel preparation quality (P Z .98) did not affect the rate of NNP. Sub-group analysis of NNP found 203 (11%) procedures that met the criteria of at least one specimen bottle with nonneoplastic tissue. Characteristics of these polyps are reported in Table 3. The increased Medicare pathology fee of 217 specimen bottles was $24,794.42, whereas the increased Medicare fee for polypectomies was $8,168.75. The total increased cost of NNPs was $32,963.17 (Appendix 1, available online at www.giejournal.org). Ultimately, NNP increased the cost of screening colonoscopy by 2% to 3%. 4 GASTROINTESTINAL ENDOSCOPY Volume
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In this series of over 1500 screening colonoscopies among 20 providers, we described the variation in PDR, ADR, and NNP individually and as a group. Our PDR and ADR from this study are comparable to prior data.7,10,22 During screening colonoscopy, 13% of polyps removed are nonneoplastic, consisting of only normal mucosa or lymphoid aggregates without hyperplastic or adenomatous features. Nonneoplastic polyps tend to be !5 mm (Fig. 4). There is a strong correlation between adenoma detection and nonneoplastic polyp detection, which is in agreement with similar studies.9 The reasons for the wide variation in NNP among endoscopists and the correlation with ADR are unclear. Possibilities include misinterpretation of enhanced mucosa with the use of high-definition imaging, higher vigilance when an adenoma is detected, or inherent meticulous personality of the endoscopist. It is possible that the pathologist may have misinterpreted the histology of the polyps classified as nonneoplastic. However, at our institution, our pathologists specialize in GI pathology. Furthermore, if, on first inspection, no adenoma or hyperplastic tissue is www.giejournal.org
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Nonneoplastic polypectomy during screening colonoscopy
Figure 4. Nonneoplastic polyps.
identified, the slide is returned for further evaluation of deeper layers to ensure that no abnormal tissue has been lost. Given the wide variation in the proportion of NNP by endoscopist, this could make the PDR a less-accurate surrogate of the ADR for some providers. Moreover, removal of these lesions may lead to postpolypectomy adverse events such as bleeding, postpolypectomy syndrome, or even perforation. This also may lead to patient distress about the potential of precancerous lesions. If visual interpretation were used, and pathology examination were omitted, surveillance recommendations would be a shorter time interval, thereby unnecessarily exposing patients to increased costs and risks associated with more procedures. Ultimately, NNP significantly increases the cost of screening colonoscopy by 2% to 3%. The motivation for NNP is unknown. Prior medical literature has addressed that gastroenterologists often recommend surveillance endoscopy sooner than recommended by established guidelines, and those motives also may have an influence on NNP.23,24 Some NNP reflects genuine error. Higher-quality colon cleansing with a split-dose preparation and the use of high-definition colonoscopy likely contribute to the rate of NNP. Endoscopists with www.giejournal.org
less experience may have difficulty differentiating between normal and preneoplastic mucosa. Further education may be required on pit patterns.25 The introduction of sessile serrated adenomas may cause an endoscopist to be prone to removing more polyps, given concern for these subtle lesions. However, with the increasing external and internal pressure to meet ADR requirements, some gastroenterologists may feel compelled to envision the presence of a polyp. Concern about medical liability may influence the rate of NNP as well. The ASGE has advocated real-time assessment of polyp histology to reduce the cost associated with colonoscopy, particularly in regard to pathology fees.26 Two strategies suggested include leaving distal diminutive polyps in place without resection versus the resect-and-discard approach without histology interpretation for these polyps that inherently have a low malignant potential. Interestingly, our study has shown a relatively equal distribution of NNP in the proximal and distal colon. This further supports the demand for better technology to assist in the differentiation of lesions during endoscopy, such as chromoendoscopy or narrow-band imaging.27-30 Increasing the awareness of endoscopic appearances of normal versus neoplastic tissue and the cost incurred by NNP may be a potential area of focus to improve cost containment in screening colonoscopy. There are some limitations to our study. This was a retrospective review with potential for incomplete data collection and associated bias. Colonoscopies were performed in a tertiary-care referral center; therefore, results may not be generalizable. Nonetheless, this study was restricted to patients requiring screening, which likely reflects the general population. It is not known what proportion of patients had a normal colonoscopy previously, and this subset of patients may have a lower before-test probability of polyps and/or adenomas. Patient-related factors such as tobacco use, nonsteroidal anti-inflammatory drug use, and body mass index, which may contribute to the risk of colorectal neoplasia, were not obtained. Finally, the use of narrow-band imaging is available to our endoscopists, but their use of this technology was not documented. To our knowledge, this study is the first to examine the rate of NNPs of lesions that are neither hyperplastic nor adenomatous. Although prior medical literature has evaluated the detection of nonadenomatous polyps,9 hyperplastic polyps were included in their analysis. Currently, however, proximal serrated polyps may represent a subset of hyperplastic polyps that are now understood to have neoplastic potential via the CpG island methylator phenotype pathway and therefore should be excluded.31,32 NNP may be a useful separate quality metric to ensure polypectomy only when appropriate. Further studies should evaluate NNP to assess its role as a marker of efficiency. Studies with a larger sample size of endoscopists should be evaluated, and the traits Volume
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of those who are able to maintain a satisfactory ADR with a low NNP should be identified. These predictive factors could then be used in education modules to promote cost effectiveness.
