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Ask About The Quality Of Your Colonoscopy: It Matters

BOSTON — Someday soon, you’ll need a routine medical test, perhaps an ultrasound or a mammogram, and you’ll obviously want the best. But the quality of health care tests and procedures can vary a lot depending on the doctor or hospital, and it’s not easy for patients to find information about quality.

Still, we’re all supposed to be choosing our care more carefully these days. So when I got a scribbled note from my doctor saying that it was time for a colonoscopy, I set out to find the best one in Boston.

I used to think a colonscopy is a colonoscopy, just one of those tests we have to get when we hit middle age. Then I met James Tracey, a gastroenterologist (GI) who does more than a thousand colonoscopies a year. He starts telling me about this running competition he has with other GI docs, one in particular at Hawthorn Medical Associates in North Dartmouth. It’s about who has the highest rate for finding polyps in patients during a colonoscopy.

“When he and I walk down the hall, it wouldn’t be uncommon for him to mention his percentage just to get me going,” Tracey says. “And of course that redoubles my effort that I’m not going to have that edge over me! I’m going to make my numbers as good as his.”

Tracey tells me some doctors in his practice find polyps in twice as many patients as others. Hold on, I think, this seems pretty important. I’m getting this not-so-pleasant test to look for adenomas, those polyps that can develop into colon cancer. So I ask Tracey, why is there such a big difference? He reminds me the colon is a five- to six-foot-long tube packed into the abdomen.

“Sixty to 70 percent of the colon you can see clearly, no matter what you do,” Tracey explains. “But 30 percent of the colon, you need to work at it. You need to irrigate the colon out if there’s any fluid or debris. You need to reexamine an area several times if the anatomy is distorted so the colonoscope cannot clearly see.”

My takeaway is that some doctors look more closely for polyps than others. And, of course, patients play a big role here. If we don’t follow the prep instructions, such as fasting, and come in for this test with a clean colon, the doctor is not going to have a clear view of potential problems. OK, enough description. So I make a list, based on conversations with doctors, of ways that one colonoscopy can be better than another. I email the list to some large hospitals and physician groups in Greater Boston and ask them how they measure up.

The first doctor who responds says, “You must be kidding,” as in, we’ve never done this before and we’re not going to start now.

The next one says, “We’ll get back to you,” so who knows what means?

A third doctor says, “We’ll see what we can do,” and another says flat-out,”No.”

I look around for other hospitals and physicians groups who’ve published information about how well they perform colonoscopies. I can’t find any public numbers even though doctors tell me they have this information. OK, now I understand the resistance. No one wants to go first, especially when there are no clear quality standards.

But knowing which doctors finds polyps more often than others is important. It can mean the difference between finding an early sign of colon cancer and missing it. And in the end, five of six physician groups I contacted agree, for the first time, they say, to give me information about how well they do on colonoscopies, but only as a group. I can’t get individual information for doctors unless I ask them individually.

Still, I have to applaud the groups who share their numbers voluntarily. They’re the docs at: Beth Israel Deaconess; Mass General; Harvard Vanguard; Hawthorn, which is affiliated with Steward Health Care; and Digestive Health Associates, whose doctors are part of the physicians group at Tufts Medical Center.

WBUR's Martha Bebinger compares colonoscopy quality.

Dr. James Richter, the director of MGH’s gastroenterology quality management, says it may be time for GI docs nationwide to begin posting information for patients as well.

“We do think that accountability for performance is something we owe society, but we want to do it in a serious, rather than a superficial, way,” Richter says.

Physicians in many specialty groups are ramping up quality measurement tools. Douglas Pleskow, president of the Massachusetts Gastroenterology Association, says private insurers are demanding more of this information and posting it for patients will be a federal requirement soon.

“We are getting ready,” Pleskow says. “We do know that this will be mandated, we do know that this is an important part of our practice, and we do know that patients are interested in finding the information as well.”

But there is understandable resistance from doctors. They say physicians who take care of sicker patients won’t score well, through no fault of their own and they don’t know what quality data will be required.

“Most data on quality is too brand new. It just hasn’t caught on. It’s changing,” says Dr. Jose Marcal, who practices in Stoneham at Digestive Health Associates. Marcal says he thinks “things are becoming more open. The concern about sharing data is obviously the concern about malpractice and issues related to that.” Marcal, by the way, did share his adenoma detection rate. He finds these polyps in 50 percent of patients — that’s a high score.

But the concerns he raises apply to many, many tests and procedures, not just to colonoscopies. Patients have to be more inquisitive.

“It’s certainly their right to ask providers about this information,” says Dr. Beverly Loudin, the medical director for patient safety at Atrius Health (which includes Harvard Vanguard physicians).

Comparing colonoscopy costs

“My hope would be that moving forward we can be completely transparent about all of these things, but Iā€™m not sure when we will get to that point of complete transparency,” Loudin says.

For now, if you need a colonoscopy, be sure you ask at least one question: How often does your doctor find adenomas, the polyps that can develop into cancer? That answer is important.

