Future of virtual colonoscopy

[Taurus]

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So VC is almost ready for prime time. Question is, who's gonna 'own' it? Will the GI docs be able to wrestle this away from the radiologists? We need to stop that from happening.

http://www.time.com/time/health/article/0,8599,1668162,00.html

Studies Endorse 'Virtual Colonoscopy'
Wednesday, Oct. 03, 2007 By AP/STEPHANIE NANO

(NEW YORK) — Having an X-ray to look for signs of colon cancer may soon be an option for those who dread the traditional scope exam. Two of the largest studies yet of "virtual colonoscopy" show the experimental technique works just as well at spotting potentially cancerous growths as the more invasive method. It's also quicker and cheaper.

The X-rays can help sort out who really needs the full exam and removal of suspicious growths, called polyps. In one study, only 8 percent of patients had to have followup traditional colonoscopies, which are done under sedation and carry a small risk of puncturing the bowel.

But what some people consider the most unpleasant part can't be avoided: drinking laxatives to purge the bowel so growths can be seen.

Still, proponents hope that the newer test will lure those who have balked at getting conventional screening.

"This is ready for prime time," said Dr. Perry Pickhardt, one of the researchers at the University of Wisconsin Medical School who are reporting the results of their study in Thursday's New England Journal of Medicine.

A second, federally funded study at 15 sites around the country is meant to be the definitive test of virtual colonoscopy. Results have not been published, but they show the test to be promising.

Colonoscopies are recommended for everyone over 50, but just about half get tested. Colon cancer is the nation's second leading cause of cancer deaths, and an estimated 52,000 people will die from it this year. Screening can save lives by finding growths before they turn cancerous. Colonoscopies, considered the gold standard test, are recommended every 10 years and more frequently after polyps are found.

In traditional colonoscopy, performed by a gastroenterologist, a long, thin tube is inserted and snaked through the large intestines. Generally, any polyps that are spotted, regardless of size, are taken out in the process.

Virtual colonography uses a CT scanner to take a series of X-rays of the colon and a computer to create a 3-D view. A small tube is inserted in the rectum to inflate the colon so it can be more easily viewed. A radiologist then checks the images for suspicious polyps. Since the patient isn't sedated, there's no recovery time required.

But if any polyps need to be removed, the patient must then have a regular colonoscopy to do that.

For the Wisconsin study, Pickhardt persuaded health insurers in Madison to pay for the less expensive virtual colonoscopies and let patients choose between the two exams. The study included 3,120 patients who opted for a virtual colonoscopy and 3,163 who chose the traditional exam.

Dr. David Kim, another of the researchers, said he plans to ask the patients what was behind their decision.

"I think we're bringing people in off the sidelines as opposed to just substituting one exam for another," he said.

About the same number of advanced polyps were found in each group, 123 for the virtual group and 121 for the conventional group. About 8 percent in the virtual group were sent for same-day colonoscopies for polyp removal. Five percent of the patients had one or two small polyps and they decided to have them watched rather than removed.

Overall, far more polyps were removed in the traditional colonoscopies; the virtual colonoscopies didn't report tiny polyps, which are unlikely to be cancer. In the traditional group, seven had perforated colons and four needed surgery.

Pickhardt, Kim and a third researcher have received lecture or consulting fees from the makers of colonoscopy products and imaging equipment.

A traditional colonoscopy at the Wisconsin hospital is $3,300 and more if polyps are removed; virtual colonoscopy costs $1,186. Insurers pay about 40 percent of that charge, Pickhardt said.

Most insurance companies don't cover virtual colonoscopy for screening but that could change if colon cancer screening guidelines endorse it. Virtual screenings are already available at some hospitals and centers for people willing to pay for it.

The American Cancer Society is updating its guidelines, but Robert Smith, director of cancer screening, wouldn't say whether they would now recommend virtual colonoscopy, also known as CT colonography. When the guidelines were last revised in 2003, there wasn't enough data to support it, he said.

"The evidence is accumulating that CT colonography may have a role in primary screening," said Smith.

Early studies of virtual colonoscopy gave mixed results. Then in 2005, the American College of Radiology Imaging Network launched a large study of more than 2,000 patients, to try to resolve the issue. Each volunteer had a virtual colonoscopy followed by a traditional one the same day and the outcomes were compared.

