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Secrets of a Bustling Gastrointestinal Center
How one GI center has nearly quadrupled its caseload ??? to more than 17,000 procedures annually ??? and continues to grow.
Dianne Taylor
Publish Date: October 10, 2007   |  Tags:   Gastroenterology

When Bergein F. "Gene" Overholt, MD, FACP, MACG, and his four partners opened the country's first state-licensed endoscopic ASC in 1986, they performed 20 procedures a day - on their busy days. Today, Dr. Overholt and his growing team of nine endoscopists in Knoxville, Tenn., perform more than 17,000 colonoscopy and upper-endoscopy procedures annually in their eight-room ASC/office complex.

Unarguably, these physicians owe their high-volume success to favorable market forces - such as improving technology, a growing awareness of the value of endoscopy and the aging population. But maintaining this volume requires more than just being in the right place at the right time. Here's some insight into the operating philosophy of this very busy single-specialty ASC.

Favorable market
To be sure, demand for the services provided by Gastrointestinal Associates is high. Current guidelines call for regular colorectal cancer screening for everyone 50 and older and for healthy younger people with certain risk factors, and colonoscopy is now widely regarded as the best of all available screening tests for colorectal cancers. Between 2000 and 2002 alone, when demand first began rising substantially, colonoscopies among Medicare recipients reportedly rose 42 percent. Now, patients wait as long as six months, and some are even being turned away for the procedure.

Demand for upper endoscopy is also steady. This year, the American College of Gastroenterology called for screening endoscopy for patients with chronic gastroesophageal reflux disease (GERD) and routine surveillance endoscopy for those with established Barrett's esophagus. Barrett's esophagus is the end stage of chronic GERD and is a major risk factor for cancer of the distal esophagus. According to a recent literature review, endoscopic screening and surveillance for Barrett's esophagus is as effective as mammography for detecting breast cancer.

About the Busiest Facilities Series

Ever wonder how some of the busiest surgical facilities operate? How they achieve such high volumes? How they maintain efficiencies and ensure quality patient care? To find out answers to questions like these, Outpatient Surgery is beginning a multi-part series in which we take a look inside some of the busier surgical facilities in the nation.

Each segment will take you into a different surgical setting - an office-based suite, a hospital-based facility and a freestanding ambulatory surgery center (ASC).

In this first installment, find out how the endoscopy team at Knoxville, Tenn.-based Gastrointestinal Associates, PC, achieved its current volume of more than 17,000 endoscopic procedures a year.

While this growing demand has fueled steady growth at Gastrointestinal Associates, it has not been the sole factor behind this practice's success. From the onset, says Dr. Overholt, the endoscopy team has placed a strict emphasis on efficiency, quality personnel and community ties.

According to Dr. Overholt, two major factors contribute to this ASC's high-volume capacity: Time management and propofol.

  • Time management. "We are very strict with time," says Dr. Overholt, noting that the ASC's nurse manager tracks pre-operative, procedure and recovery times by physician. "If a physician spills over his allotted procedure time by more than a half-hour, he adjusts his schedule." Recently this happened, and it turned out the endoscopist was spending too much time in recovery, thus delaying the next patient's procedure.

"He no longer addresses unrelated symptoms and problems the patient might bring up during recovery," says Dr. Overholt. "Instead, he focuses solely on discharge and handles these other aspects of patient care on return appointments. The recovery unit is not the place to take care of unrelated issues. The examining room is."

Importantly, adds Dr. Overholt, this approach to time management should not be top-down. Rather, he says, it only works when everyone works as a team. He explains that you should be sure to account for the fact that some physicians are faster than others and give each one the time needed to get the procedure done right. Only after you define what's reasonable for each physician can you effectively enforce such a policy. "We used to book everyone the same, but since we refined the operative schedules to give each physician the time he needs, we have reduced patient waiting time from 30 minutes to 15 minutes," says Dr. Overholt.

Ultimately, he says, this strict focus on time management makes patients happier. "The 30-minute waiting time used to be our major patient complaint," he says.

  • Propofol. About two years ago, annual procedure volume at Gastrointestinal Associates plateaued around 13,500 due to lack of space. Since then, volume has grown nearly 25 percent, says Dr. Overholt, because the endoscopists switched from a traditional benzodiazepine/narcotic regimen to propofol, which is faster-acting, produces deeper sedation (which can hasten procedure time) and is associated with a more rapid cognitive and functional recovery. "Propofol reduced average procedure time by three to five minutes. It takes the patient down quicker, and the endoscopist doesn't have to stop to administer medications because the anesthesia professional monitors the patient for you," says Dr. Overholt. "It also reduced average recovery time from 25 minutes to as low as 10 minutes, and our recovery-bed requirement from 11 to five." Now, the team uses these extra beds to prep patients before endoscopy.

While he doesn't have patient- satisfaction figures to back it up, Dr. Overholt is convinced patients are happier with this regimen. "They walk out of here talking about it," he says. Importantly, he adds, propofol requires specialized skill and expertise to administer and monitor, which is why this ASC has a CRNA administer every dose of propofol; an on-site anesthesiologist conducts risk assessment and oversight, assists during more complicated procedures and discharges patients.

Quality personnel
Dr. Overholt says the quality of the center's nine endoscopists, six RNs, six LPNs and medical assistants and techs is key. To him, ensuring quality means following four basic principles. First, he seeks out professionals with good training or the motivation and ability to be trained. All of the center's endoscopists, for example, are ACLS trained, hospital credentialed for endoscopy, board-certified and held to the state's CME requirements.

