Colonoscopies tax health industry
Since medical specialists recommended widespread testing of healthy adults for colon cancer, hundreds of thousands have queued up for colonoscopies.
The rush has strained the healthcare system, producing long waits and prompting some hospitals to bring patients in on weekends.
''The demand is endless and limitless and beyond anyone's expectations," said Dr. William Brugge, director of endoscopy at Massachusetts General Hospital, which expects to conduct 25,000 colonoscopies and other gastrointestinal imaging procedures in 2004, a 20 percent jump in one year.
The struggle to accommodate colonoscopy patients is part of a broader phenomenon in medicine. When national specialists recommend a test or treatment for patients, the health-care system is sometimes not prepared for the onslaught.
Statistics on how many Americans are undergoing colonoscopies are hard to come by. But Medicare, the government health insurance program for the elderly, paid for 381,364 screening tests for healthy enrollees last year, more than double the number two years ago. Still, medical specialists say, not enough people are getting screened for colon cancer.
According to the Centers for Disease Control and Prevention, 45 percent of men and 41 percent of women age 50 and over had undergone a colonoscopy or sigmoidoscopy, according to the most recent data in 2000. That means that millions more Americans should have screening tests, and agencies like the CDC are trying to reach them with information.
While not all hospitals have long waits, some are booked for six months. ''It's one thing to have commercials and Katie Couric and all of us espousing the importance of having colonoscopies," said Dr. Robert Burakoff, chief of gastroenterology at Brigham and Women's Hospital in Boston, which has hired nine gastroenterologists in 18 months. ''The other question is whether the capacity and person power is there."
Doctors do not know whether the delays harm patients, who might otherwise be diagnosed earlier with colon cancer. Many patients tend to put off the test, because it makes them squeamish and they fear it will hurt.
The wait for the test, patient reluctance, and overwhelmed doctors have drawn the attention of malpractice insurers and lawyers.
The Risk Management Foundation, which insures doctors affiliated with Harvard Medical School, said it is clear that some patients who should have colonoscopies are not getting them.
Patients who have developed advanced colon cancer -- but whose doctors never recommended a colonoscopy, which can detect the disease earlier, in its curable stage -- are bringing claims against their doctors. In other cases, a doctor recommended the test, but did not make sure the patient followed through, or did not monitor the results.
Robert Hanscom, director of loss prevention for the Risk Management Foundation, said that the long waits may contribute to the spate of lawsuits, because patients have more time to back out of the test and doctors then lose track of them. ''It's evidence of a strained system," he said.
Guidelines for screening adults for colon cancer have been a moving target. In 2000, the American Cancer Society recommended that adults be screened for colon cancer once they reach age 50, earlier if they have a personal or family history of the disease. The group recommended one of five screening tests, including a colonoscopy or sigmoidoscopy.
The American College of Gastroenterologists also recommended screening for older adults in 2000, but said colonoscopies every 10 years are the preferred screening test, which is what the Risk Management Foundation believes. That same year, Couric, whose husband had died of colon cancer at age 42 two years earlier, underwent a colonoscopy broadcast live on NBC's ''Today."
But in 2002 the US Preventive Services Task Force, an independent panel of specialists that evaluates clinical research, issued recommendations in 2002, said it was unclear whether the accuracy of the colonoscopy offsets its additional cost, inconvenience, and complications.
The answers are important to thousands of Americans. Cancer of the colon, or large intestine, and the rectum is the third most common cancer. It is also the second deadliest, after lung cancer, killing more than 57,000 Americans annually. One in 17 men and one in 18 women develops colon cancer.
People are more at risk for colon cancer as they age, but family history, inflammatory bowel disease, and a diet low in fruits and vegetables also increase risk. Screening tests -- such as the colonoscopy, in which doctors use a lighted instrument to examine the colon -- can detect polyps that can be removed before they become cancerous.
As medical specialists and celebrities like Couric have publicized the test, hospitals are expanding to meet the demand.
Lahey Clinic in Burlington, for example, is fielding 1,800 requests a month for colonoscopies, but can accommodate only 1,200 patients.
About two years ago, the hospital began scheduling patients on Saturdays. This year, Lahey hired schedulers to work at night, so that when a patient cancels, staff can scour the waiting list and call someone to fill the vacated slot.
Dr. Stella Chow, who signed up to perform colonoscopies on a Saturday last month, had six patients scheduled for the morning, including Lorraine Jost, whose doctor recommended in January that she have the test. Soon after, Lahey called her with the first opening: 8:30 a.m. on a Saturday in July.
''That's what they had available," said Jost, who sat up in her hospital bed drinking water after her test, which she said went smoothly. ''A lot of people put it off, but it's nothing, absolutely nothing."
Some patients dread the test, because it can be uncomfortable and because they cannot eat for 24 hours before the test and must take a laxative to clean out their intestines. ''A lot of it is getting over that initial fear," Chow said. ''People hear their friend did it and it wasn't so bad."
Boston Medical Center began scheduling colonoscopies on Saturdays in January and projects that its doctors will perform 10,000 this year, more than double the number five years ago. The hospital also increased the number of procedure rooms from five to seven, lengthened its weekday hours from 7 a.m. to 7 p.m., and asked some doctors who normally do research to help out. Still, the wait is six months for healthy patients. Those with blood in their stool or other symptoms receive priority.
Colonoscopies are generally profitable -- insurers pay up to about $1,000 to the hospital and several hundred dollars to the doctor -- prompting some physicians to open private colonoscopy centers. The doctors then also get the facility fee.
The trend has upset hospital administrators because they are losing revenue. It has also worried some healthcare advocates, who say doctors may be tempted to rush patients or provide the procedure to patients who do not need it.
Gastroenterologists counter that there is an abundance of patients and that physician-owned centers help reduce the backlog because they say they often operate more efficiently and, as a result, test more patients.
Dr. Myron Falchuk, chief of clinical gastroenterology at Beth Israel Deaconess Medical Center, said that when the hospital's gastroenterologists opened their own center in Wellesley, they helped reduce waits at the hospital to two weeks.
Boston Medical Center gastroenterologists plan to open a center across from Boston University in the fall.
''Right now, the problem is too few people getting colonoscopies rather than too many," said Dr. Daniel Podolsky, chief of gastroenterology at Mass. General.
Liz Kowalczyk can be reached at kowalczyk@globe.com.