After the results were presented at a meeting last week, the group posted a statement on their Web site saying that preliminary results showed virtual colonoscopy is "highly accurate," similar to traditional colonoscopy. Spokesman Shawn Farley said details wouldn't be released until the study is published, probably around the end of the year.

Dr. Douglas Rex, director of endoscopy at Indiana University Hospital, said that study was key because it was done at several locations. "We should have a pretty good sense of how it's going to perform in practice," he said.

Rex said he has some reservations about virtual colonoscopy because it doesn't lead to the removal of the smallest polyps and exposes patients to radiation.

 

[Whisker Barrel Cortex]

Its pretty exciting time for VC. I work with those mentioned in the article everyday and with the publication of this article and the release of the results of the ACRIN trial, the excitement is palpable.

Some have argued that VC is not good for private practice, where time is of the essence. In fact, when done correctly and using primary 3D interpretation with 2D problem solving, these examinations can be read very quickly and accurately. You definitely need GI docs on your side. We have reciprocity so that patients with polyps have the option for same day optical colonoscopy and polypectomy and patients that have an incomplete colonoscopy can get same day VC.

 

[Taurus]

You definitely need GI docs on your side. We have reciprocity so that patients with polyps have the option for same day optical colonoscopy and polypectomy and patients that have an incomplete colonoscopy can get same day VC.

I agree that after screening with VC the patients should be able to get same-day traditional colonoscopies by GI folks. However, I've read in several places that GI docs want to follow the precedent that cards set with cardiac CT and try to own VC. Traditional caolonoscopies are the cash cow for GI and they aren't gonna want to give it up easily.

 

[freddydpt]

I agree that after screening with VC the patients should be able to get same-day traditional colonoscopies by GI folks. However, I've read in several places that GI docs want to follow the precedent that cards set with cardiac CT and try to own VC. Traditional caolonoscopies are the cash cow for GI and they aren't gonna want to give it up easily.

How did cards end up stealing cardiac CT?

 

[Taurus]

How did cards end up stealing cardiac CT?

The cards asked rads to show them how to do some reading and the rads naively trained them. The cards then proclaimed cardiac CT as their own. Rads invented and dominated interventional for a while, but cards stole that too.

The moral of the story: be careful of who you train and what you show them, whether it is physicians from other specialties or midlevels like PA's or NP's. You may be training your replacement.

Many specialties are envious of rads and want a piece of the action. I've heard of neurologists wanting rads to show them how to read brain films. GI docs will no doubt ask rads to show them too.

We have to be very protective of our profession.

 

[Docxter]

In their second landmark article, the Wisconsin investigators showed the benefits of CTC as a screening tool. It was published just today in the New England Journal of Medicine.

http://content.nejm.org/cgi/content/short/357/14/1403

 

[nutcancer]

GI will definitely steal it. You people aren't understanding, the easier the technology becomes to use, the easier it becomes to steal. How hard is it to read a 3D reconstruction of the lumen and have someone co-read the rest of it? And this will not catch on. Why would any rational person who understands that the prep is the worst part of the colonoscopy experience want to receive radiation instead of receiving optical visualization of the colon? This is idiotic. Patients are scared of the wrong things with colonscopy. Nobody even remembers their colonoscopy after sedation. I think in that study 8% of VCs required optical. That's significant. Also the perf risk in that study was like 0.02% or something like that (might be wrong on that one). This only makes sense if VCs end up costing a lot less than optical colonoscopies.

 

[Taurus]

Why would any rational person who understands that the prep is the worst part of the colonoscopy experience want to receive radiation instead of receiving optical visualization of the colon?

Have you ever received a colonoscopy? It's no fun at all. People do remember the unpleasantness of the experience if not all the details. The analogy is, who wants to have their chest cracked open when they can do it percutaneously? Everyone knows what has happened to CT surgery. Same thing, who wants a tube shoved up their butt when they can be imaged instead? You also have the squeamish factor. Given a choice, I think people would choose VC. Plus, why take the risk of having your bowels perfed and then having to walk around with a bag hanging outside your body?

I wouldn't worry about the radiation part. I've heard that they're working on an MR-based VC. The field will keep advancing.

This only makes sense if VCs end up costing a lot less than optical colonoscopies.