Second, Dr. Overholt emphasizes values, which manifest foremost as an emphasis on family. "We try to shut down at 5:30 p.m. to 6:00 p.m. so we can get everyone home. Success is wonderful, but a solid family is more important than anything," he says. This philosophy, Dr. Overholt believes, is what draws ethical practitioners to this ASC in the first place. "When physicians and staff have a high moral character, they will practice the professional ethics of medicine," he says.

Third, Dr. Overholt believes in increasing every team member's value by investing in each person. "We invest very heavily in making everyone a part of our team," he explains, noting that learning new techniques and skills is commonplace and salaries are competitive. Perhaps most important, he says, is the annual beach getaway. "Our best morale builder is the beach retreat. We rent three apartments and allow our employees to take their families there for a week at our expense," he says. Camaraderie and teamwork, says Dr. Overholt, are worth their weight in gold when it comes to providing good patient care.

Fourth, Dr. Overholt holds everyone to high standards. Bonuses are performance-based, and the performance of the ASC and the office are never separated. This eliminates any competition between the two aspects of the practice and helps ensure that everyone works toward the same goals. "We also benchmark ourselves against national performance standards," adds Dr. Overholt. "For example, the national standard for reaching the cecum during colonoscopy is in the 96 percent range, and we're at 98 percent."

Community ties
While Dr. Overholt knows that ASCs cannot compete with hospitals when it comes to community service, the physician-owners of this ASC make many efforts to support their community. One endoscopist, for example, serves on the board of the Knoxville Opera Society. Another performs church-related activities. Yet another coaches youth sports. "We have also hired one firm to help develop and enhance our relationships with primary care physicians in the area and another to focus on image and media marketing," notes Dr. Overholt. "We want people here to think of Gastrointestinal Associates when they think of gastroenterology."

Although the return on these efforts is difficult to measure directly, Dr. Overholt is convinced of their effectiveness. "We set a goal of a 10-percent increase in colonoscopies per year and far exceeded that," he says. "I compared our growth with that of other practices, and we are growing as quickly as the young start-up groups. It's very difficult for a mature group like ours to continue to grow like this. I think our efforts are working."

Screening Colonoscopy on the Rise

In 1999, endoscopists performed 4.4 million colonoscopies (mostly diagnostic), according to one CPT code analysis. Today, even the most conservative estimate projects annual demand for screening colonoscopy alone at 2.6 million. While actual demand will depend on factors like patient compliance and reimbursement, the current picture is pretty clear. In certain areas, some patients are waiting six months or longer for the test, while others are being turned away.

The supply-and-demand problem arises out of five factors.

  • Colorectal cancers rank as the fourth most commonly diagnosed cancers and second among cancer deaths in the United States, according to the National Cancer Institute. Five percent to 10 percent of asymptomatic people between 50 and 75 years old have advanced colonic neoplasia.
  • Risk increases with age, and there are already 77 million Americans aged 50 years to 70 years - and that number grows by 4 million annually, according to the 2000 census.
  • The medical community now views colonoscopy as the most effective screening test, and most professional guidelines endorse screening colonoscopy beginning at age 50 for healthy people and younger for those with certain risk factors.
  • Medicare now pays for screening colonoscopy in healthy people based on the aforementioned guidelines.
  • There has been a wave of publicity about the need to screen - most notably, the "Couric effect" took hold when Katie Couric, the Today Show host, underwent the screening procedure on television in the wake of her husband's death from colon cancer.

And it appears colonoscopy will remain the screening approach of choice for the near future. Although several well-regarded recent studies showed positive results for screening virtual colonoscopy, the technology must overcome some significant barriers, say critics. For one, the virtual technology might be less sensitive for smaller lesions or polyps, which some say can be clinically significant. The technology is also costlier and more time-consuming than conventional colonoscopy, as analysis time can be upwards of 30 minutes, according to one report. In addition, it's not yet reimbursed routinely by insurers and, importantly, it does not allow for polypectomy or histologic evaluation. Finally, patients tend to recall more discomfort with the virtual procedure even though it is less invasive because it requires insufflation without anesthesia.

- Dianne Taylor

For more information
Kochman ML, Levin B. Expert Commentary: Virtual Colonoscopy: Utility as a Screening Test for Colorectal Cancer? Posted 01/26/2004. writeOutLink("http://www.medscape.com/viewarticle/466138_1",0)
Lkieberman DA, Rex DK. Editorial: Feasibility of colonoscopy screening: Discussion of issues and recommendations regarding implementation. Gastroenterology Online. 2001;54:5. writeOutLink("http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=a117594&special=genrx",0)

Next month:

In part two of our series, find out how a hospital has become one of the nation's busiest outpatient facilities.

Bold moves
When Dr. Overholt and his colleagues opened the first endoscopy ASC in the country, it was a bold move. Now, 18 years later, they remain in character. With demand for both colonoscopy and upper endoscopy still on the rise, Dr. Overholt and his associates are building two additional, two-room (expandable to four) endoscopy ASCs with attached offices to gain coverage of the entire Knoxville area. They are even considering bringing an established endoscopy group or two into their fold. "Building our endoscopic ASC attached to our office was probably the single most significant thing our practice has done to ensure success," concludes Dr. Overholt. "An ASC is a strong recruitment tool for physicians."