Thursday, January 22, 2015
Does quality of colonoscopy depend on time of day?
Over the past decade, there has been renewed effort to increase the quality of colonoscopy. New data has demonstrated that colonoscopy quality is less than gastroenterologists had previously thought. Interestingly, colonoscopy is less effective in preventing colon cancers in the right side of the colon compared to the left side. Explanations include that some pre-cancerous polyps in the right side of the colon are more subtle to recognize and that the right side of the colon has many hidden areas that are difficult to visualize. New examination techniques and equipment are addressing these issues.
The goal of colonoscopy is not to detect cancer; it is to remove benign polyps before they have an opportunity to become malignant. A new measure of medical quality is to record how often gastroenterologists (GIs) remove polyps from their patients. For example, if a GI only detects polyps in 5% of patients, which is under the quality threshold, then someone will conclude that this physician is not diligent. So, now GIs may be scouring the colons to remove every pimple in order to reach threshold. While this may result in higher “quality” colonoscopies, will patients actually benefit? We don't know. Pay-for-performance and other quality initiative create opportunities and incentives to game the systems. Is our mission to help patients or to play the game?
An interesting issue regarding colonoscopy quality has been published in medical journals. GIs who are doing colonoscopies all day long lose their edge as the day progresses. It may be that that physician fatigue is a factor, or that afternoon patients are not as thoroughly cleaned out as morning patients are. This issue has been covered in the press and patients have asked me about it. I am not aware that my procedural quality is time dependent, but I haven't looked at my own data. I wonder what my optimal colonoscopy time slot is. Perhaps, I should run my data and then charge fees in accordance with my polyp detection rate. In other words, if a patient is seeking a bargain colonoscopy, then he gets the last slot of the day. However, if a patient wants concierge medical quality, and is willing to put some cash on the line, then he'll get scheduled accordingly.
I wonder if other medical specialties, including primary care, experience quality decay over the course of the day. I am interested if any physician readers are aware of published data on this issue or can share relevant personal experiences.
The lessons gleaned from the lower portion of the alimentary canal may apply beyond the medical arena. Do other professions perform better in the morning than they do in the afternoon?
Here are some studies I propose, which can be funded in our government's usual manner: borrow.
Profession vs. Quality Measurement per Shift Hour
Policeman vs. Arrest Record
Thief vs. Successful Robberies
Financial Advisor vs. Profitable Advice
Politician vs. Promises Kept
Stage Actor vs. Lines forgotten
Judge vs. Decisions Reversed
Since pay-for-performance is the panacea that will cure the medical profession, why shouldn't we share it with the rest of you?
This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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