That Time article said traditional colonoscopies costs $3300. VC costs $1100. There, you have your answer. The insurance companies will push for VC.

Even if GI controls VC, they will take a serious hit in the wallet. It is my understanding that traditional colonoscopies are the money-maker for GI. The field exploded around 2000 when CMS changed the rules so that they would reimburse for screening colonoscopies. This is probably the start of the decline for GI.

 

[LAZYGUY]

This is probably the start of the decline for GI.

Probably not. With the advent of VC, screening will be much higher and in turn the polyps will still continue to be removed by GI docs. VC will only give more work for GIs, perhaps more than they can handle.

 

[(nicedream)]

And this will not catch on. Why would any rational person who understands that the prep is the worst part of the colonoscopy experience want to receive radiation instead of receiving optical visualization of the colon? This is idiotic. Patients are scared of the wrong things with colonscopy. Nobody even remembers their colonoscopy after sedation. I think in that study 8% of VCs required optical. That's significant. Also the perf risk in that study was like 0.02% or something like that (might be wrong on that one). This only makes sense if VCs end up costing a lot less than optical colonoscopies.

While the prep may physically be the worst part of the experience, I think anyone would prefer to go through a CT scanner rather than an interventional procedure and it's concomitant risks involved with sedation and instrumentation of the bowel. Those risks are both real and anxiety-provoking for patients. Not to mention the huge number of people who simply will never get a colonoscopy regardless of their doctors' insistence because they don't want a tube snaked up their butt. The perf risk by the way was 0.2%, which is 1/500. That is pretty significant.

 

[LAZYGUY]

While the prep may physically be the worst part of the experience, I think anyone would prefer to go through a CT scanner rather than an interventional procedure and it's concomitant risks involved with sedation and instrumentation of the bowel. Those risks are both real and anxiety-provoking for patients. Not to mention the huge number of people who simply will never get a colonoscopy regardless of their doctors' insistence because they don't want a tube snaked up their butt. The perf risk by the way was 0.2%, which is 1/500. That is pretty significant.

I completely agree with your statement. But I believe that VC will result in actually more need for colonoscopies since probably more polyps will need to be taken out, which will necessitate action by GI docs. Does anyone know what are the applications of VC for lower GI bleeding and other functions that normally would be investivated by a traditional colonoscopy?

 

[Taurus]

I completely agree with your statement. But I believe that VC will result in actually more need for colonoscopies since probably more polyps will need to be taken out, which will necessitate action by GI docs. Does anyone know what are the applications of VC for lower GI bleeding and other functions that normally would be investivated by a traditional colonoscopy?

I'm not convinced of this. If the 8% figure for needing follow-up traditional colonoscopy holds up, that's a lot of people who won't be getting traditional colonoscopies. You would need to vastly increase the number of people screened with VC to make up for that 92% that traditional colonoscopies have lost to VC. With more research and using biomarkers, they may even be able to knock that 8% down even more.

I have not met one GI doc who is happy with the advent of VC and neither is GI's official organization. It's still early for VC to replace traditional colonoscopies as the screening method of choice. Two or more major studies that show similar results and the cancer screening guidelines will probably have to change. Early results from other studies look pretty good though so I wouldn't invest in that fancy colonoscopy tube just yet. 😀

http://digital50.com/news/items/PR/...ography-in-detecting-polyps-digestive-he.html

Despite Advances in the Accuracy of CT Colonography in Detecting Polyps, Digestive Health Experts Urge Patients to Consider Risks and Realities
BETHESDA, Md., Oct. 4 PRNewswire-USNewswire — New research from the University of Wisconsin comparing optical colonoscopy to CT colonography published in the New England Journal of Medicine today raises several important issues for the public about colorectal cancer screening using a CT scan of the abdomen. "Gastrointestinal physicians are committed to preventing colorectal cancer, and to advancing new frontiers in medicine. While all of us on the front lines of battling colorectal cancer will welcome effective and clinically proven new tools, the evidence needs to be closely evaluated and patients need to recognize that a virtual test is not without significant potential risks in its own right," commented Dr. David Johnson, M.D., FACG, President of the American College of Gastroenterology.

