Colonoscopy is all about seeing. As a result, many of its technological advances promise to help users see more, and to ensure that less goes unseen, in the name of patient care. Manufacturers' most recent visualization upgrades have included wider-angle and retroscopic views, accessories for flattening the folds that hide polyps and solutions for clearing incompletely prepped bowels. There's a lot of innovation out there, but how do your physicians decide which advances are worth the investment? Three endoscopic specialists told us the factors that matter most to them.
1. Does the technology deliver improved results?
High-definition views in multiple directions without obstructions are impressive, but detection rates are always the goal, and physicians want to see that data.
"How much data, how many studies are there backing this up?" asks Imran Fayyaz, MD, president and medical director at the Hamilton (N.J.) Endoscopy & Surgery Center. "I need more hard data that says it's going to be safer and more efficient."
He and his colleagues rejected an endoscope add-on that mechanically smooths out the colon while the scope is in motion due to a scarcity of clinical literature. "We need to have larger trials," he says. "Most new devices on the market have been tested on a small number of patients, numbers that are too small to be meaningful."
"A lot of the new technologies available deal with one thing, trying to see behind folds, especially in the right colon, where there tends to be a higher miss rate," says Steven Davidoff, MD, of the Endo Center at Voorhees in New Jersey. "None have radically increased the adenoma detection rate that I've seen." While he admits that no endoscopist can boast a 100% detection rate, each is seeking demonstrable gains from the new technologies he adopts.
Also, are these gains going to be clinically valuable? "Every time there's a next-generation scope, there are incremental improvements in image quality and maneuverability. We have to ask, are they beneficial to patients' lives?" says Samir Parikh, MD, FACS, FASCRS, who practices at the Riddle Surgical Center in Media, Pa. "Wider-angle scopes are where we are beginning to see a difference. You can see everything. The question then becomes, what are you finding? Tiny polyps that are not as important as the larger pre-cancerous polyps? It's nice to detect more things, but are they only benign things that you're detecting?"
As they wait for evidence, physicians often find themselves perfecting an existing technique with existing technology, like Dr. Fayyaz. "I'm not getting faster, I'm going slower," he says of his average 10-minute, 13-second withdrawal time. "If you spend more time looking, you will find more things." And watching the horizon for the next next-big-thing, like Dr. Davidoff, who at a recent American College of Gastroenterology conference was given a private glimpse of a prototype for an upcoming scope whose software lets it see behind the folds. "That could have a significant impact on polyp detection rates," he says.
2. Do the results justify the cost?
Cost was the second reason why Dr. Fayyaz's center didn't go all-in for the endoscope accessory they'd considered. "I'm excited when I see these things, but $20 per case seemed a bit much," he recalls. "The volume we have is good, but the numbers, when we plugged them in, didn't add up." Particularly since they weren't convinced that their adenoma detection rate would increase enough to offset the additional case cost. For now, they're waiting. "When more products enter the market, there's more competition and the costs come down," says Dr. Fayyaz.
His center's decision involved a comparatively small upgrade. The cost-benefit stakes are much higher when they involve the adoption of an all-new scope or display system. "To change over is a major investment," says Dr. Davidoff, whose center bought 32 scopes about 4 years ago. "It has to be worthwhile for us to do that. We can't just throw away all the scopes we have. That's a million-dollar change."
Dr. Davidoff and his colleagues have trialed their preferred scope manufacturer's new and improved platform, and were impressed by some of its features. "There was a wider angle of view, and it was easier to move through the sigmoid colon," he says, as well as reduced incidence of looping. But these advances on their own didn't warrant the expense of a wholesale replacement, he adds.
Improving your endoscopic visualization comes down to the big question in health care of how much care can you provide in exchange for a fixed reimbursement amount. "At the end of the day, there's an incentive for surgery centers to make a profit," says Dr. Parikh. "They have to ask themselves, Is it reasonable to spend a lot of money that they're not going to get back?"
3. Is it easy to use
(and practical to have)?
In colonoscopy, as in other processes, "you're building from the ground up," says Dr. Parikh. "Is the patient well-prepped? Does the endoscopist know what he is doing? Is he taking the time to properly do the procedure? If he's just whipping the scope out like a ripcord, he's not going to see anything."
New technology is similarly evaluated from the ground up. In order for physicians to enjoy its full advantages, it should be intuitive and not obstructive to use. Does it truly enhance visualization? Can it enable swifter advance times? Will it reduce the likelihood of looping, protecting patients from the risk of perforation?
Even as an increasing number of cases are migrating to the outpatient setting, it's also advisable to ask just how complex the cases your physicians host are. Will a new technology's cutting-edge detection features be in frequent enough demand at your facility for it to be a practical investment? "As advances come out, each has a place and a space," says Dr. Parikh. "Many of them can be seen in tertiary care, used by subspecialists who handle the most difficult colonoscopies." But if your schedule is generally booked with routine colonoscopies, will your physicians ever perform enough cases with high-end functions to acquire the necessary hands-on practice with them, and to justify their costs?
Technology upgrades are exciting, but in the overview there's no rush to adopt them, says Dr. Fayyaz. The advances that truly lift the tide — like high-definition imaging, for example — will remain, and eventually become standards. "We are in touch with our peers, and want to see what they're doing and exchange views," he says, "and adapt and change with the world of GI endoscopy."