REFERENCES 1. Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012;366:687-96. 2. Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013;369: 1095-105. 3. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29. 4. Sonnenberg A, Delco F, Inadomi JM. Cost-effectiveness of colonoscopy in screening for colorectal cancer. Ann Intern Med 2000;133:573-84. 5. Froehlich F, Wietlisbach V, Gonvers JJ, et al. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest Endosc 2005;61:378-84. 6. Serper M, Gawron AJ, Smith SG, et al. Patient factors that affect quality of colonoscopy preparation. Clin Gastroenterol Hepatol 2014;12:451-7. 7. Imperiale TF, Glowinski EA, Juliar BE, et al. Variation in polyp detection rates at screening colonoscopy. Gastrointest Endosc 2009;69:1288-95. 8. Kahi CJ, Hewett DG, Norton DL, et al. Prevalence and variable detection of proximal colon serrated polyps during screening colonoscopy. Clin Gastroenterol Hepatol 2011;9:42-6. 9. Chen SC, Rex DK. Variable detection of nonadenomatous polyps by individual endoscopists at colonoscopy and correlation with adenoma detection. J Clin Gastroenterol 2008;42:704-7. 10. Barclay RL, Vicari JJ, Doughty AS, et al. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med 2006;355:2533-41. 11. Rex DK, Bond JH, Winawer S, et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002;97: 1296-308. 12. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873-85. 13. Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med 2010;362: 1795-803. 14. Corley DA, Levin TR, Doubeni CA. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370:2541. 15. Hetzel JT, Huang CS, Coukos JA, et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol 2010;105:2656-64. 16. Rex DK, Ahnen DJ, Baron JA, et al. Serrated lesions of the colorectum: review and recommendations from an expert panel. Am J Gastroenterol 2012;107:1315-29; quiz 1314, 1330.
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17. Yamada A, Notohara K, Aoyama I, et al. Endoscopic features of sessile serrated adenoma and other serrated colorectal polyps. Hepatogastroenterology 2011;58:45-51. 18. Patel NC, Islam RS, Wu Q, et al. Measurement of polypectomy rate by using administrative claims data with validation against the adenoma detection rate. Gastrointest Endosc 2013;77:390-4. 19. Gurudu SR, Ramirez FC, Harrison ME, et al. Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. Gastrointest Endosc 2012;76:603-8; e601. 20. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844-57. 21. Vieth M, Quirke P, Lambert R, et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition dannotations of colorectal lesions. Endoscopy 2012;44(suppl 3): SE131-9. 22. Sanchez W, Harewood GC, Petersen BT. Evaluation of polyp detection in relation to procedure time of screening or surveillance colonoscopy. Am J Gastroenterol 2004;99:1941-5. 23. Mysliwiec PA, Brown ML, Klabunde CN, et al. Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy. Ann Intern Med 2004;141:264-71. 24. Saini SD, Nayak RS, Kuhn L, et al. Why don’t gastroenterologists follow colon polyp surveillance guidelines? Results of a national survey. J Clin Gastroenterol 2009;43:554-8. 25. Li M, Ali SM, Umm-A-OmarahGilani S, et al. Kudo’s pit pattern classification for colorectal neoplasms: a meta-analysis. World J Gastroenterol 2014;20:12649-56. 26. Rex DK, Kahi C, O'Brien M, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011;73:419-22. 27. Axelrad AM, Fleischer DE, Geller AJ, et al. High-resolution chromoendoscopy for the diagnosis of diminutive colon polyps: implications for colon cancer screening. Gastroenterology 1996;110:1253-8. 28. East JE, Ignjatovic A, Suzuki N, et al. A randomized, controlled trial of narrow-band imaging vs high-definition white light for adenoma detection in patients at high risk of adenomas. Colorectal Dis 2012;14:e771-8. 29. Hewett DG, Huffman ME, Rex DK. Leaving distal colorectal hyperplastic polyps in place can be achieved with high accuracy by using narrowband imaging: an observational study. Gastrointest Endosc 2012;76: 374-80. 30. Fu KI, Sano Y, Kato S, et al. Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study. Endoscopy 2004;36:1089-93. 31. Brenner H, Hoffmeister M, Arndt V, et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010;102:89-95. 32. Arain MA, Sawhney M, Sheikh S, et al. CIMP status of interval colon cancers: another piece to the puzzle. Am J Gastroenterol 2010;105: 1189-95.
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APPENDIX 1 Cost analysis calculation (2010 Medicare fee schedule) – Pathology cost: $114.26 per specimen bottle – Increased cost of forceps polypectomy Z Current Procedural Terminology (CPT) code for colonoscopy with forceps polypectomy ($847.97)- CPT for screening colonoscopy ($794.04) – Increased cost of snare polypectomy Z CPT code for colonoscopy with snare polypectomy ($885.33)- CPT for screening colonoscopy ($794.04)
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Increased Medicare fee for pathology – 217 specimen bottles $114.26 Z $24,794.42 Increased Medicare fee for forceps polypectomy – 121 forceps $53.93 Z $6525.53 Increased Medicare fee for snare polypectomy – 18 snares $91.29 Z $1643.22 Total increased cost of nonneoplastic polypectomies – $24,794.42 þ $6525.53 þ $1643.22 Z $32,963.17
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