The Wisconsin study in today's NEJM compared CT colonography (CTC) performed for screening in 3120 adults with primary optical colonoscopy (OC) in 3163 similar consecutive adults. A major limitation of the study was it was not randomized, patients chose their preferred screening method. Referral for polypectomy during optical colonoscopy was offered for all polyps detected by CT colonography of at least 6 mm in size. Patients with one or two polyps in the range 6 to 9 mm were offered the option of follow-up surveillance by CT colonography. The researchers do not report whether CTC identified smaller polyps, which would routinely be removed according to established practice guidelines because it is impossible to reliably identify which small adenomas will become cancerous.

CTC and OC found similar rates of advanced neoplasms and cancers. About 8 percent of CTC screenings resulted in referrals for OC for removal of suspicious polyps. The total numbers of polypectomies in the CTC and OC groups were 561 and 2434, respectively, so far more potentially cancerous polyps were removed by colonoscopy. Seven perforations occurred in the OC group during screening, and none occurred in the CTC group.

According to Dr. Johnson, "The nonrandomized design of this study is problematic. The higher rate of cancer in the OC group suggests that the study populations were different, and a higher percentage of patients in the OC group might have received previous negative screening test results — such testing would select for a lower rate of cancers and advanced adenomas in the colonoscopy group and potentially bias to higher detection in the CTC cohort. Also, the rate of perforation in the colonoscopy arm was twice what is expected in a screening population. Thus, we need additional information to interpret this nonrandomized comparison before we can generalize the results to clinical practice."

Evaluating the Potential of CT Colonography - What Patients Should Know

When evaluating new potential screening technologies, including CT colonography, the ACG has focused its evaluation on several pieces of evidence including: sensitivity for identification of polyps of various sizes, standards for polyp removal, correlating patient risks (in this case from radiation exposure), frequency of exams and the economic impact to the healthcare system of separate diagnostic and therapeutic exams.

An important reality of CT colonography is the likelihood that patients will need a follow-up with optical colonoscopy. Of the patients undergoing CT colonography in the University of Wisconsin study published in NEJM, 7.9 percent were referred for optical colonoscopy for removal of potentially pre-cancerous polyps at least 6mm in size. Earlier findings by Dr. Pickhardt and his colleagues in 2004, at least 30 percent of patients undergoing virtual colonoscopy required conventional colonoscopy to remove polyps 6mm or larger.

ACG notes that the CTC technology requires the same bowel preparation as optical colonoscopy. There is also evidence that due to the insertion of a tube in the rectum and insufflation of the abdomen with air or gas, the patients, who are not sedated and awake tend to feel discomfort. In addition, the fact that some percentage of patients will be required to follow up a CT colonography with a therapeutic or, in cases where there the CT results are not clear, a second diagnostic colonoscopy, has patient acceptance and economic implications.

"Patient acceptance is another key factor in evaluating the promise of a new technology. The fact that patients undergoing optical colonoscopy are sedated and do not experience pain in association with the procedure and they will be able to have an examination and any necessary therapeutic intervention in a single visit will be important in evaluating which test is best for a particular patient," added Dr. Johnson.

It is important for patients to understand that no guideline group, including the American Cancer Society or the Multi-Society Task Force on Colorectal Cancer has yet endorsed CT colonography as appropriate for colorectal cancer screening.

According to the American College of Gastroenterology, colonoscopy remains the best test and the current gold standard for colorectal cancer screening and prevention. Three studies have shown that colonoscopy prevents about 80 percent of colorectal cancers from developing by removing pre-cancerous polyps. "The public should recognize that there is no evidence that any radiographic test, including CT colonography prevents the development of colorectal cancer," said Dr. David Johnson.

"There is a tremendous body of evidence that shows that clearing the colon of polyps, including small polyps, significantly reduces colorectal cancer mortality. Because of its excellent sensitivity in detecting polyps and its potential for removing them and breaking the sequence of polyp to cancer in a single diagnostic and therapeutic intervention, colonoscopy is one of the most powerful preventive tools in clinical medicine. Until a radiographic test can meet that standard, gastroenterologists will continue to champion the lifesaving potential of colonoscopy," Johnson added.

 

[LAZYGUY]

I'm not convinced of this. If the 8% figure for needing follow-up traditional colonoscopy holds up, that's a lot of people who won't be getting traditional colonoscopies. You would need to vastly increase the number of people screened with VC to make up for that 92% that traditional colonoscopies have lost to VC. With more research and using biomarkers, they may even be able to knock that 8% down even more.