If you really want to find the best “value” colonoscopy, try comparing the quality chart above and the cost chart to the right. Both are rough. The quality information has not been cleaned up or adjusted for the sickness of patients. And on the cost chart, some of the prices you see are based on what my insurer, Blue Cross, would pay, and some aren’t. This isn’t close to what we patients need to make smart choices, but it’s a start.

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  • AmanaPlan

    Great reporting. I hope these groups will keep releasing this information.

  • SquareJackson

    One thing I know is that all care is not equal. There are doctors who try to speed through as many colonoscopy procedures as possible (this is, after all, what they are paid for). To this end, their prep nurses know that their patients will need extra anesthesia to help them deal with the speedy, and painful, procedure. I suggest you talk to some of your friends or fellow patients about their experiences before you lay down on the gurney for what could be a brutal experience.

    • Martha Bebinger

      Hi SquareJackson – I heard a lot about problems with sedation as I spoke to people for this story. I tried to find a way to quantify these concerns, but it doesn’t seem to be an issue that doctors track right now. Do you have a suggestion about how to define problems with anesthesia? What question would you ask doctors or nurses to record a response to during or after the procedure?

  • Vwoolley

    What about safety? After sharing my story with others of experiencing severe abdominal pain for weeks after my colonoscopy, I heard of many more people having similar and other problems post colonoscopy. I doubt these ever get reported back to the gastroenterologists performing the colonoscopies. What about first do no harm?Really I was sickened by the doctor in the article – reducing this to a competition
    Rather than on quality care for each individual.

    • Martha Bebinger

      Hi Vwoolley – good point. It sounds like a colonoscopy quality rating should include checking with patients a week or two after the procedure to see if they are experiencing any discomfort.

      On the comment from Dr. Tracey, I think you might be misinterpreting his motivation. His competitive spirit is aimed at making sure he never misses a polyp that could develop into cancer.

      Thanks for weighing in!

  • lbd

    The perforation rates are so different, what accounts for those figures?

    • Martha Bebinger

      Hi Ibd – good question. I heard a range of answers from the physician groups:
      1) experience – meaning the no. of experienced physicians in the group
      2) the patient – patients who come in with a dirty colon because they did not understand how to complete the prep or weren’t able to do it create problems for physicians. Also, some patients have other health problems that make getting a good look at the colon difficult.
      3) the data – this is the first time that physicians are making these numbers public, so there may be discrepancies in the information they shared. For example, I asked for the results for screening colonoscopies, not screening and diagnostic (tests performed on patients already known to have problems), but I’m not sure that all the physician groups were able to isolate their rates for screening colonoscopies. I don’t know if this would make a difference in their perforation rates, but it might.

  • Beth (mysemicolon.net)

    Martha, thanks so much for this. As a colorectal cancer survivor (thanks to a colonoscopy at 42), I’m always thrilled to see information about these procedures in the news.

    I’m curious about the significant difference in detection rates. Do you know whether some of the hospitals excluded non-cancerous polyps from their numbers, or made some other distinction? And I’d love to see some follow up to this story that could help listeners understand more about colorectal cancer and what those polyps might mean. It’s not always a pleasant topic, but on the other hand, if we can talk frankly about mammograms, we can talk frankly about colonoscopies. And the procedures don’t have to be uncomfortable or unpleasant at all, with good sedation and good prep.

    • Martha Bebinger

      Hi Beth – the physicians who participated in this story were kind enough to break down their polyp detection so that what you see here is just the percentage of patients in whom physicians find adenomas. These are, as I’m sure you know, the type of polyps that can develop into colon cancer.

      Thanks for raising this issue. It is important that patients ask for the adenoma detection rate, not the polyp detection rate as a whole.

  • Ellie

    Martha, thanks for doing this story. Do you have a succinct version of the questions you sent to various care providers via email? Would you post it? Many thanks!

    • Martha Bebinger

      Ahhh yes Ellie – I meant to do this. I will put my revised “What’s a Good Colonoscopy?” list on Healthcare Savvy later today – thanks for the reminder! It will be a little different than the list of questions I sent to the doctors because there are a few things I’ll ask a doctor about that they don’t actually measure yet, including, “how often do your patients complain about problems with sedation?” I hear that this happens a lot, but it does not seem to be something physicians track.

      If you want the original list as well, I can post that too, although it’s here, more or less: http://healthcaresavvy.wbur.org/2012/11/whats-a-good-colonoscopy/

      • Ellie

        Hi Martha – I’m late in checking back. Thanks so much for posting your list of questions. I am due for a colonoscopy right now, so this could not be more timely. I plan to send the questions to my primary care provider and to the gastroenterology practice they sent me to for my last one. Thanks again!

  • emc

    My uncle, and a friend’s father, died of colon cancer that was stage 4 at diagnosis, and within a year of a colonoscopy in each case. This is a very important story. We should know how much of this problem is due to incomplete prep by patients, and how much due to incomplete evaluation by doc? In other words, how much is our fault, and how much is the docs. The prep is brutal, worse than the procedure in most cases. Doctors need to deal with this problem with their patients. If the problem is more with the procedure, then the health industry has to come up with a fix — such as better tools or protocol. I’d like to know how many advanced colon cancers are diagnosed within a year or two of colonoscopy.

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