A Colonoscopy Quest That Captures A Central Health Shopping Problem

(ex_magician/flickr)

In case you missed it on Healthcare Savvy, WBUR’s Martha Bebinger is on a mission worth watching: She’s trying to figure out how to decide where to get her next colonoscopy. And that’s no easy task, if you don’t want to passively accept your primary care doctor’s recommendation.

The trouble is not just the general lack of transparency in health care. It’s that as would-be smart patients, our toolboxes tend to lack even the most basic information: When we try to shop around, what should we be shopping for? What if we want more than basic patient satisfaction surveys? What if we want actual data about the performance of a particular practice or doctor?

Martha has made a substantial start on what may be a model for the rest of us as we become better health care consumers. Thus far, she has gathered a list of questions, and is asking for suggestions for more. They include:

•  What’s the doctor’s detection rate? One medical society (the American Society for Gastrointestinal Endoscopy) says a doctor should find a polyp in 25% of men and 15% of women (why the difference?), but I know that some physician groups around Boston say the average is 40-50% among docs who really look for polyps.

•  How much time does the doctor spend, on average, on the test? I think more is better, is that right?

•  How many colonoscopies does the doc do each year? The average, according to the ASGE, is 750. Again, more is better.

• What’s the doc’s error or complication rate per 1,000 patients? I do not want to see blood afterward, although if the doc finds and snips a polyp, I suppose I will.

 

Read the full post here, and if you know colonoscopies, please help Martha — and the rest of us — out.

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  • http://twitter.com/doctorrubin David Rubin

    Martha/Carey, why the reluctance to trust (or as you more subjectively state it, “passively accept”) your primary care doctor’s opinion? They know their peers and colleagues well, and have spent years following patients who have had a procedure that, with any luck, you’ll only need once a decade. I’m not sure I understand the desire to beat the proverbial system. Hopefully you trust your PCP, or else maybe the root problem is you need a new one.

    That said, I agree with some of your points. You want docs with low rates of complication (though most will be similarly low). You want docs with experience.

    However, more time is NOT necessarily better, and most endoscopy suites have protocols wherein they require docs to spend at least “X” amount of time (I believe 20-30 minutes is standard; studies have shown that at least six minutes spent on withdrawal [yes, only six] was associated with best results) on the test.

    The idea of “really looking for polyps” seems misguided to me. There are anecdotes of doctors removing healthy colon tissue and calling it a polyp, as they can bill for greater amounts of money when a polyp is removed. (I can’t vouch for the veracity of this.) But you can’t create what is not there. *Missed* polyps would be a bigger issue, but are harder to detect.

    I would recommend going with a colonoscopist/gastroenterologist with whom your primary care physician has a close and good relationship. After all, your PCP is the one who likely will be asked to keep tabs to your colon cancer screening (not the GI doc!), so if the data they receive from the physician doing the procedure is incomplete, you suffer. Also consider that many insurers now charge higher co-payments for procedures done at “non-preferred” hospitals, and that if (heaven forbid) a cancer is detected, the more streamlined the process of getting treatment will be if you have a unified healthcare delivery system.

    Last, I would suggest looking into the frequency of repeat colonoscopies. I can’t tell you how many patients I see called back for colonoscopy after 3 years rather than 5, or 5 years rather than 10, for practices both academic and community-based. There are fairly standard guidelines for follow up, and if you’re worried about rates of complications, you should also be worried about over-utilization of tests. (As an example, if gastro A has a complication rate of 0.5% but suggests you do colonoscopy every 5 years for a single grandparent who had colon cancer at age 80, and gastro B has a complication rate of 1% but suggests a more standard 10 year follow up, the absolute number of complications will even out.)

    Hope this helps!

    • http://twitter.com/mbebinger Martha Bebinger

      David – sorry for the delayed response.

      I LOVE my PCP – but he admittedly sends me to a GI he thinks is pretty good; my PCP doesn’t really know how well this GI does as compared to anyone else.

      What I want is a reliable set of quality measures that lets me compare one doctor to the next. The measures won’t be perfect, but the idea that they don’t exist, at least not for public viewing, is amazing.

      I can’t tell from your overall comments if you think patients should not be asking for this information or if you just pointing out the ways that measures will be inadequate or incomplete for the time being.

      I will ask about the rate of repeat colonoscopies, but so far, none of the practices that have shared their internal quality data have offered those numbers.

      Thanks so much for your insights!

  • reas

    The questions above are good, but it must be remembered that

    medicine is quite behind other industries.

    This data is best displayed to the public at the organzational level instead of the individual level. We don’t have barista ratings at Starbucks……or Pilot ratings for Southwest…. Companies share their organizational stats and manage individuals internally. Good workers are kept and bad workers are asked to improve or leave.

    Encouraging metrics may accelerate consolidation towards quality oriented organizations.

    Bottomline: Docs are more like pilots and baristas than baseball players.

    Bo