I have not met one GI doc who is happy with the advent of VC and neither is GI's official organization. It's still early for VC to replace traditional colonoscopies as the screening method of choice. Two or more major studies that show similar results and the cancer screening guidelines will probably have to change. Early results from other studies look pretty good though so I wouldn't invest in that fancy colonoscopy tube just yet. 😀

http://digital50.com/news/items/PR/...ography-in-detecting-polyps-digestive-he.html

Despite Advances in the Accuracy of CT Colonography in Detecting Polyps, Digestive Health Experts Urge Patients to Consider Risks and Realities
BETHESDA, Md., Oct. 4 PRNewswire-USNewswire — New research from the University of Wisconsin comparing optical colonoscopy to CT colonography published in the New England Journal of Medicine today raises several important issues for the public about colorectal cancer screening using a CT scan of the abdomen. "Gastrointestinal physicians are committed to preventing colorectal cancer, and to advancing new frontiers in medicine. While all of us on the front lines of battling colorectal cancer will welcome effective and clinically proven new tools, the evidence needs to be closely evaluated and patients need to recognize that a virtual test is not without significant potential risks in its own right," commented Dr. David Johnson, M.D., FACG, President of the American College of Gastroenterology.

The Wisconsin study in today's NEJM compared CT colonography (CTC) performed for screening in 3120 adults with primary optical colonoscopy (OC) in 3163 similar consecutive adults. A major limitation of the study was it was not randomized, patients chose their preferred screening method. Referral for polypectomy during optical colonoscopy was offered for all polyps detected by CT colonography of at least 6 mm in size. Patients with one or two polyps in the range 6 to 9 mm were offered the option of follow-up surveillance by CT colonography. The researchers do not report whether CTC identified smaller polyps, which would routinely be removed according to established practice guidelines because it is impossible to reliably identify which small adenomas will become cancerous.

CTC and OC found similar rates of advanced neoplasms and cancers. About 8 percent of CTC screenings resulted in referrals for OC for removal of suspicious polyps. The total numbers of polypectomies in the CTC and OC groups were 561 and 2434, respectively, so far more potentially cancerous polyps were removed by colonoscopy. Seven perforations occurred in the OC group during screening, and none occurred in the CTC group.

According to Dr. Johnson, "The nonrandomized design of this study is problematic. The higher rate of cancer in the OC group suggests that the study populations were different, and a higher percentage of patients in the OC group might have received previous negative screening test results — such testing would select for a lower rate of cancers and advanced adenomas in the colonoscopy group and potentially bias to higher detection in the CTC cohort. Also, the rate of perforation in the colonoscopy arm was twice what is expected in a screening population. Thus, we need additional information to interpret this nonrandomized comparison before we can generalize the results to clinical practice."

Evaluating the Potential of CT Colonography - What Patients Should Know

When evaluating new potential screening technologies, including CT colonography, the ACG has focused its evaluation on several pieces of evidence including: sensitivity for identification of polyps of various sizes, standards for polyp removal, correlating patient risks (in this case from radiation exposure), frequency of exams and the economic impact to the healthcare system of separate diagnostic and therapeutic exams.

An important reality of CT colonography is the likelihood that patients will need a follow-up with optical colonoscopy. Of the patients undergoing CT colonography in the University of Wisconsin study published in NEJM, 7.9 percent were referred for optical colonoscopy for removal of potentially pre-cancerous polyps at least 6mm in size. Earlier findings by Dr. Pickhardt and his colleagues in 2004, at least 30 percent of patients undergoing virtual colonoscopy required conventional colonoscopy to remove polyps 6mm or larger.

ACG notes that the CTC technology requires the same bowel preparation as optical colonoscopy. There is also evidence that due to the insertion of a tube in the rectum and insufflation of the abdomen with air or gas, the patients, who are not sedated and awake tend to feel discomfort. In addition, the fact that some percentage of patients will be required to follow up a CT colonography with a therapeutic or, in cases where there the CT results are not clear, a second diagnostic colonoscopy, has patient acceptance and economic implications.

"Patient acceptance is another key factor in evaluating the promise of a new technology. The fact that patients undergoing optical colonoscopy are sedated and do not experience pain in association with the procedure and they will be able to have an examination and any necessary therapeutic intervention in a single visit will be important in evaluating which test is best for a particular patient," added Dr. Johnson.

It is important for patients to understand that no guideline group, including the American Cancer Society or the Multi-Society Task Force on Colorectal Cancer has yet endorsed CT colonography as appropriate for colorectal cancer screening.

According to the American College of Gastroenterology, colonoscopy remains the best test and the current gold standard for colorectal cancer screening and prevention. Three studies have shown that colonoscopy prevents about 80 percent of colorectal cancers from developing by removing pre-cancerous polyps. "The public should recognize that there is no evidence that any radiographic test, including CT colonography prevents the development of colorectal cancer," said Dr. David Johnson.

"There is a tremendous body of evidence that shows that clearing the colon of polyps, including small polyps, significantly reduces colorectal cancer mortality. Because of its excellent sensitivity in detecting polyps and its potential for removing them and breaking the sequence of polyp to cancer in a single diagnostic and therapeutic intervention, colonoscopy is one of the most powerful preventive tools in clinical medicine. Until a radiographic test can meet that standard, gastroenterologists will continue to champion the lifesaving potential of colonoscopy," Johnson added.

Hmm, you need to read your own article a little closer. You seem quite happy about any doom/gloom scenarios. Remember that primary docs have the population base and radiologists are consultants, if this is your attitude toward your colleagues, I can't imagine your future being bright. (especially with those looming 50% cuts in radiology that congress has planned)

 

[Taurus]

Hmm, you need to read your own article a little closer. You seem quite happy about any doom/gloom scenarios. Remember that primary docs have the population base and radiologists are consultants, if this is your attitude toward your colleagues, I can't imagine your future being bright. (especially with those looming 50% cuts in radiology that congress has planned)

Lol. Maybe you should read the NEJM article. That's the point of the study: to show that VC is comparable to OC in detecting polyps. As I said earlier, GI docs and their organization don't like VC and that's the point of posting that article. Think about it. If VC would mean more work for GI docs as you think, why would they not be excited about VC? Unless, they think it will cut into their current practice.

Frankly, it doesn't matter to me if GI docs see an increase in work because of VC. What I care more about is that radiology maintains control of VC. I'm tired of seeing other groups stealing the work that radiology creates. Radiology needs to learn from the past and not repeat its mistakes. I think we have an excellent chance of controlling VC simply because the reimbursement rates will continue to drop and it will make more financial sense for rads to do it.

In regards to DRA, I think that it is having its intended effects. It's causing the the small bit players like the ortho and cards who own scanners to shut down because they don't have the scale of rads. There is a consolidation of imaging centers going on and only the groups with the economy of scale and enough volume will survive. Rads is the biggest beneficiary of this. I believe that what CMS is saying is that they want rads to be the imaging experts and not have imaging dispersed among many fields. They want a rad who will read 15k images in a year versus the card, ortho, or anyone else who may read 300 images in a year. It's more efficient and fewer mistakes will be made when you have someone who is dedicated to just imaging.

When you have something useful to add, let us know. Otherwise, this is a waste of my time to have to explain things to you.

 

[nutcancer]

you radiologists are too far from patients to understand how this will play out. why would any patient want a 3d-reconstructed image constructed by radiation over an optical colonoscopy?

-close to 10% likelihood of having to do an optical colonoscope anyway. that's 1 in 10 chance you'll have to have a tube stuck up in your butt.
-colonoscopies are done with propofol. the risks are minor -- anesthesia reaction but you won't remember a thing. i've done a gi rotation and no, the patients don't remember jack.
-the risk of colonoscopy is 1/10k perforation. that's right, 1 in 10,000. that's what we tell our patients. its not a lie.

1/10k perforation, 1/10 likelihood of redoing it optically, and lack of remembering the pains felt during the procedure due to the white stuff.

any rational patient who can comprehend these statistics would go for the optical scope every time.

like i said, the only good reason VC exists is because it costs a lot less than an optical scope. that's the only good, rational reason. only irrational and false fears of pain and humiliation is the reason for this hype.

 

[nutcancer]

and i laugh when i read beginning of the end for GI. you know they get paid a lot more for therapeutic scopes????? if there's more screening , then there will be more therapeutic scopes performed.

hey i'm rooting for VC. but i'm also rooting for GI to steal it.

 

[(nicedream)]

any rational patient who can comprehend these statistics would go for the optical scope every time.

like i said, the only good reason VC exists is because it costs a lot less than an optical scope. that's the only good, rational reason. only irrational and false fears of pain and humiliation is the reason for this hype.

Our own arguments aside, I think you give patients too much credit in terms of "rational" thinking when it comes to decisions about their care. As the original article notes, only half of patients that should get scoped do so. I've sat in clinic every day of some rotations telling people they needed colonoscopies and with half of them it's always "I'll think about it" or "no way". "Irrational and false fears of pain and humiliation" rule a lot of human behaviour.

Not to agree with you that OC > VC (I think the juries out), but I believe the above to be true.

 

[nutcancer]

Our own arguments aside, I think you give patients too much credit in terms of "rational" thinking when it comes to decisions about their care. As the original article notes, only half of patients that should get scoped do so. I've sat in clinic every day of some rotations telling people they needed colonoscopies and with half of them it's always "I'll think about it" or "no way". "Irrational and false fears of pain and humiliation" rule a lot of human behaviour.

Not to agree with you that OC > VC (I think the juries out), but I believe the above to be true.

haha i know patients aren't rational. but i also know the family practitioner or GI doc who has the patient right in front of him can use rational thought and make sure the patient atleast acknowledges the misconceptions. following them is another thing altogether.

he he controls the patient controls where and what care they receive.

 

[LAZYGUY]

Lol. Maybe you should read the NEJM article. That's the point of the study: to show that VC is comparable to OC in detecting polyps. As I said earlier, GI docs and their organization don't like VC and that's the point of posting that article. Think about it. If VC would mean more work for GI docs as you think, why would they not be excited about VC? Unless, they think it will cut into their current practice.

Frankly, it doesn't matter to me if GI docs see an increase in work because of VC. What I care more about is that radiology maintains control of VC. I'm tired of seeing other groups stealing the work that radiology creates. Radiology needs to learn from the past and not repeat its mistakes. I think we have an excellent chance of controlling VC simply because the reimbursement rates will continue to drop and it will make more financial sense for rads to do it.

In regards to DRA, I think that it is having its intended effects. It's causing the the small bit players like the ortho and cards who own scanners to shut down because they don't have the scale of rads. There is a consolidation of imaging centers going on and only the groups with the economy of scale and enough volume will survive. Rads is the biggest beneficiary of this. I believe that what CMS is saying is that they want rads to be the imaging experts and not have imaging dispersed among many fields. They want a rad who will read 15k images in a year versus the card, ortho, or anyone else who may read 300 images in a year. It's more efficient and fewer mistakes will be made when you have someone who is dedicated to just imaging.

When you have something useful to add, let us know. Otherwise, this is a waste of my time to have to explain things to you.

Ah, finally a nice rational post 😉 Both radiology and pathology seem to be hurt by other physicians trying to make a profit. These physicians really aren't qualified to make diagnosis or manage these services, yet it happens. I don't see an easy solution to this, unless there is some rule that totally bans this or making it an ethics violation. They really hold all the cards, since it's "their patients", so they say. However, this is not a good reason to wish them out of a job, not yet anyways.

 

[Docxter]

I don't know how widespread this practice is, but in my internship, some of the GI docs would often biopsy normal mucosa to bump up the fee for a diagnostic colonoscopy to "therapeutic" colonoscopy. I hope it's not a widespread practice, but I may be naive.

 

[Taurus]

-the risk of colonoscopy is 1/10k perforation. that's right, 1 in 10,000. that's what we tell our patients. its not a lie.

Let me quote from NEJM article:
"The perforation rate of 0.2% (7 of 3163 patients) in the OC group was within the expected range reported in previous colonoscopy series."30, 31

30. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report of complications. J Clin Gastroenterol 1992;15:347-51.

31. Levin TR, Zhao W, Conell C, et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006;145:880-6.

Go ahead and tell the patient something wrong just so you can make that extra buck by sticking a tube up their butt. When you perf their bowel, they also have the right to sue your ass for fraud.